Nursing Research Lecture №17 PART I. Is nursing a profession? Q.#1: What are the criteria for a...

Nursing Research

Lecture №17

PART I

Is nursing a profession?

Q.#1: What are the criteria for a profession?

Nursing: Profession or Technical Occupation?

Pavalko’s (1971) Continuum Model for a Profession

Theory Relevance to social values Education Motivation Autonomy Commitment Sense of community Code of ethics

Explore the Meaning of a Professional vs. Technical

Practice

Describe the similarities or differences between the chef at the Brown Palace & the cook at the Village Inn?

Chef

Cook

Professional vs. Technicalfor all practice areas

Professional Practices Have a culture that

supports professional activities: frameworks, CE, research

Has a defined body of knowledge gained by formal education

Is a discipline with peer review and a code of ethics

Autonomy in practice with legislative and legal sanctions

Is an organized system of practice recognized by society

Technical Occupations Are more likely to have

more OJT than formal education.

Are skill focused Have trade journals or

technique trainings Do not focus on what

advances the practice Develop through

certifications Want less accountability

Professional vs. TechnicalThinking and Valuing

Professional thinking More is best Specialization in depth and

breadth Evidence-based education Invests energy beyond the

work-associations, research, reading

Expects self accountability Resilient with change and

believes change is valuable

Technical Thinking Least is best Specialization in depth Experience is the

primary educator Conserves energy

beyond the workday Prefers others be

accountable Enjoys consistency and

believes change is disruptive

Is research important to the profession?Yes!! Research is important for building a unique, systematic

body of knowledge about a discipline

Nursing needs a systematic body of knowledge to ...

Promote Evidence-based practice Give credibility to profession Provide accountability for practice Help document the cost-

effectiveness of care (Nieswiadomy, 2008)

What is Evidence Based Nursing Practice?

Knowledge from science & research

Knowledge from experts Knowledge from patients Knowledge arriving in many forms Has levels of power and rigor EBP IS NOT JUST FROM RESEARCH

Evidence Based Practice: Definition

“…the integration of current best evidence with clinical expertise and patient values” (Sackett et al., 2000)

“…a framework for clinical practice that incorporates the bestbest available scientific available scientific evidenceevidence with the expertise of the expertise of the clinicianclinician and the patient’s preferences patient’s preferences and valuesand values to make decisions about health care.” (Levin, 2006)

What is Research? Process of searching for new knowledge about

phenomena Validates and refines existing knowledge (Burns &

Grove, 2007) Systematic process of inquiry or study Builds new knowledge through the dissemination

of findings

Why Research??? To Describe

To identify and understand the nature of nursing phenomena

What is the experience of growing up poor in Manhattan?

To Explain Clarifies the relationship among

phenomena, and why certain events occur What are the factors that supported DSN

graduates to pass NCLEX at 95% in 2009?

Why Research??? To Predict

This allows us to estimate the probability of a specific outcome in a given situation

There is a statistical difference in baseline patient glucose levels when using basilar method over sliding scale.

To Control or Manipulate If we can predict, the next goal would be to

control or manipulate the situation to produce the desired outcome.

We can reduce bed sores at all stages by rotating patients every two hours maximum.

Ways We Acquire Knowledge Tradition Authority Borrowing Trial and error Personal

experience Role-modeling &

mentoring Intuition

Reasoning Inductive-gather Deductive-divide Rational-logic Unstructured

Research Quantitative Qualitative Mixed / Other

Research Defined

Research is a systematic, diligent inquiry that is necessary to address: What needs to be known-what is the

question, hypothesis, or interest area What research methods are needed to

examine this question or phenomena What meaning can be extracted from the

study through data analysis to build our knowledge base of that subject

Generate outcomes and disseminate new knowledge

Ways to Study Research By its components (questions, rigors,

sampling method, measurement method, etc) Divided into two major types

Qualitative Quantitative

By the name of the method (experimental, phenomenology, etc)

By the philosophy it uses to inquire (positivistic, naturalistic, both, neither)

Burns & Grove method: Examine Your Text

Table of Contents 7 Ch. 1 Ch. 2 = Quantitative Research Ch. 3 = Qualitative Research

(philosophy discussed) CH. 4 = tries to address both

qualitative and quantitative questions

Ch. 5, 6 = Lit review, Study Frameworks & Theory

Examine Your Text Ch. 7 = ethics Ch. 8 = Clarify Designs (quantitative) Ch. 9 = Outcomes Research Ch. 10 = Populations and Sampling

for quantitative and qualitative methods

Ch. 11 = Measurement of Data quantitative and qualitative

Ch. 12 = Understanding Statistics

Examine Your Text Ch. 13 = Critiquing Research for

qualitative (five Standards) and quantitative.

