Essentials of Nursing Research PDF

LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page i Aptara (PPG-Quark) seventh edition Essentials of Nursing Research...

LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page i Aptara (PPG-Quark) seventh edition Essentials of Nursing Research Appraising Evidence for Nursing Practice D E N I S E F. P O L I T, PhD President, Humanalysis, Inc., Saratoga Springs, New York and Adjunct Professor, Griffith University School of Nursing, Gold Coast, Australia (www.denisepolit.com) C H E R Y L TATA N O B E C K , DNSc, CNM, FAAN Distinguished Professor, School of Nursing, University of Connecticut Storrs, Connecticut LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page ii Aptara (PPG-Quark) Acquisitions Editor: Hilarie Surrena Managing Editor: Helen Kogut Director of Nursing Production: Helen Ewan Senior Managing Editor / Production: Erika Kors Production Editor: Mary Kinsella Art Director, Design: Joan Wendt Art Director, Illustration: Brett McNaughton Manufacturing Coordinator: Karin Duffield Production Services / Compositor: Aptara Seventh Edition Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2006, 2001 by Lippincott Williams & Wilkins. Copyright © 1997 by Lippincott–Raven Pub- lishers. Copyright © 1993, 1989, 1985 by J. B. Lippincott Company. All rights reserved. This book is pro- tected 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 Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia PA 19106, via email at [email protected] or via website at lww.com (products and services). 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Polit, Denise F. Essentials of nursing research : appraising evidence for nursing practice / Denise F. Polit, Cheryl Tatano Beck. — 7th ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7817-8153-4 (alk. paper) ISBN-10: 0-7817-8153-1 (alk. paper) 1. Nursing—Research. I. Beck, Cheryl Tatano. II. Title. [DNLM: 1. Nursing Research. WY 20.5 P769eg 2008] RT81.5.P63 2008 610.73072—dc22 2008047112 Care has been taken to confirm the accuracy of the information presented and to describe gen- erally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no war- ranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsi- bility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. 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LWW.COM LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page iii Aptara (PPG-Quark) To Our Students From Around the World Whose interests, passions, and curiosity have fueled our dedication to good teaching and to high-quality research LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page iv Aptara (PPG-Quark) R E V I E W E R S Kathleen Barta, EdD, RN Marilyn Handley, RN, PhD Associate Professor Associate Professor University of Arkansas University of Alabama Fayetteville, Arkansas Tuscaloosa, Alabama Mary Bennett, RN, MS, DNSc, FNP Grace E. 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Hoerst, RN, PhD Associate Professor Assistant Professor Bloomsburg University of Pennsylvania La Salle University Bloomsburg, Pennsylvania Philadelphia, Pennsylvania Bernadette Curry, PhD Karyn Holm, PhD, RN, FAAN Molloy College Professor Rockville Centre, New York DePaul University Chicago, Illinois Barbara Davis, PhD, RN Professor Debra Horoho, MSN University of Southern Indiana Indiana University Evansville, Indiana Kokomo, Indiana Velma Edmonds, DNS, MSN, BSN, RN Ann Jacobson, PhD, RN Assistant Professor Associate Professor University of Texas Kent State University El Paso, Texas Kent, Ohio Kay Foland, PhD, APRN, BC, CNP Peggy Leapley, PhD, RN, FNP, CNS, APRN, BC Associate Professor Professor and Chair of Nursing South Dakota State University California State University Rapid City, South Dakota Bakersfield, California Sharon George, PhD Gayle Lee, PhD, FNP-C, CCRN University of Alabama Nursing Faculty Huntsville, Alabama Brigham Young University, Idaho Rexburg, Idaho iv LWBK131-3938G-FM.[i-xiv]qxd 11/3/08 10:01 PM Page v Aptara Inc. Margaret Louis, PhD Pammla Petrucka, RN, BSc, BScN, MN, PhD University of Nevada Associate Professor Las Vegas, Nevada University of Saskatchewan Regina, Saskatchewan Nelda Martinez, PhD, RN Associate Professor; Senior Fellow Janice Polizzi, MSN, RN University of Texas, El Paso; Hispanic Health Disparities Associate Professor Research Center Florida Hospital College El Paso, Texas Orlando, Florida Carrie McCoy, PhD, MSPH, RN, CEN Patsy Riley Professor; Director of ABSN Program Troy University Northern Kentucky University Troy, Alabama Highland Heights, Kentucky Denise Robinson, PhD, RN, FNP Marylou K. McHugh, RN, EdD Interim Chair and Regents Professor Adjunct Faculty Northern Kentucky University Drexel University; Temple University Highland Heights, Kentucky Philadelphia, Pennsylvania Nancy Schlapman Nancy Menzel, PhD, APRN-BC, COHN-S, CNE Indiana University Associate Professor Kokomo, Indiana University of Nevada, Las Vegas Las Vegas, Nevada Joanne Serembus, EdD, RN, CCRN, CNE Clinical Associate Professor Ruby Morrison Drexel University University of Alabama Philadelphia, Pennsylvania Tuscaloosa, Alabama Sandra L. Siedlecki, RN, CNS, PhD Donna Musser, PhD, RN Senior Nurse Researcher Assistant Professor Cleveland Clinic Foundation University of Central Arkansas Cleveland, Ohio Conway, Arkansas Matthew Sorenson, PhD, RN Sarah Newton, PhD, RN Assistant Professor Associate Professor DePaul University Oakland University Chicago, Illinois Rochester, Michigan Valmi Sousa, PhD Priscilla C. O’Connor, PhD, APRN, BC University of North Carolina Lecturer Charlotte, North Carolina Temple University Philadelphia, Pennsylvania Amy Spurlock, PhD, RN Associate Professor Nicole Ouellet, PhD, RN Troy State University Professor Troy, Alabama Université du Québec à Rimouski Rimouski, Quebec Thomas Stenvig, RN, PhD, MPH, CNAA Associate Professor Elizabeth Petit De Mange, RN, PhD South Dakota State University Assistant Professor Brookings, South Dakota Drexel University Philadelphia, Pennsylvania v LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page vi Aptara (PPG-Quark) Marliyn Stoner, RN, PhD Latricia Weed, PhD Associate Professor Troy State University California State University Troy, Alabama San Bernardino, California Katherine Willock, PhD, APRN, BC Helene Sylvain, PhD Associate Professor and Director of Graduate Programs Université du Québec à Rimouski Indiana University-Purdue University Rimouski, Quebec Fort Wayne, Indiana Jane Tarnow Evelyn Wills, BSN, MSN, PhD DePaul University Professor Chicago, Illinois University of Louisiana Lafayette, Louisiana Becky Thiel Shawnee State University Mary Woo, DNSc, RN Portsmouth, Ohio Professor University of California Molly Walker, PhD, RN, CNS Los Angeles, California Associate Professor Angelo State University Geri L. Wood, PhD, RN, FAAN San Angelo, Texas Associate Professor University of Texas Health Science Center Karen Ward, PhD Houston, Texas Middle Tennessee State University Murfreesboro, Tennessee Patti Rager Zuzelo, EdD, APRN, BC, CNS Associate Professor & CNS Track Coordinator; Gail Washington, DNS, RN Associate Director of Nursing for Research Assistant Professor La Salle University; Albert Einstein Healthcare Network California State University Philadelphia, Pennsylvania Los Angeles, California Joan Wasserman, PhD, MBA, RN Assistant Professor University of Texas, Houston Houston, Texas vi LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page vii Aptara (PPG-Quark) P R E F A C E This book marks the seventh time we have worked on this textbook, which is designed to teach students how to read research reports and critique the methods used in nursing studies. It is perhaps difficult to imagine that writing a seventh edi- tion of a textbook on research methods could be fun—but that is exactly the right word to describe our experience in working on this new edition. We have made many changes to the content and organization of this textbook, and the revisions kept our enthusiasm and energy for this project at a very high level. We are confi- dent that we have introduced numerous improvements—but at the same time, we have retained many features that have made this book a classic throughout the world. We think that this edition will make it easier and more satisfying for nurses to pursue a professional pathway that incorporates thoughtful appraisals of evi- dence. NEW TO THIS EDITION Up-front, Consistent Emphasis on Evidence-Based Practice To an even greater extent than in the past, we