Module 2: Reading Research (ch 3, 13)

Q: Research/Not Research "Common Problems in Hospitalized Older Adults" -Survey designed to gather data from 32 hospitals in Connecticut. 24 hospital professionals responded and the majority was found to be creative and eager to share ideas to improve quality of care.

A: Not really a study - only 32 hospitals (small sample size)

Q: How are study purposes are stated in research articles?

A: Varies depending on the type of study done -Research question -Hypothesis

Q: Melzack and Wall's Gate Control Theory is an example of... a. Grand theory b. Borrowed theory c. Shared theory d. Nursing theory

C. Other Shared Theories: -Developmental Theories -Physiologic Theories (Such as this) vs. Borrowed theories: human behavior and social cognitive theory

Hierarchy of Evidence for Intervention Studies:

....

Nursing Theories and Models

"Nursing theories and models continue to be a positive influence on nursing practice. Nursing theories are utilized to direct nursing practice. For over 50 years, many theories have been developed to guide nursing research and practice, improving the quality of care. Conceptual and theoretical models are used to develop knowledge in nursing and guide nursing practice" -"Emphasis in nursing practice and education has been given to critical thinking for more than 20 years (Cody, 2002). Science-based practice is used to deliver nursing care. Nursing practice models provide the framework of nursing knowledge to provide theory-based care (Barrett, 1988). A nursing foundation can be created and broadened by using theory in practice (Karnick, 2008)."

Theory: Pender's Model of Health Promotion (See slide 40)

*Speculates that: i.) People will work towards something that they value ii.) people will be influenced by internal and external forces* Theory Type: i.) Borrowed and Shared: developed from human behavior and social cognitive theory based on concept of expectancy ii.) Middle-range theory I. Assumptions: i.) Nursing: assists individuals in managing health behaviors by modifying the environmental context ii.) Health/Illness: Health promotion behaviors are targeted to achieve optimal well-being, personal fulfillment, and productive living. II. Specific Concepts: i.)Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting behavior ii.) Persons commit to engaging in behaviors from which they anticipated deriving personally valued benefits iii.) Perceived barriers can constrain commitment to action, a mediator of behavior as well as an actual behavior iv) Perceived competence or self-efficacy to execute a given behavior increases the likelihood of commitment to action and actual performance of the behavior III. Application: Anticipate how to help people adopt health promotion behaviors; should be focused on achieving something that they value. Also things going on within selves (self efficacy and esteem/ cognitive ability/ peer support) will affect ability to engage with activity

Essential Elements of Research Study

-A specific purpose with a.) research question b.) Hypothesis -Systematic methods of data collection and analysis -Results -Findings -Conclusion r/t results/findings

Paradigm in Research

-An overall belief system or way of viewing the nature of reality and the basis of knowledge -Involve... I. Quantitative Study: -Traditional approach to research where variables are identified and measured in a reliable and valid way II. Qualitative Study: -A natural approach to research where the focus is understanding the meaning of an experience from the individual's perspective

Evidence-based Clinical Practice Guidelines

-Begin with systematic review > E-B clinical practice guideline ( ex. Guidelines.gov, CINAHL, EBP Sheets) -A set of research-based recommendations that were systematically developed with careful consideration of the strength of supporting evidence

Theory of Planned Behavior (TPB)

-Beliefs (3) > Intention > Behavior -Modulated by actual behavior control -FACTORS AFFECTING INTENTION: I. Behavior beliefs -Attitude toward the behavior II. Normative beliefs -Subjective norm III. Control Beliefs -Perceived Control -TPB is an extension of the theory of reasoned action (TRA); it addresses the problem of incomplete volitional control -TERMS: I. Intention: -"an indication of a person's readiness to perform a given behavior and it is considered to be an immediate antecedent of behavior" II. Attitude toward behavior: -"the degree to which performance of a behavior is positively or negatively valued" (i.e. How important is the behavior to me?) III. Subjective Norm: -The perceived social pressure to engage or not engage in a behavior (i.e. Do others think I should behave this way?) IV. Perceived Behavior Control: -Refers to people's perceptions of their ability to perform a given behavior (i.e. Do I have any control over this behavior?)

