probability vs. non-probability sampling in research

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Library of Congress Cataloging-in-Publication Data

Names: Polit, Denise F., author. | Beck, Cheryl Tatano, author. Title: Essentials of nursing research : appraising evidence for nursing practice / Denise

F. Polit, Cheryl Tatano Beck. Description: Ninth edition. | Philadelphia : Wolters Kluwer Health, [2018] | Includes

bibliographical references and index. Identifiers: LCCN 2016043994 | ISBN 9781496351296 Subjects: | MESH: Nursing Research | Evidence-Based Nursing Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072—dc23 LC record available at https://lccn.loc.gov/2016043994

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Our Families—Our Husbands, Our Children (and Their Spouses/Fiancés), and Our Grandchildren

Husbands: Alan and Chuck

Children: Alex (Maryanna), Alaine (Jeff), Lauren (Vadim), Norah (Chris), Curt, and Lisa

Grandchildren: Maren, Julia, Cormac, Ronan, and Cullen

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ABOUT THE AUTHORS

Denise F. Polit, PhD, FAAN, is an American health care researcher who is recognized internationally as an authority on research methods, statistics, and measurement. She received her Bachelor’s degree from Wellesley College and her Ph.D. from Boston College. She is the president of a research consulting company, Humanalysis, Inc., in Saratoga Springs, New York, and professor at Griffith University, Brisbane, Australia. She has published in numerous journals and has written several award-winning textbooks. She has recently written a ground-breaking book on measurement in health, Measurement and the Measurement of Change: A Primer for the Health Professions. Her research methods books with Dr. Cheryl Beck have been translated into French, Spanish, Portuguese, German, Chinese, and Japanese. She has been invited to give lectures and presentations in many countries, including Australia, India, Ireland, Denmark, Norway, South Africa, Turkey, Sweden, and the Philippines. Denise has lived in Saratoga Springs for 29 years and is active in the community. She has assisted numerous nonprofit organizations in designing surveys and analyzing survey data. Currently, she serves on the board of directors of the YMCA, Opera Saratoga, and the Saratoga Foundation.

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Cheryl Tatano Beck, DNSc, CNM, FAAN, is a distinguished professor at the University of Connecticut, School of Nursing, with a joint appointment in the Department of Obstetrics and Gynecology at the School of Medicine. She received her master’s degree in maternal–newborn nursing from Yale University and her doctor of nursing science degree from Boston University. She has received numerous awards such as the Association of Women’s Health, Obstetric and Neonatal Nursing’s Distinguished Professional Service Award, Eastern Nursing Research Society’s Distinguished Researcher Award, the Distinguished Alumna Award from Yale University School of Nursing, and the Connecticut Nurses’ Association’s Diamond Jubilee Award for her contribution to nursing research. Over the past 30 years, Cheryl has focused her research efforts on developing a research program on postpartum mood and anxiety disorders. Based on the findings from her series of qualitative studies, Cheryl developed the Postpartum Depression Screening Scale (PDSS), which is published by Western Psychological Services. She is a prolific writer who has published over 150 journal articles. In addition to co-authoring award-winning research methods books with Denise Polit, Cheryl coauthored with Dr. Jeanne Driscoll Postpartum Mood and Anxiety Disorders: A Clinician’s Guide, which received the 2006 American Journal of Nursing Book of the Year Award. In addition, Cheryl has published two other books: Traumatic Childbirth and Routledge International Handbook of Qualitative Nursing Research. Her most recent book is Developing a Program of Research in Nursing.

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PREFACE

Essentials of Nursing Research, ninth edition, helps students learn how to read and critique research reports and to develop an appreciation of research as a path to enhancing nursing practice.

We continue to enjoy updating this book with important innovations in research methods and with nurse researchers’ use of emerging methods. Feedback from our loyal adopters has inspired several important changes to the content and organization. We are convinced that these revisions introduce important improvements—while retaining many features that have made this book a classic best-selling textbook throughout the world. The ninth edition of this book, its study guide, and its online resources will make it easier and more satisfying for nurses to pursue a professional pathway that incorporates thoughtful appraisals of evidence.

LEGACY OF ESSENTIALS OF NURSING RESEARCH This edition, like its predecessors, is focused on the art—and science—of research critique. The textbook offers guidance to students who are learning to appraise research reports and use research findings in practice.

Among the basic principles that helped to shape this and earlier editions of this book are as follows:

1. An assumption that competence in doing and appraising research is critical to the nursing profession

2. A conviction that research inquiry is intellectually and professionally rewarding to nurses

3. An unswerving belief that learning about research methods need be neither intimidating nor dull

Consistent with these principles, we have tried to present research fundamentals in a way that both facilitates understanding and arouses curiosity and interest.

NEW TO THIS EDITION

New Organization

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In the previous edition, we separated chapters on quantitative and qualitative designs and methods into two separate parts. In this edition, we organized the parts by methodologic content. So, for example, Part 3 in this edition covers designs and methods for quantitative, qualitative, and mixed methods research, and Part 4 is devoted to analysis and interpretation in quantitative and qualitative studies. (Please see “The Text” later in this preface for more information.) We think this new organization offers greater continuity of methodologic concepts and will facilitate better understanding of key methodologic differences between quantitative and qualitative research. We are confident that this new organization will better meet the needs of students and faculty.

Manageable Text for One-Semester Course We have streamlined the text to make it more manageable for use in a one-semester course. We reduced the length by organizing content differently and by keeping essential information in the text while moving background/advanced content online, making this an 18-chapter book rather than the previous 19 chapters in the eighth edition.

Enhanced Accessibility To make this edition even more user-friendly than in the past, we have made a concerted effort to simplify the presentation of complex topics. Most importantly, we have reduced and simplified the coverage of statistical information. We eliminated the chapter on measurement, opting to present a shorter, more digestible section on this topic in our chapter on quantitative data collection, which is supplemented by information in the chapter on statistical analysis. In addition, throughout the book we have used more straightforward, concise language.

New Content In addition to updating the book with new information on conventional research methods, we have added content on the following topics:

Quality improvement projects, describing how they are distinct from research studies and evidence-based practice (EBP) projects. This new content is found in Chapter 13.

Clinical significance, a seldom-mentioned but important topic that has gained prominence among researchers in other health care fields but has only recently gained traction among nurse researchers. This new content is found in Chapter 15.

THE TEXT The content of this edition is as follows:

Part 1, Overview of Nursing Research and Its Role in Evidence-Based Practice,

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introduces fundamental concepts in nursing research. Chapter 1 summarizes the background of nursing research, discusses the philosophical underpinnings of qualitative research versus quantitative research, and describes major purposes of nursing research. Chapter 2 offers guidance on using research to build an evidence- based practice. Chapter 3 introduces readers to key research terms and presents an overview of steps in the research process for both quantitative and qualitative studies. Chapter 4 focuses on research journal articles, explaining what they are and how to read them. Chapter 5 discusses ethics in nursing studies.

Part 2, Preliminary Steps in Quantitative and Qualitative Research, further sets the stage for learning about the research process by considering aspects of a study’s conceptualization. Chapter 6 focuses on the development of research questions and the formulation of research hypotheses. Chapter 7 discusses how to retrieve research evidence (especially in electronic bibliographic databases) and the role of research literature reviews. Chapter 8 presents information about theoretical and conceptual frameworks.

Part 3, Designs and Methods for Quantitative and Qualitative Nursing Research, presents material on the design and conduct of all types of nursing studies. Chapter 9 describes fundamental design principles and discusses many specific aspects of quantitative research design, including efforts to enhance rigor. Chapter 10 introduces the topics of sampling and data collection in quantitative studies. Concepts relating to quality in measurements—reliability and validity—are introduced in this chapter. Chapter 11 describes the various qualitative research traditions that have contributed to the growth of constructivist inquiry and presents the basics of qualitative design. Chapter 12 covers sampling and data collection methods used in qualitative research, describing how these differ from approaches used in quantitative studies. Chapter 13 emphasizes mixed methods research, but the chapter also discusses other special types of research such as surveys, outcomes research, and quality improvement projects.

Part 4, Analysis and Interpretation in Quantitative and Qualitative Research, presents tools for making sense of research data. Chapter 14 reviews methods of statistical analysis. The chapter assumes no prior instruction in statistics and focuses primarily on helping readers to understand why statistics are useful, what test might be appropriate in a given situation, and what statistical information in a research article means. Chapter 15 discusses approaches to interpreting statistical results, including interpretations linked to assessments of clinical significance. Chapter 16 discusses qualitative analysis, with an emphasis on ethnographic, phenomenologic, and grounded theory studies. Chapter 17 elaborates on criteria for appraising trustworthiness and integrity in qualitative studies. Finally, Chapter 18 describes systematic reviews, including how to understand and appraise both meta-analyses and metasyntheses.

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At the end of the book, we offer students additional critiquing support. In the appendices, we offer full-length research articles —two quantitative, one qualitative, and one mixed methods—that students can read, analyze, and critique. Students can model their critiques on the full critiques of two of those studies provided or compare their work to the ones provided. A glossary at the end of the book provides additional support for those needing to look up the meaning of a methodologic term.

FEATURES OF THE TEXT We have retained many of the classic features that were successfully used in previous editions to assist those learning to read and apply evidence from nursing research:

Clear, User-Friendly Style. Our writing style is easily digestible and nonintimidating —and we have worked even harder in this edition to write clearly and simply. Concepts are introduced carefully, difficult ideas are presented thoughtfully, and readers are assumed to have no prior knowledge of technical terms.

Critiquing Guidelines. Each chapter includes guidelines for conducting a critique of various aspects of a research report. The guidelines sections provide a list of questions that walk students through a study, drawing attention to aspects of the study that are amenable to appraisal by research consumers.

Research Examples and Critical Thinking Exercises. Each chapter concludes with one or two actual research examples designed to highlight critical points made in the chapter and to sharpen the reader’s critical thinking skills. In addition, many research examples are used to illustrate key points in the text and to stimulate students’ thinking about areas of research inquiry. We have chosen many international examples to communicate to students that nursing research is growing in importance worldwide. Some of the Critical Thinking Exercises focus on the full-length articles in Appendix A (a quantitative study) and Appendix B (a qualitative study).

Tips for Students. The textbook is filled with practical guidance and tips on how to translate the abstract notions of research methods into more concrete applications. In these tips, we have paid special attention to helping students read research reports, which are often daunting to those without specialized research training.

Graphics. Colorful graphics—in the form of supportive tables, figures, and examples —reinforce the text and offer visual stimulation.

Chapter Objectives. Learning objectives are identified in the chapter opener to focus students’ attention on critical content.

Key Terms. Each chapter opener includes a list of new terms, and we have made the list more focused and less daunting by including only key new terms. In the text, new terms are defined in context (and bolded) when used for the first time; terms of lesser

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importance are italicized. Key terms are also defined in our glossary.

Bulleted Summary Points. A succinct list of summary points that focus on salient chapter content is provided at the end of each chapter.

Essentials of Nursing Research: Appraising Evidence for Nursing Practice, ninth edition, has ancillary resources designed with both students and instructors in mind, available on website.

Student Resources Available on Supplements for Each Chapter further students’ exploration of specific topics. A full

list of the Supplements appears on page xxii. These supplements can be assigned to provide additional background or to offer advanced material to meet students’ specific needs.

Interactive Critical Thinking Activity brings the Critical Thinking Exercises from the textbook (except those focused on studies in the appendices) to an easy-to-use interactive tool that enables students to apply new skills that they learn in each chapter. Students are guided through appraisals of real research examples and then ushered through a series of questions that challenge them to think about the quality of evidence from the study. Responses can be printed or e-mailed directly to instructors for homework or testing.

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Hundreds of Student Review Questions help students to identify areas of strength and areas needing further study.

Answers to Critical Thinking Exercises are provided for questions related to the studies in Appendices A and B of the textbook.

Journal Articles—18 full articles from Wolters Kluwer journals (one corresponding to each chapter)—are provided for additional critiquing opportunities. Many of these are the full journal articles for studies used as the end-of-chapter Research Examples. All journal articles that appear on are identified in the text with and are called out in the References lists for appropriate chapters with a double asterisk (**).

Internet Resources with relevant and useful websites related to chapter content can be clicked on directly without having to retype the URL and risk a typographical error. This edition also includes links to all open-access articles cited in the textbook; these articles are called out in the References lists for appropriate chapters with a single asterisk (*).

Critiquing Guidelines and Learning Objectives from the textbook are available in Microsoft Word for your convenience.

Nursing Professionals Roles and Responsibilities.

Instructor’s Resources Available on NEW! Test Generator Questions are completely new and written by the book’s

authors for the ninth edition. Hundreds of multiple-choice questions aid instructors in assessing their students’ understanding of the chapter content.

An Instructor’s Manual includes a preface that offers guidance to improve the teaching experience. We have recognized the need for strong support for instructors in teaching a course that can be quite challenging. Part of the difficulty stems from students’ anxiety about the course content and their concern that research methods might not be relevant to their nursing practice. We offer numerous suggestions on how to make learning about—and teaching—research methods more rewarding. The contents of the Instructor’s Manual include the following for each chapter:

Statement of Intent. Discover the authors’ goals for each chapter. Special Class Projects. Find numerous ideas for interesting and meaningful class

projects. Check out the icebreakers and activities relating to the Great Cookie Experiment with accompanying SPSS files.

Test Questions and Answers. True/false questions, plus important application questions, test students’ comprehension and their ability to put their new critiquing skills to use. The application questions focus on a brief summary of a study and include several short-answer questions (with our answers), plus essay questions. These application questions are intended to assess students’ knowledge

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about methodologic concepts and their critiquing skills.

Answers to the Interactive Critical Thinking Activity. Suggested answers to the questions in the Interactive Critical Thinking Activity are available to instructors. Students can either print or e-mail their responses directly to the instructor for testing or as a homework assignment.

Two sets of PowerPoint Slides: “Test Yourself!” PowerPoint Slides. For each chapter, a slide set of five

multiple-choice “Test Yourself!” questions relating to key concepts in the chapter are followed by answers to the questions. The aim of these slides is not to evaluate student performance. We recommend these slides be given to students for self- testing, or they can be used in the classroom with i>clickers to assess students’ grasp of important concepts. To enhance the likelihood that students will see the relevance of the concepts to clinical practice, all the questions are application-type questions. We hope instructors will use the slides to clarify any misunderstandings and, just as importantly, to reward students with immediate positive feedback about newly acquired skills.

PowerPoint Presentations offer traditional summaries of key points in each chapter for use in class presentations. These slides are available in a format that permits easy adaptation and also include audience response questions that can be used on their own or are compatible with i>clicker and other audience response programs and devices.

An Image Bank includes figures from the text.

QSEN Map shows how the book content integrates QSEN competencies.

BSN Essentials Competencies Map shows how the book content integrates American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice competencies.

Strategies for Effective Teaching offer creative approaches for engaging students.

Learning Management System Course Cartridges.

Access to all student resources previously discussed.

STUDY GUIDE The accompanying Study Guide for Essentials of Nursing Research, ninth edition, is available for purchase and augments the text, providing students with opportunities to apply their learning.

Critiquing opportunities abound in the Study Guide, which includes eight research articles in their entirety. The studies represent a range of nursing topics and research approaches, including a randomized controlled trial, a correlational/mixed

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methods study, an EBP project, three qualitative studies (ethnographic, phenomenologic, and grounded theory), a meta-analysis, and a metasynthesis. The Application Exercises in each chapter guide students in reading, understanding, and critiquing these eight studies.

Answers to the “Questions of Fact” section in the Application Exercises in each chapter are presented in Appendix I of the Study Guide so that students can get immediate feedback about their responses.

Although critiquing skills are emphasized in the Study Guide, other included activities support students’ learning of fundamental research terms and principles, such as fill- in-the-blank exercises, matching exercises, and focused Study Questions. Answers to those questions that have an objective answer are provided in Appendix I.

COMPREHENSIVE, INTEGRATED DIGITAL LEARNING SOLUTIONS We are delighted to introduce an expanded suite of digital solutions to support instructors and students using Essentials of Nursing Research, ninth edition. Now for the first time, our textbook is embedded into two integrated digital learning solutions— one specific for prelicensure programs and the other for postlicensure—that build on the features of the text with proven instructional design strategies. To learn more about these solutions, visit http://www.nursingeducationsuccess.com/ or contact your local Wolters Kluwer representative.

Our prelicensure solution, Lippincott CoursePoint, is a rich learning environment that drives course and curriculum success to prepare students for practice. Lippincott CoursePoint is designed for the way students learn. The solution connects learning to real-life application by integrating content from Essentials of Nursing Research with video cases, interactive modules, and evidence-based journal articles. Ideal for active, case-based learning, this powerful solution helps students develop higher level cognitive skills and asks them to make decisions related to simple-to-complex scenarios.

Lippincott CoursePoint for Nursing Research features the following:

Leading Content in Context. Digital content from Essentials of Nursing Research, ninth edition, is embedded in our Powerful Tools, engaging students and encouraging interaction and learning on a deeper level.

The complete interactive eBook features annual content updates with the latest EBPs and provides students with anytime, anywhere access on multiple devices.

Full online access to Stedman’s Medical Dictionary for the Health Professions and Nursing ensures students work with the best medical dictionary available.

Powerful Tools to Maximize Class Performance. Additional course-specific tools provide case-based learning for every student:

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Video Cases show how nursing research and evidence-based practice relates to real-life nursing practice. By watching the videos and completing related activities, students will flex their evidence-based practice skills and build a spirit of inquiry.

Interactive Modules help students quickly identify what they do and do not understand, so they can study smartly. With exceptional instructional design that prompts students to discover, reflect, synthesize, and apply, students actively learn. Remediation links to the digital textbook are integrated throughout.

Curated Collections of Journal Articles are provided via Lippincott NursingCenter, Wolters Kluwer’s premier destination for peer-reviewed nursing journals. Through integration of CoursePoint and NursingCenter, students will engage in how nursing research influences practice.

Data to Measure Students’ Progress. Student performance data provided in an intuitive display lets instructors quickly assess whether students have viewed interactive modules and video cases outside of class as well as see students’ performance on related NCLEX-style quizzes, ensuring students are coming to the classroom ready and prepared to learn.

To learn more about Lippincott CoursePoint, please visit www.nursingeducationsuccess.com/coursepoint.

Lippincott RN to BSN Online: Nursing Research is a postlicensure solution for online and hybrid courses, marrying experiential learning with the trusted content in Essentials of Nursing Research, ninth edition.

Built around learning objectives that are aligned to the BSN Essentials and QSEN

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nursing curriculum standards, every aspect of Lippincott RN to BSN Online is designed to engage, challenge, and cultivate postlicensure students.

Self-Paced Interactive Modules employ key instructional design strategies— including storytelling, modeling, and case-based and problem-based scenarios—to actively involve students in learning new material and focus students’ learning outcomes on real-life application.

Pre- and Postmodule Assessments activate students’ existing knowledge prior to engaging with the module, then assess their competency after completing the module.

Discussion Board Questions create an ongoing dialogue to foster social learning. Writing and Group Work Assignments hone students’ competence in writing and

communication, instilling the skills needed to advance their nursing careers. Collated Journal Articles acquaint students to the body of nursing research ongoing

in recent literature. Case Study Assignments, including unfolding cases that evolve from cases in the

interactive modules, aid students in applying theory to real-life situations. Best Practices in Scholarly Writing Guide covers APA formatting and style

guidelines.

Used alone or in conjunction with other instructor-created resources, Lippincott RN to BSN Online adds interactivity to courses. It also saves instructors time by keeping both textbook and course resources current and accurate through regular updates to the content.

To learn more about Lippincott RN to BSN Online, please visit http://www.nursingeducationsuccess.com/nursing-education-solutions/lippincott-

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rn-bsn-online/.

CLOSING NOTE It is our hope and expectation that the content, style, and organization of this ninth edition of Essentials of Nursing Research will be helpful to those students who want to become skillful, thoughtful readers of nursing studies and to those wishing to enhance their clinical performance based on research findings. We also hope that this textbook will help to develop an enthusiasm for the kinds of discoveries and knowledge that research can produce.

