CNUR 209
Sources of research problems
Clinical experience Nursing literature Social issues Theory Suggestions from external sources (e.g., priority statements of national organizations or funders), give recommendations for research in the future, external sources- funding
Data
Data (singular = datum): the pieces of information researchers collect in a study Quantitative researchers collect numeric (quantitative) data. Qualitative researchers collect narrative (verbal) data.
The nuremberg trials
Nuremberg code- remember the principles- guide the research, 1.Voluntary consent of the human subjects is essential- has to have free power of choice, information about everything 2.Experiment should be such as to yield further results for the good of society, unprocurable by other methods or means of study, and not random and unnecessary in nature 3.Experiment should be designed and based on the results of animal experimentation and a knowledge of the natural history of the disease or other problem under study that the anticipated results will justify the performance of the experiment 4.Experiment should be conducted as to avoid all unnecessary physical and mental suffering and injury 5.No experiment should be conducted where there is a priority reason to believe that death or disabling injury will occur, except, perhaps in those experiments where the experimental physicians also serve as subjects 6.The degree of risk to be taken should never exceed that determined by the humanitarian importance of the problem to be solved by the experiment 7.Proper preparation should be made and adequate facilities provided to protect the experimental subject against even remote possibilities of injury, disability, or death 8.The experiment should be conducted only by scientifically qualified persons. The highest degree of skill and care should be required through all stages of the experiment of those who conduct or engage in the experiment 9.During the course of the experiment the human subject should be at liberty to bring the experiment to an end if he has reached they physical or mental sates where continuation of the experiment seems to him to be impossible 10.During the course of the experiment, the scientist in charge must be prepared to terminate the experiment at any stage, if he has probable cause to believe, in the exercise of the good faith, superior skill, and careful judgment required of him, that a continuation of the experiment is likely to result in injury, disability, or death to the experimental subject
Difference between qualitative and Quantitative
Qualitative- stats, numbers, not personalized, results can be repeated, objective, concrete, measured. Quantitative- interviews, case studies, loose observations, subjective, descriptive, interpreted
Bias
Quantative vA distortion or influence that results in an error in inference vExamples of factors creating bias •Lack of participants' candor •Faulty methods of data collection •Researcher's preconceptions •Participants' awareness of being in a special study •Faulty study design, highlight if present and what they did to minimize it
Nursing Research: Past and Present
u1850s: Pioneered by Florence Nightingale u1950s: First journal on research (Nursing Research) u1979: First Center for Nursing Research established at McGill University u1980s: Nursing research increasingly important by federal funding agencies u1990s: More journals for nurse researchers, with specialty journal u1993: National Institute of Nursing Research (NINR) established u2004: Meeting to promote research in nursing, Canadian Consortium for nursing research and innovation u2000s: NINR budget in 2016 just under $150 million
EBP Movement
uArchie Cochrane uCalled for efforts to make research summaries about interventions available to health care providers uEfforts led to the development of Cochrane Center in Oxford and the Cochrane Collaboration. uDavid Sackett uDeveloped a learning strategy called evidence-based medicine, which has broadened to the use of best evidence by all health care practitioners
Future Directions for Nursing Research
uContinued focus on evidence-based practice uStronger evidence through confirmatory strategies uContinued emphasis on systematic reviews- gives us best evidence uExpanded local research in health care settings uExpanded dissemination of research findings uIncreased focus on cultural issues and health disparities uClinical significance and patient input- inform pt, best outcome for pt
Nonexperimental studies: Correlational designs
vCause-probing questions (e.g., prognosis or harm/etiology questions) for which manipulation is not possible are typically addressed with a correlational design. vA correlation is an association between variables and can be detected through statistical analysis. vCorrelational studies are weaker than RCTs for cause-probing questions, but different designs offer varying degrees of supportive evidence.
Why are research articles hard to read?
vCompactness—page constraints vJargon vObjectivity, impersonality vStatistical information •Last two especially prominent in quantitative research articles
Research Hypotheses
States an expectation, a predicted answer to the research question Should almost always involve two or more variables Suggests the predicted relationship between the independent variable and the dependent variable, what results are you waiting for, must contain terms that indicate a relationship (more than, different from, associated with), is articulated almost exclusively in quantitative studies, is tested through statistical procedures, •Directional hypothesis- see the effect •Specifies the expected direction of the relationship between variables •Nondirectional hypothesis •Predicts the existence of a relationship, not its direction •Research hypothesis •States the actual prediction of a relationship •Null hypothesis •Expresses the absence of a relationship (used only in statistical testing, Hypotheses are never proved or disproved. Statistical hypothesis testing cannot provide absolute proof—only probabilistic information to support an inference that a hypothesis is probably correct (or not). Hypotheses are supported, or rejected, by the study data.