emphasize in this edition that research is a crucial enterprise for building an evidence base for nursing practice. We have given the topic of evidence-based practice (EBP) greater prominence by making the chapter on EBP the second chapter of the book (previously the last chapter), and by expanding its content. We emphasize throughout that high-quality evidence is a product of researchers’ decisions in designing and executing a study. Every chapter offers guidance on how to appraise research evidence for its utility in informing nurses’ clinical deci- sions. We have also added a new chapter on how to read, interpret, and critique sys- tematic reviews, which are considered by many to be a cornerstone of EBP. The Study Guide that supplements this textbook includes a full report of an EBP project. The increased focus on EBP prompted us to modify the book’s title to emphasize the impor- tant link between research and evidence. New Material Relating to Medical Research Methodology Nurse researchers have tended to use methods and jargon that originated in the social sciences, but the push for EBP in medicine has led to methodologic innova- tions that are relevant to all healthcare research. Moreover, nurses can profit from familiarity with medical research terms and approaches so they can comfortably read articles in a broad range of health care journals. This edition offers a more bal- anced presentation of medical and social science methods and nomenclature. Improved Content on Qualitative Methods In every new edition we have expanded content on qualitative research methods, and this edition is no exception. We are especially pleased to include a new chapter vii LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page viii Aptara (PPG-Quark) viii PREFACE on the issue of quality and trustworthiness in qualitative inquiry, Chapter 18. We believe that the content and breadth of this important chapter is unparalleled in other general text- books on research methods for nurses. Greater Assistance With Interpretation Many books on research methods describe the techniques used to generate evidence, but they typically offer little or no guidance on interpreting research results. We have made efforts to address this deficiency by offering an interpretive framework for both quantita- tive (Chapter 16) and qualitative (Chapter 18) research. Additional Support for Research Appraisals—The Toolkit Each chapter of the book includes questions to aid students in reading and appraising research journal articles. In this edition, these critiquing guidelines are also available on the accompanying Student CD-ROM and. With electronic files of these resources, students can download the guidelines, adapt them as needed, and then enter their answers to the questions directly, without having to photocopy pages from the book. Many faculty have told us that the general critiquing guidelines (which we have put in an earlier chapter than in previous editions) are useful as handouts, and now they are more readily accessible. ORGANIZATION OF THE TEXT The content of this edition is organized into five main parts. * Part I—Overview of Nursing Research and Its Role in Evidence-Based Practice introduces fundamental concepts in nursing research. Chapter 1 summarizes the histo- ry and future of nursing research, discusses the philosophical underpinnings of quali- tative research versus quantitative research, and describes major purposes of nursing research. Chapter 2 offers guidance on using research to build an EBP. Chapter 3 intro- duces readers to key research terms, and presents an overview of steps in the research process for both qualitative and quantitative studies. Chapter 4 focuses on research reports, explaining what they are and how to read them. Chapter 5 discusses ethics in nursing studies. * Part II—Preliminary Steps in the Appraisal of Evidence further sets the stage for learning about the research process by considering aspects of a study’s conceptualiza- tion. Chapter 6 focuses on the development of research questions and the formulation of research hypotheses. Chapter 7 discusses how to prepare and critique literature reviews. Chapter 8 presents information about theoretical and conceptual frameworks. * Part III—Designs for Nursing Research presents material on the design of qualitative and quantitative nursing studies. Chapter 9 describes some fundamental design princi- ples and discusses many specific aspects of quantitative research design. Chapter 10 LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page ix Aptara (PPG-Quark) PREFACE ix addresses the various research traditions that have contributed to the growth of natu- ralistic inquiry and qualitative research. Chapter 11 provides an introduction to some specific types of research (e.g., evaluations, surveys, secondary analyses), and also describes mixed method studies that integrate qualitative and quantitative components. Chapter 12 introduces designs for sampling study participants. * Part IV—Data Collection concerns the gathering of data to address research ques- tions. Chapter 13 discusses a range of data collection options for nurse researchers, including both qualitative and quantitative approaches. Chapter 14 describes the concept of measurement and criteria for assessing data quality in quantitative studies. * Part V—Data Analysis and Interpretation discusses analytic methods for qualitative and quantitative research. Chapter 15 reviews methods of quantitative analysis. The chapter assumes no prior instruction in statistics and focuses primarily on helping read- ers to understand why statistics are needed, what tests might be appropriate in a given situation, and what statistical information in a research report means. Chapter 16 dis- cusses ways of appraising rigor in quantitative studies, and approaches to interpreting statistical results. Chapter 17 presents a discussion of qualitative analysis, with an emphasis on ethnographies, phenomenologic studies, and grounded theory studies. Chapter 18 elaborates on criteria for appraising integrity and quality in qualitative stud- ies. Finally, Chapter 19 describes systematic reviews, including how to understand and appraise both meta-analyses and metasyntheses. KEY FEATURES This edition, like its predecessors, is focused on the art—and science—of research critiques. It offers guidance to students who are learning to appraise research reports and use research findings in practice. Among the basic principles that helped to shape this and ear- lier editions of this book are (1) an assumption that competence in doing and appraising research are critical to the nursing profession; (2) a conviction that research inquiry is intellectually and professionally rewarding to nurses; and (3) an unswerving belief that learning about research methods need be neither intimidating nor dull. Consistent with these principles, we have tried to present research fundamentals in a way that both facili- tates understanding and arouses curiosity and interest. General Features We have retained many of the key features that were successfully used in previous editions to assist consumers of nursing research: * 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 knowledge of tech- nical terms. LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page x Aptara (PPG-Quark) x PREFACE * Critiquing Guidelines. Each chapter includes guidelines for conducting a critique of various aspects of a research report. The guidelines sections provide a list of questions that walk students through a study, drawing attention to aspects of the study that are amenable to appraisal by research consumers. Electronic versions of the guidelines are available on the accompanying student CD-ROM and thePoint. * 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 crit- ical thinking skills. In addition, many research examples are used to illustrate key points in the text and to stimulate students’ thinking about areas of research inquiry. We have chosen many international examples to communicate to students that nursing research is growing in importance worldwide. * Tips for Consumers. The textbook is filled with practical guidance and “tips” on how to translate the abstract notions of research methods into more concrete applications. In these tips, we have paid special attention to helping students read research reports, which are often daunting to those without specialized research training. * Graphics. Colorful graphics, in