Ch. 14 = Building an Evidence Based Practice

Ch. 14 Evidence Based Practice Research Utilization (RU) may have a lag time

for Practice up to 20 years Involves being a Change Agent. (DSN uses the

I2E2 model for change in third quarter) Best Evidence by research type

Integrative Reviews (many types of designs) Systematic Reviews (focused on a particular type of

research designs) Meta-Analysis (has statistical evaluation of

quantitative designs). Metasummaries & Metasynthesis (qualitative

research)

Hierarchy of EvidenceCompare to Florczak article

Level I: A systematic review or RCTs, meta-analysis of many randomized controlled trials (RCTs)

Level II: Integrative Reviews of experimental designs

Level III: from a well-designed controlled trial without randomization

Level IV: From case-control or cohort studies

Hierarchy of EvidenceCompare to Florczak article

Level V: From systematic reviews of descriptive or qualitative studies, metasummaries, metasynthesis,

Level VI: a single descriptive or qualitative study

Level VII: It is an opinion from authorities on that subject, or expert committee

Recent Changes in Nursing Page 500, second paragraph, Using

ASA 81 mg. in at risk adults Page 517, I.V. flush using 0.9% NS

vs. heparin. P & P on page 520. Algorithms on page 524 for tx HTN. I.V. skin prep using chlorhexidine vs.

Iodine products like providone-iodine

Strait cath urethra prep

Mydsn.org, NRS 338 Evidence Based Research

www.cochrane.org/www.guideline.govhttp://www.cebm.utoronto.ca/resources/websites.htm

www.ahcpr.gov/clinic/ http://www.crd.york.ac.uk/crdweb/

Research Philosophy Method:Positivistic versus Naturalistic

Inquiry This is a 100 year old debate It is often correlated to research

methodology It is a philosophy on the way we think about

human phenomenon & inquiry (research) We can integrate two different inquiry

methodologies, but philosophically they are very different (mixed or blended design)

Our philosophy is the foundation for how we design research

Positivistic Inquiry Naturalistic Inquiry (Constructivism) 

Quantitative Triangulated Qualitative  

Solomon Design Blended Designs Post-modern -four group design - use quantitative -pretest-treat-post test Intervention Res & qualitative -research self -pretest-no treat- post test methods -novel sounding -no pre- no treat- post test lacks theory -random group Quasi-Experimental Grounded Theory Phenomenology -validated tools -two of three -theory building - descriptive

Exp. controls -Basic Social Process - interpretive - hermeneutic Descriptive

Experimental Design - quantitative or Ethnography -random sample qualitative methods -living in the experience -control group -cultural

immersion -a treatment given Outcome Research

Case Study Epidemiology (humans & Ds) -single-double cases Analytic Epi -In-depth analysis Descriptive Epi - comparative analysis

Action ResearchAdequate time commitmentCollaborative effortOpenness to changeQuality of data collection and analysis Impact on one’s practice

Positivistic Inquiry Naturalistic Inquiry (Constructivism) 

Quantitative Triangulated Qualitative  

Solomon Design Blended Designs Post-modern Quasi-Experimental Grounded Theory Phenomenology

Constant Comparative Analysis

Descriptive Experimental Design Ethnography

Case Study

Scientific Rigors by DesignQuantitative Research RigorValidity & Reliability (internal-external) Qualitative Research Rigor Conceptual Framework Developed Descriptive Vividness Statistical Inference Methodological CongruenceGeneralizability Analytical PrecisenessTemporality Theoretical Connectedness Selection and Bias Heuristic RelevanceMeasurement validity / reliability Trustworthiness, Credibility, Controlling confounders and AuditabilityAppropriate study design for the questions Confirmability, transferabilityStylistic & Personal

Relevance, Heuristic

Sample Size by DesignPositivistic Inquiry Naturalistic Inquiry (Constructivism) 

Quantitative Triangulated Qualitative  

Solomon Design Blended Designs Post-modern Power Analysis 20-40 1 Quasi-Experimental Grounded Theory Phenomenology

>40 10-1000 10+saturation (10-30) Descriptive

Experimental Design 1-12 Ethnography

Power Analysis 1

Case Study 1-2

Action Research ?-100

Assumptions of Positivistic Thinking Reality is singular,

tangible, & and can be dissected

The researcher and those being studied are independent

Time and context-free generalizations are possible

Inquiry is value-free

value free singular reality

Positivistic thinking

generalizableindependentvariables

Assumptions of Positivistic Thinking There are real

causes or at least high probability of a relationship.