Faces and Places of Research
Study subject or participant: people being studied or cooperating in study Study site: the overall location for a study Multisite studies: tend to yield more diverse group of study participants, potentially enhancing generalizability of findings, researchers are the ones who conduct the research
Codes of Ethics: History
-1930s and 1940s: Nazi medical experiments: Subjects exposed to harm and forced to participate -1932-1972: Tuskegee Syphilis Study: Withheld medical treatment -1940s: U.S. radiation experiments -1949: Nuremberg Code: response to Nazi atrocities -1964: Declaration of Helsinki: World Medical Assn. -1978: Belmont Report -1995: ANA Ethical Guidelines in the Conduct, Dissemination, and Implementation of Nursing Research -2002: CNA: Ethical Research Guidelines for RNs -2015: ANA declares Year of Ethics: Revised Code of Ethics for Nurses with Interpretive Statements
Confidentiality Procedures
-Anonymity—researchers cannot link participants to their data. -Confidentiality in the absence of anonymity—other confidentiality procedures need to be implemented. -Taking steps to ensure breach of confidentiality does not occur -Certificate of Confidentiality (NIH)—a certificate obtained to prevent forced disclosure of confidential information to authorities- you will not force people and you will respect their identity and privacy
Vulnerable groups
-Children -Severely ill or physically disabled people , terminally ill people -Institutionalized people, elderly -Pregnant women and fetus -Lack of decision making ability (mental illness, brain injury) -Institutionalized people (Prisoners) -Educationally and economically disadvantaged -persons or groups whose circumstances make them particularly vulnerable to physical or psychological harm, exploitation, abuse, stigmatization, or discrimination, Vulnerable subjects are study participants who require special protections. May be incapable of giving fully informed consent (e.g., cognitively impaired people) or may be at high risk for unintended side effects (e.g., pregnant women) Some (e.g., children) cannot make a truly informed decision about voluntary participation. child the opportunity to assent (agree) or dissent (disagree) to the research Capacity to consent There is no age of consent. Rather consent is dependent on capacity; i.e., the ability to understand the elements of the information relating to the decision, and the ability to appreciate the reasonably foreseeable consequences of participating or not participating in that specific research project. When the individual cannot give consent, a substitute decision maker i.e., parent or guardian is approached.
Conceptual models of nursing
-Formal explanations of what nursing practice is -Four concepts central to models of nursing -Human beings/person -Environment -Health -Nursing •Conceptual models of nursing that have been used in nursing research include: •Roy's Adaptation Model and other •Middle-range theories focus on more specific phenomena. •Beck's Theory of Postpartum Depression (2012) •Mishel's Uncertainty in Illness Theory (Mishel, 1990) •Pender's Health Promotion Model (2015) Related factors Trajectory will be different if they meet barriers Conceptual model helps to support and guide you through research and data anaylsis
External Review and Protection of Human Rights
-Human subjects committees -Institutional Review Boards (IRBs) -Research Ethics Boards (REBs—in Canada)- Adapt to the policies for each submission -A panel of people who decide if the proposed research study is ethical -Ethical aspects of a study are increasingly likely to be reviewed before permission is granted to conduct a study. -Every institution that conducts research, like a university, has an ethics board -A researcher must complete an ethic proposal and submit it to the REB prior to starting any research.
Debriefings and Referrals
-It is sometimes advisable to offer debriefing sessions following data collection so that participants can ask questions or share concerns. -Researchers can also demonstrate their interest in participants by offering to share study findings with them after the data have been analyzed. -Finally, researchers may need to assist participants by making referrals to appropriate health, social, or psychological services. Talk about side effects
Volunteer
-Must be willing to participate and give consent -No coercion or pressure to participate -Consent obtained by signing a form or verbally agreeing to participate.