Denise F. Polit, PhD, FAAN Cheryl Tatano Beck, DNSc, CNM, FAAN

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USER’S GUIDE

Learning Objectives focus students’ attention on critical content Key Terms alert students to important terminology

Examples help students apply content to real-life research

Tip boxes describe what is found in actual research articles

How-to-Tell Tip boxes explain confusing issues in actual research articles

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Critiquing Guidelines boxes lead students through key issues in a research article

Research Examples highlight critical points made in the chapter and sharpen critical thinking skills

Critical Thinking Exercises provide opportunities to practice critiquing actual research articles

Summary Points review chapter content to ensure success

Special icons alert students to important content found on and in the

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accompanying Study Guide

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REVIEWERS

Lisa Aiello-Laws, RN, MSN, AOCNS, APN-C Assistant Clinical Professor College of Nursing and Health Professions Drexel University Philadelphia, Pennsylvania

Elizabeth W. Black, MSN, CSN Assistant Professor Gwynedd Mercy University Gwynedd Valley, Pennsylvania

Lynn P. Blanchette, RN, PhD Program Director Rhode Island College Providence, Rhode Island

Anne Watson Bongiorno, PhD, APHN-BC, CNE Associate Professor State University of New York at Plattsburgh Plattsburgh, New York

Katherine Bowman, PhD, RN Assistant Teaching Professor Sinclair School of Nursing University of Missouri Columbia, Missouri

Barb Braband, EdD, RN, CNE Master’s Program Director University of Portland Portland, Oregon

Vera Brancato, EdD, MSN, RN, CNE Professor of Nursing

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Alvernia University Reading, Pennsylvania

Jennifer Bryer, PhD, RN, CNE Chairperson and Associate Professor Department of Nursing Farmingdale State College Farmingdale, New York

Wendy Budin, PhD, RN-BC, FACCE, FAAN Adjunct Professor New York University New York, New York

Carol Caico, PhD, CS, NP Associate Professor New York Institute of Technology New York, New York

Mary Ann Cantrell, PhD, RN, CNE, FAAN Assistant Professor Villanova University Villanova, Pennsylvania

Ruth Chaplen, RN, MSN, DNP, ACNS BC, AOCN Associate Professor of Nursing Rochester College Rochester Hills, Michigan

Lori Ciafardoni, RN, MSN/ED Assistant Professor State University of New York at Delhi Delhi, New York

Leah Cleveland, EdD, RN, CNS, PHN, CDE Lecturer California State University, Fullerton Fullerton, California

Susan Davidson, EdD, APN, NP-C Professor School of Nursing Coordinator Gateway RN-BSN Program

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School of Nursing University of Tennessee at Chattanooga Chattanooga, Tennessee

Pamela de Cordova, PhD, RN-BC Assistant Professor Rutgers University New Brunswick, New Jersey

Josephine DeVito, PhD, RN Undergraduate Chair and Associate Professor College of Nursing Seton Hall University South Orange, New Jersey

Nancy Ann C. Falvo, BSN, MSN, PhD Assistant Professor Clarion University of Pennsylvania Clarion, Pennsylvania

Jeanie Flood, PhD, RN-C, IBCLC RN to BSN Faculty Advisor University of Hawaii at Hilo Hilo, Hawaii

Deborah Hunt, PhD, RN Associate Professor College of New Rochelle New Rochelle, New York

Linda Johanson, EdD, RN Associate Professor Appalachian State University Boone, North Carolina

Lucina Kimpel, PhD, RN Associate Professor Mercy College of Health Sciences Des Moines, Iowa

Pamela Kohlbry, PhD, RN, CNL Associate Professor Med/Surg Lead and CNL Program Coordinator California State University San Marcos

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San Marcos, California

Leann Laubach PhD, RN Professor Career Advancement Coordinator University of Central Oklahoma Edmond, Oklahoma

Hayley Mark, PhD, MSN, MPH, RN Chairperson Department of Nursing Towson University Towson, Maryland

Donna Martin, DNP, MSN, RN-BC, CDE Assistant Professor Lewis University Romeoville, Illinois

Ditsapelo McFarland, PhD, MSN, EdD Associate Professor Adelphi University Garden City, New York

Kristina S. Miller, DNP, RN, PCNS-BC Instructor of Maternal Child Nursing College of Nursing University of South Alabama Mobile, Alabama

Kathy T. Morris, EdD, MSN, RN Assistant Professor Armstrong State University Savannah, Georgia

Elizabeth Murray, PhD, RN, CNE Assistant Professor Florida Gulf Coast University Fort Myers, Florida

Sarah Newton, PhD, RN Associate Professor School of Nursing Oakland University

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Rochester, Michigan

Mae Ann Pasquale, RN, BSN, MSN Assistant Professor of Nursing Cedar Crest College Allentown, Pennsylvania

Kim L. Paxton DNP, APRN, ANP-BC, LIHT-C Assistant Professor Cardinal Stritch University Milwaukee, Wisconsin

Janet Reagor, PhD, RN Interim Dean and Assistant Professor of Nursing Director RN-BSN Program Avila University Kansas City, Missouri

Elizabeth A. Roe, PhD, RN Acting Assistant Dean College of Human and Health Sciences Saginaw Valley State University Saginaw, Michigan

Cathy Rozmus, PhD, RN Professor Associate Dean for Academic Affairs University of Texas Health Science Center at Houston Houston, Texas

Milena P. Staykova, EdD, FNC-BC Director Post-Licensure Bachelor of Science in Nursing Jefferson College of Health Sciences Roanoke, Virginia

Amy Stimpfel, PhD, RN Assistant Professor College of Nursing New York University New York, New York

Yiyuan Sun, DNSc

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Associate Professor Adelphi University Garden City, New York

Annie Thomas, PhD, RN Assistant Professor Loyola University Chicago Chicago, Illinois

Elizabeth VandeWaa, PhD Professor of Adult Health Nursing University of South Alabama Mobile, Alabama

Adrienne Wald, BSN, MBA, EdD Assistant Professor College of New Rochelle New Rochelle, New York

Camille Wendekier, PhD, CRRN, CSN, RN Assistant Professor Saint Francis University Loretto, Pennsylvania

Kathleen Williamson, RN, PhD Chair Wilson School of Nursing Midwestern State University Wichita Falls, Texas

Roxanne Wilson, PhD, RN Assistant Professor St. Cloud State University St. Cloud, Minnesota

Paige Wimberley, RN, CNS, CNE Assistant Professor of Nursing Arkansas State University Jonesboro, Arkansas

Charlotte A. Wisnewski, PhD, RN, CDE, CNE Associate Professor University of Texas Medical Branch Galveston, Texas

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ACKNOWLEDGMENTS

This ninth edition, like the previous eight editions, depended on the contribution of many generous people. To all of the many faculty and students who used the text and have made invaluable suggestions for its improvement, we are very grateful. Suggestions were made to us both directly in personal interactions (mostly at the University of Connecticut and Griffith University in Australia) and via e-mail correspondence. We would like in particular to thank Valori Banfi, nursing librarian at the University of Connecticut, and John McNulty, a faculty member at the University of Connecticut. We would also like to acknowledge the reviewers of the ninth edition of Essentials.

Other individuals made specific contributions. Although it would be impossible to mention all, we note with thanks the nurse researchers who shared their work with us as we developed examples, including work that in some cases was not yet published. We also extend our warm thanks to those who helped to turn the manuscript into a finished product. The staff at Wolters Kluwer has been of tremendous assistance in the support they have given us over the years. We are indebted to Christina C. Burns, Emily Lupash, Meredith L. Brittain, Marian Bellus, and all the others behind the scenes for their fine contributions. Thanks also to Rodel Fariñas for his patience and good humor in turning our manuscript into this textbook.

Finally, we thank our families, our loved ones, and our friends, who provided ongoing support and encouragement throughout this endeavor and who were tolerant when we worked long into the night, over weekends, and during holidays to get this ninth edition finished.

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CONTENTS

Part 1 Overview of Nursing Research and Its Role in Evidence-Based Practice

1 Introduction to Nursing Research in an Evidence-Based Practice Environment 2 Fundamentals of Evidence-Based Nursing Practice 3 Key Concepts and Steps in Quantitative and Qualitative Research 4 Reading and Critiquing Research Articles 5 Ethics in Research

Part 2 Preliminary Steps in Quantitative and Qualitative Research

6 Research Problems, Research Questions, and Hypotheses 7 Finding and Reviewing Research Evidence in the Literature 8 Theoretical and Conceptual Frameworks

Part 3 Designs and Methods for Quantitative and Qualitative Nursing Research

9 Quantitative Research Design 10 Sampling and Data Collection in Quantitative Studies 11 Qualitative Designs and Approaches 12 Sampling and Data Collection in Qualitative Studies 13 Mixed Methods and Other Special Types of Research

Part 4 Analysis and Interpretation in Quantitative and Qualitative Research

14 Statistical Analysis of Quantitative Data 15 Interpretation and Clinical Significance in Quantitative Research 16 Analysis of Qualitative Data 17 Trustworthiness and Integrity in Qualitative Research

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18 Systematic Reviews: Meta-Analysis and Metasynthesis

Appendix A Swenson et al.’s (2016) Study: Parents’ Use of Praise and Criticism in a Sample of Young Children Seeking Mental Health Services

Appendix B Beck and Watson’s (2010) Study: Subsequent Childbirth After a Previous Traumatic Birth

Appendix C Wilson et al.’s (2016) Study: A Randomized Controlled Trial of an Individualized Preoperative Education Intervention for Symptom Management After Total Knee Arthroplasty

Critique of Wilson and Colleagues’ Study

Appendix D Sawyer et al.’s (2010) Study: Differences in Perceptions of the Diagnosis and Treatment of Obstructive Sleep Apnea and Continuous Positive Airway Pressure Therapy Among Adherers and Nonadherers

Critique of Sawyer and Colleagues’ Study

Glossary

Index

CHAPTER SUPPLEMENTS AVAILABLE ON

Supplement for Chapter 1 The History of Nursing Research

Supplement for Chapter 2 Evaluating Clinical Practice Guidelines—AGREE II

Supplement for Chapter 3 Deductive and Inductive Reasoning

Supplement for Chapter 4 Guide to an Overall Critique of a Quantitative Research Report and Guide to an Overall Critique of a Qualitative Research Report

Supplement for Chapter 5 Informed Consent

Supplement for Chapter 6 Simple and Complex Hypotheses

Supplement for Chapter 7 Finding Evidence for an EBP Inquiry in PubMed

Supplement for Chapter 8 Prominent Conceptual Models of Nursing Used by Nurse Researchers

Supplement for Chapter 9 Selected Experimental and Quasi-Experimental Designs: Diagrams, Uses, and Drawbacks

Supplement for Chapter 10 Vignettes and Q-Sorts

Supplement for Chapter 11 Qualitative Descriptive Studies

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Supplement for Chapter 12 Transferability and Generalizability

Supplement for Chapter 13 Other Specific Types of Research

Supplement for Chapter 14 Multivariate Statistics

Supplement for Chapter 15 Research Biases

Supplement for Chapter 16 A Glaserian Grounded Theory Study: Illustrative Materials

Supplement for Chapter 17 Whittemore and Colleagues’ Framework of Quality Criteria in Qualitative Research

Supplement for Chapter 18 Publication Bias in Meta-Analyses

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Part 1 Overview of Nursing Research and Its Role in Evidence-Based Practice

1 Introduction to Nursing Research in an Evidence-Based Practice Environment

Learning Objectives On completing this chapter, you will be able to:

Understand why research is important in nursing Discuss the need for evidence-based practice Describe broad historical trends and future directions in nursing research Identify alternative sources of evidence for nursing practice Describe major characteristics of the positivist and constructivist paradigm Compare the traditional scientific method (quantitative research) with constructivist

methods (qualitative research) Identify several purposes of quantitative and qualitative research Define new terms in the chapter

Key Terms Assumption Cause-probing research Clinical nursing research Clinical significance Constructivist paradigm Empirical evidence Evidence-based practice (EBP) Generalizability Journal club

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Nursing research Paradigm Positivist paradigm Qualitative research Quantitative research Research Research methods Scientific method Systematic review

NURSING RESEARCH IN PERSPECTIVE We know that many of you readers are not taking this course because you plan to become nurse researchers. Yet, we are also confident that many of you will participate in research-related activities during your careers, and virtually all of you will be expected to be research-savvy at a basic level. Although you may not yet grasp the relevance of research in your career as a nurse, we hope that you will come to see the value of nursing research during this course and will be inspired by the efforts of the thousands of nurse researchers now working worldwide to improve patient care. You are embarking on a lifelong journey in which research will play a role. We hope to prepare you to enjoy the voyage.

What Is Nursing Research? Whether you know it or not, you have already done a lot of research. When you use the Internet to find the “best deal” on a laptop or an airfare, you start with a question (e.g., Who has the best deal for what I want?), collect the information by searching different websites, and then come to a conclusion. This “everyday research” has much in common with formal research—but, of course, there are important differences, too.

As a formal enterprise, research is systematic inquiry that uses disciplined methods to answer questions and solve problems. The ultimate goal of formal research is to gain knowledge that would be useful for many people. Nursing research is systematic inquiry designed to develop trustworthy evidence about issues of importance to nurses and their clients. In this book, we emphasize clinical nursing research, which is research designed to guide nursing practice. Clinical nursing research typically begins with questions stemming from practice problems—problems you may have already encountered.

Examples of nursing research questions Does a text message notification process help to reduce follow-up time for women

with abnormal mammograms? (Oakley-Girvan et al., 2016) What are the daily experiences of patients receiving hemodialysis treatment for

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end-stage renal disease? (Chiaranai, 2016)

TIP You may have the impression that research is abstract and irrelevant to practicing nurses. But nursing research is about real people with real problems, and studying those problems offers opportunities to solve or address them through improvements to nursing care.

The Importance of Research to Evidence-Based Nursing Nursing has experienced profound changes in the past few decades. Nurses are increasingly expected to understand and undertake research and to base their practice on evidence from research—that is, to adopt an evidence-based practice (EBP). EBP, broadly defined, is the use of the best evidence in making patient care decisions. Such evidence typically comes from research conducted by nurses and other health care professionals. Nurse leaders recognize the need to base specific nursing decisions on evidence indicating that the decisions are clinically appropriate and cost-effective and result in positive client outcomes.

In some countries, research plays an important role in nursing credentialing and status. For example, the American Nurses Credentialing Center—an arm of the American Nurses Association—has developed a Magnet Recognition Program to recognize health care organizations that provide high-quality nursing care. To achieve Magnet status, practice environments must demonstrate a sustained commitment to EBP and nursing research. Changes to nursing practice are happening every day because of EBP efforts.

Example of evidence-based practice Many clinical practice changes reflect the impact of research. For example, “kangaroo care,” the holding of diaper-clad preterm infants skin-to-skin, chest-to- chest by parents, is now widely practiced in neonatal intensive care units (NICUs), but in the early 1990s, only a minority of NICUs offered kangaroo care options. The adoption of this practice reflects good evidence that early skin-to-skin contact has clinical benefits and no negative side effects (Ludington-Hoe, 2011; Moore et al., 2012). Some of this evidence comes from rigorous studies by nurse researchers (e.g., Campbell-Yeo et al., 2013; Cong et al., 2009; Cong et al., 2011; Holditch-Davis et al., 2014; Lowson et al., 2015).

Roles of Nurses in Research In the current EBP environment, every nurse is likely to engage in one or more activities along a continuum of research participation. At one end of the continuum are users or consumers of nursing research—nurses who read research reports to keep up-to-date on

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findings that may affect their practice. EBP depends on well-informed nursing research consumers.

At the other end of the continuum are the producers of nursing research: nurses who actively design and undertake studies. At one time, most nurse researchers were academics who taught in schools of nursing, but research is increasingly being conducted by practicing nurses who want to find what works best for their clients.

Between these two end points on the continuum lie a variety of research activities in which nurses engage. Even if you never conduct a study, you may do one of the following:

1. Contribute an idea for a clinical inquiry 2. Assist in collecting research information 3. Offer advice to clients about participating in a study 4. Search for research evidence 5. Discuss the implications of a study in a journal club in your practice setting, which

involves meetings to discuss research articles

In all research-related activities, nurses who have some research skills are better able than those without them to contribute to nursing and to EBP. Thus, with the research skills you gain from this book, you will be prepared to contribute to the advancement of nursing.

Nursing Research: Past and Present Most people agree that research in nursing began with Florence Nightingale in the mid- 19th century. Based on her skillful analysis of factors affecting soldier mortality and morbidity during the Crimean War, she was successful in bringing about changes in nursing care and in public health. For many years after Nightingale’s work, however, research was absent from the nursing literature. Studies began to appear in the early 1900s but most concerned nurses’ education.

In the 1950s, nursing research began to flourish. An increase in the number of nurses with advanced skills and degrees, an increase in the availability of research funding, and the establishment of the journal Nursing Research helped to propel nursing research. During the 1960s, practice-oriented research began to emerge, and research- oriented journals started publication in several countries. During the 1970s, there was a change in research emphasis from areas such as teaching and nurses’ characteristics to improvements in client care. Nurses also began to pay attention to the utilization of research findings in nursing practice.

The 1980s brought nursing research to a new level of development. Of particular importance in the United States was the establishment in 1986 of the National Center for Nursing Research (NCNR) at the National Institutes of Health (NIH). The purpose of NCNR was to promote and financially support research projects and training relating to patient care. Nursing research was strengthened and given more visibility when NCNR was promoted to full institute status within the NIH: In 1993, the National

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Institute of Nursing Research (NINR) was established. The birth and expansion of NINR helped put nursing research more into the mainstream of research activities enjoyed by other health disciplines. Funding opportunities expanded in other countries as well.

The 1990s witnessed the birth of several more journals for nurse researchers, and specialty journals increasingly came to publish research articles. International cooperation in integrating EBP into nursing also began to develop in the 1990s. For example, Sigma Theta Tau International sponsored the first international research utilization conference, in cooperation with the faculty of the University of Toronto, in 1998.

TIP For those interested in learning more about the history of nursing research, we offer an expanded summary in the Supplement to this chapter on website.

Future Directions for Nursing Research Nursing research continues to develop at a rapid pace and will undoubtedly flourish in the 21st century. In 1986, NCNR had a budget of $16 million, whereas NINR funding in fiscal year 2016 was just under $150 million. Among the trends we foresee for the near future are the following:

Continued focus on EBP. Encouragement for nurses to use research findings in practice is sure to continue. This means that improvements will be needed in the quality of nursing studies and in nurses’ skills in locating, understanding, critiquing, and using relevant study results. Relatedly, there is an emerging interest in translational research—research on how findings from studies can best be translated into practice.

Stronger evidence through confirmatory strategies. Practicing nurses rarely adopt an innovation on the basis of poorly designed or isolated studies. Strong research designs are essential, and confirmation is usually needed through replication (i.e., repeating) of studies in different clinical settings to ensure that the findings are robust.

Continued emphasis on systematic reviews. Systematic reviews are a cornerstone of EBP and have assumed increasing importance in all health disciplines. Systematic reviews rigorously integrate research information on a topic so that conclusions about the state of evidence can be reached.

Expanded local research in health care settings. Small studies designed to solve local problems will likely increase. This trend will be reinforced as more hospitals apply for (and are recertified for) Magnet status in the United States and in other countries.

Expanded dissemination of research findings. The Internet and other technological advances have had a big impact on the dissemination of research information, which

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in turn helps to promote EBP. Increased focus on cultural issues and health disparities. The issue of health

disparities has emerged as a central concern, and this in turn has raised consciousness about the cultural sensitivity of health interventions. Research must be sensitive to the beliefs, behaviors, epidemiology, and values of culturally and linguistically diverse populations.

Clinical significance and patient input. Research findings increasingly must meet the test of being clinically significant, and patients have taken center stage in efforts to define clinical significance. A major challenge in the years ahead will involve incorporating both research evidence and patient preferences into clinical decisions.

What are nurse researchers likely to be studying in the future? Although there is tremendous diversity in research interests, research priorities have been articulated by NINR, Sigma Theta Tau International, and other nursing organizations. For example, NINR’s Strategic Plan, launched in 2011 and updated in 2013, described five areas of focus: promoting health and preventing disease, symptom management and self- management, end-of-life and palliative care, innovation, and the development of nurse scientists (http://www.ninr.nih.gov).

TIP All websites cited in this chapter, plus additional websites with useful content relating to the foundations of nursing research, are in the Internet Resources on website. This will allow you to simply use the “Control/Click” feature to go directly to the website, without having to type in the URL and risk a typographical error. Websites corresponding to the content of all chapters of the book are also on .

SOURCES OF EVIDENCE FOR NURSING PRACTICE Nurses make clinical decisions based on a large repertoire of knowledge. As a nursing student, you are gaining skills on how to practice nursing from your instructors, textbooks, and clinical placements. When you become a registered nurse (RN), you will continue to learn from other nurses and health care professionals. Because evidence is constantly evolving, learning about best-practice nursing will carry on throughout your career.

Some of what you have learned thus far is based on systematic research, but much of it is not. What are the sources of evidence for nursing practice? Where does knowledge for practice come from? Until fairly recently, knowledge primarily was handed down from one generation to the next based on clinical experience, trial and error, tradition, and expert opinion. These alternative sources of knowledge are different from research-based information.

Tradition and Authority 37

Some nursing interventions are based on untested traditions, customs, and “unit culture” rather than on sound evidence. Indeed, a recent analysis suggests that some “sacred cows” (ineffective traditional habits) persist even in a health care center recognized as a leader in EBP (Hanrahan et al., 2015). Another common source of knowledge is an authority, a person with specialized expertise. Reliance on authorities (such as nursing faculty or textbook authors) is unavoidable. Authorities, however, are not infallible— particularly if their expertise is based primarily on personal experience; yet, their knowledge is often unchallenged.

Example of “myths” in nursing textbooks One study suggests that nursing textbooks may contain many “myths.” In their analysis of 23 widely used undergraduate psychiatric nursing textbooks, Holman and colleagues (2010) found that all books contained at least one unsupported assumption (myth) about loss and grief—i.e., assumptions not supported by current research evidence. And many evidence-based findings about grief and loss failed to be included in the textbooks.

TIP The consequences of not using research-based evidence can be devastating. For example, from 1956 through the 1980s, Dr. Benjamin Spock published several editions of Baby and Child Care, a parental guide that sold over 19 million copies worldwide. As an authority figure, he wrote the following advice: “I think it is preferable to accustom a baby to sleeping on his stomach from the beginning if he is willing” (Spock, 1979, p. 164). Research has clearly demonstrated that this sleeping position is associated with heighted risk of sudden infant death syndrome (SIDS). In their systematic review of evidence, Gilbert and colleagues (2005) wrote, “Advice to put infants to sleep on the front for nearly half a century was contrary to evidence from 1970 that this was likely to be harmful” (p. 874). They estimated that if medical advice had been guided by research evidence, over 60,000 infant deaths might have been prevented.

Clinical Experience and Trial and Error Clinical experience is a functional source of knowledge. Yet, personal experience has limitations as a source of evidence for practice because each nurse’s experience is too narrow to be generally useful, and personal experiences are often colored by biases. Trial and error involves trying alternatives successively until a solution to a problem is found. Trial and error can be practical, but the method tends to be haphazard, and solutions may be idiosyncratic.

Assembled Information

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In making clinical decisions, health care professionals also rely on information that has been assembled for various purposes. For example, local, national, and international benchmarking data provide information on such issues as the rates of using various procedures (e.g., rates of cesarean deliveries) or rates of clinical problems (e.g., nosocomial infections). Quality improvement and risk data, such as medication error reports, can be used to assess practices and determine the need for practice changes. Such sources offer useful information but provide no mechanism to actually guide improvements.

Disciplined Research Disciplined research is considered the best method of acquiring reliable knowledge that humans have developed. Evidence-based health care compels nurses to base their clinical practice, to the extent possible, on rigorous research-based findings rather than on tradition, authority, or personal experience. However, nursing will always be a rich blend of art and science.

PARADIGMS AND METHODS FOR NURSING RESEARCH The questions that nurse researchers ask and the methods they use to answer their questions spring from a researcher’s view of how the world “works.” A paradigm is a worldview, a general perspective on the world’s complexities. Disciplined inquiry in nursing has been conducted mainly within two broad paradigms. This section describes the two paradigms and outlines the research methods associated with them.

The Positivist Paradigm The paradigm that dominated nursing research for decades is called positivism. Positivism is rooted in 19th century thought, guided by such philosophers as Newton and Locke. Positivism is a reflection of a broad cultural movement (modernism) that emphasizes the rational and scientific.

As shown in Table 1.1, a fundamental assumption of positivists is that there is a reality out there that can be studied and known. An assumption is a principle that is believed to be true without verification. Adherents of positivism assume that nature is ordered and regular and that a reality exists independent of human observation. In other words, the world is assumed not to be merely a creation of the human mind. The assumption of determinism refers to the positivists’ belief that phenomena are not haphazard but rather have antecedent causes. If a person has a stroke, a scientist in a positivist tradition assumes that there must be one or more reasons that can be potentially identified. Within the positivist paradigm, research activity is often aimed at understanding the underlying causes of natural phenomena.

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TIP What do we mean by phenomena? In a research context, phenomena are those things in which researchers are interested—such as a health event (e.g., a patient fall), a health outcome (e.g., pain), or a health experience (e.g., living with chronic pain).

Because of their belief in objective reality, positivists prize objectivity. Their approach involves the use of orderly, disciplined procedures with tight controls over the research situation to test hunches about the nature of phenomena being studied and relationships among them.

Strict positivist thinking has been challenged, and few researchers adhere to the tenets of pure positivism. Postpositivists still believe in reality and seek to understand it, but they recognize the impossibility of total objectivity. Yet, they see objectivity as a goal and strive to be as unbiased as possible. Postpositivists also appreciate the barriers to knowing reality with certainty and therefore seek probabilistic evidence—i.e., learning what the true state of a phenomenon probably is. This modified positivist position remains a dominant force in nursing research. For the sake of simplicity, we refer to it as positivism.

The Constructivist Paradigm The constructivist paradigm (sometimes called the naturalistic paradigm) began as a countermovement to positivism with writers such as Weber and Kant. The constructivist paradigm is a major alternative system for conducting research in nursing. Table 1.1 compares four major assumptions of the positivist and constructivist paradigms.

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For the naturalistic inquirer, reality is not a fixed entity but rather a construction of the people participating in the research; reality exists within a context, and many constructions are possible. Naturalists take the position of relativism: If there are multiple interpretations of reality that exist in people’s minds, then there is no process by which the ultimate truth or falsity of the constructions can be determined.

The constructivist paradigm assumes that knowledge is maximized when the distance between the inquirer and participants in the study is minimized. The voices and interpretations of those under study are crucial to understanding the phenomenon of interest, and subjective interactions are the best way to access them. Findings from a constructivist inquiry are the product of the interaction between the inquirer and the participants.