We believe we can have independent and dependent variables as separate entities

Validity of a design is very critical to results

value free

singular reality

validity

Positivistic thinking

generalizable

cause &effectindependentvariables

Assumptions of Positivistic Thinking

Reliability is based on how the design is reproducible

Generalizability is related to good internal validity and reliability with comparable samples

Hypothesis testing

generalizable

value-free

Positivistic thinking

validity

singularreality

hypothesistesting

reliability

cause & effectindependentvariable

Assumptions of Naturalistic Inquiry Realities are multiple,

pluralistic, and holistic The researcher cannot

really be separated from those being studied and relation-ships are explained

hypotheses are time and context bound - they are only working statements

researcher& subjectconnected

hypothesis is a focus area

multiple realities

naturalisticinquiry

Assumptions of Naturalistic Inquiry All entities are in a

state of mutual simultaneous shaping

Inquiry is value-bound

Validity is designed into the process

Reliability & general- izable are not concepts of value with this thinking

researcher& subject connected

hypothesisis a focusarea

Naturalistic inquiry

thick description

multiple realities inquiry is value bound

Differences in Scientific Rigorpositivistic naturalistic Validity Internal and external

reliability Hypothesis testing Statistical inferences Independent and

dependent variables Variable controls Generalizability

Descriptive Vividness Methodological

Congruence Analytical

Preciseness Theoretical

Connectedness Heuristic Relevance Others

Data Collection Differencepositivistic naturalistic Tools

surveys, questionnaires objective assessment &

identification Measure the dependent

variable Convert to numeric

symbols Apply statistical

inferences to numbers Large sample sizes help

with confidence levels

Tool is the investigator by

interview, focus groups, & observation

Data is subjective and objective. It is collected & not measured

Themes or clusters are identified and data is sorted in a theme analysis

The themes are supported by participants or experts

Differences in Results positivistic naturalistic Statistical

significance for pre-post treatment

Statistical correlations & relationships identified

Probability of errors & confidence identified

Causal relationships

The exploration & description of a phenomenon

Identification of linkages, relationships, or interpretations based on theory connections

Results are themes, clusters of ideas, or theory constructs

Positivistic Discussion of Results 250 nurses were surveyed with an 80%

response rate or N=200. Questions were rated using the Likert 5 scale. Question 1 had a mean of 4.2 with a S.D. of 0.5 suggesting the nurses had favorable opinions about continuing education. Compared to a 1994 survey asking the same question, there was a statistical difference that was less favorable (mean 3.1, S.D. 0.7, p<.05)

Naturalistic Description I sat in the classroom as a peripheral

member staying as unobtrusive as possible. The instructor came out from behind her desk, sitting on the edge as she opened with a question that brought all eyes in the room to meet her own eyes. She paused - looked at the eyes of the students.

The instructor displayed immediacy from the moment she started the class.

Ethics and Research (Ch. 7)

Starts with the study purpose, design, methods of measurement, and subjects

Guidelines for all of these It is still a concern today More recent ethical issues are:

Fabrication of a study Falsification or forging of data Dishonest manipulation of the design or methods Plagiarism

50% of the top 50 research institutions in US have been investigated for research fraud

Ethical Problems in History

Nazi medical experiments (1933-1945)

Tuskegee syphilis study by the USPHS (1932-1972)

Willowbrook study (1950-1970) Hepatitis study

Jewish Chronic Disease Hospital study with live CA cells in 1960s

Ethical Problems in History University –Atomic Energy Government Exp.

18 men and women injected with plutonium to determine body distribution (at the time said to be terminal) 1945-47

20 subjects ages 63-83 given doses of radioactive radium and thorium inj. or oral. 1961-65

64 male inmates at Washington St. Prison had testicular radiation to determine the smallest does to makes someone sterile. 1963-70

125 retarded residents were fed radioactive ir9n and calcium to see if a diet rich in cereal would block the digestion of those two minerals. 1946-56

Nuremberg Code-1949 Voluntary consent Must yield fruitful results for society Anticipated results justify the type of experiment Avoids all unnecessary physical-mental injury Cannot do studies that have a known injury or

death unless the exp. Physician is a subject Risk does not out weight humanitarian benefit Proper precautions to prevent injury, dis., death Conducted by qualified persons Subjects can always stop the study Researcher must always be ready to stop the

study (risk)