Comprehension
-People must be able to comprehend the information provided -Information is provided in a way that people can understand - grade 6 level -Special circumstances: children under 18, cognitively impaired, comatose, terminally ill, mentally ill -A third party may be required: parent, legal guardian, power of attorney, court appointed - protect from harm
Nazi human experiments
-Prisoners were coerced into participating; they did not willingly volunteer and there was never informed consent. -the experiments resulted in death, disfigurement or permanent disability, and as such are considered as examples of medical torture. Finally someone said no more experiments on humans- Nuremburg Trials
Procedures for Protecting Study Participants
-Risk-benefit assessments- researcher has to show how they are going to balance -Informed consent- info in level and language pt can understand -Confidentiality procedures- have to get approval -Debriefings and referrals- ask pt how they felt -Treatment of vulnerable groups -External reviews and the protection of human rights -Ethical issues in using animals in research
Key Constructs from shared theories
-Self-efficacy (Social Cognitive Theory) -Stages of change (Transtheoretical Model) Behavioral intentions(Theory of Planned Behavior •Becker's Health Belief Model (HBM)
Commonalities between Theories and conceptual models
-Use concepts as building blocks -Require conceptual definitions of key concepts -Can be represented in a schematic model -Are created by humans -Are developed inductively -Cannot be proven—they are supported to greater or lesser degrees -Can be used to generate hypotheses -Can serve as a stimulus to research Quantitative- hypothesis can emerge
Quantitative Research- broad design options
1. Experimental Randomized Control Studies (randomized control trial)- everyone has an equal chance of being chosen, characteristics of a person are not important •Show the cause and effect: drug improves condition 2. Quasi experimental (controlled trial without randomization) 3. Descriptive non-experimental (observational study) Ask yourself: did the researcher do something to the participants: participated in an educational program, had a treatment or drug, given a support program- An intervention: vthe researcher does something to/gives something to the participants. vthe intervention can be manipulated (give to some and not to others) vmeasurements Then vExperimental vQuasi experimental
Steps in EBP
1.Asking clinical questions that can be answered with research evidence 2.Searching for and retrieving relevant evidence 3.Appraising and synthesizing the evidence 4.Integrating the evidence with your own clinical expertise, patient preferences, and local context 5.Assessing the effectiveness of the decision, intervention, or advice
Informed Consent
1.Information 2.Comprehension 3.Voluntary participation Participants have adequate information about the research- risk and benefits Participants can comprehend that information. Informed consent means that participants have adequate information about the study, comprehend the information, and have the power of free choice, enabling them to consent to or decline participation voluntarily. Implied consent (e.g., for self-administered questionnaires) Process consent (renegotiated over time, qualitative studies) Participants have free choice in deciding whether to participate in or withdraw from the study. Researchers usually document informed consent by having participants sign a consent form. Informed consent means that participants have adequate information about the study, comprehend the information, and have the power of free choice, enabling them to consent to or decline participation voluntarily. Implied consent (e.g., for self-administered questionnaires) Process consent (renegotiated over time, qualitative studies) Includes: The purpose of the research -Study methods -Time required to participate -Potential risks and benefits -You can ask questions -You can withdraw at any time
Variable
A characteristic or quality that takes on different values, that is, that varies from one person to the next, from time to time Examples Blood type, need unmet Weight, anxiety, fatigue Length of stay in hospital The term "variable" is used almost exclusively in quantitative research. Defines the type of people who you want to study, Independent variable—the presumed cause (of a dependent variable) Dependent variable—the presumed effect (of an independent variable) Often referred to as the outcome variable or outcome Example: smoking (IV) à lung cancer (DV) IV and DV terms can be used to indicate direction of influence rather than cause and effect- specify the position for the independent variable
Relationships
A relationship is a bond or connection between variables. Cause-and-effect (causal) relationship (e.g., cigarette smoking and lung cancer) Associative (functional) relationship (e.g., gender and life expectancy) Qualitative study of pattern: Qualitative researchers may seek patterns of association as a way of illuminating the underlying meaning and dimensionality of phenomena of interest (e.g., Factors that influence care trajectories among African immigrants living with HIV in Quebec)
Evidence based practice
A practice that involves making clinical decisions based on an integration of the best available evidence, most often from disciplined research, with clinical expertise and pt preferences
Appraising/ integrating evidence in EBP
Appraisal- uWhat is the quality of the evidence? uWhat is the magnitude of effects? uHow precise are estimates of effects? uIs there evidence of side effects? uWhat are the financial costs of applying the evidence? uIs there relevance to my clinical situation? uResearch evidence needs to be integrated with: uYour own clinical expertise and knowledge of clinical setting uPatient preferences and values uEvidence from qualitative research
Evaluating Studies for a Review
Assess quality of study- to what extent do the findings reflect the truth/ flaws determine the believability of evidence
3 primary ethical principles in the Belmont Report
Central to all research -3 core concepts of ethical research -Respect for person (human dignity): Includes the right to self-determination and the right to full disclosure, •Recognition of human dignity •Evident in the informed consent process •Tell people about the study and ask if they would like to participate- ensure they have enough information Beneficence: Imposes a duty on researchers to minimize harm and maximize benefits, •Protecting people in research from harm •Maximize benefit •Minimize risk •Benefits and harms can be: •Physical •Psychological •Social/societal -Justice: Includes participants' right to fair treatment and their right to privacy, •The benefits and burden of the research should be distributed fairly •Researchers shouldn't be biased in terms of gender, race, social status, etc- Everyone has a chance to participate in treatment- cannot reject people based on gender or race
Concepts and Constructs
Concepts/phenomena: abstractions of particular aspects of human behavior or characteristics (e.g., pain, weight, fatigue, obesity) Constructs: slightly more complex abstractions (e.g., self-care) For example, self-care in Orem's model of health maintenance is a construct. Theories: an explanation of some aspect of reality. A set of concepts linked together by a complex relationships to explain phenomena
Conceptual vs operational
Conceptual: the abstract or theoretical meaning of a concept being studied Operational: the operations (measurements) a researcher must perform to measure the concept and collect the desired information Example: smoking (IV) - lung cancer (DV)
Critiquing Research Problems, Questions, and Hypotheses
Critique statements of purpose, research questions, and hypotheses in research reports with respect to their placement, clarity, wording, and importance§Evaluate whether researchers have adequately communicated their research problem. §Consider whether the problem has significance for nursing and evidence-based practice. §Determine whether the research problem is compatible with the chosen research paradigm and its associated methods. §Evaluate whether the statement of purpose or research questions lend themselves to research inquiry.