the form of supportive tables, figures, and examples, reinforce the text and offer visual stimulation. Features for Student Learning We have used many features to enhance and reinforce learning—and, especially, to facili- tate the development of critiquing skills. These include the following: * Student Objectives. Learning objectives are identified in the chapter opener to focus students’ attention on critical content. * Key Terms. New terms are defined in context (and bolded) when used for the first time in the text. Each chapter concludes with a list of new terms, and we have made the list less daunting by including only key new terms. A glossary at the end of the book provides additional support for those needing to look up the meaning of a methodologic term. * Bulleted Summary Points. A succinct list of summary points that focus on salient chapter content is included at the end of each chapter. * Full-Length Research Articles. In this edition, the textbook includes four recent full- length studies—two quantitative and two qualitative—that students can read, analyze, and critique. Two appear in the appendices of the textbook, and two are on the CD-ROM packaged with the book and thePoint. * Critiquing Supports. Each chapter of the textbook concludes with “Critical Thinking Activities”—exercises that provide opportunities to practice critiquing. Some exercises are based on the studies that are included in their entirety in the appendices of the book, while others are based on studies that are summarized at the end of the chapters. Impor- tantly, students can then consult the accompanying CD-ROM and thePoint to find our “answers” (our expert thoughts about each question), so that students can get immediate feedback about their grasp of material in the chapter. (In some cases, there are also thoughtful comments by the actual researchers who conducted the studies). This edition LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page xi Aptara (PPG-Quark) PREFACE xi also includes full critiques of the two studies on the CD-ROM and thePoint, which stu- dents can use as models for a comprehensive research critique. Many more critiquing opportunities are available in the Study Guide, which includes seven studies in their entirety in the appendices and exercises in each chapter that guide students in reading, understanding, and critiquing these studies. TEACHING-LEARNING PACKAGE Essentials of Nursing Research: Appraising Evidence for Nursing Practice, seventh edi- tion, has an ancillary package designed with both students and instructors in mind. * The Study Guide augments the text and provides students with application exercises for each text chapter. Critiquing skills are emphasized, but there are also activities to sup- port the learning of fundamental research terms and principles. Seven recent studies— including one report of an EBP project—are included in the appendices, and many chapter exercises are based on these studies. The studies represent a range of research types, including a clinical trial, a survey, an evaluation of an EBP project, a grounded theory study, a feminist study, a meta-analysis, and a metasynthesis. * Free CD-ROM. The textbook includes a CD-ROM that has many important resources. First, as noted, we provide our answers to the Critical Thinking Activities from the text- book. Critiquing guidelines for each chapter, as well as some other resources, are included as a toolkit in electronic files for downloading, adapting, and printing. Next, the CD-ROM provides hundreds of review questions to assist students in self-testing. This review program provides a rationale for both correct and incorrect answers, help- ing students to identify areas of strength and areas needing further study. Finally, the CD-ROM 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. All of these resources are also available on thePoint. * The Instructor’s Resource CD-ROM (IRCD) includes a chapter corresponding to every chapter in the textbook. Each IRCD chapter contains the following: Statement of Intent, Special Class Projects, Answers to Selected Study Guide Exercises, and Test Questions and Answers. In the special class projects, we offer opportunities for students to develop a quantitative and (or) a qualitative data set. With regard to test questions to evaluate student learning, we offer multiple choice and true/false questions and, impor- tantly, we have added questions specifically designed to test students’ ability to compre- hend research reports. In addition, PowerPoint slides summarizing key points in each chapter are available in a format that permits easy adaptation. All of this content is also available on thePoint. It is our hope and expectation that the content, style, and organization of this seventh edition of Essentials of Nursing Research will be helpful to those students desiring to become skillful and thoughtful readers of nursing studies and to those wishing to enhance their clinical per- formance based on research findings. We also hope that this textbook will help to develop an enthusiasm for the kinds of discoveries and knowledge that research can produce. LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page xii Aptara (PPG-Quark) xii ACKNOWLEDGMENTS DENISE F. POLIT, PhD CHERYL TATANO BECK, DNSc, CNM, FAAN ACKNOWLEDGMENTS This seventh edition, like the previous six editions, depended on the contribution of many generous people. Many faculty and students who used the text have made invaluable sug- gestions for its improvement, and to all of you we are very grateful. Suggestions were made to us both directly in personal interactions (mostly at the University of Connecticut and Griffith University in Australia), and via the wonderful communication tool of email corre- spondence. In addition to all those who assisted us during the past three decades with the earlier editions, there are some who deserve special mention for this new work. We would like to acknowledge the comments of the reviewers of the previous edition of Essentials, whose anonymous feedback influenced our revisions. Several of the comments triggered several important changes, and for this we are indebted. Other individuals made specific contributions. Although it would be impossible to men- tion all, we note with thanks the nurse researchers who shared their work with us as we developed examples, including work that in some cases was not yet published. Through the Internet, we worked with authors of the reports that appear in the appendices. We shared with them our critiques and “answers” to the critiquing exercises to make sure that we had not misread or misinterpreted their reports, and they gave generously of their time in reviewing our material. Special thanks to Carol Howell, Marti Rice, Linda Walsh, and Michael McGillion for their help. We also got extraordinary cooperation from the authors of studies that were summarized at the end of the chapters, and we are grateful to them all. We extend our warm thanks as well to those who helped to turn the manuscript into a finished product. The staff at Lippincott Williams & Wilkins has been of tremendous assis- tance in the support they have given us over the years. We are indebted to Hilarie Surrena, Helen Kogut, Mary Kinsella, Annette Ferran, Joan Wendt, and all the others behind the scenes for their fine contributions. Finally, we thank our family, our loved ones, and our friends, who provided ongoing sup- port and encouragement throughout this endeavor and who were tolerant when we worked long into the night, over weekends, and during holidays to get this seventh edition finished. LWBK131-3938G-FM.[i-xiv]qxd 11/14/08 12:48 AM Page xiii Aptara Inc. C O N T E N T S PART 1: OVERVIEW OF NURSING RESEARCH AND ITS ROLE IN EVIDENCE-BASED PRACTICE 1 Introduction to Nursing Research in an Evidence-Based Practice Environment 3 2 Evidence-Based Nursing Practice: Fundamentals 33 3 Key Concepts and Steps in Qualitative and Quantitative Research 61 4 Reading and Critiquing Research Reports 87 5 Ethics in Research 117 PART 2: PRELIMINARY STEPS IN THE APPRAISAL OF EVIDENCE 6 Research Problems, Research Questions, and Hypotheses 145 7 Literature Reviews: Finding and Reviewing Research Evidence 169 8 Theoretical and Conceptual Frameworks 194 PART 3: DESIGNS FOR NURSING RESEARCH 9 Quantitative Research Design 221 10 Qualitative Designs and Approaches 258 11 Specific Types of Research 284 12 Sampling Plans 305 PART 4: DATA COLLECTION 13 Data Collection Methods 337 14 Measurement and Data Quality 369 PART 5: DATA ANALYSIS AND INTERPRETATION 15 Statistical Analysis of Quantitative Data 391 16 Rigor and Interpretation in Quantitative Research 440 17 Analysis of Qualitative Data 462 18 Trustworthiness and Integrity in Qualitative Research 489 19 Systematic Reviews: Meta-Analysis and Metasynthesis 514 Methodologic and Theoretical References 541 Glossary 547 Glossary of Selected Statistical Symbols 572 xiii LWBK131-3938G-FM.