Declaration of Helsinki-1964-84

Differentiated therapeutic vs. non-therapeutic research

Clinical vs. Basic Greater care to protect subjects in non-

therapeutic research There must be a strong, independent

justification for exposing a healthy vol. to substantial risk

The investigator is to protect the health and life of research subjects

The Belmont ReportThree Ethical Principles

Principle of respect for persons Right to self determination and freedom to participate or

not Principle of Beneficence

Do no harm to others Principle of Justice

Treat everyone fairly without discrimination Led to USDHHS Code on Ethics

Title 45, Part 46 (45 CFR 46) Office of Human Subjects Research (OHSR) within NIH http://helix.nih.gov:8001/ohsr

Institutional Review Board (IRB) Provides oversight on all ethical

issues related to someone doing research

Consent forms (voluntary subjects) Disclosure forms Confidentiality Compensation disclosure Ethics documented in the research Accountability to rules, regulations, and

legal entities Protects at risk populations

The Literature Review Primary Sources Secondary Sources Theoretical literature Empirical (Research) literature Evidence Based Research Sites

www.cochrane.org/www.guideline.govhttp://www.cebm.utoronto.ca/resources/websites.htm www.ahcpr.gov/clinic/ http://www.crd.york.ac.uk/crdweb/

Definition of a Literature Review (Ch. 5)

A systematic and explicit approach to the identification, retrieval, and bibliographical management of independent studies … locating information … synthesizing … developing guidelines …

Purposes of the Lit. Review Facilitate development of the Conceptual

Framework by summarizing knowledge Clarify the research topic Clarify the research problem Verify the significance of the research

problem Specify the purpose of the study Describe relevant studies or theories Develop definitions of major variables Select a research design, data measurement,

data collection & analysis, & interpret findings

Literature Searches Ebscohost with CINAHL:

http://search.ebscohost.com Log in: DSN Password: evidence Mydsn.org

NRS 338 Data bases

Understanding Research Designs Can have confusing terms Research Methodology

The entire process from question to analysis Research Design

Clearly defined structures within which the study is implemented

Is a large blueprint, but must be tailored to the study and then mapped out in detail

Quantitative Designs (Ch. 2)

What are the four types ofQuantitative Designs?

Quantitative Designs Experimental Quasi-experimental Descriptive Correlational

Aim to describe, compare, and predict in order to understand or control phenomena

Quantitative Designs

What characterizes true Experimental Research

Designs?

True Experimental Research Designs

Are characterized by: Random assignment of subjects to

groups

Comparison of treatment group(s) with a

Control or “business as usual” group

True Experimental Research Designs (cont.)

Also characterized by …

Strict control of extraneous variables to obtain true representation of “cause and effect” Note: use “causality” language with

caution!!! (there is always a P-value) Ex: Smoking and cancer

Randomized Controlled Clinical Trials (RCT)

True Experimental Design

Large N (# of subjects) Draw subjects from reference population Randomly assign subjects to treatment/experimental or control group Examine for baseline equivalence Multiple sites used for generalizability

Quasi-Experimental Research Designs

Are characterized by:

Treatment or intervention Comparison of treatment group(s) with a control or “business as usual” group Non-equivalence of groups--not randomly

assigned; group assignment often evolves naturally “convenience” sampling)

Ex: Pts. on one unit compared to pts. on another

Quasi-Experimental Research Designs (cont.)

Also are characterized by…

Aiming to represent “cause and effect” in situations where less control over variables exists

Most frequently used design in nursing

Correlational Designs Descriptive correlational designs

Used to describe variables and to examine relationships between or among variables

Predictive correlational designs Used to predict value of one variable based

on values obtained for another variable Independent variable used to “predict”

Dependent variable Regression Model-testing design

Looks at relationships among a # of variables

Correlational Designs Descriptive correlational designs

Used to describe variables and to examine relationships between or among variables

Predictive correlational designs Used to predict value of one variable

based on values obtained for another variable

Independent variable used to “predict” Dependent variable

Quantitative Design Concerns

Primary purpose (check question) Is there a treatment (intervention) Will the treatment be controlled Is there a control (untreated) group Is there a pre or post test (or both) Is sample random Will sample be a single group or divided

into several groups

Quantitative Design Concerns-2

How many groups will there be What is the size of each group Will groups be randomly assigned Will there be repeated measurements over

time or will the data be collected cross-sectionally at one or two points in time

Have extraneous variables been identified and controlled for

What strategies are being used to compare variables or groups

Research Question Considerations Ethics Significance Motivation Qualifications Feasibility

Hypotheses and Research Qs Hypotheses: Intelligent guesses

about predicted relationships

Problem statement what the issue/concern/problem is and why it should be addressed

Research Qs: “Burning question”

What are Criteria for Hypotheses? (Ch. 4)

Declarative Written in present tense Include population Identify variables Reflect the problem/concern Are empirically testable

Independent & Dependent Variables

Independent (IV) The treatment The intervention That which is manipulated

Dependent (DV) Outcome What is being measured The difference

Types of Hypotheses: Simple & Complex

Simple One Independent Variable (IV) and

one Dependent Variable (DV)

Complex Two or more IVs, two or more DVs, or both, being investigated at same

time

Hypothesis: #1 Average length of gestation is

shorter for infants of mothers who use cocaine than among mothers who use alcohol during the last six months of pregnancy.