Major Classes of Quantitative Research
Experimental research, clinical trials- introduce intervention or treatment, casual relationships or intervention changes in the outcome Nonexperiemental research,- no cause and effect between variables observational studies- observation, no treatment or intervention, sometimes explore casual relationships but casual inferences are less conclusive. Define what type of research you are doing- quantitative or qualitative
Generalizability and Transferability
G- vthe criterion used in quantitative studies to assess the extent to which the findings can be applied to other groups and settings vTransferability (qualitative research): the extent to which qualitative findings can be transferred to other settings vAn important mechanism for promoting transferability is the amount of rich descriptive information qualitative researchers provide about study contexts. increase credibility- in discussion section
Qualitative Research: Disciplinary Traditions
Helps to collect and analyze data •Qualitative Research- •Grounded theory research, •Seeks to understand key social psychological processes, •Generate explanations of phenomena that are grounded in reality, -•Phenomenological research- •Focuses on the lived experiences of humans,•People's live experiences •Meaning/essence- •Ethnographic research- •Focuses on the patterns and lifeways of a cultural group, •Field work •Participation in the life of the cultural group
Content of Research Journal Articles
IMRAD Format Title and abstract Introduction Method Results And Discussion References
Components of a problem statement
Identification of the problem (What is wrong with the current situation?) Background (What is the nature or context of the problem?) Scope (How big is the problem, and how many people are affected?) Consequences (What are the consequences of not fixing the problem)? Knowledge gaps (What information about the problem is lacking?)- what is known and what do you want to bring - contributions Proposed solution (How will the study contribute to the problem's solution?)- broad enough for central concerns, narrow enough to serve as a guide to study design, talk about context- where did the problem happen, where did you get the idea, what will happen if we do not work on the problem
Analyzing and Synthesizing Information
Identify themes, substantive, methodologic, generalizability/ transferability
Evidence hierarchy- research questions
Level 1 (top of pyramid), highest level of evidence- Systemic review, level 2 for therapy questions- Single RCT, Level 3 for some etiology questions- Single non- randomized trial (Quasi- Experiement), Level 2 for Prognosis questions- single prospective/ cohort study, level 3 for some diagnosis questions- single case- control stufy, level 2 for descriptive quantitative questions- single cross- sectional study (survey), level 3 for meaning/ process questions- single in depth qualitative study, expert opinion, case reports, etc.
Writing
Organize the review- flow, number of references is not as important as relevance, objective synthesis of current evidence on a topic, summarized, unbiased
Asking Clinical questions
PIO uPopulation or patients: What are the characteristics of the patients or people? uIntervention (influence or exposure): What are the interventions or therapies of interest? or What are the potentially harmful influences/exposures of concern? uOutcome: What are the outcomes or consequences in which we are interested? May add time frame (T), comparison (C), or setting (S) to PIO, uTemplates can greatly facilitate wording of questions, for example, an intervention question: uIn _____ (population), what is the effect of ________ (intervention), in comparison to _______ (comparison), on __________(outcome)?