Paradigms and Methods: Quantitative and Qualitative Research Research methods are the techniques researchers use to structure a study and to gather and analyze relevant information. The two paradigms correspond to different methods of developing evidence. A key methodologic distinction is between quantitative research, which is most closely allied with positivism, and qualitative research, which is associated with constructivist inquiry—although positivists sometimes undertake qualitative studies, and constructivist researchers sometimes collect quantitative information. This section gives an overview of the methods linked to the two alternative paradigms.

The Scientific Method and Quantitative Research The traditional, positivist scientific method involves using a set of orderly procedures to gather information. Quantitative researchers typically move in a systematic fashion from the definition of a problem to a solution. By systematic, we mean that investigators progress through a series of steps, according to a prespecified plan. Quantitative researchers use objective methods designed to control the research situation with the goal of minimizing bias and maximizing validity.

Quantitative researchers gather empirical evidence—evidence that is rooted in objective reality and gathered directly or indirectly through the senses rather than through personal beliefs or hunches. Evidence for a quantitative study is gathered systematically, using formal instruments to collect needed information. Usually (but not always) the information is quantitative—that is, numeric information that results from some type of formal measurement and that is analyzed statistically. Quantitative researchers strive to go beyond the specifics of a research situation; the ability to generalize research findings to individuals other than those who took part in the study (referred to as generalizability) is an important goal.

The traditional scientific method has been used productively by nurse researchers studying a wide range of questions. Yet, there are important limitations. For example,

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quantitative researchers must deal with problems of measurement. To study a phenomenon, scientists must measure it, that is, attach numeric values that express quantity. For example, if the phenomenon of interest were patient stress, researchers would want to assess whether stress is high or low, or higher under certain conditions or for some people. Physiologic phenomena such as blood pressure and temperature can be measured with accuracy and precision, but the same cannot be said of most psychological phenomena, such as stress or resilience.

Another issue is that nursing research focuses on human beings, who are inherently complicated and diverse. The traditional scientific method typically focuses on a relatively small set of phenomena (e.g., weight gain, depression) in a study. Complexities tend to be controlled and, if possible, eliminated rather than studied directly, and this narrowness of focus can sometimes obscure insights. Relatedly, quantitative research within the positivist paradigm has sometimes been accused of a narrowness of vision that does not capture the full breadth of human experience.

TIP Students often find quantitative studies more intimidating and difficult than qualitative ones. Try not to worry too much about the jargon at first— remember that each study has a story to tell, and grasping the main point of the story is what is initially important.

Constructivist Methods and Qualitative Research Researchers in constructivist traditions emphasize the inherent complexity of humans, their ability to shape and create their own experiences, and the idea that truth is a composite of realities. Consequently, constructivist studies are heavily focused on understanding the human experience as it is lived, through the careful collection and analysis of qualitative materials that are narrative and subjective.

Researchers who reject the traditional scientific method believe that a major limitation is that it is reductionist—that is, it reduces human experience to only the few concepts under investigation, and those concepts are defined in advance by researchers rather than emerging from the experiences of those under study. Constructivist researchers tend to emphasize the dynamic, holistic, and individual aspects of human life and try to capture those aspects in their entirety, within the context of those who are experiencing them.

Flexible, evolving procedures are used to capitalize on findings that emerge during the study, which typically is undertaken in naturalistic settings. The collection of information and its analysis usually progress concurrently. As researchers sift through information, insights are gained, new questions emerge, and further evidence is sought to confirm the insights. Through an inductive process (going from specifics to the general), researchers integrate information to develop a theory or description that illuminates the phenomena under observation.

Constructivist studies yield rich, in-depth information that can potentially clarify the

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varied dimensions (or themes) of a complicated phenomenon. Findings from qualitative research are typically grounded in the real-life experiences of people with firsthand knowledge of a phenomenon. Nevertheless, the approach has several limitations. Human beings are used directly as the instrument through which information is gathered, and humans are highly intelligent—but fallible—tools.

Another potential limitation involves the subjectivity of constructivist inquiry, which sometimes raises concerns about the idiosyncratic nature of the conclusions. Would two constructivist researchers studying the same phenomenon in similar settings arrive at similar conclusions? The situation is magnified by the fact that most constructivist studies involve a small group of participants. Thus, the generalizability of findings from constructivist inquiries is an issue of potential concern.

TIP Researchers usually do not discuss or even mention the underlying paradigm of their studies in their reports. The paradigm provides context, without being explicitly referenced.

Multiple Paradigms and Nursing Research Paradigms are lenses that help to sharpen researchers’ focus on phenomena of interest, not blinders that limit curiosity. We think that the emergence of alternative paradigms for studying nursing problems is a desirable trend that can maximize the breadth of new evidence for practice. Nursing knowledge would be thin if it were not for a rich array of methods—methods that are often complementary in their strengths and limitations.

We have emphasized differences between the two paradigms and associated methods so that distinctions would be easy to understand. It is equally important, however, to note that the two paradigms have many features in common, some of which are mentioned here:

Ultimate goals. The ultimate aim of disciplined research, regardless of paradigm, is to answer questions and solve problems. Both quantitative and qualitative researchers seek to capture the truth with regard to the phenomena in which they are interested.

External evidence. The word empiricism is often associated with the scientific method, but researchers in both traditions gather and analyze evidence gathered empirically, that is, through their senses.

Reliance on human cooperation. Human cooperation is essential in both quantitative and qualitative research. To understand people’s characteristics and experiences, researchers must encourage people to participate in the study and to speak candidly.

Ethical constraints. Research with human beings is guided by ethical principles that sometimes interfere with research goals. Ethical dilemmas often confront researchers, regardless of paradigms or methods.

Fallibility. Virtually all studies have limitations. Every research question can be addressed in different ways, and inevitably, there are tradeoffs. Financial constraints

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are often an issue, but limitations exist even in well-funded research. This means that no single study can ever definitively answer a research question. The fallibility of any single study makes it important to understand and critique researchers’ methods when evaluating evidence quality.

Thus, despite philosophic and methodologic differences, researchers using the traditional scientific method or constructivist methods share basic goals and face many similar challenges. The selection of an appropriate method depends not only on researchers’ philosophy and worldview but also on the research question. If a researcher asks, “What are the effects of cryotherapy on nausea and oral mucositis in patients undergoing chemotherapy?” the researcher needs to examine effects through the careful quantitative assessment of patients. On the other hand, if a researcher asks, “What is the process by which parents learn to cope with the death of a child?” the researcher would be hard pressed to quantify such a process. Personal worldviews of researchers help to shape their questions.

In reading about the alternative paradigms, you likely were more attracted to one of the two paradigms—the one that corresponds most closely to your view of the world. It is important, however, to learn about and value both approaches to disciplined inquiry and to recognize their respective strengths and limitations.

HOW-TO-TELL TIP How can you tell if a study is quantitative or qualitative? As you progress through this book, you should be able to identify most studies as quantitative versus qualitative based simply on the study’s title or on terms in the summary at the beginning of an article. At this point, though, it may be easiest to distinguish the two types of studies based on how many numbers appear in the article, especially in tables. Quantitative studies typically have several tables with numbers and statistical information. Qualitative studies may have no tables with quantitative information, or only one numeric table describing participants’ characteristics (e.g., the percentage who were male or female). Qualitative studies often have “word tables” or diagrams and figures illustrating processes inferred from the narrative information gathered.

THE PURPOSES OF NURSING RESEARCH Why do nurses do research? Several different systems have been devised to classify different research goals. We describe two such classification systems—not because it is important for you to categorize a study as having one purpose or the other but rather because this will help us to illustrate the broad range of questions that have intrigued nurses and to further show differences between quantitative and qualitative inquiry.

TIP Sometimes a distinction is made between basic and applied research.

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Basic research is appropriate for discovering general principles of human behavior and biophysiologic processes. Applied research is designed to examine how these principles can be used to solve problems in nursing practice.

Research to Achieve Varying Levels of Explanation One way to classify research purposes is by the extent to which studies are designed to provide explanations. A fundamental distinction that is especially relevant in quantitative research is between studies whose primary goal is to describe phenomena and those that are cause-probing—that is, studies designed to illuminate the underlying causes of phenomena.

Using a descriptive/explanatory framework, the specific purposes of nursing research include identification, description, exploration, explanation, and prediction/control. When researchers state their study purpose, they often use these terms (e.g., The purpose of this study was to explore . . . ). For each purpose, various types of question are addressed—some more amenable to quantitative than to qualitative inquiry, and vice versa.

Identification and Description In quantitative research, researchers begin with a phenomenon that has been previously studied or defined. Qualitative researchers, by contrast, sometimes study phenomena about which little is known. In some cases, so little is known that the phenomenon has yet to be clearly identified or named or has been inadequately defined. The in-depth, probing nature of qualitative research is well suited to answering such questions as “What is this phenomenon?” and “What is its name?” (Table 1.2).

Quantitative example of description Palese and colleagues (2015) conducted a study to describe the average healing time of stage II pressure ulcers. They found that it took approximately 23 days to achieve complete reepithelialization.

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Qualitative example of identification Stapleton and Pattison (2015) studied the experience of men with advanced cancer in relation to their perceptions of masculinity. Through in-depth interviews, the researchers identified a new aspect of masculinity, which they called thwarted ambition.

Description of phenomena is an important purpose of research. In descriptive studies, researchers count, delineate, and classify. Nurse researchers have described a wide variety of phenomena, such as patients’ stress, health beliefs, and so on. Quantitative description focuses on the prevalence, size, and measurable aspects of phenomena. Qualitative researchers describe the nature, dimensions, and salience of phenomena, as shown in Table 1.2.

Exploration Exploratory research begins with a phenomenon of interest; but rather than simply describing it, exploratory researchers examine the nature of the phenomenon, the manner in which it is manifested, and other factors to which it is related—including factors that might be causing it. For example, a descriptive quantitative study of patients’ preoperative stress might document how much stress patients experience. An exploratory study might ask: What factors increase or lower a patient’s stress? Qualitative methods can be used to explore the nature of little understood phenomena and to shed light on the ways in which a phenomenon is expressed.

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Qualitative example of exploration Wazneh and colleagues (2016) used in-depth interviews to explore the extent to which the contents of a special backpack called the “Venturing Out Pack” met the practical, psychosocial, and information needs of young adults being treated for cancer.

Explanation Explanatory research seeks to understand the underlying causes or full nature of a phenomenon. In quantitative research, theories or prior findings are used deductively to generate hypothesized explanations that are tested statistically. Qualitative researchers search for explanations about how or why a phenomenon exists or what a phenomenon means as a basis for developing a theory that is grounded in rich, in-depth, experiential evidence.

Quantitative example of explanation Golfenshtein and Drach-Zahavy (2015) tested a theoretical model to explain the role of patients’ attributions in nurses’ regulation of emotions in pediatric hospital wards.

Prediction and Control Many phenomena defy explanation, yet it is often possible to predict or control them based on research evidence. For example, research has shown that the incidence of Down syndrome in infants increases with maternal age. We can predict that a woman aged 40 years is at higher risk of bearing a child with Down syndrome than a woman aged 25 years. We can attempt to influence the outcome by educating women about the risks and offering amniocentesis to women older than 35 years of age. The ability to predict and control in this example does not rely on an explanation of what causes older women to be at a higher risk. In many quantitative studies, prediction and control are key goals. Although explanatory studies are powerful, studies whose purpose is prediction and control are also critical to EBP.

Quantitative example of prediction Jain and colleagues (2016) conducted a study to assess whether scores on a measure of neurological impairment at hospital arrival, among patients who had a transient ischemic attack or a stroke, predicted their functional outcomes, such as ambulatory status at hospital discharge.

Research Purposes Linked to Evidence-Based Practice Another system for classifying studies has emerged in efforts to communicate EBP- related purposes (e.g., DiCenso et al., 2005; Guyatt et al., 2008; Melnyk & Fineout-

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Overholt, 2015). Table 1.3 identifies some of the questions relevant for each EBP purpose and offers an actual nursing research example. In this classification scheme, the various purposes can best be addressed with quantitative research, with the exception of the last category (meaning/process), which requires qualitative research.

Therapy, Treatment, or Intervention Studies with a therapy purpose seek to identify effective treatments for improving or preventing health problems. Such studies range from evaluations of highly specific treatments (e.g., comparing two types of cooling blankets for febrile patients) to complex multicomponent interventions designed to effect behavioral changes (e.g., nurse-led smoking cessation interventions). Intervention research plays a critical role in EBP.

Diagnosis and Assessment Many nursing studies concern the rigorous development and testing of formal instruments to screen, diagnose, and assess patients and to measure clinical outcomes. High-quality instruments with documented accuracy are essential both for clinical practice and for research.

Prognosis

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Studies of prognosis examine the consequences of a disease or health problem, explore factors that can modify the prognosis, and examine when (and for which types of people) the consequences are most likely. Such studies facilitate the development of long-term care plans for patients. They also provide valuable information for guiding patients to make beneficial lifestyle choices or to be vigilant for key symptoms.

Etiology (Causation) and Harm It is difficult to prevent harm or treat health problems if we do not know what causes them. For example, there would be no smoking cessation programs if research had not provided firm evidence that smoking cigarettes causes or contributes to many health problems. Thus, determining the factors and exposures that affect or cause illness, mortality, or morbidity is an important purpose of many studies.

Meaning and Processes Many health care activities (e.g., motivating people to comply with treatments, providing sensitive advice to patients, designing appealing interventions) can greatly benefit from understanding the clients’ perspectives. Research that offers evidence about what health and illness mean to clients, what barriers they face to positive health practices, and what processes they experience in a transition through a health care crisis is important to evidence-based nursing practice.

TIP Most EBP-related purposes (except diagnosis and meaning) involve cause-probing research. For example, research on interventions focuses on whether an intervention causes improvements in key outcomes. Prognosis research examines whether a disease or health condition causes subsequent adverse consequences. Etiology research seeks explanations about the underlying causes of health problems.

ASSISTANCE FOR CONSUMERS OF NURSING RESEARCH We hope that this book will help you develop skills that will allow you to read, appraise, and use nursing studies and to appreciate nursing research. In each chapter, we present information relating to methods used by nurse researchers and provide guidance in several ways. First, we offer tips on what you can expect to find in actual research articles, identified by the icon . There are also special “how-to-tell” tips (identified with the icon ) that help with some potentially confusing issues in research articles. Second, we include guidelines for critiquing various aspects of a study. The guiding questions in Box 1.1 are designed to assist you in using the information in this chapter in a preliminary assessment of a research article. And third, we offer opportunities to apply your new skills. The critical thinking exercises at the end of each chapter guide

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you through appraisals of real research examples of both quantitative and qualitative studies. These activities also challenge you to think about how the findings from these studies could be used in nursing practice. Answers to many of these questions are on

website. Some of these examples are featured in our interactive Critical Thinking Activity on website. Some of the journal articles are found in the appendices. The full journal article for studies identified with ** in the references list of each chapter are available on website.

Box 1.1 Questions for a Preliminary Overview of a Research Report

1. How relevant is the research problem to the actual practice of nursing? 2. Was the study quantitative or qualitative? 3. What was the underlying purpose (or purposes) of the study—identification,

description, exploration, explanation, or prediction/control? Does the purpose correspond to an EBP focus such as therapy/treatment, diagnosis, prognosis, etiology/harm, or meaning?

4. What might be some clinical implications of this research? To what type of people and settings is the research most relevant? If the findings were accurate, how might I use the results of this study in my clinical work?

This section presents examples of studies with different purposes. Read the research summaries for Examples 1 and 2 and then answer the critical thinking questions that follow, referring to the full research reports if necessary. The critical thinking questions for Examples 3 and 4 are based on the studies that appear in their entirety in Appendices A and B of this book.

TIP Examples 1 and 2 are also featured in our interactive Critical Thinking Activity on website, where you can record, print, and e- mail your responses to your instructor. Our comments for the questions in Examples 3 and 4 are in the Student Resources section on .

EXAMPLE 1: QUANTITATIVE RESEARCH Study: Psychological outcomes after a sexual assault video intervention: A randomized trial (Miller et al., 2015)

Study Purpose: The purpose of the study was to test whether a brief video- based intervention had positive effects on the mental health of victims of a sexual assault. The intervention provided psychoeducation and information

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about coping strategies to survivors at the time of a sexual assault nurse examination.

Study Methods: Female sexual assault victims who received forensic examinations within 72 hours of their victimization were assigned to one of two groups: (1) those receiving standard care plus the video intervention and (2) those receiving care as usual, without the video. A total of 164 women participated in the study. They completed mental health assessments 2 weeks and 2 months after the forensic examination.

Key Findings: The researchers found that women in both groups had lower anxiety at the follow-up assessments. However, women in the special intervention group had significantly lower levels of anxiety symptoms than those in the usual care group at both follow-ups.

Conclusions: Miller and colleagues (2015) concluded that forensic nurses have an opportunity to intervene immediately after a sexual assault with an effective and inexpensive intervention.

Critical Thinking Exercises 1. Answer the relevant questions from Box 1.1 regarding this study. 2. Also consider the following targeted questions, which may assist you in

assessing aspects of the study’s merit: a. Why do you think levels of anxiety improved over time in both the

intervention and standard care groups? b. Could this study have been undertaken as a qualitative study? Why or

why not?

EXAMPLE 2: QUALITATIVE RESEARCH Study: The pain experience of patients hospitalized with inflammatory bowel disease: A phenomenological study (Bernhofer et al., 2015)

Study Purpose: The purpose of this study was to understand the unique experience of pain in hospitalized patients with an admitting diagnosis of inflammatory bowel disease (IBD).

Study Methods: Sixteen men and women with diverse backgrounds (e.g., age, length of IBD diagnosis) were recruited from two colorectal units of a large academic medical center. Patients participated in interviews that lasted about a half hour. The interviews, which were audiotaped and then transcribed, focused on what the patients’ pain experiences were like in the hospital.

Key Findings: Five recurring themes emerged in the analysis of the interview data: (1) feeling discredited and misunderstood, (2) a desire to

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dispel the stigma, (3) frustration with constant pain, (4) a need for caregiver knowledge and understanding, and (5) nurses as the connector between the patient and physicians. Here is an excerpt from an interview that illustrates the second theme on stigma: “I’ve been judged on numerous amounts of occasions in regards to them thinking that I’m just simply seeking out some kind of pain medication when in reality, I’m seeking out to feel better, to make the pain go away” (p. 5).

Conclusions: The researchers concluded that nurses caring for hospitalized patients with IBD could provide better pain management if they understand the issues highlighted in these themes.

Critical Thinking Exercises 1. Answer the relevant questions from Box 1.1 regarding this study. 2. Also consider the following targeted questions, which may assist you in

assessing aspects of the study’s merit: a. Why do you think that the researchers audiotaped and transcribed their

in-depth interviews with study participants? b. Do you think it would have been appropriate for the researchers to

conduct this study using quantitative research methods? Why or why not?

EXAMPLE 3: QUANTITATIVE RESEARCH IN APPENDIX A • Read the abstract and the introduction of Swenson and colleagues’ (2016)

study (“Parents’ use of praise and criticism in a sample of young children seeking mental health services”) in Appendix A of this book.

Critical Thinking Exercises 1. Answer the relevant questions from Box 1.1 regarding this study. 2. Also consider the following targeted questions:

a. Could this study have been undertaken as a qualitative study? Why or why not?

b. Who provided some financial support for this research? (This information appears on the first page of the report.)

EXAMPLE 4: QUALITATIVE RESEARCH IN APPENDIX B • Read the abstract and the introduction of Beck and Watson’s (2010) study

(“Subsequent childbirth after a previous traumatic birth”) in Appendix B of this book.

Critical Thinking Exercises

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1. Answer the relevant questions from Box 1.1 regarding this study. 2. Also consider the following targeted questions:

a. What gap in the existing research was the study designed to fill? b. Was Beck and Watson’s study conducted within the positivist

paradigm or the constructivist paradigm? Provide a rationale for your choice.

WANT TO KNOW MORE? A wide variety of resources to enhance your learning and understanding of this chapter are available on .

• Interactive Critical Thinking Activity • Chapter Supplement on The History of Nursing Research • Answers to the Critical Thinking Exercises for Examples 3 and 4 • Internet Resources with useful websites for Chapter 1 • A Wolters Kluwer journal article in its entirety—the study described as

Example 1 on pp. 15-16.

Additional study aids, including eight journal articles and related questions, are also available in Study Guide for Essentials of Nursing Research, 9e.

Summary Points

Nursing research is systematic inquiry undertaken to develop evidence on problems of importance to nurses.

Nurses in various settings are adopting an evidence-based practice (EBP) that incorporates research findings into their decisions and interactions with clients.

Knowledge of nursing research enhances the professional practice of all nurses— including both consumers of research (who read and evaluate studies) and producers of research (who design and undertake studies).

Nursing research began with Florence Nightingale but developed slowly until its rapid acceleration in the 1950s. Since the 1980s, the focus has been on clinical nursing research—that is, on problems relating to clinical practice.

The National Institute of Nursing Research (NINR), established at the U.S. National Institutes of Health in 1993, affirms the stature of nursing research in the United States.

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Future emphases of nursing research are likely to include EBP projects, replications of research, research integration through systematic reviews, expanded dissemination efforts, increased focus on health disparities, and a focus on the clinical significance of research results.

Disciplined research stands in contrast to other knowledge sources for nursing practice, such as tradition, authority, personal experience, and trial and error.

Disciplined inquiry in nursing is conducted mainly within two broad paradigms— worldviews with underlying assumptions about reality: the positivist paradigm and the constructivist paradigm.

In the positivist paradigm, it is assumed that there is an objective reality and that natural phenomena are regular and orderly. The related assumption of determinism refers to the belief that phenomena result from prior causes and are not haphazard.

In the constructivist paradigm, it is assumed that reality is not a fixed entity but is rather a construction of human minds—and thus, “truth” is a composite of multiple constructions of reality.

Quantitative research (associated with positivism) involves the collection and analysis of numeric information. Quantitative research is typically conducted within the traditional scientific method, which is systematic and controlled. Quantitative researchers base their findings on empirical evidence (evidence collected by way of the human senses) and strive for generalizability beyond a single setting or situation.

Constructivist researchers emphasize understanding human experience as it is lived through the collection and analysis of subjective, narrative materials using flexible procedures; this paradigm is associated with qualitative research.

A fundamental distinction that is especially relevant in quantitative research is between studies whose primary intent is to describe phenomena and those that are cause-probing—i.e., designed to illuminate underlying causes of phenomena. Specific purposes on the description/explanation continuum include identification, description, exploration, explanation, and prediction/control.

Many nursing studies can also be classified in terms of an EBP-related aim: therapy/treatment/intervention, diagnosis and assessment, prognosis, etiology and harm, and meaning and process.

REFERENCES FOR CHAPTER 1 Bernhofer, E., Masina, V., Sorrell, J., & Modic, M. (2015). The pain experience of patients hospitalized with

inflammatory bowel disease: A phenomenological study. Gastroenterology Nursing. Advance online publication.

*Campbell-Yeo, M., Johnston, C., Benoit, B., Latimer, M., Vincer, M., Walker, C., . . . Caddell, K. (2013). Trial of repeated analgesia with kangaroo mother care (TRAKC trial). BMC Pediatrics, 13, 182.

Chiaranai, C. (2016). The lived experience of patients receiving hemodialysis treatment for end-stage renal disease: A qualitative study. The Journal of Nursing Research, 24, 101–108.