Purpose of Study

-Can be a statement of what the study will focus on based on what is missing from research literature -May be listed as study question -May also have hypotheses that were tested in research -Beginning of research - introduction - helps focus research article. Might be listed as problem statements about what is missing, Study question, or Hypothesis.

Research Methods

-Depend on question -R/t what is already known (ex. children experiencing injection pain - gap) May choose... i. Qualitative: a.) Qualitative description b.) Ethnography c.) Phenomenological d.) Grounded Theory ii. Quantitative: describe something from objective standpoint a.) Descriptive b.) Correlational c.) Experimental (RCT) d.) Cohort

Qualitative Concepts

-Design driven by nature of information to be gained -Research should articulate: a.) Concepts of interest b.) Theories about relationships c.) Processes of interest

Shared Theories

-EXAMPLES: I. Developmental Theory -Maturation -Age appropriate responses II. Physiologic Theories -Pain (ex. Melzack & Wall's Gate Control Theory of Pain) -Movement -Fluid Management

Strategies to Achieve Control

-Eliminate the threat of extraneous variables -Control the threat for extraneous variables -Account for it in the write-up of the study to give context to interpreting results -Goal: The change that we effected in treatment group is *directly related* to the treatment we gave; Measured response of dependent variables directly related to intervention groups/independent variables

The Theoretical framwork

-Foundation of research design -Theory: an attempt to explain the world; a method of perceiving reality; Process of mapping human action and interaction -May be used in research either... a.) Inductively: qualitative design b.) Deductively: common in quantitative design

Why use Theories and Models?

-Guides direction of research study to address clinical problem/question -Moving forward in scientific understanding and building on what is known

Purposes of Individual Studies

-Help us understand health, illness, or healthcare experience -Develop a theory -Describe a health-related happening -Measure strength of relationships between several health related events or stages (age and pain management) -Test hypothesis about effectiveness of an intervention

Middle-Range Theories in the ICU

-Patient's family members may experience anxiety, depression, and symptoms associated with PTSD during their loved one's critical illness (process by which a person would normally learn from and contextualize experiences are overwhelmed with flood of stress hormone). -Interventions that facilitate sensemaking may minimize the risk of PTSD by engaging the prefrontal cortex and/or minimizing the release of stress hormones. IF prefrontal cortex is not engaged, symptoms ass. with PTSD are triggered (avoidance, numbing, hyperarousal, repeated thoughts/nightmares) *Facilitated sense-making is a new middle range theory to guide nursing interventions in the ICU to help patient's family members make sense of what has happened and of their new roles. (Themes of family-centered care)* -Nurses are encouraged to test the theory by using research methods -Suggests *Planned nursing Interventions to decrease family member's fear, horror, and helplessness*: a.) Empathetic listening b.) Potential care conferences/referals c.) Reflective Inquiry d.) End-of-visit Clarifications e.) Review of unmet needs f.) Questions for Physician g.) Bedside activities

Hypotheses

-Predictions about expected relationships among variables of interest -Based on known concepts, theories, models, and the previous literature -Types: i.) Directional ii.) Null iii. Causal iv.) Associative -Ex. i.) There are no associatons bw environmental factors and reactive airway disease in otherwise healthy adults ii.) There will be a difference in the medication error rate bw units that do and do not use barcoding iii.) Infants who recieve the touch and massage intervention will be discharged sooner than infants who do not

Primary Report of Research

-Primary research: any type of research that you collect yourself (surveys, interviews, observations, and ethnographic research). -Uses both primary and secondary sources in writing. -Involves collecting data about a given subject directly from real world.

Critical Appraisal (article 5)

-Purpose of critical appraisal is to determine worth to practice -Rapid critical appraisal (RCA): reviews each study to find... a.) Level of evidence b.) How well conducted c.) How useful it is to practice -Learn Research terminology (IV, DV, Sample) -Determine Level of Evidence -Use evaluation table (see article) -Usually the important information in a study can be found in the abstract -Keep the data in the table consistent by using simple, inclusive terminology Guideline for Appraisal of Quantitative Studies: 1.) Why was the study done? 2.) What is the sample size (were there enough ppl in the study to est. that the findings did not occur by chance?) 3.) Are the instruments of the major variables valid and reliable? How were the variables defined? (Reliable-measure concept the same way consistently) 4.) How were the data analyzed? (What statistics were used to determine if the purpose was achieved?) 5.) Were there any untoward events during the study? (people leaving study and why) 6.) How do the results fit with previous research in area 7.) What does this research mean for clinical practice? Is the study purpose an important clinical issue?