Phases in a Quantitative Study
Phase 1: Conceptual Phase Phase 2: Design and Planning Phase Phase 3: Empirical Phase Phase 4: Analytic Phase Phase 5: Dissemination Phase, work on protocol to set up everything
Primary vs Secondary sources
Primary- original descriptions of studies written by the researchers who conducted them. Secondary- descriptions of studies prepared by someone else
Statement of Purpose
Quantitative Study- specify variable, show how you will measure effects, identifies key study variables, identifies possible relationships among variables, indicates the population of interest, suggests through use of verbs, the nature of the inquiry (to test, to compare, to evaluate) Qualitative Study- show direction you want to develop research tradition, identifies the central phenomenon, suggests the research tradition (grounded theory, ethnography), indicates the group, community, or setting of interest, suggests through use of verbs the nature of the inquiry (to describe, to discover, to explore)
Identifying the research problem and questions
Research problem: What is wrong? §An enigmatic, perplexing, or troubling condition §Any concern in your professional practice, among patient, population §Topic you would like to address, investigate, or study, whether descriptively or experimentally. §a call for research proposals Problem statement §A statement articulating the research problem and making an argument to conduct a new study, problem that has an affect on nursing so that we can act on it, show the importance and deliverance of the problem- argue Statement of purpose: Why? Summary of an overall goal Research questions The specific queries the researcher wants to answer in addressing the research problem Hypotheses The researcher's predictions about relationships among variables, components are all r/t each other, do research to see if research is T/F
Types of Scholarly Publication
Research/ Empirical- Papers reporting on the results of one or more studies or experiments, written by the individuals who conduct research. Case Study- Details account of clinically important cases of common or rare conditions. Review- Summarizes the findings of others studies or experiments to identify trend or draw broader conclusions. Systematic Review- A summary of evidence on a particular research question that uses a rigorous process to identify, appraise, and synthesize studies to answer the question and come to a conclusion Meta- Synthesis-A specific kind of review paper-one with a mathematical synthesis of the results of two or more primary studies that addressed the same hypothesis in the same way. Letters of communication-Short descriptions of important latest study of research findings, which are usually considered urgent for immediate publication. Theoretical- A paper containing or referring to a set of abstract principles related to a specific field of knowledge Professional communications, book reviews, letters to the editor- Papers that pertain to the working of the professional that are not scholarly in nature-expert opinion pieces.
Literature Review
Written summary of evidence on a research problem- purpose- summarize evidence on a topic- what is known and what is unknown, Qualitative- collect data and then turn to literature to see how findings relate to theoryvFocuses on a specific topic vCompiles the research that has been published on the topic by scholars and experts vProvides background for the problem or puts the problem into historical perspective vInforms the reader about the current concepts and state of research on the topic and any controversies vDescribes the pros and cons of particular studies and may suggest areas for future research NOT... vYour opinion- want to interpret what researcher found vArgument on a position vReview of an article vA literary review describing and evaluating a specific book, poem, play, etc. vAn exhaustive, alphabetical list of every work consulted in your research, nor a list of references cited vAn annotated bibliography listing references and adding brief notes about the value of each source Stages- vProblem formulation—deciding the topic to be examined and its sub-topics- what you want to work on vLiterature search—finding materials relevant to the topic being explored vData evaluation—determining which literature makes a significant contribution to understanding the topic- is it good for PICO question vAnalysis and interpretation—discussing the findings and conclusions in a formal, scientific, and structured manner- Discussion
Good searching strategies
ancestry approach (footnote chasing), descendancy approach- finds pivotal early study and searching forward for more recent studies, bibliographic databases- accessed by computer- keywords- words or phrases that captures key concepts in your question (quantitative- I/D variables, quantitative- central phenomenon and population), subject heading/ search, mapping, textword search, boolean operators to expand/ delimit a search (AND, OR, NOT), wild card and trunication symbol (*)- all forms of the root, all spellings of word, "", use CINHAL- info about locating references and abstracts, add restrictions, and MEDLINE- bibliography coverage of biomedical literature- Pubmed, uses MESH (medical subject headings), Google scholar- includes scholarly articles, boots, technical reports, greater access to free full text publications
Roles of nurses in research
explain research to pt- expectations, look for cause- what is wrong? assist in data collection, uIdentification and description uExploration uExplanation uPrediction and control uUsing findings from studies in a practical application that is unrelated to the original research uTranslating new knowledge into real-world applications uReducing the gap between research and practice, advocate for change
Screen and gather references
for relevance, documentation in literature retrieval, abstracting and recording information - code characteristics of each study
Is this a quantitative study?