*Cong, X., Ludington-Hoe, S., McCain, G., & Fu, P. (2009). Kangaroo care modifies preterm infant heart rate

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variability in response to heel stick pain: Pilot study. Early Human Development, 85, 561–567. Cong, X., Ludington-Hoe, S., & Walsh, S. (2011). Randomized crossover trial of kangaroo care to reduce

biobehavioral pain responses in preterm infants: A pilot study. Biological Research for Nursing, 13, 204–216. DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based nursing: A guide to clinical practice. St. Louis,

MO: Elsevier Mosby. *Gilbert, R., Salanti, G., Harden, M., & See, S. (2005). Infant sleeping position and the sudden infant death

syndrome: Systematic review of observational studies and historical review of recommendations from 1940 to 2002. International Journal of Epidemiology, 34, 874–887.

Golfenshtein, N., & Drach-Zahavy, A. (2015). An attribution theory perspective on emotional labour in nurse- patient encounters: A nested cross-sectional study in paediatric settings. Journal of Advanced Nursing, 71, 1123–1134.

Guyatt, G., Rennie, D., Meade, M., & Cook, D. (2008). Users’ guides to the medical literature: Essentials of evidence-based clinical practice (2nd ed.). New York, NY: McGraw Hill.

Hagerty, T., Kertesz, L., Schmidt, J., Agarwal, S., Claassen, J., Mayer, S., . . . Shang, J. (2015). Risk factors for catheter-associated urinary tract infections in critically ill patients with subarachnoid hemorrhage. Journal of Neuroscience Nursing, 47, 51–54.

Hanrahan, K., Wagner, M., Matthews, G., Stewart, S., Dawson, C., Greiner, J., . . . Williamson, A. (2015). Sacred cow gone to pasture: A systematic evaluation and integration of evidence-based practice. Worldviews on Evidence-Based Nursing, 12, 3–11.

*Holditch-Davis, D., White-Traut, R., Levy, J., O’Shea, T., Geraldo, V., & David, R. (2014). Maternally administered interventions for preterm infants in the NICU: Effects on maternal psychological distress and mother-infant relationship. Infant Behavior & Development, 37, 695–710.

Holman, E., Perisho, J., Edwards, A., & Mlakar, N. (2010). The myths of coping with loss in undergraduate psychiatric nursing books. Research in Nursing & Health, 33, 486–499.

Jain, A., van Houten, D., & Sheikh, L. (2016). Retrospective study on National Institutes of Health Stroke Scale as a predictor of patient recovery after stroke. Journal of Cardiovascular Nursing, 31, 69–72.

Kwon, J. H., Shin, Y., & Juon, H. (2016). Effects of Nei-Guan (P6) acupressure wristband: On nausea, vomiting, and retching in women after thyroidectomy. Cancer Nursing, 39, 61–66.

*Lowson, K., Offer, C., Watson, J., McGuire, B., & Renfrew, M. (2015). The economic benefits of increasing kangaroo skin-to-skin care and breastfeeding in neonatal units: Analysis of a pragmatic intervention in clinical practice. International Breastfeeding Journal, 10, 11.

Ludington-Hoe, S. M. (2011). Thirty years of Kangaroo Care science and practice. Neonatal Network, 30, 357– 362.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

**Miller, K., Cranston, C., Davis, J., Newman, E., & Resnick, H. (2015). Psychological outcomes after a sexual assault video intervention: A randomized trial. Journal of Forensic Nursing, 11, 129–136.

*Moore, E., Anderson, G., Bergman, N., & Dowswell, T. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, (5), CD003519.

Oakley-Girvan, I., Londono, C., Canchola, A., & Watkins Davis, S. (2016). Text messaging may improve abnormal mammogram follow-up in Latinas. Oncology Nursing Forum, 43, 36–43.

Palese, A., Luisa, S., Ilenia, P., Laquintana, D., Stinco, G., & Di Giulio, P. (2015). What is the healing time of stage II pressure ulcers? Findings from a secondary analysis. Advances in Skin & Wound Care, 28, 69–75.

Pieters, H. C. (2016). “I’m still here”: Resilience among older survivors of breast cancer. Cancer Nursing, 39, E20–E28.

Sitzer, V. (2016). Development of an automated self-assessment of Fall Risk Questionnaire for hospitalized patients. Journal of Nursing Care Quality, 31, 46–53.

Spock, B. (1979). Baby and child care. New York, NY: Dutton. Stapleton, S., & Pattison, N. (2015). The lived experience of men with advanced cancer in relation to their

perceptions of masculinity: A qualitative phenomenological study. Journal of Clinical Nursing, 24, 1069–1078. Storey, S., & Von Ah, D. (2015). Prevalence and impact of hyperglycemia on hospitalized leukemia patients.

European Journal of Oncology Nursing, 19, 13–17. Wazneh, L., Tsimicalis, A., & Loiselle, C. (2016). Young adults’ perceptions of the Venturing Out Pack program

as a tangible cancer support service. Oncology Nursing Forum, 43, E34–E42.

*A link to this open-access article is provided in the Internet Resources section on website.

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**This journal article is available on for this chapter.

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2 Fundamentals of Evidence-Based Nursing Practice

Learning Objectives On completing this chapter, you will be able to:

Distinguish research utilization and evidence-based practice (EBP) and discuss their current status within nursing

Identify several resources available to facilitate EBP in nursing practice List several models for implementing EBP Discuss the five major steps in undertaking an EBP effort for individual nurses Identify the components of a well-worded clinical question and be able to frame such a

question Discuss broad strategies for undertaking an EBP project at the organizational level Distinguish EBP and quality improvement (QI) efforts Define new terms in the chapter

Key Terms Clinical practice guideline Cochrane Collaboration Evidence hierarchy Evidence-based practice Implementation potential Meta-analysis Metasynthesis Pilot test Quality improvement (QI) Research utilization (RU) Systematic review

Learning about research methods provides a foundation for evidence-based practice (EBP) in nursing. This book will help you to develop methodologic skills for reading research articles and evaluating research evidence. Before we elaborate on

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methodologic techniques, we discuss key aspects of EBP to further help you understand the key role that research now plays in nursing.

BACKGROUND OF EVIDENCE-BASED NURSING PRACTICE This section provides a context for understanding evidence-based nursing practice and two closely related concepts: research utilization and knowledge translation.

Definition of Evidence-Based Practice Pioneer Sackett and his colleagues (2000) defined evidence-based practice as “the integration of best research evidence with clinical expertise and patient values” (p. 1). The definition proposed by Sigma Theta Tau International (2008) is as follows: “The process of shared decision-making between practitioner, patient, and others significant to them based on research evidence, the patient’s experiences and preferences, clinical expertise or know-how, and other available robust sources of information” (p. 57). A key ingredient in EBP is the effort to personalize “best evidence” to a specific patient’s needs within a particular clinical context.

A basic feature of EBP as a clinical problem-solving strategy is that it de- emphasizes decisions based on custom, authority, or ritual. A core aspect of EBP is on identifying the best available research evidence and integrating it with other factors in making clinical decisions. Advocates of EBP do not minimize the importance of clinical expertise. Rather, they argue that evidence-based decision making should integrate best research evidence with clinical expertise, patient preferences, and local circumstances. EBP involves efforts to personalize evidence to fit a specific patient’s needs and a particular clinical situation.

Because research evidence can provide valuable insights about human health and illness, nurses must be lifelong learners who have the skills to search for, understand, and evaluate new information about patient care and the capacity to adapt to change.

Research Utilization Research utilization (RU) is the use of findings from studies in a practical application that is unrelated to the original research. In RU, the emphasis is on translating new knowledge into real-world applications. EBP is a broader concept than RU because it integrates research findings with other factors, as just noted. Also, whereas RU begins with the research itself (e.g., How can I put this new knowledge to good use in my clinical setting?), the starting point in EBP is usually a clinical question (e.g., What does the evidence say is the best approach to solving this clinical problem?).

During the 1980s, RU emerged as an important topic. In education, nursing schools began to include courses on research methods so that students would become skillful research consumers. In research, there was a shift in focus toward clinical nursing

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problems. Yet, concerns about the limited use of research evidence in the delivery of nursing care continued to mount.

The need to reduce the gap between research and practice led to formal RU projects, including the groundbreaking Conduct and Utilization of Research in Nursing (CURN) Project, a 5-year project undertaken by the Michigan Nurses Association in the 1970s. CURN’s objectives were to increase the use of research findings in nurses’ daily practice by disseminating current findings and facilitating organizational changes needed to implement innovations (Horsley et al., 1978). The CURN Project team concluded that RU by practicing nurses was feasible but only if the research is relevant to practice and if the results are broadly disseminated.

During the 1980s and 1990s, RU projects were undertaken by numerous hospitals and organizations. During the 1990s, however, the call for RU began to be superseded by the push for EBP.

The Evidence-Based Practice Movement One keystone of the EBP movement is the Cochrane Collaboration, which was founded in the United Kingdom based on the work by British epidemiologist Archie Cochrane. Cochrane published a book in the 1970s that drew attention to the shortage of solid evidence about the effects of health care. He called for efforts to make research summaries about interventions available to health care providers. This led to the development of the Cochrane Center in Oxford in 1993 and the international Cochrane Collaboration, with centers now established in locations throughout the world. Its aim is to help providers make good decisions by preparing and disseminating systematic reviews of the effects of health care interventions.

At about the same time that the Cochrane Collaboration was started, a group from McMaster Medical School in Canada developed a learning strategy they called evidence-based medicine. The evidence-based medicine movement, pioneered by Dr. David Sackett, has broadened to the use of best evidence by all health care practitioners. EBP has been considered a major paradigm shift in health care education and practice. With EBP, skillful clinicians can no longer rely on a repository of memorized information but rather must be adept in accessing, evaluating, and using new research evidence.

The EBP movement has advocates and critics. Supporters argue that EBP is a rational approach to providing the best possible care with the most cost-effective use of resources. Advocates also note that EBP provides a framework for self-directed lifelong learning that is essential in an era of rapid clinical advances and the information explosion. Critics worry that the advantages of EBP are exaggerated and that individual clinical judgments and patient inputs are being devalued. They are also concerned that insufficient attention is being paid to the role of qualitative research. Although there is a need for close scrutiny of how the EBP journey unfolds, an EBP path is the one that health care professions will almost surely follow in the years ahead.

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TIP A debate has emerged concerning whether the term evidence-based practice should be replaced with evidence-informed practice (EIP). Those who advocate for a different term have argued that the word “based” suggests a stance in which patient values and preferences are not sufficiently considered in EBP clinical decisions (e.g., Glasziou, 2005). Yet, as noted by Melnyk (2014), all current models of EBP incorporate clinicians’ expertise and patients’ preferences. She argued that “changing terms now . . . will only create confusion at a critical time where progress is being made in accelerating EBP” (p. 348). We concur and we use EBP throughout this book.

Knowledge Translation RU and EBP involve activities that can be undertaken at the level of individual nurses or at a higher organizational level (e.g., by nurse administrators), as we describe later in this chapter. A related movement emerged that mainly concerns system-level efforts to bridge the gap between knowledge generation and use. Knowledge translation (KT) is a term that is often associated with efforts to enhance systematic change in clinical practice. The World Health Organization (WHO) (2005) has defined KT as “the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health.”

TIP Translation science (or implementation science) is a new discipline devoted to promoting KT. In nursing, the need for translational research was an important stimulus for the development of the Doctor of Nursing Practice degree. Several journals have emerged that are devoted to this field (e.g., the journal Implementation Science).

EVIDENCE-BASED PRACTICE IN NURSING Before describing procedures relating to EBP in nursing, we briefly discuss some important issues, including the nature of “evidence,” challenges to pursuing EBP, and resources available to address some of those challenges.

Types of Evidence and Evidence Hierarchies There is no consensus about what constitutes usable evidence for EBP, but there is general agreement that findings from rigorous research are paramount. Yet, there is some debate about what constitutes “rigorous” research and what qualifies as “best” evidence.

Early in the EBP movement, there was a strong bias favoring evidence from a type

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of study called a randomized controlled trial (RCT). This bias reflected the Cochrane Collaboration’s initial focus on evidence about the effectiveness of therapies rather than about broader health care questions. RCTs are especially well-suited for drawing conclusions about the effects of health care interventions (see Chapter 9). The bias in ranking research approaches in terms of questions about effective therapies led to some resistance to EBP by nurses who felt that evidence from qualitative and non-RCT studies would be ignored.

Positions about the contribution of various types of evidence are less rigid than previously. Nevertheless, many published evidence hierarchies rank evidence sources according to the strength of the evidence they provide, and in most cases, RCTs are near the top of these hierarchies. We offer a modified evidence hierarchy that looks similar to others but is unique in illustrating that the ranking of evidence-producing strategies depends on the type of question being asked.

Figure 2.1 shows that systematic reviews are at the pinnacle of the hierarchy (Level I) because the strongest evidence comes from careful syntheses of multiple studies. The next highest level (Level II) depends on the nature of inquiry. For Therapy questions regarding the efficacy of a therapy or intervention (What works best for improving health outcomes?), individual RCTs constitute Level II evidence (systematic reviews of multiple RCTs are Level I). Going down the “rungs” of the evidence hierarchy for Therapy questions results in less reliable evidence. For example, Level III evidence comes from a type of study called quasi-experimental. In-depth qualitative studies are near the bottom, in terms of evidence regarding intervention effectiveness. (Terms in Fig. 2.1 will be discussed in later chapters.)

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For a Prognosis question, by contrast, Level II evidence comes from a single prospective cohort study, and Level III evidence is from a type of study called case- control (Level I evidence is from a systematic review of cohort studies). Thus, contrary to what is often implied in discussions of evidence hierarchies, there really are multiple hierarchies. If one is interested in best evidence for questions about meaning, an RCT would be a poor source of evidence, for example. Figure 2.1 illustrates these multiple hierarchies, with information on the right indicating the type of individual study that would offer the best evidence (Level II) for different questions. In all cases, appropriate systematic reviews are at the pinnacle.

Of course, within any level in an evidence hierarchy, evidence quality can vary considerably. For example, an individual RCT could be well designed, yielding strong Level II evidence for Therapy questions, or it could be so flawed that the evidence would be weak.

Thus, in nursing, best evidence refers to research findings that are methodologically appropriate, rigorous, and clinically relevant for answering pressing questions. These questions cover not only the efficacy, safety, and cost effectiveness of nursing interventions but also the reliability of nursing assessment tests, the causes and consequences of health problems, and the meaning and nature of patients’ experiences. Confidence in the evidence is enhanced when the research methods are compelling, when there have been multiple confirmatory studies, and when the evidence has been

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carefully evaluated and synthesized.

Evidence-Based Practice Challenges Studies that have explored barriers to evidence-based nursing have yielded similar results in many countries. Most barriers fall into one of three categories: (1) quality and nature of the research, (2) characteristics of nurses, and (3) organizational factors.

With regard to the research itself, one problem is the limited availability of strong research evidence for some practice areas. The need for research that directly addresses pressing clinical problems and for replicating studies in a range of settings remains a challenge. Also, nurse researchers need to improve their ability to communicate evidence to practicing nurses. In non-English-speaking countries, another impediment is that most studies are reported in English.

Nurses’ attitudes and education are also potential barriers to EBP. Studies have found that some nurses do not value or understand research, and others simply resist change. And, among the nurses who do appreciate research, many do not have the skills for accessing research evidence or for evaluating it for possible use in clinical decision making.

Finally, many challenges to using research in practice are organizational. “Unit culture” can undermine research use, and administrative or organizational barriers also play a major role. Although many organizations support the idea of EBP in theory, they do not always provide the necessary supports in terms of staff release time and provision of resources. Strong leadership in health care organizations is essential to making EBP happen.

RESOURCES FOR EVIDENCE-BASED PRACTICE In this section, we describe some of the resources that are available to support evidence- based nursing practice and to address some of the challenges.

Pre-Appraised Evidence Research evidence comes in various forms, the most basic of which is from individual studies. Primary studies published in journals are not pre-appraised for quality and use in practice.

Preprocessed (pre-appraised) evidence is evidence that has been selected from primary studies and evaluated for use by clinicians. DiCenso and colleagues (2005) have described a hierarchy of preprocessed evidence. On the first rung above primary studies are synopses of single studies, followed by systematic reviews, and then synopses of systematic reviews. Clinical practice guidelines are at the top of the hierarchy. At each successive step in the hierarchy, there is greater ease in applying the evidence to clinical practice. We describe several types of pre-appraised evidence sources in this section.

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Systematic Reviews EBP relies on meticulous integration of all key evidence on a topic so that well- grounded conclusions can be drawn about EBP questions. A systematic review is not just a literature review. A systematic review is in itself a methodical, scholarly inquiry that follows many of the same steps as those for other studies.

Systematic reviews can take various forms. One form is a narrative (qualitative) integration that merges and synthesizes findings, much like a rigorous literature review. For integrating evidence from quantitative studies, narrative reviews increasingly are being replaced by a type of systematic review known as a meta-analysis.

Meta-analysis is a technique for integrating quantitative research findings statistically. In essence, meta-analysis treats the findings from a study as one piece of information. The findings from multiple studies on the same topic are combined and then all of the information is analyzed statistically in a manner similar to that in a usual study. Thus, instead of study participants being the unit of analysis (the most basic entity on which the analysis focuses), individual studies are the unit of analysis in a meta-analysis. Meta-analysis provides an objective method of integrating a body of findings and of observing patterns that might not have been detected.

Example of a meta-analysis Shah and colleagues (2016) conducted a meta-analysis of the evidence on the effect of bathing intensive care unit (ICU) patients with 2% chlorhexidine gluconate (CHG) on central line–associated bloodstream infection (CLABSI). Integrating results from four intervention studies, the researchers concluded that 2% CHG is effective in reducing infections. They noted that “nursing provides significant influence for the prevention of CLABSIs in critical care via evidence-based best practices” (p. 42).

For qualitative studies, integration may take the form of a metasynthesis. A metasynthesis, however, is distinct from a quantitative meta-analysis: A metasynthesis is less about reducing information and more about interpreting it.

Example of a metasynthesis Magid and colleagues (2016) undertook a metasynthesis of studies exploring the perceptions of key elements of caregiving among patients using a left ventricular assist device. Their metasynthesis of eight qualitative studies resulted in the identification of eight important themes.

Systematic reviews are increasingly available. Such reviews are published in professional journals that can be accessed using standard literature search procedures (see Chapter 7) and are also available in databases that are dedicated to such reviews. In particular, the Cochrane Database of Systematic Reviews (CDSR) contains thousands of systematic reviews relating to health care interventions.

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TIP Websites with useful content relating to EBP, including ones for locating systematic reviews, are in the Internet Resources for Chapter 2 on

for you to access simply by using the “Control/Click” feature.

Clinical Practice Guidelines and Care Bundles Evidence-based clinical practice guidelines distill a body of evidence into a usable form. Unlike systematic reviews, clinical practice guidelines (which often are based on systematic reviews) give specific recommendations for evidence-based decision making. Guideline development typically involves the consensus of a group of researchers, experts, and clinicians. The implementation or adaptation of a clinical practice guideline is often an ideal focus for an organizational EBP project.

Also, organizations are developing and adopting care bundles—a concept developed by the Institute for Healthcare Improvement—that encompass a set of interventions to treat or prevent a specific cluster of symptoms (www.ihi.org). There is growing evidence that a combination or bundle of strategies produces better outcomes than a single intervention.

Example of a care bundle project Tayyib et al. (2015) studied the effectiveness of a pressure ulcer prevention care bundle in reducing the incidence of pressure ulcers in critically ill patients. Patients who received the bundled interventions had a significantly lower incidence of pressure ulcers than patients who did not.

Finding care bundles and clinical practice guidelines can be challenging because there is no single guideline repository. A standard search in a bibliographic database such as MEDLINE (see Chapter 7) will yield many references; however, the results are likely to include not only the actual guidelines but also commentaries, implementation studies, and so on.

A recommended approach is to search in guideline databases or through specialty organizations that have sponsored guideline development. A few of the many possible sources deserve mention. In the United States, nursing and health care guidelines are maintained by the National Guideline Clearinghouse (www.guideline.gov). In Canada, the Registered Nurses’ Association of Ontario (RNAO) (www.rnao.org/bestpractices) maintains information about clinical practice guidelines. Two sources in the United Kingdom are the Translating Research Into Practice (TRIP) database and the National Institute for Health and Care Excellence (NICE).

There are many topics for which practice guidelines have not yet been developed, but the opposite problem is also true: Sometimes there are multiple guidelines on the same topic. Worse yet, because of differences in the rigor of guideline development and interpretation of evidence, different guidelines sometimes offer different or even

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conflicting recommendations (Lewis, 2001). Thus, those who wish to adopt clinical practice guidelines should appraise them to identify ones that are based on the strongest evidence, have been meticulously developed, are user-friendly, and are appropriate for local use or adaptation.

Several appraisal instruments are available to evaluate clinical practice guidelines. One with broad support is the Appraisal of Guidelines Research and Evaluation (AGREE) Instrument, now in its second version (Brouwers et al., 2010). The AGREE II instrument has ratings for 23 dimensions within six domains (e.g., scope and purpose, rigor of development, presentation). As examples, a dimension in the scope and purpose domain is “The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described,” and one in the rigor of development domain is “The guideline has been externally reviewed by experts prior to its publication.” The AGREE tool should be applied to a guideline by a team of two to four appraisers.

Example of using AGREE II Homer and colleagues (2014) evaluated English-language guidelines on the screening and management of group B Streptococcus (GBS) colonization in pregnant women and the prevention of early-onset GBS disease in newborns. Four guidelines were appraised using the AGREE II instrument.

TIP For those interested in learning more about the AGREE II instrument, we offer more information in the chapter supplement on website.

Models of the Evidence-Based Practice Process EBP models offer frameworks for designing and implementing EBP projects in practice settings. Some models focus on the use of research by individual clinicians (e.g., the Stetler Model, one of the oldest models that originated as an RU model), but most focus on institutional EBP efforts (e.g., the Iowa Model). The many worthy EBP models are too numerous to list comprehensively but include the following:

Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model (Melnyk & Fineout-Overholt, 2015)

Diffusion of Innovations Model (Rogers, 1995) Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler, 2010) Johns Hopkins Nursing Evidence-Based Practice Model (Dearholt & Dang, 2012) Promoting Action on Research Implementation in Health Services (PARiHS) Model,

(Rycroft-Malone, 2010; Rycroft-Malone et al., 2013) Stetler Model of Research Utilization (Stetler, 2010)

For those wishing to follow a formal EBP model, the cited references should be consulted. Several are also nicely synthesized by Melnyk and Fineout-Overholt (2015).

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Each model offers different perspectives on how to translate research findings into practice, but several steps and procedures are similar across the models. We provide an overview of key activities and processes in EBP efforts, based on a distillation of common elements from the various models, in a subsequent section of this chapter. We rely heavily on the Iowa Model, shown in Figure 2.2.

TIP Gawlinski and Rutledge (2008) offer suggestions for selecting an EBP model.

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EVIDENCE-BASED PRACTICE IN INDIVIDUAL NURSING PRACTICE This and the following section provide an overview of how research can be put to use in clinical settings. We first discuss strategies and steps for individual clinicians and then describe activities used by organizations or teams of nurses.