[i-xiv]qxd 11/1/08 12:41 PM Page xiv Aptara (PPG-Quark) xiv CONTENTS APPENDICES: RESEARCH REPORTS A The Relationships Among Anxiety, Anger, and Blood Pressure in Children 574 B The Anniversary of Birth Trauma 581 Index 591 LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 2 Aptara (PPG-Quark) LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 1 Aptara (PPG-Quark) 1 p a r t Overview of Nursing Research and Its Role in Evidence-Based Practice LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 3 Aptara (PPG-Quark) c h a p t e r Introduction to 1 Nursing Research in an Evidence-Based Practice Environment NURSING RESEARCH IN PERSPECTIVE PARADIGMS FOR NURSING RESEARCH What Is Nursing Research? The Positivist Paradigm The Importance of Research to Evidence-Based Nursing The Naturalistic Paradigm Practice Paradigms and Methods: Quantitative and Qualitative Roles of Nurses in Research Research Multiple Paradigms and Nursing Research NURSING RESEARCH: PAST, PRESENT, AND FUTURE The Early Years: From Nightingale to the 1970s PURPOSES OF NURSING RESEARCH Nursing Research Since 1980 Research to Achieve Various Levels of Explanation Directions for Nursing Research in the New Millennium Research Purposes Linked to EBP SOURCES OF EVIDENCE FOR NURSING PRACTICE ASSISTANCE FOR CONSUMERS OF NURSING RESEARCH Tradition and Authority RESEARCH EXAMPLES AND CRITICAL THINKING Clinical Experience, Trial and Error, and Intuition ACTIVITIES Logical Reasoning CHAPTER REVIEW Assembled Information Key New Terms Disciplined Research Summary Points STUDIES CITED IN CHAPTER 1 STUDENT OBJECTIVES On completing this chapter, you will be able to: * Describe why research is important in the nursing profession and discuss the need for evidence-based practice * Describe historic trends and future directions in nursing research * Describe alternative sources of evidence for nursing practice * Describe major characteristics of the positivist and naturalistic paradigm, and discuss similarities and differences between the traditional scientific method (quantitative research) and naturalistic methods (qualitative research) * Identify several purposes of qualitative and quantitative research * Define new terms in the chapter LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 4 Aptara (PPG-Quark) 4 Nursing Research in Perspective NURSING RESEARCH IN PERSPECTIVE It is an exciting—and challenging—time to be a nurse. Nurses are performing their clinical responsibilities at a time when the nursing profession and larger health care systems require an extraordinary range of skills and talents of them. Nurses are expected to deliver competent, high-quality care in a compassionate but also cost-effective manner. To accomplish these diverse goals, nurses continually need to access and evaluate new information, and incorporate it into their clinical decision- making. In today’s world, nurses must become lifelong learners, capable of reflecting on, evaluating, and modifying their clinical practice based on emerging knowledge from systematic nursing and health care research. What Is Nursing Research? Research is systematic inquiry that uses disciplined methods to answer questions and solve problems. The ultimate goal of research is to develop, refine, and expand a body of knowledge. Nurses are increasingly engaged in disciplined studies that benefit the profes- sion and its clients. Nursing research is systematic inquiry designed to develop trustworthy evidence about issues of importance to the nursing profession, includ- ing nursing practice, education, administration, and informatics. In this book, we emphasize clinical nursing research, that is, research designed to guide nursing practice and to improve the health and quality of life of nurses’ clients. Clinical nursing research typically begins with questions stemming from practice-related problems—problems such as ones you may have already encountered. Examples of nursing research questions: * Among current smokers, are more sources of secondhand smoke exposure associated with higher nicotine dependence and lower intention to quit smoking? (Okoli, Browning, Rayens, & Hahn, 2008) * What are the late effects of cancer treatment among long-term cancer survivors, and what are ways in which survivors find support and information that are not provided via follow-up care? (Klemm, 2008) The Importance of Research to Evidence-Based Nursing Practice In all parts of the world, nursing has experienced a profound culture change over the past few decades. Nurses are increasingly expected to understand and conduct research, and to base their professional practice on emerging evidence from research—that is, to adopt an evidence-based practice (EBP). EBP is broadly defined as the use of the best clinical evidence in making patient care decisions, and such evidence typically comes from research conducted by nurses and other health care professionals. LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 5 Aptara (PPG-Quark) CHAPTER 1 * Introduction to Nursing Research in an Evidence-Based Practice Environment 5 Evidence for EBP can come from various sources, but there is widespread agreement that research findings from rigorous studies provide especially strong evidence for informing nurses’ decisions and actions. Nurses are accepting the need to base specific nursing actions and decisions on evidence indicating that the actions are clinically appropriate, cost-effective, and result in positive out- comes for clients. In the United States, research has come to play an important role in nursing in terms of credentialing and status. The American Nurses Credentialing Center—an arm of the American Nurses Association—has developed a Magnet Recognition Program® to recognize health care organizations that provide very high-quality nursing care, and to elevate the standards and reputation of the nursing profession. As noted by Turkel and colleagues (2005), to achieve Magnet status, it is essential for nurse leaders to create, advance, and sustain a practice environment grounded in EBP and nursing research. Changes to nursing practice are occurring regularly because of EBP efforts. Often these practice changes are local initiatives, many of which are not publicized, but broader clinical changes are also occurring based on accumulating research evidence about beneficial practice innovations. Example of evidence-based practice: “Kangaroo care,” the holding of diaper-clad preterm infants skin-to-skin, chest-to-chest by parents, is now widely practiced in neonatal intensive care units (NICUs) in the United States and elsewhere, but this is a new trend. As recently as the early 1990s, only a minority of NICUs offered kangaroo care options. The adoption of this practice reflects the mounting evidence that early skin-to-skin contact has clinical benefits without any apparent negative side effects (Dodd, 2005; Galligan, 2006). Some of the accumulated evidence was developed in rigorous studies by nurse researchers in the United States, Australia, Canada, Taiwan, Korea, and other countries (e.g., Chwo et al., 2002; Ludington-Hoe et al., 2004, 2006; Moore & Anderson, 2007). Roles of Nurses in Research With the current emphasis on EBP, it has become every nurse’s responsibility to engage in one or more roles along a continuum of research participation. At one end of the continuum are users (consumers) of nursing research—nurses who read research reports to develop new skills and to keep up to date on relevant findings that may affect their practice. Nurses are now expected to maintain this level of involvement with research, at a minimum. EBP depends on well-informed nursing research consumers. At the other end of the continuum are the producers of nursing research—nurses who actively participate in designing and implementing studies. At one time, most nurse researchers were academics who taught in schools of nursing, but research is increasingly being conducted by practicing nurses who want to find what works best