Population? IV? DV?

Simple or complex?

Hypothesis: #2 The greater the degree of

sleep deprivation, the higher the anxiety levels of intensive care unit patients.

Population? IV? DV?

Simple or complex?

Hypothesis: #3 The total wt. loss of overweight

elementary students who follow a reduced calorie diet and exercise 20 minutes four times a week will be greater than those students who do not follow a reduced calorie diet and do not exercise 20 minutes four times a week.

Population? IV? DV?

Simple or complex?

Hypothesis: #4 The degree of stress reported by

flight-for-life nurses is greater than the degree of stress reported by ICU nurses.

Population? IV? DV?

Simple or complex?

Name that Hypothesis: #5 More domestic violence and levels

of anger are reported by veterans who served in the military in Iraq compared to those in the military who served in Afghanistan.

Population? IV? DV?

Simple or complex?

Sample of Research Topic & Questions

Topic: Adolescent sexuality Problem statement: (e.g., pregnancy rates in US

are much higher compared to most Western countries)

Research Question: Will high school adolescent males report higher levels

of comfort with their own sexuality than will females? Hypothesis:

Adolescent males in grades 9 – 12 will report statistically higher levels of comfort with their own sexuality than will females in the same grades.

Quantitative Design Concerns

Primary purpose (check question) Is there a treatment (intervention) Will the treatment be controlled Is there a control group (untreated) Is there a pre or post test (or both) Is the sample a random sample Will the sample be a single group or

divided into several groups

Quantitative Design Concerns-2

How many groups will there be What is the size of each group Will groups be randomly assigned Will there be repeated measurements Will the data be collected cross-sectionally

or over time Have extraneous variables been identified

and controlled for What strategies are being used for

comparison of variables or groups

Components of Study Validity

Definition: It is an examination of the approximation of truth or falsity of the propositions Statistical Validity (right stats used) Internal Validity (sample represents the

population being studied) Construct Validity (concept & Operational

def. of variable match, & instrument accuratly measures theoretical constructs it purports to measure.

External Validity (methods allow for generalizability)

(Cook and Campbell, 1979)

Statistical Validity Errors Violate assumptions about the data

Nominal, ordinal, interval, ratio data Type I and Type II errors Need for Power Analysis

Predicts the necessary N value Inappropriate use of certain statistics

for the various types of data Random irrelevancies in setting Random heterogeneity of respondents

Statistical Conclusion ValidityType I and Type II Errors

Accept the Null Hypothesis Reject the Null Hypothesis Reality is: Type I ErrorNo Desired There is no differencedifference caused by fishing

Reality is: Type II Error, there is There is a difference often caused Desired Difference by a low N value

Internal Validity Definition:

*It is the extent to which the effects detected in the study are a true reflection of reality rather than the result of extraneous variables;

* The independent variable did have an impact on the dependent variable and it was not by random chance (p value)

Threats to Internal Validity History: Natural events over time impacting

the subjects Maturation: A person’s growth in any area

impacting his/her response Testing effect caused by subjects

remembering previous testing Instrument reliability of treatment Selection process (randomized) Mortality threat Interaction with subjects No equalization of treatment

External Validity Definition:

To provide development of the design that allows it to be generalized beyond the sample used in the study.

Most serious threat is that the results can only be said of the group being studied

Threats to External Validity Small N No randomization when it is needed Poor sample representation either

by type, geography, or some other characteristic

Cannot be replicated for some extraneous variable

Factors Influencing Sample Size

Effect Size The degree to which the phenomenon

is present in the population or to which the null hypothesis is false.

It is hard to detect an effect from an intervention if the sample is small

Type of study conducted Case study, phenomenology,

experimental, Descriptive

Factors Influencing Sample Size

The number of variables This requires a power analysis to

determine the necessary N Measurement Sensitivity

The ability of the measurement to find what it thinks it is finding.

Data Analysis Techniques The various statistics can impact the

number of subjects needed.

Types of Probability Sampling Simple Random Sampling (select those

with specific characteristics)

Stratified Random Sampling (2 or more strata of population)

Cluster Sampling (all states, cities) Systematic Sampling (every nth) Random Assignment to Groups

(Treatment and Control)