Clinical Scenarios and the Need for Evidence Individual nurses make many decisions and are called upon to provide health care advice, and so they have ample opportunity to put research into practice. Here are four clinical scenarios that provide examples of such opportunities:

Clinical Scenario 1. You work on an ICU and notice that Clostridium difficile infection has become more prevalent among surgical patients in your hospital. You want to know whether there is a reliable screening tool for assessing the risk of infection so that preventive measures can be initiated in a more timely and effective manner.

Clinical Scenario 2. You work in an allergy clinic and notice how difficult it is for many children to undergo allergy scratch tests. You wonder whether an interactive distraction intervention would help reduce children’s pain when they are being tested for allergens.

Clinical Scenario 3. You work in a rehabilitation hospital, and one of your elderly patients, who had total hip replacement, tells you she is planning a long airplane trip. You know that a long plane ride will increase her risk of deep vein thrombosis and wonder whether compression stockings are an effective in-flight treatment. You decide to look for the best possible evidence to answer this question.

Clinical Scenario 4. You are caring for a hospitalized cardiac patient who tells you that he has sleep apnea. He confides in you that he is reluctant to undergo continuous positive airway pressure (CPAP) treatment because he worries it will hinder intimacy with his wife. You wonder if there is any evidence about what it is like to undergo CPAP treatment so that you can better understand how to address your patient’s concerns.

In these and thousands of other clinical situations, research evidence can be put to good use to improve nursing care. Some situations might lead to unit-wide or institution-wide scrutiny of current practices, but in other situations, individual nurses can personally examine evidence to help address specific problems.

For individual EBP efforts, the major steps in EBP include the following:

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

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5. Assessing the effectiveness of the decision, intervention, or advice

Asking Well-Worded Clinical Questions: PIO and PICO A crucial first step in EBP involves asking relevant clinical questions that reflect uncertainties in clinical practice. Some EBP writers distinguish between background and foreground questions. Background questions are foundational questions about a clinical issue, such as What is cancer cachexia (progressive body wasting), and what is its pathophysiology? Answers to such questions are typically found in textbooks. Foreground questions, by contrast, are those that can be answered based on current best research evidence on diagnosing, assessing, or treating patients or on understanding the meaning or prognosis of their health problems. For example, we may wonder, is a fish oil–enhanced nutritional supplement effective in stabilizing weight in patients with advanced cancer? The answer to such a question may provide guidance on how best to address the needs of patients with cachexia.

Most guidelines for EBP use the acronyms PIO or PICO to help practitioners develop well-worded questions that facilitate a search for evidence. In the most basic PIO form, the clinical question is worded to identify three components:

1. P: the population or patients (What are the characteristics of the patients or people?) 2. I: the intervention, influence, or exposure (What are the interventions or therapies of

interest? or What are the potentially harmful influences/exposures of concern?) 3. O: the outcomes (What are the outcomes or consequences in which we are

interested?)

Applying this scheme to our question about cachexia, our population (P) is cancer patients with cachexia, the intervention (I) is fish oil–enhanced nutritional supplements, and the outcome (O) is weight stabilization. As another example, in the second clinical scenario about scratch tests cited earlier, the population is children being tested for allergies, the intervention is interactive distraction, and the outcome is pain.

For questions that can best be answered with qualitative information (e.g., about the meaning of an experience or health problem), two components are most relevant:

1. The population (What are the characteristics of the patients or clients?) 2. The situation (What conditions, experiences, or circumstances are we interested in

understanding?)

For example, suppose our question was, What is it like to suffer from cachexia? In this case, the question calls for rich qualitative information; the population is patients with advanced cancer and the situation is the experience of cachexia.

In addition to the basic PIO components, other components are sometimes important in an evidence search. In particular, a comparison (C) component may be needed, when the intervention or influence of interest is contrasted with a specific alternative. For example, we might be interested in learning whether fish oil–enhanced supplements (I) are better than melatonin (C) in stabilizing weight (O) in cancer patients (P). When a

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specific comparison is of interest, a PICO question is required, but if we were interested in uncovering evidence about all alternatives to an intervention of primary interest, then PIO components are sufficient. (By contrast, when asking questions to undertake an actual study, the “C” must always be specified).

TIP Other components may be relevant, such as a time frame in which an intervention might be appropriate (adding a “T” for PICOT questions) or a setting (adding an “S” for PICOS questions).

Table 2.1 offers templates for asking well-worded clinical questions for different types of foreground questions. The far right column includes questions with an explicit comparison (PICO), whereas the middle column does not have a comparison (PIO). The questions are categorized in a manner similar to that discussed in Chapter 1 (EBP Purpose), as featured in Table 1.3. One exception is that we have added description as a category. Note that although there are some differences in components across question types, there is always a P component.

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TIP It is crucial to practice asking clinical questions—it is the starting point for evidence-based nursing. Take some time to fill in the blanks in Table 2.1 for each question category. Do not be too self-critical at this point. Your comfort in developing questions will increase over time. Chapter 2 of the study guide that accompanies this book offers additional opportunities for you to practice asking well-worded questions.

Finding Research Evidence By wording clinical queries as PIO or PICO questions, you should be able to search the research literature for the information you need. Using the templates in Table 2.1, the information you insert into the blanks are keywords that can be used in an electronic search.

For an individual EBP endeavor, the best place to begin is by searching for evidence in a systematic review, clinical practice guideline, or other preprocessed source because

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this approach leads to a quicker answer and, if your methodologic skills are limited, potentially a superior answer as well. Researchers who prepare reviews and clinical guidelines typically are well trained in research methods and use rigorous standards in evaluating the evidence. Moreover, preprocessed evidence is often prepared by a team, which means that the conclusions are cross-checked and fairly objective. Thus, when preprocessed evidence is available to answer a clinical question, you may not need to look any farther unless the review is outdated. When preprocessed evidence cannot be located or is old, you will need to look for best evidence in primary studies, using strategies we describe in Chapter 7.

TIP Searching for evidence for an EBP project has been greatly simplified in recent years. Guidance on doing a search for evidence on clinical questions is available in the supplement for Chapter 7 (the chapter on literature reviews) on the book’s website, .

Appraising the Evidence for Evidence-Based Practice Evidence should be appraised before clinical action is taken. The critical appraisal of evidence for the purposes of EBP may involve several types of assessments (Box 2.1) but often focuses primarily on evidence quality.

Box 2.1 Questions for Appraising the Evidence

1. What is the quality of the evidence—i.e., how rigorous and reliable is it? 2. What is the evidence—what is the magnitude of effects? 3. How precise is the estimate of effects? 4. What evidence is there of any side effects/side benefits? 5. What is the financial cost of applying (and not applying) the evidence? 6. Is the evidence relevant to my particular clinical situation?

Evidence Quality The overriding appraisal issue is the extent to which the findings are valid. That is, were the study methods sufficiently rigorous that the evidence can be trusted? Ideally, you would find pre-appraised evidence, but a goal of this book is to help you evaluate research evidence yourself. If there are several primary studies and no existing systematic review, you would need to draw conclusions about the body of evidence taken as a whole. Clearly, you would want to put most weight on the most rigorous studies.

Magnitude of Effects You would also need to assess whether study findings are clinically important. This

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criterion considers not whether the results are “real” but how powerful the effects are. For example, consider clinical scenario 3 cited earlier, which suggests this question: Does the use of compression stockings lower the risk of flight-related deep vein thrombosis for high-risk patients? In our search, we found a relevant systematic review in the nursing literature—a meta-analysis of nine RCTs (Hsieh & Lee, 2005)—and others in the Cochrane database (Clarke et al., 2006; O’Meara et al., 2012). The conclusion of these reviews, based on reliable evidence, was that compression stockings are effective and the magnitude of the risk-reducing effect is fairly substantial. Thus, advice about using compression stockings may be appropriate, pending an appraisal of other factors. The magnitude of effects can be quantified, and several methods are described later in this book. The magnitude of effects also has a bearing on clinical significance, which we also discuss in a later chapter.

Precision of Estimates When the evidence is quantitative, another consideration is how precise the estimate of effect is. This type of appraisal requires some statistical knowledge, and so we postpone our discussion of confidence intervals to Chapter 14. Suffice it to say that research results provide only an estimate of effects, and it is useful to understand not only the exact estimate but also the range within which the actual effect probably lies.

Peripheral Effects Even if the evidence is judged to be valid and the magnitude of effects is sizeable, peripheral benefits and costs may be important in guiding decisions. In framing your clinical question, you would have identified the outcomes (O) in which you were interested—for example, weight stabilization for an intervention to address cancer cachexia. Research on this topic, however, would likely have considered other outcomes that need to be taken into account—for example, effects on quality of life.

Financial Costs Another issue concerns the costs of applying the evidence. Costs may be small or nonexistent. For example, in clinical scenario 4 concerning the experience of CPAP treatment, nursing action would be cost-neutral because the evidence would be used to reassure and inform patients. When interventions and assessments are costly, however, the resources needed to put best evidence into practice need to be factored into any decision. Of course, although the cost of a clinical decision needs to be considered, the cost of not taking action is equally important.

Clinical Relevance Finally, it is important to appraise the evidence in terms of its relevance for the clinical situation at hand—that is, for your patient in a specific clinical setting. Best practice evidence can most readily be applied to an individual patient in your care if he or she is

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sufficiently similar to people in the study or studies under review. Would your patient have qualified for participation in the study—or would some factor (e.g., age, illness severity, comorbidities) have disqualified him or her? DiCenso and colleagues (2005), who advised clinicians to ask whether there is a compelling reason to conclude that results may not be applicable in their clinical situation, have written some useful tips on applying evidence to individual patients.

Actions Based on Evidence Appraisals Appraisals of the evidence may lead you to different courses of action. You may reach this point and conclude that the evidence base is not sufficiently sound, or that the likely effect is too small, or that the cost of applying the evidence is too high. The evidence appraisal may suggest that “usual care” is the best strategy. If, however, the initial appraisal of evidence suggests a promising clinical action, then you can proceed to the next step.

Integrating Evidence in Evidence-Based Practice Research evidence needs to be integrated with other types of information, including your own clinical expertise and knowledge of your clinical setting. You may be aware of factors that would make implementation of the evidence, no matter how sound and how promising, inadvisable. Patient preferences and values are also important. A discussion with the patient may reveal negative attitudes toward a potentially beneficial course of action, contraindications (e.g., comorbidities), or possible impediments (e.g., lack of health insurance).

One final issue is the desirability of integrating evidence from qualitative research. Qualitative research can provide rich insights about how patients experience a problem or about barriers to complying with a treatment. A potentially beneficial intervention may fail to achieve desired outcomes if it is not implemented with sensitivity to the patients’ perspectives. As Morse (2005) so aptly noted, evidence from an RCT may tell us whether a pill is effective, but qualitative research can help us understand why patients may not swallow the pill.

Implementing the Evidence and Evaluating Outcomes After the first four steps of the EBP process have been completed, you can use the resulting information to make an evidence-based decision or to provide evidence-based advice. Although the steps in the process, as just described, may seem complicated, in reality, the process can be quite efficient—if there is adequate evidence, and especially if it has been skillfully preprocessed. EBP is most challenging when findings from research are contradictory, inconclusive, or “thin”—that is, when better quality evidence is needed.

One last step in an individual EBP effort concerns evaluation. Part of the evaluation process involves following up to determine whether your actions achieved the desired

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outcome. Another part, however, concerns an evaluation of how well you are performing EBP. Sackett and colleagues (2000) offer self-evaluation questions that relate to the previous EBP steps, such as asking answerable questions (Am I asking any clinical questions at all? Am I asking well-worded questions?) and finding external evidence (Do I know the best sources of current evidence? Am I efficient in my searching?). A self-appraisal may lead to the conclusion that at least some of the clinical questions of interest to you are best addressed as a group effort.

EVIDENCE-BASED PRACTICE IN AN ORGANIZATIONAL CONTEXT For some clinical scenarios, individual nurses may be able to implement EBP strategies on their own (e.g., giving advice about compression stockings). Many situations, however, require decision making by an organization or by a team of nurses working to solve a recurrent problem. This section describes some issues that are relevant to institutional efforts at EBP—efforts designed to result in a formal policy or protocol affecting the practice of many nurses.

Many steps in organizational EBP projects are similar to the ones described in the previous section. For example, gathering and appraising evidence are key activities in both, as shown in the Iowa Model in Figure 2.2 (assemble relevant research; critique and synthesize research). Additional issues are relevant at the organizational level, however, including the selection of a problem; an assessment of whether the topic is an organizational priority; deciding whether to test an EBP innovation on a trial basis; and deciding, based on a trial, whether the innovation should be adopted. We briefly discuss some of these topics.

Selecting a Problem for an Institutional Evidence-Based Practice Project Some EBP projects originate in deliberations among clinicians who have encountered a recurrent problem and seek a resolution. Others, however, are “top-down” efforts in which administrators take steps to stimulate the use of research evidence among clinicians. This latter approach is increasingly likely to occur in U.S. hospitals as part of the Magnet recognition process.

Several models of EBP, such as the Iowa Model, distinguish two types of stimulus (“triggers”) for an EBP endeavor: (1) problem-focused triggers—the identification of a clinical practice problem in need of solution, or (2) knowledge-focused triggers —readings in the research literature. The problem identification approach is likely to be clinically relevant and to have staff support if the problem is one that numerous nurses have encountered.

A second catalyst for an EBP project is a knowledge-focused trigger, which is akin to RU. The catalyst might be a new clinical guideline or a research article discussed in a

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journal club. With knowledge-focused triggers, the clinical relevance of the research might need to be assessed. The central issue is whether a problem of significance to nurses in a particular setting will be solved by introducing an innovation.

Appraising Implementation Potential With either type of trigger, the feasibility of undertaking an organizational EBP project needs to be assessed. In the Iowa Model (Fig. 2.2), the first major decision point involves determining whether the topic is a priority for the organization considering practice changes. Titler and colleagues (2001) advised considering the following issues before finalizing a topic for EBP: the topic’s fit with the organization’s strategic plan, the magnitude of the problem, the number of people invested in the problem, support of nurse leaders and of those in other disciplines, costs and availability of resources, and possible barriers to change.

Some EBP models involve a formal assessment of organizational “fit,” often called implementation potential (or environmental readiness). In assessing the implementation potential of an innovation, several issues should be considered, particularly the transferability of the innovation (i.e., the extent to which the innovation might be appropriate in new settings), the feasibility of implementing it, and its cost– benefit ratio. If the implementation assessment suggests that there might be problems in testing the innovation in a particular practice setting, then the team can either identify a new problem and begin the process anew or develop a plan to improve the implementation potential (e.g., seeking external resources if costs are prohibitive).

Evidence Appraisals and Subsequent Actions In the Iowa Model, the second major decision relies on the synthesis and appraisal of research evidence. The crux of the decision concerns whether the research base is sufficient to justify an evidence-based change—for example, whether a new clinical practice guideline is of sufficient quality that it can be used or adapted, or whether the research evidence is rigorous enough to recommend a practice innovation.

Assessments about the adequacy of the evidence can lead to different action paths. If the research evidence is weak, the team could assemble nonresearch evidence (e.g., through consultation with experts or client surveys) to determine the benefit of a practice change. Another option is to conduct an original study to address the practice question, thereby gathering new evidence. This course of action may be impractical and would result in years of delay.

If, on the other hand, there is a solid research base or a high-quality clinical practice guideline, then the team would develop plans to implement a practice innovation. A key activity usually involves developing or adapting a local evidence-based clinical practice protocol or guideline. Strategies for developing clinical practice guidelines are suggested in DiCenso et al. (2005) and Melnyk and Fineout-Overholt (2015).

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Implementing and Evaluating the Innovation Once the EBP product has been developed, the next step is to pilot test it (give it a trial run) and evaluate the outcome. Building on the Iowa Model, this phase of the project likely would involve the following activities:

1. Developing an evaluation plan (e.g., identifying outcomes to be achieved, determining how many clients to include, deciding when and how often to measure outcomes)

2. Measuring client outcomes prior to implementing the innovation so that there is a comparison against which the outcomes of the innovation can be assessed

3. Training relevant staff in the use of the new guideline and, if necessary, “marketing” the innovation to users

4. Trying the guideline out on one or more units or with a group of clients 5. Evaluating the pilot project, in terms of both process (e.g., How was the innovation

received? What problems were encountered?) and outcomes (e.g., How were client outcomes affected? What were the costs?)

A fairly informal evaluation may be adequate, but formal efforts are often appropriate and provide opportunities for dissemination to others at conferences or in professional journals.

TIP Every nurse can play a role in using research evidence. Here are some strategies:

Read widely and critically. Attend professional conferences. Become involved in a journal club. Pursue and participate in EBP projects.

QUALITY IMPROVEMENT We conclude this chapter with a brief discussion of quality improvement (QI) projects, which are efforts ongoing in many health care settings and which sometimes involve nurses. In recent years, there has been a lot of discussion in health journals about the differences and similarities between QI projects and research. And in nursing, efforts have been made to distinguish QI, research, and EBP projects (Shirey et al., 2011). All three have much in common, notably the use of systematic methods of solving health problems with an overall aim of fostering improvements in health care. Often, the research methods used overlap: Patient data are used in all three, and statistical analysis—sometimes combined with analysis of qualitative data—are also used in all three.

The definitions of QI, research, and EBP activities are distinct, and yet it is not always easy to distinguish them in real-world projects, resulting in confusion. QI has

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been defined by the U.S. Centers for Medicare & Medicaid Services (CMS) as “an assessment, conducted by or for a QI organization, of a patient care problem for the purpose of improving patient care through peer analysis, intervention, resolution of the problem, and follow-up” (CMS, 2003). Under the Code of Federal Regulations in the United States, research is defined as a “systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge” (U.S. Code of Federal Regulations, 2009). And EBP projects, as we have seen, are efforts to translate “best evidence” into protocols to guide the actions of health care staff to maximize good outcomes for clients. Shirey and colleagues (2011) summarize the differences between the three as follows: “All three have an important, but different, relationship with knowledge: research generates it, EBP translates it, and QI incorporates it” (p. 60).

QI projects are discussed briefly in Chapter 13. Here, we note a few characteristics of QI:

In QI efforts, the intervention or protocol can change as it is being evaluated to incorporate new ideas or insights.

The purpose of a QI project is often to effect immediate improvement in health care delivery.

QI is designed with the intent of sustaining an improvement. QI is a necessary, integral activity for a health care institution; research is not. A literature review may not be undertaken in a QI project. QI projects are not externally funded.

Example of a nurse-led quality improvement project McMullen and colleagues (2016) undertook a QI project in a Magnet hospital to promote safe sleep guidelines for hospitalized infants based on recommendations from the American Academy of Pediatrics. The project involved an educational initiative for parents and hospital staff.

Hundreds of projects to translate research evidence into nursing practice are underway worldwide. Those that have been described in the nursing literature offer good information about planning and implementing such an endeavor. In this section, we summarize one such project.

Read the research summary for Example 1 and then answer the critical thinking questions that follow, referring to the full research report if necessary (this example is featured on the interactive Critical Thinking Activity on website). The critical thinking questions for Examples 2 and 3 are based on the studies that appear in their entirety in Appendices A

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and B of this book. Our comments for these exercises are in the Student Resources section on .

EXAMPLE 1: EVIDENCE-BASED PRACTICE PROJECT Study: Implementation of the ABCDE bundle to improve patient outcomes in the intensive care unit in a rural community hospital (Kram et al., 2015)

Purpose: A team of nurses undertook an EBP to implement an existing care bundle designed to manage delirium—the ABCDE bundle—in a rural community ICU. The bundle incorporates awakening, breathing, coordination (or choice of sedative), delirium monitoring and management, and early mobility on a daily basis. The question for this EBP project was: Does the implementation of the ABCDE bundle care, versus the usual care (absence of the ABCDE bundle components), reduce the incidence of delirium, decrease patient length of stay (LOS) in the ICU, decrease patient total hospital LOS, and decrease length of mechanical ventilation of patients, thus decreasing costs in the ICU?

Framework: The project used the Johns Hopkins Nursing Evidence-Based Practice Model as its guiding framework.

Approach: The team began by reviewing the current body of evidence on the ABCDE bundle. They also undertook an organizational assessment and identified which practice changes were required. Key stakeholder support was sought. Approval was obtained from the nurse executive committee, the chief medical officer, and from physicians with ICU admitting privileges. Educational sessions, using various instructional methods, were conducted with staff from nursing, respiratory therapy, and rehabilitation services. The ABCDE bundle was implemented for all adult patients admitted to the ICU starting in October 2014.

Evaluation: To assess the effects of the ABCDE bundle, the team collected and organized relevant information for two periods: from October 2013 to January 2014 (pre-bundle) and from October 2014 to January 2015 (post- bundle). The outcomes of interest included rate of compliance to bundle elements by direct care providers, changes in hospital and ICU length of stay between the two periods, changes in the number of ventilator days from pre- bundle to post-bundle, and prevalence of post-bundle delirium. Information was obtained for 47 patients in the pre-bundle group and 36 patients in the post-bundle group.

Findings and Conclusions: The team found that compliance with the bundle protocols was high. The average hospital stay was 1.8 days lower after the implementation of the bundle. Mechanical ventilation was lower by an

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average of 1 day in the post-bundle group. A delirium prevalence rate of 19% was established as a baseline after the bundle was implemented. The EBP team concluded that the ABCDE bundle “can be implemented in rural, community-based hospitals and provides a safe, cost-effective method for enhancing ICU patient outcomes” (p. 250).

Critical Thinking Exercises 1. Of the EBP-focused research purposes (Table 1.3), which purpose was the

central focus of this project? 2. What is the clinical question that the EBP team asked in this project?

Identify the components of the question using the PICO framework. 3. Discuss how this project could have been based on either a knowledge-

focused or problem-focused trigger.

EXAMPLE 2: QUANTITATIVE RESEARCH IN APPENDIX A • Read the abstract and the introduction of Swenson and colleagues’ (2016)

study (“Parents’ use of praise and criticism in a sample of young children seeking mental health services”) in Appendix A of this book.

Critical Thinking Exercises 1. Identify one or more clinical foreground questions that, if posed, would be

addressed by this study. Which PIO or PICO components does your question capture?

2. How, if at all, might evidence from this study be used in an EBP project (individual or organizational)?

EXAMPLE 3: QUALITATIVE RESEARCH IN APPENDIX B • Read the abstract and the introduction of Beck and Watson’s (2010) study

(“Subsequent childbirth after a previous traumatic birth”) in Appendix B of this book.

Critical Thinking Exercises 1. Identify one or more clinical foreground questions that, if posed, would be

addressed by this study. Which PIO or PICO components does your question capture?

2. How, if at all, might evidence from this study be used in an EBP project (individual or organizational)?

WANT TO KNOW MORE?

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A wide variety of resources to enhance your learning and understanding of this chapter are available on .

• Interactive Critical Thinking Activity • Chapter Supplement on Evaluating Clinical Practice Guidelines—AGREE

II • Answers to the Critical Thinking Exercises for Examples 2 and 3 • Internet Resources with useful websites for Chapter 2 • A Wolters Kluwer journal article in its entirety—the EBP project

described as Example 1 on p. 37.

Additional study aids, including eight journal articles and related questions, are also available in Study Guide for Essentials of Nursing Research, 9e.

Summary Points

Evidence-based practice (EBP) is the conscientious use of current best evidence in making clinical decisions about patient care; it is a clinical problem-solving strategy that de-emphasizes decision making based on custom and emphasizes the integration of research evidence with clinical expertise and patient preferences.