method section- show what type of study Ask yourself- vWas there an intervention?- did the researcher do anything to the participant- vDid the researcher do something to the participants? An intervention: vthe researcher does something to/gives something to the participants. vthe intervention can be manipulated (give to some and not to others) vmeasurements Then vExperimental vQuasi experimental •Participated in an educational program •Had a treatment or drug •Given a support program vWhat types of comparisons was made? •Is there a control group?- see the effect, pre and post study •Within-subjects design: same people, at different points in time or under different conditions? •Between-subjects design: different people are compared (e.g., men and women). vWhat specific design was used? vHow were confounding variables controlled? •Is it a random sample? •Which specific confounding variables were controlled? •Randomization, crossover, homogeneity, matching, statistical control vWas masking/blinding be used? •From whom will critical information be withheld to avert bias? hide information (participants may not know who is the intervention group and who is the placebo group, research team may not know either) vHow often was data collected? Time frames •When, relative to other events, was data collected? §single point in time (cross-sectionally) multiple points of data collection over time (longitudinal design vAre measurements being taken? vWhen were "effects" measured, relative to potential causes? Relative timing •When will information on independent and dependent variables be collected—looking forward or backward in time? •Retrospective (case-control)- going back •Prospective (cohort) vWhere will the study take place? •Where will the study take place? §Setting choice (various settings) ; single site versus multisite (different sites involved)- context is different
Clinical nursing research
research designed to generate knowledge to guide practice in health care fields
Nursing Research
systemic inquiry designed to develop knowledge about issues of importance in the nursing profession
Research
systemic inquiry that uses orderly methods to answer questions/ solve problems
Implementing and Evaluating Innovation
uDeveloping an evaluation plan uMeasuring client outcomes prior to implementing the innovation so that there is a comparison against which the outcomes of the innovation can be assessed uTraining relevant staff in the use of the new guideline and, if necessary, "marketing" the innovation to users uTrying the guideline out on one or more units or with a group of clients uEvaluating the pilot project in terms of both process and outcomes
Models for EBP
uDozens of models exist. uSome referenced models: uThe Stetler Model of research utilization to promote evidence-based practice uThe Iowa Model of evidence-based practice to promote quality care uRogers' Diffusion of Innovations Theory
Knowledge translation
uEffort to enhance systematic change in clinical practice uIssue: Researchers are funded with public money. Therefore results should be accessible to the public uTranslation of clinical knowledge into improved health uActivities at the individual nurses and organisational level uGet key messages to target audiences uInformation that has an impact- translate to terms that they can understand
Evidence based practice
uEvidence-based decision making should integrate best research evidence with clinical expertise, patient preferences, and local circumstances. uA key ingredient in EBP is the effort to personalize "best evidence" to a specific patient's needs within a particular clinical context. The emphasis is on identifying the best available research evidence and integratingit with other factors in making clinical decisions, barriers- uQuality and nature of the research uFor example, scarcity of strong research evidence uCharacteristics of nurses uFor example, inadequate skills in locating and appraising evidence uOrganizational factors uFor example, lack of financial support and staff release time for EBP
Positive Versus Constructivist Paradigms
uKey paradigms for nursing research uPositivist paradigm uConstructivist paradigm uPositivist-Objectivity uReality exists; real world driven by natural causes uResearcher is independent from those researched. uValues and biases are to be held in check. uUnderstanding the underlying causes of natural phenomena, more quantitative Constructivist/naturalist uReality is multiple and subjective- according to context and experience uResearcher interacts with those being researched. uSubjectivity and values are inevitable and desirable. Pragmatism uBoth uMultiple objectives, focus, contexts, forms of data- use different methods to solve the problem, more qualitative Common features in both paradigms- 1.Ultimate goals 2.External evidence 3.Reliance on human cooperation 4.Ethical constraints 5.Fallibility
Resources for EBP
uPre-appraised evidence: has been selected from primary studies and evaluated for use by clinicians uSystematic reviews: integrate evidence about a topic in a rigorous, systematic way uMeta-analysis: technique for integrating quantitative research findings statistically- many studies r/t one topic uMetasynthesis: less about reducing information and more about interpreting it uClinical practice guidelines and care bundles: give specific recommendations for evidence-based decision making
NINR's Strategic Plan: Five Areas of Focus
uPromoting health and preventing disease uSymptom management and self-management uEnd-of-life and palliative care uInnovation uThe development of nurse scientists
Best evidence
uRefers to research findings that are methodologically appropriate, rigorous, and clinically relevant for answering pressing questions uThese questions cover the efficacy, safety, and cost effectiveness of nursing interventions. uThey also cover the reliability of nursing assessment tests, the causes and consequences of health problems, and the meaning and nature of patients' experiences.
Characteristics of quality improvement
uThe intervention or protocol can change as it is being evaluated, to incorporate new ideas or insights. uThe purpose of a QI project is often to effect immediate improvement in health care delivery. uQI is designed to sustain an improvement. uQI is a necessary, integral activity for a health care institution; research is not. uA literature review may not be undertaken in a QI project. uQI projects are not externally funded.
Research Methods
uThe techniques used to structure a study and to gather, analyze, and interpret information- can be used to clarify and lend specificity to the purpose statement uQuantitative research: most closely allied with the positivist tradition, pure vs past- positivist- want obectivity but there may be problems with objectivity, relationships among variables- typically pose queries Quantitative studies: usually involve concepts that are well developed and for which methods of measurement have been (or can be) developed uQualitative research: associated with the constructivist tradition, Qualitative studies: are undertaken because a researcher wants to develop a rich, context-bound understanding of a poorly understood phenomenon, grounded theory: process question, phenomenology- meaning questions- what does this mean to you? Ethnography- cultural description questions uPositivists sometimes undertake qualitative studies, and constructivist researchers sometimes collect quantitative information. Problems are related to the paradigms, two concepts/ variables- positivist- cause and effect, constructivist- want to explore a problem
Research Purposes Linked to EBP
uTherapy, treatment, or intervention uDiagnosis and assessment uPrognosis uEtiology and harm uMeaning and processes
Clinical Practice Guidelines
uThere is no single guideline repository. uWhen multiple guidelines exist, the clinician must identify ones based on strongest evidence. uAppraisal of Guidelines Research and Evaluation (AGREE) has ratings for 23 dimensions within six domains (e.g., scope and purpose, rigor of development, presentation).