Mixed Method Studies

-Research approach that combines quantitative and qualitative elements -Involves the *measurable state of a phenomenon* and the *individual's subjective response* to it

Descriptive Studies

-Research designed to describe in detail some process, event, or outcome. The design is used when very little is known about the research question.

Research Plan

-Sampling strategy -Measurement strategy -Data collection Plan -Data Analysis Plan

Abstract

-Short overview of article or research findings -150-300 words -Sometimes have a specific format with essential elements -Purpose -Significance -Methods -Results -Implications for practice "small snapchat of rest of paper"

Reading a report of an individual study

-Starting point: Is this a report of an original research study (has essential elements) -Primary: research study publish by person who did research -Secondary: systematic review, not original data but interpretation of

Systematic Review

-Systematic and comprehensive way of identifying, analyzing, and summarizing all research r/t specific topic/issue/question -Rating of the research -Integrative review of findings

Nursing Metaparaidgm

-The idea of nursing theory that began to develop in 1950's forward -Defining nursing -Environment -Persons -Health ...and relationships between these concepts

Credibility / strength of recommendation for clinical practice depends on...

-The researcher reaching a right conclusion based on i.) how the study was done (research design) ii.) and controlled, and the iii.) statistical analysis of the data

How Theory Guides Research

-Theoretical Propositions > Research Hypotheses ex. Lay workers given a health promotion opportunity will adopt a healthy behaviors -Research will test the theory -If hypotheses are supported, the support reflects back on the theory

Types of Variables

-Things that you measure (measurable concept that you want to study - put into objective form) I. Descriptive -Relationship of/bw variables (i.e. age of child and ability to tolerate injection) -Correlations II. Independent (variable) -The manipulation in study design III. Dependent -Variable that experimenter would like to impact/study in experimental design.

Bias in Research

-True findings distorted d/t a factor other than one studied -May be due to... a.) Researcher: b.) Measurements: blood pressure cough incorrectly calibrated c.) Procedures: manner of questions introduced throughout study (consistency? variability?) d.) Analysis: was data cleaned and ready to be analyzed; with appropriate statistics e.) Subjects: how they answer Q's

Questioning Understanding:

...

Article Format

Answers why, how, what I. Title II. Abstract (summary of what was done) III. Introduction (background of information relevant to study) IV. Methods (used conducting study) V. Results VI. Discussion/Conclusions (strengths, weakness, implications for clinical practice) VII. References

Q: Which of the following is not a part of a report of a research report? a. Specified methods of data collection b. A short resume of the lead author c. Findings d. Conclusions

B.

Q: Which of the following sets of purpose verbs contains a purpose that is not a study purpose? a. Explore, compare, predict b. Examine, relationships, describe, synthesize c. Describe, examine relationships, test hypothesis d. Examine, compare, test hypothesis

B. Study Purpose Verbs: -Explore -Compare -Predict -Describe -Examine relationships -Test hypothesis -Examine NOT STUDY PURPOSE: -Synthesize

Theory and Design

Choose concept of interest > Perform an initial literature search > Define selected concepts > Link the concepts together in terms of expected relationships > Select a framework that best depicts the concepts > Review the literature for studies that have used the framework

Q: How are study purposes stated in research articles? a. Always as research questions b. Always as hypotheses c. Vary depending on the journal's requirements d. Vary depending on the type of study done

D. Study purposes are stated according to the type of study (hypothesis vs...)

Different purposes require

Different methods

Quantitative (A) vs. Qualitative (B)