Research utilization (RU) and EBP are overlapping concepts that concern efforts to use research as a basis for clinical decisions, but RU starts with a research- based innovation that gets evaluated for possible use in practice. Knowledge translation (KT) is a term used primarily about system-wide efforts to effect systematic change in clinical practice or policies.

Two underpinnings of the EBP movement are the Cochrane Collaboration (which is based on the work of British epidemiologist Archie Cochrane) and the clinical learning strategy developed at the McMaster Medical School called evidence-based medicine.

EBP involves evaluating evidence to determine best evidence. Often an evidence hierarchy is used to rank study findings according to the strength of evidence provided, but different hierarchies are appropriate for different types of questions. In all evidence hierarchies, however, systematic reviews are at the pinnacle.

Systematic reviews are rigorous integrations of research evidence from multiple studies on a topic. Systematic reviews can involve either quantitative methods (meta-analysis) that integrate findings statistically or narrative approaches to integration (including metasynthesis of qualitative studies).

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Evidence-based clinical practice guidelines combine an appraisal of research evidence with specific recommendations for clinical decisions.

Many models of EBP have been developed, including models that provide a framework for individual clinicians (e.g., the Stetler Model) and others for organizations or teams of clinicians (e.g., the Iowa Model).

Individual nurses have opportunities to put research into practice. The five basic steps for individual EBP are (1) asking an answerable clinical question, (2) searching for relevant research-based evidence, (3) appraising and synthesizing the evidence, (4) integrating evidence with other factors, and (5) assessing effectiveness of actions.

One scheme for asking well-worded clinical questions involves four primary components, an acronym for which is PICO: population (P), intervention or influence (I), comparison (C), and outcome (O). When there is no explicit comparison, the acronym is PIO.

An appraisal of the evidence involves such considerations as the validity of study findings, their clinical importance, the magnitude and precision of effects, associated costs and risks, and utility in a particular clinical situation.

EBP in an organizational context involves many of the same steps as individual EBP efforts but is more formalized and must take organizational factors into account.

Triggers for an organizational project include both pressing clinical problems (problem-focused) and existing knowledge (knowledge-focused).

Before an EBP-based guideline or protocol can be tested, there should be an assessment of its implementation potential, which includes the issues of transferability, feasibility, and the cost–benefit ratio of implementing a new practice in a clinical setting.

Once an evidence-based protocol or guideline has been developed and deemed worthy of implementation, the EBP team can move forward with a pilot test of the innovation and an assessment of the outcomes prior to widespread adoption.

The purpose of quality improvement (QI) is to improve practices and processes within a specific organization—not to generate new knowledge that can be generalized. QI does not typically involve translating “best evidence” into a protocol.

REFERENCES FOR CHAPTER 2 *Brouwers, M., Kho, M., Browman, G., Burgers, J., Cluzeau, F., Feder, G., . . . Zitzelsberger, L. (2010). AGREE

II: Advancing guideline development, reporting and evaluation in health care. Canadian Medical Association Journal, 182, E839–E842.

Centers for Medicare & Medicaid Services. (2003). Quality improvement organization manual. Retrieved from http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs- Items/CMS019035.html

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Clarke, M., Hopewell, S., Juszczak, E., Eisinga, A., & Kjeldstrøm, M. (2006). Compression stockings for preventing deep vein thrombosis in airline passengers. Cochrane Database of Systematic Reviews, (2), CD004002.

Dearholt, D., & Dang, D. (Eds.). (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.

DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based nursing: A guide to clinical practice. St. Louis, MO: Elsevier Mosby.

Gawlinski, A., & Rutledge, D. (2008). Selecting a model for evidence-based practice changes. AACN Advanced Critical Care, 19, 291–300.

Glasziou, P. (2005). Evidence-based medicine: Does it make a difference? Make it evidence informed with a little wisdom. BMJ, 330(7482), 92.

Homer, C. S., Scarf, V., Catling, C., & Davis, D. (2014). Culture-based versus risk-based screening for the prevention of group B streptococcal disease in newborns: A review of national guidelines. Women and Birth, 27(1), 46–51.

Horsley, J. A., Crane, J., & Bingle, J. D. (1978). Research utilization as an organizational process. Journal of Nursing Administration, 8, 4–6.

Hsieh, H. F., & Lee, F. P. (2005). Graduated compression stockings as prophylaxis for flight-related venous thrombosis: Systematic literature review. Journal of Advanced Nursing, 51, 83–98.

**Kram, S., DiBartolo, M., Hinderer, K., & Jones, R. (2015). Implementation of the ABCDE bundle to improve patient outcomes in the intensive care unit in a rural community hospital. Dimensions of Critical Care Nursing, 34, 250–258.

Lewis, S. (2001). Further disquiet on the guidelines front. Canadian Medical Association Journal, 165, 180–181. Magid, M., Jones, J., Allen, L., McIlvennan, C., Magid, K., Thompson, J., & Matlock, D. (2016). The perceptions

of important elements of caregiving for a left ventricular assist device patient: A qualitative meta-synthesis. Journal of Cardiovascular Nursing, 31, 215–225.

McMullen, S., Fioravanti, I., Brown, K., & Carey, M. (2016). Safe sleep for hospitalized infants. MCN: American Journal of Maternal Child Nursing, 41, 43–50.

Melnyk, B. M. (2014). Evidence-based practice versus evidence-informed practice: A debate that could stall forward momentum in improving healthcare quality, safety, patient outcomes, and costs. Worldviews on Evidence-Based Nursing, 11, 347–349.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Morse, J. (2005). Beyond the clinical trial: Expanding criteria for evidence. Qualitative Health Research, 15, 3–4. O’Meara, S., Cullum, N., Nelson, E., & Dumville, J. (2012). Compression for venous ulcers. Cochrane Database

of Systematic Reviews, (1), CD000265. Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York, NY: Free Press. Rycroft-Malone, J. (2010). Promoting Action on Research Implementation in Health Services (PARiHS). In J.

Rycroft-Malone & T. Bucknall (Eds.), Models and frameworks for implementing evidence-based practice: Linking evidence to action (pp. 109–133). Malden, MA: Wiley-Blackwell.

*Rycroft-Malone, J., Seers, K., Chandler, J., Hawkes, C., Crichton, N., Allen, C., . . . Strunin, L. (2013). The role of evidence, context, and facilitation in an implementation trial: Implications for the development of the PARIHS framework. Implementation Science, 8, 28.

Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). Edinburgh, United Kingdom: Churchill Livingstone.

Shah, H., Schwartz, J., Luna, G., & Cullen, D. (2016). Bathing with 2% chlorhexidine gluconate: Evidence and costs associated with central line-associated bloodstream infections. Critical Care Nursing Quarterly, 39, 42– 50.

Shirey, M., Hauck, S., Embree, J., Kinner, T., Schaar, G., Phillips, L., . . . McCool, I. (2011). Showcasing differences between quality improvement, evidence-based practice, and research. Journal of Continuing Education in Nursing, 42, 57–68.

Sigma Theta Tau International. (2008). Sigma Theta Tau International position statement on evidence-based practice, February 2007 summary. Worldviews of Evidence-Based Nursing, 5, 57–59.

Stetler, C. B. (2010). Stetler model. In J. Rycroft-Malone & T. Bucknall (Eds.), Models and frameworks for implementing evidence-based practice: Linking evidence to action (pp. 51–77). Malden, MA: Wiley-Blackwell.

Tayyib, N., Coyer, F., & Lewis, P. (2015). A two-arm cluster randomized control trial to determine the effectiveness of a pressure ulcer prevention bundle for critically ill patients. Journal of Nursing Scholarship, 47, 237–247.

Titler, M. (2010). Iowa model of evidence-based practice. In J. Rycroft-Malone & T. Bucknall (Eds.), Models and

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frameworks for implementing evidence-based practice: Linking evidence to action (pp. 137–144). Malden, MA: Wiley-Blackwell.

Titler, M. G., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L., . . . Goode, C. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13, 497– 509.

U.S. Code of Federal Regulations, 45 C.F.R. 46.102 (2009). Retrieved from http://www.hhs.gov/ohrp/sites/default/files/ohrp/policy/ohrpregulations.pdf.

*World Health Organization. (2005). Bridging the “Know-Do” gap: Meeting on knowledge translation in global health. Retrieved from http://www.who.int/kms/WHO_EIP_KMS_2006_2.pdf

*A link to this open-access article is provided in the Internet Resources section on website.

**This journal article is available on for this chapter.

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3 Key Concepts and Steps in Quantitative and Qualitative Research

Learning Objectives On completing this chapter, you will be able to:

Define new terms presented in the chapter and distinguish terms associated with quantitative and qualitative research

Distinguish experimental and nonexperimental research Identify the three main disciplinary traditions for qualitative nursing research Describe the flow and sequence of activities in quantitative and qualitative research

and discuss why they differ

Key Terms Cause-and-effect (causal) relationship Clinical trial Concept Conceptual definition Construct Data Dependent variable Emergent design Ethnography Experimental research Gaining entrée Grounded theory Hypothesis Independent variable Informant Intervention protocol Literature review

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Nonexperimental research Observational study Operational definition Outcome variable Phenomenology Population Qualitative data Quantitative data Relationship Research design Sample Saturation Statistical analysis Study participant Subject Theme Theory Variable

THE BUILDING BLOCKS OF RESEARCH Research, like any discipline, has its own language—its own jargon—and that jargon can sometimes be intimidating. We readily admit that the jargon is abundant and can be confusing. Some research jargon used in nursing research has its roots in the social sciences but, sometimes, different terms are used in medical research. Also, some terms are used by both quantitative and qualitative researchers, but others are used mainly by one or the other group. Please bear with us as we cover key terms that you will likely encounter in the research literature.

The Faces and Places of Research When researchers answer a question through disciplined research, they are doing a study (or an investigation). Studies with humans involve two sets of people: those who do the research and those who provide the information. In a quantitative study, the people being studied are called subjects or study participants, as shown in Table 3.1. In a qualitative study, the people cooperating in the study are called study participants or informants. The person who conducts the research is the researcher or investigator. Studies are often undertaken by a research team rather than by a single researcher.

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HOW-TO-TELL TIP How can you tell if an article appearing in a nursing journal is a study? In journals that specialize in research (e.g., the journal Nursing Research), most articles are original research reports, but in specialty journals, there is usually a mix of research and nonresearch articles. Sometimes you can tell by the title, but sometimes you cannot. You can tell, however, by looking at the major headings of an article. If there is no heading called “Method” or “Research Design” (the section that describes what a researcher did) and no heading called “Findings” or “Results” (the section that describes what a researcher learned), then it is probably not a study.

Research can be undertaken in a variety of settings (the types of place where information is gathered), like in hospitals, homes, or other community settings. A site is the specific location for the research—it could be an entire community (e.g., a Haitian neighborhood in Miami) or an institution (e.g., a clinic in Seattle). Researchers sometimes do multisite studies because the use of multiple sites offers a larger and often more diverse group of participants.

Concepts, Constructs, and Theories Research involves real-world problems, but studies are conceptualized in abstract terms. For example, pain, fatigue, and obesity are abstractions of human characteristics. These abstractions are called phenomena (especially in qualitative studies) or concepts.

Researchers sometimes use the term construct, which also refers to an abstraction, but often one that is deliberately invented (or constructed). For example, self-care in Orem’s model of health maintenance is a construct. The terms construct and concept are sometimes used interchangeably, but a construct often refers to a more complex abstraction than a concept.

A theory is an explanation of some aspect of reality. In a theory, concepts are

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knitted together into a coherent system to describe or explain some aspect of the world. Theories play a role in both quantitative and qualitative research. In a quantitative study, researchers often start with a theory and, using deductive reasoning, make predictions about how phenomena would behave in the real world if the theory were valid. The specific predictions are then tested. In qualitative studies, theory often is the product of the research: The investigators use information from study participants inductively to develop a theory rooted in the participants’ experiences.

TIP The reasoning process of deduction is associated with quantitative research, and induction is associated with qualitative research. The supplement for Chapter 3 on website explains and illustrates the distinction.

Variables In quantitative studies, concepts are usually called variables. A variable, as the name implies, is something that varies. Weight, anxiety, and fatigue are all variables—they vary from one person to another. Most human characteristics are variables. If everyone weighed 150 pounds, weight would not be a variable; it would be a constant. But it is precisely because people and conditions do vary that most research is conducted. Quantitative researchers seek to understand how or why things vary and to learn how differences in one variable relate to differences in another. For example, in lung cancer research, lung cancer is a variable because not everybody has this disease. Researchers have studied factors that might be linked to lung cancer, such as cigarette smoking. Smoking is also a variable because not everyone smokes. A variable, then, is any quality of a person, group, or situation that varies or takes on different values. Variables are the central building blocks of quantitative studies.

TIP Every study focuses on one or more phenomena, concepts, or variables, but these terms per se are not necessarily used in research reports. For example, a report might say, “The purpose of this study is to examine the effect of nurses’ workload on hand hygiene compliance.” Although the researcher did not explicitly label anything a variable, the variables under study are workload and hand hygiene compliance. Key concepts or variables are often indicated in the study title.

Characteristics of Variables Variables are often inherent human traits, such as age or weight, but sometimes researchers create a variable. For example, if a researcher tests the effectiveness of patient-controlled analgesia compared to intramuscular analgesia in relieving pain after surgery, some patients would be given one type of analgesia, and some would receive

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the other. In the context of this study, method of pain management is a variable because different patients are given different analgesic methods.

Some variables take on a wide range of values that can be represented on a continuum (e.g., a person’s age or weight). Other variables take on only a few values; sometimes such variables convey quantitative information (e.g., number of children), but others simply involve placing people into categories (e.g., male, female, other; or blood type A, B, AB, or O).

Dependent and Independent Variables As noted in Chapter 1, many studies seek to understand causes of phenomena. Does a nursing intervention cause improvements in patient outcomes? Does smoking cause lung cancer? The presumed cause is the independent variable, and the presumed effect is the dependent or outcome variable. The dependent variable is the outcome that researchers want to understand, explain, or predict. In terms of the PICO scheme discussed in Chapter 2, the dependent variable corresponds to the “O” (outcome). The independent variable corresponds to the “I” (the intervention, influence, or exposure), plus the “C” (the comparison).

TIP In searching for evidence, a nurse might want to learn about the effects of an intervention or influence (I), compared to any alternative, on a designated outcome. In a cause-probing study, however, researchers always specify what the comparative intervention or influence (the “C”) is.

The terms independent variable and dependent variable also can be used to indicate direction of influence rather than cause and effect. For example, suppose we compared levels of depression among men and women diagnosed with pancreatic cancer and found men to be more depressed. We could not conclude that depression was caused by gender. Yet the direction of influence clearly runs from gender to depression: It makes no sense to suggest that patient’s depression influenced their gender. In this situation, it is appropriate to consider depression as the outcome variable and gender as the independent variable.

TIP Few research reports explicitly label variables as dependent and independent. Moreover, variables (especially independent variables) are sometimes not fully spelled out. Take the following research question: What is the effect of exercise on heart rate? In this example, heart rate is the dependent variable. Exercise, however, is not in itself a variable. Rather, exercise versus something else (e.g., no exercise) is a variable; “something else” is implied rather than stated in the research question.

Many outcomes have multiple causes or influences. If we were studying factors that

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influence people’s body mass index, the independent variables might be height, physical activity, and diet. And, two or more outcome variables may be of interest. For example, a researcher may compare two alternative dietary interventions in terms of participants’ weight, lipid profile, and self-esteem. It is common to design studies with multiple independent and dependent variables.

Variables are not inherently dependent or independent. A dependent variable in one study could be an independent variable in another. For example, a study might examine the effect of an exercise intervention (the independent variable) on osteoporosis (the dependent variable) to answer a therapy question. Another study might investigate the effect of osteoporosis (the independent variable) on bone fracture incidence (the dependent variable) to address a prognosis question. In short, whether a variable is independent or dependent is a function of the role that it plays in a particular study.

Example of independent and dependent variables Research question (Etiology/Harm question): Among heart failure patients, is reduced gray matter volume (as measured through magnetic resonance imagery) associated with poorer performance in instrumental activities of daily living? (Alosco et al., 2016).

Independent variable: Volume of gray matter in the brain Dependent variable: Performance in instrumental activities of daily living

Conceptual and Operational Definitions The concepts of interest to researchers are abstractions, and researchers’ worldviews shape how those concepts are defined. A conceptual definition is the theoretical meaning of a concept. Researchers need to conceptually define even seemingly straightforward terms. A classic example is the concept of caring. Morse and colleagues (1990) examined how researchers and theorists defined caring and identified five categories of conceptual definitions: as a human trait, a moral imperative, an affect, an interpersonal relationship, and a therapeutic intervention. Researchers undertaking studies of caring need to clarify how they conceptualized it.

In qualitative studies, conceptual definitions of key phenomena may be a major end product, reflecting an intent to have the meaning of concepts defined by those being studied. In quantitative studies, however, researchers must define concepts at the outset because they must decide how the variables will be measured. An operational definition indicates what the researchers specifically must do to measure the concept and collect needed information.

Readers of research articles may not agree with how researchers conceptualized and operationalized variables. However, definitional precision is important in communicating what concepts mean within the context of the study.

Example of conceptual and operational definitions

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Stoddard and colleagues (2015) studied the relationship between young adolescents’ hopeful future expectations on the one hand and bullying on the other. The researchers defined bullying conceptually as “intentional aggressive behaviors that are repetitive and impose a power imbalance between students who bully and students who are victimized” (p. 422). They operationalized bullying behavior by asking a set of 12 questions. One question asked how often in the past month did the study participant “say things about another student to make others laugh?” (p. 426). Participants were asked to respond on a scale from 0 (never) to 5 (five or more times).

Data Research data (singular, datum) are the pieces of information gathered in a study. In quantitative studies, researchers identify and define their variables and then collect relevant data from subjects. The actual values of the study variables constitute the data. Quantitative researchers collect primarily quantitative data—information in numeric form. For example, if we conducted a quantitative study in which a key variable was depression, we would need to measure how depressed participants were. We might ask, “Thinking about the past week, how depressed would you say you have been on a scale from 0 to 10, where 0 means ‘not at all’ and 10 means ‘the most possible’?” Box 3.1 presents quantitative data for three fictitious people. The subjects provided a number along the 0 to 10 continuum corresponding to their degree of depression—9 for subject 1 (a high level of depression), 0 for subject 2 (no depression), and 4 for subject 3 (little depression).

Box 3.1 Example of Quantitative Data

Question: Tell me about how you’ve been feeling lately—have you felt sad or depressed at all, or have you generally been in good spirits?

Data: 9 (Subject 1) 0 (Subject 2) 4 (Subject 3)

In qualitative studies, researchers collect primarily qualitative data, that is, narrative descriptions. Narrative data can be obtained by conversing with participants, by making notes about their behavior in naturalistic settings, or by obtaining narrative records, such as diaries. Suppose we were studying depression qualitatively. Box 3.2 presents qualitative data for three participants responding conversationally to the question “Tell me about how you’ve been feeling lately—have you felt sad or depressed at all, or have you generally been in good spirits?” Here, the data consist of rich narrative descriptions of participants’ emotional state. In reports on qualitative studies, researchers include excerpts from their narrative data to support their interpretations.

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Box 3.2 Example of Qualitative Data

Question: Tell me about how you’ve been feeling lately—have you felt sad or depressed at all, or have you generally been in good spirits?

Data: “Well, actually, I’ve been pretty depressed lately, to tell you the truth. I wake up each morning and I can’t seem to think of anything to look forward to. I mope around the house all day, kind of in despair. I just can’t seem to shake the blues and I’ve begun to think I need to go see a shrink.” (Participant 1)

“I can’t remember ever feeling better in my life. I just got promoted to a new job that makes me feel like I can really get ahead in my company. And I’ve just gotten engaged to a really great guy who is very special.” (Participant 2)

“I’ve had a few ups and downs the past week but basically things are on a pretty even keel. I don’t have too many complaints.” (Participant 3)

Relationships Researchers usually study phenomena in relation to other phenomena—they examine relationships. A relationship is a connection between phenomena; for example, researchers repeatedly have found that there is a relationship between frequency of turning bedridden patients and the incidence of pressure ulcers. Quantitative and qualitative studies examine relationships in different ways.

In quantitative studies, researchers are interested in the relationship between independent variables and outcomes. Relationships are often explicitly expressed in quantitative terms, such as more than or less than. For example, consider a person’s weight as our outcome variable. What variables are related to (associated with) a person’s weight? Some possibilities include height, caloric intake, and exercise. For each independent variable, we can make a prediction about its relationship to the outcome:

Height: Tall people will weigh more than short people. Caloric intake: People with high caloric intake will be heavier than those with low

caloric intake. Exercise: The lower the amount of exercise, the greater will be the person’s weight.

Each statement expresses a predicted relationship between weight (the outcome) and a measurable independent variable. Most quantitative research is conducted to assess whether relationships exist among variables and to measure how strong the relationship is.

TIP Relationships are expressed in two basic forms. First, relationships can

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be expressed as “if more of Variable X, then more of (or less of) Variable Y.” For example, there is a relationship between height and weight: With greater height, there tends to be greater weight, i.e., tall people tend to weigh more than short people. The second form involves relationships expressed as group differences. For example, there is a relationship between gender and height: Men tend to be taller than women.

Variables can be related to one another in different ways, including cause-and- effect (or causal) relationships. Within the positivist paradigm, natural phenomena are assumed to have antecedent causes that are discoverable. For example, we might speculate that there is a causal relationship between caloric intake and weight: All else being equal, eating more calories causes greater weight. As noted in Chapter 1, many quantitative studies are cause-probing—they seek to illuminate the causes of phenomena.

Example of a study of causal relationships Bench and colleagues (2015) studied whether a critical care discharge information pack for patients and their families would result in improved psychological well- being (anxiety and depression) 5 days and 28 days after discharge.

Not all relationships can be interpreted as causal. There is a relationship, for example, between a person’s pulmonary artery and tympanic temperatures: People with high readings on one tend to have high readings on the other. We cannot say, however, that pulmonary artery temperature caused tympanic temperature or vice versa. This type of relationship is sometimes referred to as an associative (or functional) relationship rather than a causal one.

Example of a study of associative relationships Goh and colleagues (2016) studied factors associated with patients’ degree of satisfaction with nursing care. They found significant differences in satisfaction in different ethnic subgroups.

Qualitative researchers are not concerned with quantifying relationships or in testing and confirming causal relationships. Rather, qualitative researchers may seek patterns of association as a way of illuminating the underlying meaning and dimensionality of phenomena of interest. Patterns of interconnected concepts are identified as a means of understanding the whole.

Example of a qualitative study of patterns Brooten and colleagues (2016) studied rituals of White, Black, and Hispanic parents after the intensive care unit (ICU) death of an infant or child. They reported that the

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grieving parents’ experiences differed on two important factors: (1) whether or not the parents were recent immigrants to the United States with language barriers and (2) level of family support systems.

MAJOR CLASSES OF QUANTITATIVE AND QUALITATIVE RESEARCH Researchers usually work within a paradigm that is consistent with their worldview and that gives rise to the types of question that excite their curiosity. In this section, we briefly describe broad categories of quantitative and qualitative research.