for their clients. Between these two endpoints on the consumer–producer continuum lie a rich variety of research activities in which nurses may engage. Even if you never con- duct a study, you may well do one or more of the following: LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 6 Aptara (PPG-Quark) 6 Nursing Research: Past, Present, and Future * Participate in a journal club in a practice setting, which involves meetings to discuss and critique research articles * Attend research presentations at professional conferences * Solve clinical problems and make clinical decisions based on rigorous research * Help to develop an idea for a clinical study * Review a proposed research plan and offer clinical expertise to improve the plan * Assist researchers by recruiting potential study participants or collecting research information (e.g., distributing questionnaires to clients) * Provide information and advice to clients about participation in studies * Discuss the implications and relevance of research findings with clients Example of research publicized in the mass media: Here is a headline about a health study that was publicized in newspapers and major television networks in the United States and Canada in April, 2007: “Study doesn’t back abortion-cancer link.” According to the study, which involved more than 100,000 nurses who were followed for over a decade, having an abortion does not raise a woman’s risk of breast cancer. What would you say if clients asked you about this study? Would you be able to comment on the believability of the findings, based on your assessment of how rig- orously the study was conducted? This book should enable you to do this. In all the possible research-related activities, nurses who have some research skills are better able than those without them to make a contribution to nursing and to EBP. An understanding of nursing research can improve the depth and breadth of every nurse’s professional practice. NURSING RESEARCH: PAST, PRESENT, AND FUTURE Although nursing research has not always had the prominence and importance it enjoys today, its long and interesting history portends a distinguished future. Table 1.1 summarizes some of the key events in the historic evolution of nursing research. The Early Years: From Nightingale to the 1970s Most people would agree that research in nursing began with Florence Nightingale. Her landmark publication, Notes on Nursing (1859), describes her early interest in environmental factors that promote physical and emotional well-being—an interest that continues among nurses 150 years later. Based on her skillful analysis of fac- tors affecting soldier mortality and morbidity during the Crimean War, she was successful in effecting some changes in nursing care—and, more generally, in pub- lic health. For many years after Nightingale’s work, the nursing literature contained little research. Studies began to be published in the early 1900s, mostly concerning LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 7 Aptara (PPG-Quark) CHAPTER 1 * Introduction to Nursing Research in an Evidence-Based Practice Environment 7 TABLE 1.1 HISTORIC LANDMARKS IN NURSING RESEARCH YEAR EVENT 1859 Nightingale’s Notes on Nursing is published 1900 American Nursing Journal begins publication 1923 Columbia University establishes first doctoral program for nurses Goldmark Report with recommendations for nursing education published 1930s American Journal of Nursing publishes clinical cases studies 1936 Sigma Theta Tau awards first nursing research grant in the United States 1948 Brown publishes report on inadequacies of nursing education 1952 The journal Nursing Research begins publication 1955 Inception of the American Nurses’ Foundation to sponsor nursing research 1957 Establishment of nursing research center at Walter Reed Army Institute of Research 1963 International Journal of Nursing Studies begins publication 1965 American Nurses’ Association (ANA) begins sponsoring nursing research conferences 1969 Canadian Journal of Nursing Research begins publication 1971 ANA establishes a Commission on Research 1972 ANA establishes its Council of Nurse Researchers 1976 Stetler and Marram publish guidelines on assessing research for use in practice 1978 The journals Research in Nursing & Health and Advances in Nursing Science begin publication 1979 Western Journal of Nursing Research begins publication 1982 The Conduct and Utilization of Research in Nursing (CURN) project publishes report 1983 Annual Review of Nursing Research begins publication 1985 ANA Cabinet on Nursing Research establishes research priorities 1986 National Center for Nursing Research (NCNR) established within U.S. National Institutes of Health 1988 The journal Applied Nursing Research begins publication 1989 U.S. Agency for Health Care Policy and Research (AHCPR) is established (renamed Agency for Healthcare Research and Quality or AHRQ in 1999) 1993 NCNR becomes a full institute, the National Institute of Nursing Research (NINR) The Cochrane Collaboration is established 1994 The journal Qualitative Health Research begins publication 1995 The Joanna Briggs Institute, an international EBP collaborative, is established in Australia 1997 Canadian Health Services Research Foundation is established with federal funding 2000 NINR’s annual funding exceeds $100 million The Canadian Institute of Health Research is launched 2004 The journal Worldviews on Evidence-Based Nursing begins publication 2005 Sigma Theta Tau International publishes research priorities nurses’ education. As more nurses received university-based education, studies con- cerning nursing students—their characteristics, problems, and satisfactions— became a major focus. During the 1940s, government-initiated studies of nursing education continued, spurred on by the unprecedented demand for nursing per- sonnel during World War II. When hospital staffing patterns changed, fewer stu- dents were available over a 24-hour period. As a consequence, researchers focused their investigations not only on the supply and demand of nurses but also on the amount of time required to perform certain nursing activities. A number of forces combined during the 1950s to put nursing research on a rapidly accelerating upswing in the United States. An increase in the number of LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 8 Aptara (PPG-Quark) 8 Nursing Research: Past, Present, and Future nurses with advanced degrees and better research training, an increase in the avail- ability of funds from the government and private foundations, and the establish- ment of the journal Nursing Research are a few of the forces propelling nursing research at mid-century. During the 1960s, practice-oriented research on various clinical topics began to emerge in the literature and nursing research advanced worldwide: the Interna- tional Journal of Nursing Studies began publication in 1963, and both the Journal of Nursing Scholarship and the Canadian Journal of Nursing Research were first published in the late 1960s. Example of nursing research breakthroughs in the 1960s: Jeanne Quint Benoliel began a program of research that had a major impact on medicine, medical sociology, and nursing. Quint explored the subjective experiences of patients after diagnosis with a life- threatening illness (1967). Of particular note, physicians in the early 1960s usually did not advise women that they had breast cancer, even after a mastectomy. Quint’s (1963) seminal study of the per- sonal experiences of women after radical mastectomy contributed to changes in communication and information control by physicians and nurses. During the 1970s, there was a decided change in emphasis in nursing research from areas such as teaching and nurses themselves to improvements in client care. Nurses also began to pay attention to the utilization of research findings in nursing practice. A seminal article by Stetler and Marram (1976) offered guidance on assessing research for application in practice settings. By the 1970s, the growing number of nurses conducting studies and the discussions of theoretic and contex- tual issues surrounding nursing research created the need for additional commu- nication outlets. Several journals that focus on nursing research were established in the 1970s, including Research in Nursing & Health, the Journal of Advanced Nurs- ing, and the Western Journal of Nursing Research. Example of nursing research breakthroughs in the 1970s: Kathryn Barnard’s research led to breakthroughs in the area of neonatal and child development. Her research program focused on the identification and assessment of children at risk of developmental and health problems, such as abused and neglected children and failure-to-thrive children (Barnard, 1973; Barnard, Wenner, Weber, Gray, & Peterson, 1977). Her research contributed to early interventions for children with disabilities, and also to the field of developmental psychology. Nursing Research Since 1980 The 1980s brought nursing research to a new level of development. Several events contributed to the momentum. For example, the first volume of the Annual Review of Nursing Research was published in 1983. These annual reviews include sum- maries of current research evidence on selected areas of research practice and encourage utilization of research findings. Of particular importance in the United States was the establishment in 1986 of the National Center for Nursing Research (NCNR) at the National Institutes of Health (NIH). The purpose of NCNR was to LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 9 Aptara (PPG-Quark) CHAPTER 1 * Introduction to Nursing Research in an Evidence-Based Practice Environment 9 promote—and financially support—research projects and training relating to patient care. Funding for nursing research also became available in Canada in the 1980s through the National Health Research Development Program (NHRDP) and the Medical Research Council of Canada. Also in the 1980s, nurses began to conduct formal projects specifically designed to increase research utilization, such as the Conduct and Utilization of Research in Nursing (CURN) project. Additional research-related journals were established in the 1980s, including Applied Nursing Research and, in Australia, the Australian Jour- nal of Nursing Research. Several forces outside of nursing in the late 1980s helped to shape today’s nurs- ing 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 pro- found shift for medical education and practice, and has had a major effect on all health care professions. In 1989, the U.S. government established the Agency for Health Care Policy and Research (AHCPR). AHCPR (renamed the Agency for Healthcare Research and Quality, or AHRQ, in 1999) is the federal agency that has been charged with sup- porting research specifically designed to improve the quality of health care, reduce health costs, and enhance patient safety, and thus plays a pivotal role in supporting EBP. Example of nursing research breakthroughs in the 1980s: A team of researchers headed by Dorothy Brooten engaged in studies that led to the development and testing of a model of site transitional care. For example, Brooten and her colleagues (1986, 1988) conducted studies of nurse specialist-managed home follow-up services for very-low-birth-weight infants who were discharged early from the hospital, and demonstrated a significant cost savings—with com- parable health outcomes. The site transitional care model, which was developed in anticipation of gov- ernment cost-cutting measures, has been used as a framework for patients who are at health risk as a result of early discharge from hospitals, and has been recognized by numerous health care disciplines. Nursing research was strengthened and given more national visibility when NCNR was promoted to full institute status within the NIH: in 1993, the National Institute of Nursing Research (NINR) was established. The birth of NINR helped put nursing research more into the mainstream of research activities enjoyed by other health disciplines. Funding for nursing research has also grown. In 1986, the NCNR had a budget of $16 million, whereas by fiscal year 1999, the budget for NINR had grown to about $70 million. Funding opportunities expanded in other countries as well. For example, the Canadian Health Services Research Foundation (CHSRF) was established in 1997 with an endowment from federal funds, and plans for the Canadian Institute for Health Research got underway. Beginning in 1999, the CHSRF allocated $25 million for nursing research. In addition to growth in funding opportunities, the 1990s witnessed the birth of several more journals for nurse researchers, including Qualitative Health Research, Clinical Nursing Research, and Clinical Effectiveness. These journals emerged in LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 10 Aptara (PPG-Quark) 10 Nursing Research: Past, Present, and Future response to the growth in clinically oriented and in-depth research among nurses, and interest in EBP. Another major contribution to EBP was inaugurated in 1993: the Cochrane Collaboration, an international network of institutions and individu- als that maintains and updates systematic reviews of hundreds of clinical inter- ventions to facilitate EBP. International cooperation around the issue of EBP in nursing also began to develop in the 1990s. For example, Sigma Theta Tau Inter- national began to focus attention on research utilization, and sponsored the first international research utilization conference, in cooperation with the faculty of the University of Toronto, in 1998. Example of nursing research breakthroughs in the 1990s: Many studies that Donaldson (2000) identified as breakthroughs in nursing research were conducted in the 1990s. This reflects, in part, the growth of research programs in which teams of researchers engage in a series of related research on important topics, rather than discrete and unconnected stud- ies. As but one example, several nurse researchers had breakthroughs during the 1990s in the area of psychoneuroimmunology, which has been adopted as the model of mind–body interactions. Swanson and Zeller, for example, conducted several studies relating to human immunodeficiency virus (HIV) infection and neuropsychologic function (Swanson, Cronin-Stubbs, Zeller, Kessler, & Bielauskas, 1993; Swanson, Zeller & Spear, 1998) that have led to discoveries in environmental management as a means of improving immune system status. Directions for Nursing Research in the New Millennium Nursing research continues to develop at a rapid pace and will undoubtedly flour- ish in the 21st century. Funding continues to grow; for example, NINR funding in fiscal year 2008 was nearly $140 million, more than twice what funding levels were in 1999. Broadly speaking, the priority for nursing research in the future 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. Certain trends for the 21st century are evident from developments taking shape in the early years of the millennium: * Heightened focus on EBP. Concerted efforts to use research findings in practice are sure to continue, and nurses at all levels will be encouraged to engage in evidence-based patient care. In turn, improvements will be needed both in the quality of nursing studies and in nurses’ skills in locating, understanding, cri- tiquing, and using relevant study results. Relatedly, there is an emerging inter- est in translational research—research on how findings from studies can best be translated into nursing practice. * Stronger evidence base through more rigorous methods and multiple, confirmatory strategies. Practicing nurses rarely adopt an innovation on the basis of weakly designed or isolated studies. Strong research designs are essential, and confir- mation is usually needed through deliberate replication (i.e., repeating) of stud- ies with different clients, in different clinical settings, and at different times to LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 11 Aptara (PPG-Quark) CHAPTER 1 * Introduction to Nursing Research in an Evidence-Based Practice Environment 11 ensure that the findings are robust. Another confirmatory strategy is the conduct of multisite studies by researchers in several locations. * Greater emphasis on systematic reviews. Systematic reviews are a cornerstone of EBP, and undoubtedly will increase in importance in all health disciplines. Sys- tematic reviews amass and integrate comprehensive research information on a topic to draw conclusions about the state of evidence. * Expanded local research in health care settings. There will almost certainly be an increase of small, localized research designed to solve immediate problems. In the United States, this trend will be reinforced as more hospitals apply for (and are recertified for) Magnet status. Mechanisms need to be developed to ensure that evidence from these small projects becomes