Sources of Evidence for Nursing Practice
uTradition and authority uClinical experience and trial and error uAssembled information uBenchmarking data and quality improvement and risk data uDisciplined research: best method of acquiring reliable knowledge; evidence-based findings
Research Critique
vDefinition •an objective assessment of a study's strengths and limitations- how did they select participants vCritiques •To inform EBP: accurate, believable, and clinically relevant. •The researcher's major conceptual and methodologic decisions •Variety of reasons §Student assignment §Making decisions about whether or not to publish a manuscript- peer reviews §EBP purposes vVary in scope, length, and form, depending on purpose- Objective data we want to research
Key Research Challenges
vDesigning studies to support inferences that are: •Reliable and valid (quantitative studies) •Trustworthy (qualitative studies) •An inference is a conclusion drawn from the study evidence using logical reasoning and taking into account the methods used to generate that evidence.
Research questions and research designs
vDifferent designs are appropriate for different questions. •Therapy, prognosis, etiology/harm, and description vExperimental designs (RCTs) offer the strongest evidence of whether a cause (an intervention) results in an effect (a desired outcome). •That's why they are high on evidence hierarchies for questions about causes and effects.
Nonexperiemental studies
vIf researchers do not intervene by controlling independent variable, the study is nonexperimental (observational). vNot all independent variables ("causes") of interest to nurse researchers can be experimentally manipulated. •For example, gender cannot ever be manipulated. •Smoking cannot ethically be manipulated. Types vDescriptive Non - Experimental •Case control •Cohort •Survey vCorrelational designs-see relationships between the variables
Cohort study
vIn a prospective correlational design, a potential cause in the present (e.g., experiencing vs. not experiencing a miscarriage) is linked to a hypothesized later outcome (e.g., depression 6 months later). •Look forward - prospective •Exposure of interest §Eg: Group 1- men who have worked in fire fighters for 10 years §Group 2 similar group of men with no exposure •Look ahead: follow cohort over time (years) •What are the outcomes vProspective designs are stronger than retrospective designs in supporting causal inferences—but neither is as strong as experimental designs
Retrospective Designs
vIn a retrospective correlational design, an outcome in the present (e.g., depression) is linked to a hypothesized cause occurring in the past (e.g., having had a miscarriage). vOne retrospective design is a case-control design in which "cases" (e.g., those with lung cancer) are compared to "controls" (e.g., those without lung cancer) on prior potential causes (e.g., smoking habits).
Research Control
vIn quantitative studies, research control involves holding constant extraneous factors (confounding variables) that influence the dependent variable to better understand relationships between the independent and dependent variables. vResearch control is one method of addressing bias.
Quasi Experiment
vInvolve an intervention but lack either randomization or control group (No control group, No randomization) v vTwo main categories of quasi-experimental designs •Nonequivalent control group designs §Those getting the intervention are compared with a nonrandomized comparison group. •Within-subjects designs §One group is studied before and after the intervention. v vEg: Student performance when they sit on comfortable vs uncomfortable chairs vYou can not control the people factors - bum shape, pain tolerance, ability to perform on a test. Two groups receive treatment at the same time, pre and post- take measurement before and after intervention
Case control
vLook back at cases - retrospective •EG: over 60 with influenza B vs no influenza vLook at what might have caused influenza vWhy did some get and others did not? What's the difference
Forms of Systematic Reviews
vNarrative, Using non-statistical methods to synthesize research findings. vMeta-analysis statistical integration of results used to compute common effect size(e.g. Cochrane Reviews) vMeta-synthesis integration of findings from qualitative studies
How to study the problem: The literature search
vNever ever dictionary or Wikipedia vGoogle, google scholar vBrowse through a journal •Eg: Qualitative health research vCheck the references (authors on topic) vA formal literature search
Descriptive research
vNot all research is cause probing. vThe purpose of descriptive studies is to observe, describe, and document aspects of a situation. vSome research is descriptive (e.g., ascertaining the prevalence of a health problem). vOther research is descriptive correlational—the purpose is to describe whether variables are related, without ascribing a cause-and-effect connection. Ex) report cases of HIV in each province, collect data and see how many people are exposed comparing to the other provinces
Types of Research Reports
vPresentations at professional conferences •Oral presentations •Poster sessions vJournal articles •Papers often subjected to peer review •Peer reviews are often blind (reviewers are not told names of authors and vice versa).