Quantitative Research: Experimental and Nonexperimental Studies A basic distinction in quantitative studies is between experimental and nonexperimental research. In experimental research, researchers actively introduce an intervention or treatment—most often, to address therapy questions. In nonexperimental research, on the other hand, researchers are bystanders—they collect data without introducing treatments (most often, to address etiology, prognosis, or diagnosis questions). For example, if a researcher gave bran flakes to one group of subjects and prune juice to another to evaluate which method facilitated elimination more effectively, the study would be experimental because the researcher intervened. If, on the other hand, a researcher compared elimination patterns of two groups whose regular eating patterns differed, the study would be nonexperimental because there is no intervention. In medical and epidemiological research, experimental studies usually are called clinical trials, and nonexperimental inquiries are called observational studies.

Experimental studies are explicitly designed to test causal relationships—to test whether an intervention caused changes in the outcome. Sometimes, nonexperimental studies also explore causal relationships, but causal inferences in nonexperimental research are tricky and less conclusive, for reasons we explain in a later chapter.

Example of experimental research In their experimental study, Demirel and Guler (2015) tested the efficacy of uterine stimulation and nipple stimulation on birth duration and the incidence of synthetic induction among women giving birth by vaginal delivery. Some study participants received nipple stimulation, others received uterine stimulation, and some received neither.

In this example, the researchers intervened by designating that some women would receive one of two interventions and that others would receive no special intervention. In other words, the researcher controlled the independent variable, which in this case

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was the stimulation interventions.

Example of nonexperimental research Lai and colleagues (2015) compared women who had vaginal births and those who had cesarean births in terms of postpartum fatigue and maternal–infant attachment. Women with a cesarean delivery had higher fatigue, which in turn was associated with weaker maternal–infant attachment.

In this nonexperimental study to address a prognosis question, the researchers did not intervene in any way. They were interested in a similar population as in the previous example (women giving birth), but their intent was to explore relationships among existing conditions rather than to test a potential solution to a problem.

Qualitative Research: Disciplinary Traditions Many qualitative nursing studies are rooted in research traditions that originated in anthropology, sociology, and psychology. Three such traditions are briefly described here. Chapter 11 provides a fuller discussion of these and other traditions and the methods associated with them.

The grounded theory tradition seeks to describe and understand key social psychological processes. Grounded theory was developed in the 1960s by two sociologists, Glaser and Strauss (1967). The focus of most grounded theory studies is on a developing social experience—the social and psychological phases that characterize a particular event or episode. A major component of grounded theory is the discovery of a core variable that is central in explaining what is going on in that social scene. Grounded theory researchers strive to generate explanations of phenomena that are grounded in reality.

Example of a grounded theory study Keogh and colleagues (2015) used grounded theory methods to understand how mental health service users transitioned home from a hospital stay. The researchers found that the core variable was the patients’ management of preconceived expectations.

Phenomenology is concerned with the lived experiences of humans. Phenomenology is an approach to thinking about what life experiences of people are like and what they mean. The phenomenological researcher asks the questions: What is the essence of this phenomenon as experienced by these people? or What is the meaning of the phenomenon to those who experience it?

Example of a phenomenological study Tornøe and colleagues (2015) used a phenomenological approach in their study of

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nurses’ experiences with spiritual and existential care for dying patients in a general hospital.

Ethnography, the primary research tradition in anthropology, provides a framework for studying the patterns and lifeways of a defined cultural group in a holistic fashion. Ethnographers typically engage in extensive fieldwork, often participating to the extent possible in the life of the culture under study. Ethnographers strive to learn from members of a cultural group, to understand their worldview, and to describe their customs and norms.

Example of an ethnographic study Sandvoll and colleagues (2015) used ethnographic methods to explore how nursing home staff members managed unpleasant resident behaviors in two public nursing homes in Norway.

MAJOR STEPS IN A QUANTITATIVE STUDY In quantitative studies, researchers move from the beginning point of a study (posing a question) to the end point (obtaining an answer) in a reasonably linear sequence of steps that is broadly similar across studies (Fig. 3.1). This section describes that flow, and the next section describes how qualitative studies differ.

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Phase 1: The Conceptual Phase The early steps in a quantitative study typically involve activities with a strong conceptual element. During this phase, researchers call on such skills as creativity, deductive reasoning, and a grounding in research evidence on the topic of interest.

Step 1: Formulating and Delimiting the Problem Quantitative researchers begin by identifying an interesting research problem and formulating research questions. The research questions identify what the study variables are. In developing questions, nurse researchers must attend to substantive issues (Is this problem important?), theoretical issues (Is there a conceptual framework

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for this problem?), clinical issues (Will findings be useful in clinical practice?), methodologic issues (How can this question be answered to yield high-quality evidence?), and ethical issues (Can this question be addressed in an ethical manner?).

Step 2: Reviewing the Related Literature Quantitative research is conducted within the context of previous knowledge. Quantitative researchers typically strive to understand what is already known about a topic by undertaking a thorough literature review before any data are collected.

Step 3: Undertaking Clinical Fieldwork Researchers embarking on a clinical study often benefit from spending time in relevant clinical settings (in the field), discussing the topic with clinicians and observing current practices. Such clinical fieldwork can provide perspectives on clinicians’ and clients’ viewpoints.

Step 4: Defining the Framework and Developing Conceptual Definitions When quantitative research is performed within the context of a theoretical framework, the findings may have broader significance and utility. Even when the research question is not embedded in a theory, researchers should have a conceptual rationale and a clear vision of the concepts under study.

Step 5: Formulating Hypotheses Hypotheses state researchers’ expectations about relationships between study variables. Hypotheses are predictions of the relationships researchers expect to observe in the study data. The research question identifies the concepts of interest and asks how the concepts might be related; a hypothesis is the predicted answer. Most quantitative studies are designed to test hypotheses through statistical analysis.

Phase 2: The Design and Planning Phase In the second major phase of a quantitative study, researchers decide on the methods they will use to address the research question. Researchers make many methodologic decisions that have crucial implications for the quality of the study evidence.

Step 6: Selecting a Research Design The research design is the overall plan for obtaining answers to the research questions. Quantitative designs tend to be structured and controlled, with the goal of minimizing bias. Research designs also indicate how often data will be collected and what types of comparisons will be made. The research design is the architectural backbone of the study.

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Step 7: Developing Protocols for the Intervention In experimental research, researchers create the independent variable, which means that participants are exposed to different treatments. An intervention protocol for the study must be developed, specifying exactly what the intervention will entail (e.g., who will administer it, over how long a period the treatment will last, and so on) and what the alternative condition will be. In nonexperimental research, this step is not necessary.

Step 8: Identifying the Population Quantitative researchers need to specify what characteristics study participants should possess—that is, they must identify the population to be studied. A population is all the individuals or objects with common, defining characteristics (the “P” component in PICO questions).

Step 9: Designing the Sampling Plan Researchers typically collect data from a sample, which is a subset of the population. The researcher’s sampling plan specifies how the sample will be selected and how many subjects there will be. The goal is to have a sample that adequately reflects the population’s traits.

Step 10: Specifying Methods to Measure Variables Quantitative researchers must find methods to measure the research variables accurately. A variety of quantitative data collection approaches exist; the primary methods are self-reports (e.g., interviews and questionnaires), observations (e.g., watching and recording people’s behavior), and biophysiologic measurements. The task of measuring research variables and developing a data collection plan is complex and challenging.

Step 11: Developing Methods to Safeguard Human/Animal Rights Most nursing research involves human subjects, although some involve animals. In either case, procedures need to be developed to ensure that the study adheres to ethical principles.

Step 12: Reviewing and Finalizing the Research Plan Before collecting data, researchers often undertake assessments to ensure that procedures will work smoothly. For example, they may evaluate the readability of written materials to see if participants with low reading skills can comprehend them. Researchers usually have their research plan critiqued by reviewers to obtain clinical or methodologic feedback. Researchers seeking financial support submit a proposal to a funding source, and reviewers usually suggest improvements.

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Phase 3: The Empirical Phase The third phase of quantitative studies involves collecting the research data. This phase is often the most time-consuming part of the study. Data collection may require months of work.

Step 13: Collecting the Data The actual collection of data in a quantitative study often proceeds according to a preestablished plan. The plan typically spells out procedures for training data collection staff, for actually collecting data (e.g., where and when the data will be gathered), and for recording information.

Step 14: Preparing the Data for Analysis Data collected in a quantitative study must be prepared for analysis. For example, one preliminary step is coding, which involves translating verbal data into numeric form (e.g., coding gender information as “1” for females, “2” for males, and “3” for other).

Phase 4: The Analytic Phase Quantitative data must be subjected to analysis and interpretation, which occur in the fourth major phase of a project.

Step 15: Analyzing the Data To answer research questions and test hypotheses, researchers analyze their data in a systematic fashion. Quantitative data are analyzed through statistical analyses, which include some simple procedures (e.g., computing an average) as well as more complex, sophisticated methods.

Step 16: Interpreting the Results Interpretation involves making sense of study results and examining their implications. Researchers attempt to explain the findings in light of prior evidence, theory, and clinical experience and in light of the adequacy of the methods they used in the study. Interpretation also involves coming to conclusions about the clinical significance of the new evidence.

Phase 5: The Dissemination Phase In the analytic phase, researchers come full circle: The questions posed at the outset are answered. The researchers’ job is not completed, however, until study results are disseminated.

Step 17: Communicating the Findings A study cannot contribute evidence to nursing practice if the results are not

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communicated. Another—and often final—task of a research project is the preparation of a research report that can be shared with others. We discuss research reports in the next chapter.

Step 18: Putting the Evidence Into Practice Ideally, the concluding step of a high-quality study is to plan for its use in practice settings. Although nurse researchers may not implement a plan for using research findings, they can contribute to the process by developing recommendations on how the evidence could be used in practice, by ensuring that adequate information has been provided for a meta-analysis, and by pursuing opportunities to disseminate the findings to practicing nurses.

ACTIVITIES IN A QUALITATIVE STUDY Quantitative research involves a fairly linear progression of tasks—researchers plan what steps to take and then follow those steps. In qualitative studies, by contrast, the progression is closer to a circle than to a straight line. Qualitative researchers continually examine and interpret data and make decisions about how to proceed based on what has been discovered (Fig. 3.2).

Because qualitative researchers have a flexible approach, we cannot show the flow of activities precisely—the flow varies from one study to another, and researchers themselves may not know in advance how the study will unfold. We provide a general sense of qualitative studies by describing major activities and indicating when they might be performed.

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Conceptualizing and Planning a Qualitative Study Identifying the Research Problem Qualitative researchers usually begin with a broad topic, often focusing on an aspect about which little is known. Qualitative researchers often proceed with a fairly broad initial question that allows the focus to be sharpened and delineated more clearly once the study is underway.

Doing a Literature Review Some qualitative researchers avoid consulting the literature before collecting data. They worry that prior studies might influence the conceptualization of the phenomenon under study, which they believe should be based on participants’ viewpoints rather than on prior findings. Others believe that researchers should conduct at least a brief literature review at the outset. In any case, qualitative researchers typically find a relatively small body of relevant previous work because of the type of questions they ask.

Selecting and Gaining Entrée Into Research Sites Before going into the field, qualitative researchers must identify an appropriate site. For example, if the topic is the health beliefs of the urban poor, an inner-city neighborhood with a concentration of low-income residents must be identified. In some cases, researchers may have access to the selected site, but in others, they need to gain entrée into it. Gaining entrée typically involves negotiations with gatekeepers who have the authority to permit entry into their world.

TIP The process of gaining entrée is usually associated with doing fieldwork in qualitative studies, but quantitative researchers often need to gain entrée into sites for collecting data as well.

Developing an Overall Approach Quantitative researchers do not collect data before finalizing their research design. Qualitative researchers, by contrast, use an emergent design that materializes during data collection. Certain design features are guided by the study’s qualitative tradition, but qualitative studies rarely have rigid designs that prohibit changes while in the field.

Addressing Ethical Issues Qualitative researchers must also develop plans for addressing ethical issues—and, indeed, there are special concerns in qualitative studies because of the more intimate nature of the relationship that typically develops between researchers and participants.

Conducting a Qualitative Study

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In qualitative studies, the tasks of sampling, data collection, data analysis, and interpretation typically take place iteratively. Qualitative researchers begin by talking with people with firsthand experience with the phenomenon under study. The discussions and observations are loosely structured, allowing participants to express a full range of beliefs, feelings, and behaviors. Analysis and interpretation are ongoing activities that guide choices about “next steps.”

The process of data analysis involves clustering together related narrative information into a coherent scheme. Through inductive reasoning, researchers identify themes and categories, which are used to build a rich description or theory of the phenomenon. Data gathering becomes increasingly purposeful: As conceptualizations develop, researchers seek participants who can confirm and enrich theoretical understandings as well as participants who can potentially challenge them.

Quantitative researchers decide in advance how many subjects to include in the study, but qualitative researchers’ sampling decisions are guided by the data. Many qualitative researchers use the principle of saturation, which occurs when participants’ accounts about their experiences become redundant, such that no new information can be gleaned by further data collection.

Quantitative researchers seek to collect high-quality data by measuring their variables with instruments that have been demonstrated to be accurate and valid. Qualitative researchers, by contrast, are the main data collection instrument and must take steps to demonstrate the trustworthiness of the data. The central feature of these efforts is to confirm that the findings accurately reflect the viewpoints of participants rather than researchers’ perceptions. One confirmatory activity, for example, involves going back to participants, sharing preliminary interpretations with them, and asking them to evaluate whether the researcher’s thematic analysis is consistent with their experiences.

Qualitative nursing researchers also strive to share their findings at conferences and in journal articles. Qualitative studies help to shape nurses’ perceptions of a problem, their conceptualizations of potential solutions, and their understanding of patients’ concerns and experiences.

TIP An emerging trend is for researchers to design mixed methods (MM) studies that involve the collection, analysis, and integration of quantitative and qualitative data. Mixed methods research is discussed in Chapter 13.

GENERAL QUESTIONS IN REVIEWING A STUDY Box 3.3 presents some further suggestions for performing a preliminary overview of a research report, drawing on concepts explained in this chapter. These guidelines supplement those presented in Box 1.1 (see Chapter 1).

Box 3.3 Additional Questions for a Preliminary Review of a Study

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1. What was the study all about? What were the main phenomena, concepts, or constructs under investigation?

2. If the study was quantitative, what were the independent and dependent variables? 3. Did the researcher examine relationships or patterns of association among

variables or concepts? Did the report imply the possibility of a causal relationship? 4. Were key concepts defined, both conceptually and operationally? 5. What type of study does it appear to be, in terms of types described in this chapter

—experimental or nonexperimental/observational? Grounded theory, phenomenologic, or ethnographic?

6. Did the report provide information to suggest how long the study took to complete?

In this section, we illustrate the progression of activities and discuss the time schedule of a study conducted by the second author of this book. Read the research summary and then answer the critical thinking questions that follow, referring to the full research report if necessary. Example 1 is featured in our interactive Critical Thinking Activity on website. The critical thinking questions for Examples 2 and 3 are based on the studies that appear in their entirety in Appendices A and B of this book. Our comments for these exercises are in the Student Resources section on .

EXAMPLE 1: PROJECT SCHEDULE FOR A QUANTITATIVE STUDY Study: Postpartum depressive symptomatology: Results from a two-stage U.S. national survey (Beck et al., 2011)

Study Purpose: Beck and colleagues (2011) undertook a study to estimate the prevalence of mothers with elevated postpartum depressive (PPD) symptom levels in the United States and factors associated with differences in symptom levels.

Study Methods: This study took a little less than 3 years to complete. Key activities and methodological decisions included the following:

Phase 1. Conceptual Phase: 1 Month. Beck had been a member of the Listening to Mothers II National Advisory Council. The data for their national survey (the Childbirth Connection: Listening to Mothers II U.S. National Survey) had already been collected when Beck was approached to analyze the variables in the survey relating to PPD symptoms. The first phase

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took only 1 month because data collection was already completed, and Beck, a world expert on PPD, just needed to update a review of the literature.

Phase 2. Design and Planning Phase: 3 Months. The design phase entailed identifying which of the hundreds of variables on the national survey the researchers would focus on in their analysis. Also, their research questions were formalized during this phase. Approval from a human subjects committee also was obtained during this phase.

Phase 3. Empirical Phase: 0 Months. In this study, the data from nearly 1,000 postpartum women had already been collected.

Phase 4. Analytic Phase: 12 Months. Statistical analyses were performed to (1) estimate the percentage of new mothers experiencing elevated PPD symptom levels and (2) identify which demographic, antepartum, intrapartum, and postpartum variables were significantly related to elevated symptom levels.

Phase 5. Dissemination Phase: 18 Months. The researchers prepared and submitted their report to the Journal of Midwifery & Women’s Health for possible publication. It was accepted within 5 months and was “in press” (awaiting publication) another 4 months before being published. The article received the Journal of Midwifery & Women’s Health 2012 Best Research Article Award.

Critical Thinking Exercises 1. Answer the relevant questions from Box 3.3 regarding this study. 2. Also consider the following targeted questions:

a. Could the data for this study have been collected anonymously? b. Comment on the appropriateness of the participant stipend in this study. c. Do you think an appropriate amount of time was allocated to the various

phases and steps in this study? d. Would it have been appropriate for the researchers to address the

research question using qualitative research methods? Why or why not?

EXAMPLE 2: QUANTITATIVE RESEARCH IN APPENDIX A • Read the abstract and introduction of Swenson and colleagues’ (2016)

study (“Parents’ use of praise and criticism in a sample of young children seeking mental health services”) in Appendix A of this book.

Critical Thinking Exercises 1. Answer the relevant questions from Box 3.3 regarding this study. 2. Also consider the following targeted questions:

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a. Comment on the composition of the research team for this study. b. Did this report present any actual data from the study participants? c. Would it have been possible for the researchers to use an experimental

design for this study?

EXAMPLE 3: QUALITATIVE RESEARCH IN APPENDIX B • Read the abstract and the introduction of Beck and Watson’s (2010) study

(“Subsequent childbirth after a previous traumatic birth”) in Appendix B of this book.

Critical Thinking Exercises 1. Answer the relevant questions from Box 3.3 regarding this study. 2. Also consider the following targeted questions:

a. Find an example of actual data in this study. (You will need to look at the “Results” section of this study.)

b. How long did it take Beck and Watson to collect the data for this study? (You will find this information in the “Procedure” section.)

c. How much time elapsed between when the paper was accepted for publication and when it was actually published? (You will find relevant information at the end of the paper.)

WANT TO KNOW MORE? A wide variety of resources to enhance your learning and understanding of this chapter are available on .

• Interactive Critical Thinking Activity • Chapter Supplement on Deductive and Inductive Reasoning • Answers to the Critical Thinking Exercises for Examples 2 and 3 • Internet Resources with useful websites for Chapter 3 • A Wolters Kluwer journal article in its entirety—the study by Alosco et

al., described on p. 44.

Additional study aids, including eight journal articles and related questions, are also available in Study Guide for Essentials of Nursing Research, 9e.

Summary Points

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The people who provide information to the researchers in a study are called subjects or study participants in quantitative research or study participants or informants in qualitative research; collectively, they comprise the sample.

The site is the location for the research; researchers sometimes engage in multisite studies.

Researchers investigate concepts and phenomena (or constructs), which are abstractions inferred from people’s behavior or characteristics.

Concepts are the building blocks of theories, which are systematic explanations of some aspect of the real world.

In quantitative studies, concepts are called variables. A variable is a characteristic or quality that takes on different values (i.e., varies from one person or object to another).

The dependent (or outcome) variable is the behavior, characteristic, or outcome the researcher is interested in explaining, predicting, or affecting (the “O” in the PICO scheme). The independent variable is the presumed cause of or influence on the dependent variable. The independent variable corresponds to the “I” and the “C” components in the PICO scheme.

A conceptual definition describes the abstract meaning of a concept being studied. An operational definition specifies how the variable will be measured.

Data—the information collected during the course of a study—may take the form of numeric values (quantitative data) or narrative information (qualitative data).

A relationship is a connection (or pattern of association) between variables. Quantitative researchers study the relationship between independent variables and outcome variables.

When the independent variable causes or affects the outcome, the relationship is a cause-and-effect (or causal) relationship. In an associative (or functional) relationship, variables are related in a noncausal way.

A key distinction in quantitative studies is between experimental research, in which researchers actively intervene to test an intervention or therapy, and nonexperimental (or observational) research, in which researchers collect data about existing phenomena without intervening.

Qualitative research often is rooted in research traditions that originate in other disciplines. Three such traditions are grounded theory, phenomenology, and ethnography.

Grounded theory seeks to describe and understand key social psychological processes that occur in a social setting.

Phenomenology focuses on the lived experiences of humans and is an approach to gaining insight into what the life experiences of people are like and what they mean.

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Ethnography provides a framework for studying the meanings, patterns, and lifeways of a culture in a holistic fashion.

In a quantitative study, researchers usually progress in a linear fashion from asking research questions to answering them. The main phases in a quantitative study are the conceptual, planning, empirical, analytic, and dissemination phases.

The conceptual phase involves (1) defining the problem to be studied, (2) doing a literature review, (3) engaging in clinical fieldwork for clinical studies, (4) developing a framework and conceptual definitions, and (5) formulating hypotheses to be tested.

The planning phase entails (6) selecting a research design, (7) developing intervention protocols if the study is experimental, (8) specifying the population, (9) developing a plan to select a sample, (10) specifying a data collection plan and methods to measure variables, (11) developing strategies to safeguard subjects’ rights, and (12) finalizing the research plan.

The empirical phase involves (13) collecting data and (14) preparing data for analysis (e.g., coding data).

The analytic phase involves (15) performing statistical analyses and (16) interpreting the results.

The dissemination phase entails (17) communicating the findings and (18) promoting the use of the study evidence in nursing practice.

The flow of activities in a qualitative study is more flexible and less linear. Qualitative studies typically involve an emergent design that evolves during data collection.

Qualitative researchers begin with a broad question regarding a phenomenon of interest, often focusing on a little-studied aspect. In the early phase of a qualitative study, researchers select a site and seek to gain entrée into it, which typically involves enlisting the cooperation of gatekeepers within the site.

Once in the field, researchers select informants, collect data, and then analyze and interpret them in an iterative fashion; experiences during data collection help in an ongoing fashion to shape the design of the study.

Early analysis in qualitative research leads to refinements in sampling and data collection, until saturation (redundancy of information) is achieved. Analysis typically involves a search for critical themes or categories.

Both quantitative and qualitative researchers disseminate their findings, most often by publishing their research reports in professional journals.

REFERENCES FOR CHAPTER 3 **Alosco, M., Brickman, A., Spitznagel, M., Narkhede, A., Griffith, E., Cohen, R., . . . Gunstad, J. (2016).

Reduced gray matter volume is associated with poorer instrumental activities of daily living performance in heart failure. Journal of Cardiovascular Nursing, 31, 31–41.

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Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Postpartum depressive symptomatology: Results from a two-stage U.S. national survey. Journal of Midwifery & Women’s Health, 56, 427–435.

*Bench, S., Day, T., Heelas, K., Hopkins, P., White, C., & Griffiths, P. (2015). Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: A pilot cluster randomised controlled trial. BMJ Open, 5(11), e006852.

Brooten, D., Youngblut, J. M., Charles, D., Roche, R., Hidalgo, I., & Malkawi, F. (2016). Death rituals reported by White, Black, and Hispanic parents following the ICU death of an infant or child. Journal of Pediatric Nursing, 31, 132–140.

Demirel, G., & Guler, H. (2015). The effect of uterine and nipple stimulation on induction with oxytocin and the labor process. Worldviews on Evidence-Based Nursing, 12, 273–280.

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Piscataway, NJ: Aldine.