available to others facing sim- ilar problems. * Strengthening of multidisciplinary collaboration. Interdisciplinary collaboration of nurses with researchers in related fields (as well as intradisciplinary collabo- ration among nurse researchers) is likely to continue to expand in the 21st cen- tury as researchers address fundamental problems at the biobehavioral and psy- chobiologic interface. * Expanded dissemination of research findings. The Internet and other electronic communications have a big impact on the dissemination of research informa- tion, which in turn helps to promote EBP. Through such technologic advances as electronic location and retrieval of research articles; on-line publishing (e.g., the Online Journal of Knowledge Synthesis for Nursing); on-line resources such as Lippincott’s NursingCenter.com; e-mail; and electronic mailing lists, infor- mation about innovations can be communicated more widely and more quickly than ever before. * Increasing the visibility of nursing research. Efforts to increase the visibility of nursing research will likely expand. Most people are unaware that nurses are scholars and researchers. Nurse researchers internationally must market them- selves and their research to professional organizations, consumer organizations, governments, and the corporate world to increase support for their research. * Increased focus on cultural issues and health disparities. The issue of health dis- parities has emerged as a central concern in nursing and other health disci- plines, and this in turn has raised consciousness about the ecologic validity and cultural sensitivity of health interventions. Ecologic validity refers to the extent to which study designs and findings have relevance and meaning in a variety of real-world contexts. There is growing awareness that research must be sensitive to the health beliefs, behaviors, epidemiology, and values of culturally and lin- guistically diverse populations. Research priorities for the future are under discussion, both by nursing spe- cialty organizations and by broader groups and institutions. In 2005, Sigma Theta Tau International issued a position paper on nursing research priorities that incor- porated priorities from nursing organizations internationally, including NINR. This synthesis of global nursing priorities identified the following: (1) health promotion and disease prevention; (2) promotion of health of vulnerable and marginalized LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 12 Aptara (PPG-Quark) 12 Sources of Evidence for Nursing Practice communities; (3) patient safety; (4) development of evidence-based practice and translational research; (5) promotion of the health and well-being of older people; (6) patient-centered care and care coordination; (7) palliative and end-of-life care; (8) care implications of genetic testing and therapeutics; (8) capacity development of nurse researchers; and (9) nurses’ working environments (Sigma Theta Tau International, 2005). Examples of landmark nursing studies of the 21st century: Celebrating its 20th anniversary, NINR published a report in 2006 on 10 landmark studies that had been supported with NINR funds. The 10 selected studies encompassed a wide range of research, including a study on the relationship between nurse staffing and patient well-being by Aiken and colleagues (2002); a test of a clinical intervention to improve metabolic outcomes for adolescents with type I diabetes by Grey and colleagues (2001); and an evaluation of a multidisciplinary project to reduce high blood pressure in inner-city hypertensive men by Hill and colleagues (2003). TIP All websites cited in this chapter, plus additional websites with useful content relating to the founda- tions of nursing research, are in the “Useful Websites for Chapter 1” file on the accompanying CD-ROM. This will allow you to simply use the “Control/Click” feature to go directly to the website, without having to type in the URL and risk a typographic error. Websites corresponding to the con- tent of most chapters of the book are also in files on the CD-ROM. SOURCES OF EVIDENCE FOR NURSING PRACTICE As a nursing student, you are gaining skills on how to practice nursing, but it is important to recognize that learning about best-practice nursing will continue throughout your career. Some of what you have learned thus far is based on sys- tematic research, but much of it is not. Only a little over a decade ago, Millenson (1997) estimated that a full 85% of health care practice was not scientifically vali- dated. Although the percentage of validated practices may have increased since 1997, there is widespread support for the idea that nursing practice should rely more heavily on evidence from research. Information sources for clinical practice vary in dependability and validity. Increasingly there are discussions of evidence hierarchies that acknowledge that certain types of evidence are superior to others. A brief discussion of some alternative sources of evidence shows how research- based information is different. Tradition and Authority Within Western culture and within the nursing profession, certain beliefs are accepted as truths—and certain practices are accepted as effective—simply based on custom. Tradition may, however, undermine effective problem solving. Traditions LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 13 Aptara (PPG-Quark) CHAPTER 1 * Introduction to Nursing Research in an Evidence-Based Practice Environment 13 may be so entrenched that their validity or usefulness is not questioned or evalu- ated. There is growing concern that many nursing interventions are based on tra- dition, customs, and “unit culture” rather than on sound evidence. Another common source of knowledge is an authority, a person with special- ized expertise and recognition for that expertise. Reliance on nursing authorities (e.g., nursing faculty) is to some degree unavoidable; however, like tradition, authorities as a source of information have limitations. Authorities are not infalli- ble (particularly if their expertise is based primarily on personal experience), yet their knowledge often goes unchallenged. Clinical Experience, Trial and Error, and Intuition Clinical experience is a familiar and functional source of knowledge. The ability to recognize regularities, and to make predictions based on observations is a hallmark of the human mind. Nevertheless, personal experience has limitations as a source of evidence for practice because each nurse’s experience is typically too narrow to be generally useful, and personal experiences are often colored by biases. Related to clinical experience is the method of trial and error. In this approach, alternatives are tried successively until a solution to a problem is found. Trial and error may be practical in some cases, but it is often fallible and inefficient. The method tends to be haphazard and the solutions may be idiosyncratic. Finally, intuition is a type of knowledge that cannot be explained on the basis of reasoning or prior instruction. Although intuition and hunches undoubtedly play a role in nursing practice—as they do in the conduct of research—it is difficult to develop policies and practices for nurses on the basis of intuition. Logical Reasoning Solutions to many problems are developed by logical reasoning, which combines experience, intellectual faculties, and formal systems of thought. Inductive rea- soning is the process of developing generalizations from specific observations. For example, a nurse may observe the anxious behavior of (specific) hospitalized chil- dren and conclude that (in general) children’s separation from their parents is stressful. Deductive reasoning is the process of 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 local hospital whose parents do not room-in will manifest symptoms of stress. Both types of reasoning are useful as a means of understanding phenomena, and both play a role in nursing research. However, reasoning in and of itself is lim- ited because the validity of reasoning depends on the accuracy of the information (or premises) with which one starts. Assembled Information In making clinical decisions, health care professionals also rely on information that has been assembled for a variety of purposes. For example, local, national, and LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 14 Aptara (PPG-Quark) 14 Paradigms for Nursing Research international bench-marking