ELEMENT: I. View of Reality a.) Objective and measurable b.) Constructed by Individuals II. View of Time a.) Reality is constant b.) Reality is continuous III. Context a.) Reality separate from Context b.) Reality embedded in context IV. Researcher a.) Objective, detached b.) Personally involved V. Populations a.) Samples b.) Cases VI. Measures a.) Observable phenomena b.) Meanings created by Individuals VII. Observations a.) Definable variables b.) Holistic observations VIII. Design a.) Preconceived; Highly controlled b.) Emergent; adaptable VIIII. Analysis a.) Statistics b.) Analytic induction X. Generalization a.) To defined populations b.) Transfer knowledge

Causality

Effect achieved is the direct result of specific experimental manipulation/intervention

Research Classifications

I. Basic Research -Theoretical, pure, fundamental, or bench research done to advance knowledge in a given subject area -Lab -Often animal models -Takes a while to become applicable to clinical practice II. Applied Research -"Translational research" -Research to gain knowledge that has a practical application and contributes in some way to a modification of practice III. Retrospective Study: -Studies that use secondary data that have already been collected about events that have already happened -Ex. Twin registry data has already been collected. R.S. would seek additional information/clarification moving forward. IV. Prospective Study: -Studies planned by the researcher for the collection for primary data for the specific research study; Implemented in the future. V. Longitudinal: -Done over extended period of time -Studies conducted by following subjects over a period of time with data collection occurring at *prescribed intervals* VI. Cross Sectional Study: -Studies conducted by looking at a single phenomenon across multiple participants at a *single point in time*. -Single measure and then analyze signifigance

Building Blocks of Theory

I. Concept: -An abstract idea that is used to describe or identify phenomenon; not generally observable II. Variable: -A measurable aspect of a concept; the concrete manifestation of a concept Ex. Concept-caring; Variable- eye contact, using open-ended questions

Theoretical Framework

I. Conceptual definition: -Clearly stated meaning of an abstract idea II. Relational Statement: -Expected relationships between concepts; forms the foundation for a theory III. Conceptual Model: -A visualization of these relationships

Research that Examines Relationships

I. Correlation Research: -Quantifies (in numerical form) strengths and direction of a relationship -Direct/Inverse relationship between variables II. Predictive Research: -Search for variables that can explain or predict an outcome. -i.e. Risk factors: low bearing exercises inc. risk for osteoporosis

Watson's Model of Human Caring

I. Defined: -Focus on holistic care and the authentic relationship between caregivers and patients. -Caring-healing process; "Caring is the heart of nursing" II. 4 Elements: i.) Caritas Process- evoked by providing love and holistic care to patient through carative factors ii.) Transpersonal Caring Relationship: reciprocal relationship iii.) Caring Moment iv.) Caring Healing Modalities

Theory of Music, Mood and Movement to Improve Health Outcomes (MMM)

I. Defined: -Middle-range nursing theory -high rate of physical inactivity and associated negative health outcomes worldwide, nurses need new E-B theories and interventions to inc. physical activity -Data sources: CINAHL, MEDLINE, ProQuest Nursing and Allied Health Source, PsycINFO, Cochrane Library Databases -Proposition: Music alters mood, which is a cue for movement, and makes physical activity more enjoyable l/t improved health outcomes of weight, BP, blood sugar and cardiovascular risk factor management, and improved quality of life II. Theoretical Statements: i.) Music produces the psychological response of altered mood leading to improved health outcomes ii.) the physiological responses to music are a cue for movement (timing and cadence) leading to the initiation and maintenance of physical activity (from auditory cortex, neural impulses of auditory fhythm stimulate the neural motor impulses, resulting int eh auditory motor entrainment described in RAS technique [interactions between auditory and motor systems/sound and mvmt) iii.) Both the psychological response of altered mood and the physiological response of altered mood and the physiological response to movement to music promotes the initiation of physical activity leading to improved health outcomes. III.) Implications for Practice and/or Policy: -Non-pharmological intervention -Music is safe, cost-effective, non-invasive, easy to implement in variety of settings -Should advance nursing research and practice -Explains and predicts links between music, physical activity, and health outcomes.