Experimental
vRandom assignment Everyone has an equal change of being in the group
Reducing Bias
vRandomness—allowing certain aspects of the study to be left to chance rather than to researcher or participant choice •An important tool for achieving control over confounding variables and for avoiding bias vBlinding (or masking), which is used in some quantitative studies to prevent biases stemming from people's awareness •Blinding involves concealing information from participants, data collectors, or care providers to enhance objectivity.
Tips on reading research articles
vRead regularly, get used to style. vRead copied articles—underline, highlight, write notes. vRead slowly vRead actively. vLook up technical terms in glossary. vDon't be intimidated by statistics—grasp gist of story. "Translate" articles or abstracts. (try saying it in your words
Criteria for Evaluating quantitative research
vReliability •The accuracy and consistency of obtained information- how consistent the info is- from beginning to end vValidity •The soundness of the evidence—whether findings are convincing, are well-grounded, and support the desired inferences- Is the evidence strong enough to support conclusion
Reflexivity
vThe process of reflecting critically on the self and of attending to personal values that could affect data collection and interpretations of the data vQualitative researchers are trained to explore these issues, to be reflective about decisions made during the inquiry, and to record their thoughts in personal diaries and memos. vReflexivity can be a useful tool in quantitative as well as qualitative research—self awareness and introspection can enhance the quality of any study.
Research integration and synthesis
vThe systematic and rigorous integration and synthesis of evidence is a cornerstone of EBP. vImpossible to develop "best practice" guidelines, protocols, and procedures without organizing and evaluating research evidence through a systematic review- helps to synthesize information found
Variables
vThere are 2 types of variables 1.Dependant (DV)- vWhat we watch to see if something is occurring in the Independent variable, effect 2.Independent (IV)- vThe independent variable is manipulated to influence the dependant variable, cause
The aim of quantitative methodology
vTo explain vDemonstrate the relation of cause and effect •Explain the truth vResults are factual, and universally applicable •Generalizable
Triangulation
vTriangulation is the use of multiple sources or referents to draw conclusions- support our conclusions about what constitutes the truth- same data •Triangulation can contribute to credibility- tests validity •Triangulation is a useful strategy in both qualitative and quantitative research.
Evaluative Criteria in Qualitative Studies
vTrustworthiness •Credibility—a key criterion, achieved to the extent that researchers can engender confidence in the truth of the data and their interpretations •Confirmability •Dependability •Transferability- research can be repeated with same results, generalize •Authenticity
Theory
•An abstract generalization that explains how phenomena are interrelated •Used less restrictively to refer to a broad characterization of a phenomenon • Theories consist of two or more concepts and a set of propositions that form a logically interrelated system, providing a mechanism for deducing hypotheses. Types of theories- -Classical theory—an abstract generalization that systematically explains relationships among phenomena -Descriptive theory—a theory that thoroughly describes a phenomenon, based on rich observations of it -Grand theory—a theory that attempts to explain large aspects of human experiences -Middle-range theory—a theory that focuses on a specific aspect of human experience (e.g., stress); more specific and more amenable to empirical testing, many concepts fit together to give us a better understanding
Model
•Conceptual model: deals with abstractions/concepts that are relevant to a common theme- may need to develop own conceptual model if an existing one doesn't fit •Represents an understanding of a phenomenon and reflects the assumptions of the model's designer; can serve as springboards for generating hypotheses •Schematic model: Visually represents relationships among phenomena and is used in both quantitative and qualitative research
Main objectives of the search
•Extract only those articles that relate to the research question (this is called "specificity") Do not miss any of these articles (this is called "sensitivity").
Theories in Qualitative Research
•Substantive theory—conceptualizations of a specific/target phenomena •Theory embedded in a research tradition •Grounded theory (mixture of sociologic perspectives: symbolic interactionism). •Theoretical Underpinning of Grounded Theory: Humans act toward things based on the meanings that the things have for them; The meaning of things is derived from the human interactions; Meanings are handled in, and modified through, an interpretive process. •Ethnography (cultural theories: ideational and materialistic)- understand in a group •Phenomenology (the phenomenological philosophy of human experience)- meaning and experience
The use of theories in Quantitative Research
•Testing a theory through deducing hypothesis to be tested •Testing a theory-based intervention •Using a theory/model as an organizing or interpretive structure •Fitting a problem into theory, after the fact (not recommended) Grand- understand the process
Framework
•The overall conceptual foundation of a study •Theoretical framework (based on theory) •Conceptual framework (based on a conceptual model)- Jean Watson, different people develop different conceptual models- drive hospitals •A study's framework is often implicit. •Quantitative researchers are less likely to identify their frameworks than qualitative researchers