data provide information on such issues as the rates of using various procedures (e.g., rates of cesarean deliveries) or rates of infection (e.g., nosocomial pneumonia rates), and can serve as a guide in evaluating clinical practices. Quality improvement and risk data, such as medication error reports, can be used to assess practices and determine the need for practice changes. Such sources, although offering some information that can be used in practice, provide no mechanism for determining whether improvements in patient outcomes result from their use. Disciplined Research Research conducted within a disciplined format is the most sophisticated method of acquiring knowledge that humans have developed. Nursing research combines aspects of logical reasoning with other features to create evidence that, although fal- lible, tends to be more reliable than other methods of knowledge acquisition. Cumu- lative findings from rigorous, systematically appraised research are at the pinnacle of most evidence hierarchies. The current emphasis on evidence-based health care requires nurses to base their clinical practice—to the extent possible—on research- based findings rather than on tradition, authority, intuition, or personal experience, although nursing will always remain a rich blend of art and science. PARADIGMS FOR NURSING RESEARCH A paradigm is a world view, a general perspective on the complexities of the real world. Disciplined inquiry in the field of nursing is being conducted mainly (although not exclusively, as described in Chapter 10) within two broad para- digms, both of which have legitimacy for nursing research. This section describes the two paradigms and broadly outlines the research methods associated with them. The Positivist Paradigm The paradigm that has dominated nursing research for decades is known as posi- tivism (sometimes referred to as logical positivism). Positivism is rooted in 19th century thought, guided by such philosophers as Comte, Newton, and Locke. Posi- tivism is a reflection of a broader cultural phenomenon (modernism) that empha- sizes 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 principle that is believed to be true without proof or verification.) Adherents of positivism assume that nature is basically ordered and regular and that an objective 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 determin- ism refers to the positivists’ belief that phenomena (observable facts and events) are LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 15 Aptara (PPG-Quark) CHAPTER 1 * Introduction to Nursing Research in an Evidence-Based Practice Environment 15 MAJOR ASSUMPTIONS OF THE POSITIVIST AND TABLE 1.2 NATURALISTIC PARADIGMS TYPE OF ASSUMPTION POSITIVIST PARADIGM NATURALISTIC PARADIGM The nature of reality Reality exists; there is a real world Reality is multiple and subjective, driven by real natural causes mentally constructed by individuals Relationship between The inquirer is independent from The inquirer interacts with those researcher and those those being researched being researched; findings are the being researched creation of the interactive process The role of values in Values and biases are to be held Subjectivity and values are the inquiry in check; objectivity is sought inevitable and desirable Best methods for * Deductive processes * Inductive processes obtaining evidence * Emphasis on discrete, specific * Emphasis on the whole concepts * Focus on the objective and * Focus on the subjective and quantifiable nonquantifiable * Verification of researchers’ * Emerging insight grounded in predictions participants’ experiences * Fixed, prespecified design * Flexible, emergent design * Outsider knowledge— * Insider knowledge—researcher researcher as external as internal * Control over context * Context-bound, contextualized * Measured, quantitative * Narrative information; information; statistical analysis qualitative analysis * Seeks generalizations * Seeks in-depth understanding * Focus on the product * Focus on the product and the process not haphazard or random, but rather have antecedent causes. If a person has a cerebrovascular accident, the scientist in a positivist tradition assumes that there must be one or more reasons that can be potentially identified. Within the posi- tivist paradigm, much research activity is directed at understanding the underly- ing causes of natural phenomena. Because of their belief in an objective reality, positivists seek to be objective. Their approach involves the use of orderly, disciplined procedures with tight con- trols over the research situation to test hunches about the nature of phenomena being studied and relationships among them. Strict positivist thinking has been challenged and undermined, 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 rec- ognize 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 (i.e., learning what the true state of a phenomenon probably is, with a LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 16 Aptara (PPG-Quark) 16 Paradigms for Nursing Research high and ascertainable 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 Naturalistic Paradigm The naturalistic paradigm (sometimes called the constructivist paradigm) began as a countermovement to positivism with writers such as Weber and Kant. The nat- uralistic paradigm represents a major alternative system for conducting disciplined research in nursing. Table 1.2 compares four major assumptions of the positivist and naturalistic paradigms. For the naturalistic inquirer, reality is not a fixed entity but rather a construc- tion of the individuals participating in the research; reality exists within a context, and many constructions are possible. Naturalists take the position of relativism: If there are always multiple interpretations of reality, then there is no process by which the ultimate truth or falsity of the constructions can be determined. The naturalistic paradigm assumes that knowledge is maximized when the dis- tance between the inquirer and the participants in the study is minimized. The voices and interpretations of those under study are crucial to understanding the phenomenon of interest, and subjective interactions are the primary way to access them. The findings from a naturalistic 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 alternative paradigms have strong implications for the research methods to be used to develop evidence. The methodologic distinction typically focuses on differences between quantitative research, which is most closely allied with the positivist tradition, and qualitative research, which is associated with naturalistic inquiry—although positivists sometimes undertake qualitative studies, and naturalistic researchers sometimes collect quantitative information. This section provides an overview of the methods linked to the two alternative paradigms. The Scientific Method and Quantitative Research The traditional, positivist scientific method entails 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 investigators progress logically through a series of steps, according to a prespecified plan. Quantitative researchers use mechanisms designed to control the research situation so that biases are minimized and precision and validity are maximized. Quantitative researchers gather empirical evidence—evidence that is rooted in objective reality and gathered directly or indirectly through the senses rather LWBK131-3938G-C01_01-32.qxd 1/11/08 9:50 am Page 17 Aptara (PPG-Quark) CHAPTER 1 * Introduction to Nursing Research in an Evidence-Based Practice Environment 17 than through personal beliefs or hunches. Evidence for a study in the positivist par- adigm is gathered systematically, using formal instruments to collect needed infor- mation. Usually (but not always) the information gathered is quantitative—that is, numeric information that results from some type of formal measurement and that is analyzed with statistical procedures. Scientists strive to go beyond the specifics of a research situation; the ability to generalize research findings to individuals other than those who participated in the study (referred to as generalizability) is an important goal. The traditional scientific method has enjoyed considerable stature as a method of inquiry, and it has been used productively by nurse researchers studying a wide range of nursing problems. This is not to say, however, that this approach can solve all nursing problems. One important limitat