Appraising Theory in Research

I. Determine the concepts in the study and locate conceptual definitions II. Determine how relationships bw concepts are described, analyzed, and validated III. Examine the claims of the researcher in linking the theory to the study

Searching for Evidence (article 4)

I. Determine the level and quality of evidence -Research evidence (AKA external evidence) -Research methodology most appropriate to the type of clinical question asked *Intervention-focused: Systematic Review suggested II. Select relevant databases to search (containing SR's and metaanalyses of RCT's) -Cumulative Index to Nursing -Allied Health Literature -CDSR database -DARE database -PubMed and CINAHL (nursing and allied health literature) III. Searching Strategies -Choose keywords from PICOT question -Use database controlled vocabulary -Combine searches ("AND") -Place limits on final combined search to narrow results ("ENGLISH", eliminating "ANIMAL SUBJECT" studies) IV. Conduct Search -MeSH term search for keywords -Advanced Search into Search History to evaluate narrowing of results with limiting factors

Types of Research Evidence

I. Existing e-b guideline (shortcut) II. Science summary (medium path) -ex. meta-analysis or systematic review. Intention evident but not yet visible as guideline for practice. III. Individual studies (long-trek)

Clarification of Designs

I. Exploratory -how to move forward in future studies II. Confirmatory -Knowledge + your theoretical knowledge and confirm that your assumption about intervention is correct -Multiple researchers and studies to confirm validity of research results

Traditional Evolution of Research Process

I. General focus or interest II. Identification of concern or problem III. Exploration of a gap (literature) IV. Development of problem statement V. Development of a research question (guides every decision you make in research process) ex. Pain management: -Issue: pain management for child receiving injection -Literature Review: few studies exist to guide or support pain management in children receiving injection -Purpose of study: to compare outcomes between two pain management approaches (use of pinwheel, chewing on jellybean)

Classification of Theories

I. Grand Theories (most exposed to) II. Middle-range Theories (more directly applicable to clinical practice) III. Microtheories (more focused) IV. Borrowed Theories (from other professions and apply in nursing) V. Shared Theories (among disciplines)

Three Phases of Design

I. Identify assumptions about the knowledge to be gained from the study II. Select design that serves the purpose of the study III. Develop detailed plans for implementation of the study

Grand Theories vs Middle Range Theories (EXAMPLES)

I. Middle-range theories: -Developed to guide practice directly at bedside. Focus on single aspect of practice and thus are less generalizable - narrower scope and more concrete and therefore easier to test by using research methods and more applicable to patient care EX: a.) Weick's Organizational Sense-making Theory: - Explains in detail and refines interventions to assist family as they adapt to critical illness. Explains that employees, like family members, receive cues from the work environment. These cues must be sorted to form an impression of the workplace. -Strong leaders help employees with cue sorting to form a positive image of organization and yet recognize when the cues suggest a need for action. - In facilitated sense-making, nurses proactively take cues from the environment and sort them for the patient's family, helping the family members make sense of what is going on. (providing information and interpretation of information) -Advocates that nurse provide concrete activities to family to help during period of helplessness a.) Personal care/healing: Applying lip-balm; Giving a hand/foot massage; Assist in passive ROM exercises; Praying if spiritual assessment indicates prayer is appropriate; Cognitive exercise engagement such as cards, puzzles, etc. b.) Bring normalcy into Room: Read aloud; Talking about daily events; Bringing in cards/pictures from home II. Grand Theories: - Provide framework for describing, predicting, explaining, or prescribing within nursing practice as a whole EX: I. Roy's Adaptation Model: -Proposes that families must adapt to new situation but does not define what the nurse must do to assist the families. (illness = disruption which necessitates period of compensation). Framework for actions of facilitated sense-making. -Disruption > Compensation > Adaptation

The Basis for Design Selection

I. Purpose to be achieved II. Nature of the subjects III. Ethical Limitations IV. Measurements needed V. Researcher resources and skills VI. Amount of control required VII. Ultimate audience > Other Considerations: -Philosophical orientation of the researcher -Nature of the research Q or problem -Skills, abilities, and preferences of the researcher -Resources available -Access to samples

Assumptions about Knowledge Needed

I. Quantititative -Measure effectiveness of interventions -Test a theory of relationships -Describe a phenomenon with objective precision II. Qualitative -Understand social relationships -Determine the meaning of events and phenomenon > Both... a.) are characterized by rigorous attention to scholarly nature of work b.) aim for reliability and trustworthiness of results c.) goal of generating credible evidence that nurses can use with confidence

Experimental or Quasi-Experimental Designs: Criteria for Causality includes...

I. Temporality -Cause must precede the effect II. Influence -Must establish the probability t hat the cause influenced the outcome III. Control -All rival explanations are ruled out

Quantitative Designs

I. True Experimental -Manipulation -At least 2 groups -Random assignment of subjects II. Quasi-Experimental: -Manipulation -Either control group or random assignment is missing in design III. Non-experimental -Descriptive -Correlational

Level 3

I. Type of Evidence: -Controlled Trial without Randomization II. Description: -An experiment in which subjects are non-randomly assigned to a treatment group or control group

Level 4

I. Type of Evidence: -Case-control -Cohort Study II. Description: -Case-Control Study: a comparison of subjects with a condition (case) with those who don't have the condition (control) to determine characteristics that might predict the condition (etiology - con: statistical relationship doesn't necessarily equal causation) -Cohort study: An observation of a group(s) cohort(s) to determine the development of an outcome(s) such as a disease. (Con: correlation does not equal causation)

Level 7

I. Type of Evidence: -Opinions or Consensus II. Description: -Authoritative opinion of expert committee

Level 6

I. Type of Evidence: -Qualitative study - Descriptive Study II. Description: -Qualitative Study: Gathers data on human behavior to understand *why and how* decisions are made -Descriptive Study: provides background information on the *what, where, and when* of a topic of interest.

Level 2

I. Type of Evidence: -Randomized, controlled Trial II. Description: -An experiment in which subjects are randomized to a treatment group or control group

Level I

I. Type of Evidence: -Systematic review -Metaanalysis II. Description: -Synthesis of evidence from all relevant randomized, controlled trials

Level 5

I. Type of Evidence: -Systematic review of qualitative or descriptive studies II. Description: -A synthesis of evidence from qualitative or descriptive studies to answer a clinical question

Q: Research/Not Research "Unmasking Delirium" - An estimated 60-80% hospitalized frail older adults experience at least one preventable episode of delirium, often leading to prolonged hospitalization, functional decline, inc. morbidity, and eventual Nursing Home placement or death. Delirium is a......

Not a study, just an article about delirium.

Hypothesis will never be stated in a...

Qualitative Study (only in quantitative studies)

Research Design

The overall approach to the study that details all the major components describing how the research will be carried out

Relationship of Theories and Models to Interventions

Theories > Constructs/Concepts > Variable (how it is operationalized in research study for use in interventions) -Using appropriate theory and practice greatly enhances the chances of effective health promotion practice

Q: Research/Not Research "Delirium: a Process Improvement Approach to Changing Prescribing Practices in a Community Teaching Hospital" - An analysis of prescribing practices after the educational intervention revealed a reduction in the sue for 57% of the drugs targeted. Other outcomes from this process improvement methodology are also examined....

This one is debatable. Could be a QI report (quality improvement report)

Approach to Reading a Research Article (Ask)

Why was the study done How was it done What was found

Q: Research/Not Research "Delirium in Hospitalized Older Patients with Cancer" - PURPOSE/OBJECTIVES: .... MAIN RESEARCH VARIABLES: ... FINDINGS:.... CONCLUSION:...

Yes - has elements of a study Essential elements of abstract present

Q: Research/Not Research "Delirium Prevention for Cognitive, Sensory, and Mobility Impairments" - The purpose of this study was to determine the effectiveness of a protocol designed to prevent delirium in hospitalized elders with the risk factors of dementia and/or vision, hearing, and/or mobility patients. A group of 80 patients....

Yes???

Design of Research Project

i. DEFINE PROBLEM in clinical setting ii. SCAN LITERATURE to determine what is known about problem iii. SELECT THEORY which guides you to further decide how to conduct research (clinical expertise/observed) and literature? (known vs unknown) iv. DETERMINE RESEARCH DESIGN (Quantitative vs. Qualitative) v. Decide SAMPLING STRATEGY (most efficient?) vi. MEASUREMENT STRATEGY (what to measure and how to best measure it) vii. COLLECT DATA using measurements chosen viii. ANALYZE DATA