Goh, M. L., Ang, E. N., Chan, Y., He, H. G., & Vehviläinen-Julkunen, K. (2016). A descriptive quantitative study on multi-ethnic patient satisfaction with nursing care as measured by the Revised Humane Caring Scale. Applied Nursing Research, 31, 126–131.

Keogh, B., Callaghan, P., & Higgins, A. (2015). Managing preconceived expectations: Mental health service users’ experiences of going home from hospital: A grounded theory study. Journal of Psychiatric and Mental Health Nursing, 22, 715–723.

Lai, Y., Hung, C., Stocker, J., Chan, T., & Liu, Y. (2015). Postpartum fatigue, baby-care activities, and maternal- infant attachment of vaginal and cesarean births following rooming-in. Applied Nursing Research, 28, 116–120.

Morse, J. M., Solberg, S. M., Neander, W. L., Bottorff, J. L., & Johnson, J. L. (1990). Concepts of caring and caring as a concept. Advances in Nursing Science, 13, 1–14.

*Sandvoll, A., Grov, E., Kristoffersen, K., & Hauge, S. (2015). When care situations evoke difficult emotions in nursing staff members: An ethnographic study in two Norwegian nursing homes. BMC Nursing, 14, 40.

Stoddard, S., Varela, J., & Zimmerman, M. (2015). Future expectations, attitude toward violence, and bullying perpetration during early adolescence: A mediation evaluation. Nursing Research, 64, 422–433.

*Tornøe, K., Danbolt, L., Kvigne, K., & Sørlie, V. (2015). The challenge of consolation: Nurses’ experiences with spiritual and existential care for the dying—a phenomenological hermeneutical study. BMC Nursing, 14, 62.

*A link to this open-access article is provided in the Internet Resources section on website.

**This journal article is available on for this chapter.

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4 Reading and Critiquing Research Articles

Learning Objectives On completing this chapter, you will be able to:

Identify and describe the major sections in a research journal article Characterize the style used in quantitative and qualitative research reports Read a research article and broadly grasp its “story” Describe aspects of a research critique Understand the many challenges researchers face and identify some tools for

addressing methodologic challenges Define new terms in the chapter

Key Terms Abstract Bias Blinding Confounding variable Credibility Critique Findings IMRAD format Inference Journal article Level of significance p Placebo Randomness Reflexivity Reliability Research control Scientific merit

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Statistical significance Statistical test Transferability Triangulation Trustworthiness Validity

Evidence from nursing studies is communicated through research reports that describe what was studied, how it was studied, and what was found. Research reports are often daunting to readers without research training. This chapter aims to make research reports more accessible and also provides some guidance regarding critiques of research reports.

TYPES OF RESEARCH REPORTS Nurses are most likely to encounter research evidence in journals or at professional conferences. Research journal articles are descriptions of studies published in professional journals. Competition for journal space is keen, so research articles are brief—generally only 10 to 20 double-spaced pages. This means that researchers must condense a lot of information about the study into a short report.

Usually, manuscripts are reviewed by two or more peer reviewers (other researchers) who make recommendations about acceptance of or revisions to the manuscript. Reviews are usually blind—reviewers are not told researchers’ names, and authors are not told reviewers’ names. Consumers thus have some assurance that journal articles have been vetted by other impartial nurse researchers. Nevertheless, publication does not mean that the findings can be uncritically accepted. Research method courses help nurses to evaluate the quality of evidence reported in journal articles.

At conferences, research findings are presented as oral presentations or poster sessions. In an oral presentation, researchers are typically allotted 10 to 20 minutes to describe key features of their study to an audience. In poster sessions, many researchers simultaneously present visual displays summarizing their studies, and conference attendees walk around the room looking at the displays. Conferences offer an opportunity for dialogue: Attendees can ask questions to help them better understand what the findings mean; moreover, they can offer the researchers suggestions relating to clinical implications of the study. Thus, professional conferences are a valuable forum for clinical audiences.

THE CONTENT OF RESEARCH JOURNAL ARTICLES Many research articles follow an organization called the IMRAD format. This format organizes content into four main sections—Introduction, Method, Results, and

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Discussion. The paper is preceded by a title and an abstract and concludes with references.

The Title and Abstract Research reports have titles that succinctly convey key information. In qualitative studies, the title normally includes the central phenomenon and group under investigation. In quantitative studies, the title communicates key variables and the population (in other words, PICO components).

The abstract is a brief description of the study placed at the beginning of the article. The abstract answers questions like the following: What were the research questions? What methods were used to address those questions? What were the findings? and What are the implications for nursing practice? Readers can review an abstract to judge whether to read the full report.

The Introduction The introduction to a research article acquaints readers with the research problem and its context. This section usually describes the following:

The central phenomena, concepts, or variables under study The study purpose and research questions or hypotheses A review of the related literature The theoretical or conceptual framework The significance of and need for the study

Thus, the introduction lets readers know the problem the researcher sought to address.

Example of an introductory material “Little is known about how the back-to-school transition following cancer treatment influences adolescents’ developing self-identity and social relationships.” Data from the adolescent’s perspective are particularly limited . . . The purpose of this study was to describe how the return to school affects adolescents’ beliefs about themselves, their self-identity, and their social relationships (Choquette et al., 2015).

In this paragraph, the researchers described the central concept of interest (experiences of adolescents returning to school after cancer treatment), the need for the study (the fact that little is known about the experience directly from adolescents), and the study purpose.

TIP The introduction section of most reports is not specifically labeled “Introduction.” The report’s introduction immediately follows the abstract.

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The Method Section The method section describes the methods used to answer the research questions. In a quantitative study, the method section usually describes the following, which may be presented in labeled subsections:

The research design The sampling plan Methods of measuring variables and collecting data Study procedures, including procedures to protect human rights Data analysis methods

Qualitative researchers discuss many of the same issues but with different emphases. For example, a qualitative study often provides more information about the research setting and the context of the study. Reports of qualitative studies also describe the researchers’ efforts to enhance the integrity of the study.

The Results Section The results section presents the findings that were obtained by analyzing the study data. The text presents a narrative summary of key findings, often accompanied by more detailed tables. Virtually all results sections contain descriptive information, including a description of the participants (e.g., average age, percent male, female, and other).

In quantitative studies, the results section also reports the following information relating to statistical tests performed:

The names of statistical tests used. Researchers test their hypotheses and assess the probability that the results are right using statistical tests. For example, if the researcher finds that the average birth weight of drug-exposed infants in the sample is lower than the birth weight of infants not exposed to drugs, how probable is it that the same would be true for other infants not in the sample? A statistical test helps answer the question, Is the relationship between prenatal drug exposure and infant birth weight real, and would it likely be observed with a new sample from the same population? Statistical tests are based on common principles; you do not have to know the names of all statistical tests to comprehend the findings.

The value of the calculated statistic. Computers are used to calculate a numeric value for the particular statistical test used. The value allows researchers to reach conclusions about their hypotheses. The actual value of the statistic, however, is not inherently meaningful and need not concern you.

Statistical significance. A critical piece of information is whether the statistical tests were significant (not to be confused with clinically important). If a researcher reports that the results are statistically significant, it means the findings are probably true and replicable with a new sample. Research reports also indicate the level of significance, which is an index of how probable it is that the findings are reliable. For example, if a report indicates that a finding was significant at the .05 probability

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level (symbolized as p), this means that only 5 times out of 100 (5 ÷ 100 = .05) would the obtained result be spurious. In other words, 95 times out of 100, similar results would be obtained with a new sample. Readers can thus have a high degree of confidence—but not total assurance—that the results are accurate.

Example from the results section of a quantitative study Park and coresearchers (2015) tested the effects of a 16-session Patient-Centered Environment Program (PCEP) on a variety of outcomes for home-dwelling patients with dementia. Here is a sentence adapted from the reported results: “Findings showed that agitation (t = 2.91, p < .02) and pain (t = 4.51, p < .002) improved after receiving the PCEP” (p. 40).

In this example, the researchers indicated that both agitation and pain were significantly improved following receipt of the PCEP intervention. The changes in agitation and pain were not likely to have been haphazard and probably would be replicated with a new sample. These findings are very reliable. For example, with regard to pain reduction, it was found that an improvement of the magnitude obtained would occur just as a “fluke” less than 2 times in 1,000 (p < .002). Note that to comprehend this finding, you do not need to understand what a t statistic is, nor do you need to concern yourself with the actual value of the t statistic, 4.51.

TIP Results are more reliable if the p value is smaller. For example, there is a higher probability that the results are accurate when p = .01 (1 in 100 chance of a spurious result) than when p = .05 (5 in 100 chances of a spurious result). Researchers sometimes report an exact probability (e.g., p = .03) or a probability below conventional thresholds (e.g., p < .05—less than 5 in 100).

In qualitative reports, researchers often organize findings according to the major themes, processes, or categories that were identified in the data. The results section of qualitative reports sometimes has several subsections, the headings of which correspond to the researcher’s labels for the themes. Excerpts from the raw data (the actual words of participants) are presented to support and provide a rich description of the thematic analysis. The results section of qualitative studies may also present the researcher’s emerging theory about the phenomenon under study.

Example from the results section of a qualitative study Larimer and colleagues (2015) studied the experiences, challenges, and coping behaviors of young adults with pacemakers or implantable cardioverter defibrillators. Participants described four categories of challenges, one of which was labeled “Limited support.” Here is an excerpt illustrating that category: “If I go to pediatric

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doctors, their waiting rooms have blocks and pink elephants. But in cardiopulmonary rehab, I’m the youngest by 60 years. It feels like I’m in a no man’s land, stuck in the middle” (p. 3).

The Discussion Section In the discussion, the researcher presents conclusions about the meaning and implications of the findings, i.e., what the results mean, why things turned out the way they did, how the findings fit with other evidence, and how the results can be used in practice. The discussion in both quantitative and qualitative reports may include the following elements:

An interpretation of the results Clinical and research implications Study limitations and ramifications for the believability of the results

Researchers are in the best position to point out deficiencies in their studies. A discussion section that presents the researcher’s grasp of study limitations demonstrates to readers that the authors were aware of the limitations and probably took them into account in interpreting the findings.

References Research articles conclude with a list of the books and articles that were referenced. If you are interested in additional reading on a topic, the reference list of a recent study is a good place to begin.

THE STYLE OF RESEARCH JOURNAL ARTICLES Research reports tell a story. However, the style in which many research journal articles are written—especially for quantitative studies—makes it difficult for some readers to understand or become interested in the story.

Why Are Research Articles So Hard to Read? To unaccustomed audiences, research reports may seem bewildering. Four factors contribute to this impression:

1. Compactness. Journal space is limited, so authors compress a lot of information into a small space. Interesting, personalized aspects of the investigation cannot be reported, and, in qualitative studies, only a handful of supporting quotes can be included.

2. Jargon. The authors of research articles use research terms that may seem esoteric. 3. Objectivity. Quantitative researchers tend to avoid any impression of subjectivity, so

they tell their research stories in a way that makes them sound impersonal. Most

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quantitative research articles are written in the passive voice, which tends to make the articles less inviting and lively. Qualitative reports, by contrast, are often written in a more conversational style.

4. Statistical information. In quantitative reports, numbers and statistical symbols may intimidate readers who do not have statistical training.

A goal of this textbook is to assist you in understanding the content of research reports and in overcoming anxieties about jargon and statistical information.

HOW-TO-TELL TIP How can you tell if the voice is active or passive? In the active voice, the article would say what the researchers did (e.g., “We used a mercury sphygmomanometer to measure blood pressure”). In the passive voice, the article indicates what was done, without indicating who did it, although it is implied that the researchers were the agents (e.g., “A mercury sphygmomanometer was used to measure blood pressure”).

Tips on Reading Research Articles As you progress through this book, you will acquire skills for evaluating research articles, but the skills involved in critical appraisal take time to develop. The first step is to comprehend research articles. Here are some hints on digesting research reports.

Grow accustomed to the style of research articles by reading them frequently, even though you may not yet understand the technical points.

Read journal articles slowly. It may be useful to skim the article first to get the major points and then read the article more carefully a second time.

On the second reading, train yourself to become an active reader. Reading actively means that you constantly monitor yourself to verify that you understand what you are reading. If you have difficulty, you can ask someone for help. In most cases, that “someone” will be your instructor, but also consider contacting the researchers themselves.

Keep this textbook with you as a reference when you read articles so that you can look up unfamiliar terms in the glossary or index.

Try not to get bogged down in (or scared away by) statistical information. Try to grasp the gist of the story without letting symbols and numbers frustrate you.

CRITIQUING RESEARCH REPORTS A critical reading of a research article involves a careful appraisal of the researcher’s major conceptual and methodologic decisions. It will be difficult to criticize these decisions at this point, but your skills will improve as you progress through this book.

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What Is a Research Critique? A research critique is an objective assessment of a study’s strengths and limitations. Critiques usually conclude with the reviewer’s summary of the study’s merits, recommendations regarding the value of the evidence, and suggestions about improving the study or the report.

Research critiques of individual studies are prepared for various reasons, and they vary in scope. Peer reviewers who are asked to prepare a written critique for a journal considering publication of a manuscript may evaluate the strengths and weaknesses in terms of substantive issues (Was the research problem significant to nursing?), theoretical issues (Were the conceptual underpinnings sound?), methodologic decisions (Were the methods rigorous, yielding believable evidence?), interpretive (Did the researcher reach defensible conclusions?), ethics (Were participants’ rights protected?), and style (Is the report clear, grammatical, and well organized?). In short, peer reviewers do a comprehensive review to provide feedback to the researchers and to journal editors about the merit of both the study and the report and typically offer suggestions for revisions.

Critiques designed to inform evidence-based nursing practice are seldom comprehensive. For example, it is of little consequence to evidence-based practice (EBP) that an article is ungrammatical. A critique of the clinical utility of a study focuses on whether the evidence is accurate, believable, and clinically relevant. These narrower critiques focus more squarely on appraising the research methods and the findings themselves.

Students taking a research methods course also may be asked to critique a study. Such critiques are often intended to cultivate critical thinking and to induce students to apply newly acquired skills in research methods.

Critiquing Support in This Textbook We provide several types of support for research critiques. First, detailed critiquing suggestions relating to chapter content are included at the end of most chapters. Second, it is always illuminating to have a good model, so we prepared critiques of two studies. The two studies in their entirety and the critiques are in Appendices C and D.

Third, we offer a set of key critiquing guidelines for quantitative and qualitative reports in this chapter, in Tables 4.1 and 4.2, respectively. The questions in the guidelines concern the rigor with which the researchers dealt with critical research challenges, some of which we outline in the next section.

TIP For those undertaking a comprehensive critique, we offer more inclusive critiquing guidelines in the Supplement to this chapter on website.

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The second columns of Tables 4.1 and 4.2 list some key critiquing questions, and the third column cross-references the more detailed guidelines in the various chapters of the book. We know that most of the critiquing questions are too difficult for you to answer at this point, but your methodologic and critiquing skills will develop as you progress through this book.

The question wording in these guidelines calls for a yes or no answer (although it may well be that the answer sometimes will be “Yes, but . . . ”). In all cases, the desirable answer is yes, that is, a no suggests a possible limitation and a yes suggests a strength. Therefore, the more yeses a study gets, the stronger it is likely to be.

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Cumulatively, then, these guidelines can suggest a global assessment: A report with 10 yeses is likely to be superior to one with only two. However, these guidelines are not intended to yield a formal quality “score.”

We acknowledge that our critiquing guidelines have shortcomings. In particular, they are generic even though critiquing cannot use a one-size-fits-all list of questions. Important critiquing questions that are relevant to certain studies (e.g., those that have a Therapy purpose) do not fit into a set of general questions for all quantitative studies. Thus, you need to use some judgment about whether the guidelines are sufficiently comprehensive for the type of study you are critiquing. We also note that there are questions in these guidelines for which there are no totally objective answers. Even experts sometimes disagree about methodological strategies.

TIP Just as a careful clinician seeks research evidence that certain practices are or are not effective, you as a reader should demand evidence that the researchers’ methodological decisions were sound.

Critiquing With Key Research Challenges in Mind In critiquing a study, it is useful to be aware of the challenges that confront researchers. For example, they face ethical challenges (e.g., Can the study achieve its goals without infringing on human rights?), practical challenges (Will I be able to recruit enough participants?), and methodologic challenges (Will the methods I use yield results that can be trusted?). Most of this book provides guidance relating to the last question, and this section highlights key methodologic challenges. This section offers us an opportunity to introduce important terms and concepts that are relevant in a critique. The worth of a study’s evidence for nursing practice often relies on how well researchers deal with these challenges.

Inference Inference is an integral part of doing and critiquing research. An inference is a conclusion drawn from the study evidence using logical reasoning and taking into account the methods used to generate that evidence.

Inference is necessary because researchers use proxies that “stand in” for things that are fundamentally of interest. A sample of participants is a proxy for an entire population. A control group that does not receive an intervention is a proxy for what would happen to the same people if they simultaneously received and did not receive an intervention.

Researchers face the challenge of using methods that yield good and persuasive evidence in support of inferences that they wish to make. Readers must draw their own inferences based on a critique of methodological decisions.

Reliability, Validity, and Trustworthiness

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Researchers want their inferences to correspond to the truth. Research cannot contribute evidence to guide clinical practice if the findings are inaccurate, biased, or fail to represent the experiences of the target group.

Quantitative researchers use several criteria to assess the quality of a study, sometimes referred to as its scientific merit. Two especially important criteria are reliability and validity. Reliability refers to the accuracy and consistency of information obtained in a study. The term is most often associated with the methods used to measure variables. For example, if a thermometer measured Alan’s temperature as 98.1°F 1 minute and as 102.5°F the next minute, the thermometer would be unreliable.

Validity is a more complex concept that broadly concerns the soundness of the study’s evidence. Like reliability, validity is an important criterion for evaluating methods to measure variables. In this context, the validity question is whether the methods are really measuring the concepts that they purport to measure. Is a paper-and- pencil measure of depression really measuring depression? Or is it measuring something else, such as loneliness or stress? Researchers strive for solid conceptual definitions of research variables and valid methods to operationalize them.

Another aspect of validity concerns the quality of evidence about the relationship between the independent variable and the dependent variable. Did a nursing intervention really bring about improvements in patients’ outcomes—or were other factors responsible for patients’ progress? Researchers make numerous methodologic decisions that can influence this type of study validity.

Qualitative researchers use different criteria and terminology in evaluating a study’s integrity. In general, qualitative researchers discuss methods of enhancing the trustworthiness of the study’s data and findings (Lincoln & Guba, 1985). Trustworthiness encompasses several different dimensions—credibility, transferability, confirmability, dependability, and authenticity—which are described in Chapter 17.

Credibility is an especially important aspect of trustworthiness. Credibility is achieved to the extent that the research methods inspire confidence that the results are truthful and accurate. Credibility in a qualitative study can be enhanced in several ways, but one strategy merits early discussion because it has implications for the design of all studies, including quantitative ones. Triangulation is the use of multiple sources or referents to draw conclusions about what constitutes the truth. In a quantitative study, this might mean having two ways to measure an outcome, to assess whether results are consistent. In a qualitative study, triangulation might involve efforts to understand the complexity of a phenomenon by using multiple data collection methods to converge on the truth (e.g., having in-depth discussions with participants as well as watching their behavior in natural settings). Nurse researchers are also beginning to triangulate across paradigms—that is, to integrate both quantitative and qualitative data in a single study to enhance the validity of the conclusions. We discuss such mixed methods research in Chapter 13.

Example of triangulation

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Montreuil and colleagues (2015) explored helpful nursing care from the perspective of children with suicide risk factors and their parents. The researchers triangulated data from observations of the children, debriefing sessions with the children, and interviews with their parents.

Nurse researchers need to design their studies in such a way that threats to the reliability, validity, and trustworthiness of their studies are minimized, and users of research must evaluate the extent to which they were successful.

TIP In reading and critiquing research articles, it is appropriate to have a “show me” attitude—that is, to expect researchers to build and present a solid case for the merit of their inferences. They do this by providing evidence that the findings are reliable and valid or trustworthy.

Bias Bias can threaten a study’s validity and trustworthiness. A bias is a distortion or influence that results in an error in inference. Bias can be caused by various factors, including study participants’ lack of candor, researchers’ preconceptions, or faulty methods of collecting data.

Some bias is haphazard and affects only small segments of the data. As an example, a few study participants might provide inaccurate information because they were tired at the time of data collection. Systematic bias results when the bias is consistent or uniform. For example, if a scale consistently measured people’s weight as being 2 pounds heavier than their true weight, there would be systematic bias in the data on weight. Rigorous research methods aim to eliminate or minimize bias.

Researchers adopt a variety of strategies to address bias. Triangulation is one such approach, the idea being that multiple sources of information or points of view offer avenues to identify biases. In quantitative research, methods to combat bias often entail research control.

Research Control A central feature of most quantitative studies is that they involve efforts to control aspects of the research. Research control usually involves holding constant influences on the outcome variable so that the true relationship between the independent and outcome variables can be understood. In other words, research control attempts to eliminate contaminating factors that might cloud the relationship between the variables that are of central interest.

Contaminating factors, often called confounding (or extraneous) variables, can best be illustrated with an example. Suppose we were studying whether urinary incontinence (UI) leads to depression. Prior evidence suggests that this is the case, but previous studies have not clarified whether it is UI per se or other factors that contribute

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to risk of depression. The question is whether UI itself (the independent variable) contributes to higher levels of depression or whether there are other factors that can account for the relationship between UI and depression. We need to design a study to control other determinants of the outcome—determinants that are also related to the independent variable, UI.

One confounding variable here is age. Levels of depression tend to be higher in older people, and people with UI tend to be older than those without this problem. In other words, perhaps age is the real cause of higher depression in people with UI. If age is not controlled, then any observed relationship between UI and depression could be caused by UI, or by age.

Three possible explanations might be portrayed schematically as follows:

1. UI→depression 2. Age→UI→depression

3.

The arrows symbolize a causal mechanism or influence. In model 1, UI directly affects depression, independently of other factors. In model 2, UI is a mediating variable—the effect of age on depression is mediated by UI. According to this representation, age affects depression through the effect that age has on UI. In model 3, both age and UI have separate effects on depression, and age also increases the risk of UI. Some research is specifically designed to test paths of mediation and multiple causations, but in the present example, age is extraneous to the research question. We want to design a study that tests the first explanation. Age must be controlled if our goal is to explore the validity of model 1, which posits that, no matter what a person’s age, having UI makes a person more vulnerable to depression.

How can we impose such control? There are a number of ways, as we discuss in Chapter 9, but the general principle underlying each alternative is that the confounding variable must be held constant. The confounding variable must somehow be handled so that, in the context of the study, it is not related to the independent variable or the outcome. As an example, let us say we wanted to compare the average scores on a depression scale for those with and without UI. We would want to design a study in such a way that the ages of those in the UI and non-UI groups are comparable, even though, in general, the groups are not comparable in terms of age.

By exercising control over age, we would be taking a step toward understanding the relationship between UI and depression. The world is complex, and many variables are interrelated in complicated ways. The value of evidence in quantitative studies is often related to how well researchers control confounding influences.

Research rooted in the constructivist paradigm does not impose controls. With their emphasis on holism and individual human experience, qualitative researchers typically believe that imposing controls removes some of the meaning of reality.

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Bias Reduction: Randomness and Blinding For quantitative researchers, a powerful tool for eliminating bias involves randomness —having certain features of the study established by chance rather than by researcher preference. When people are selected at random to participate in a study, for example, each person in the initial pool has an equal chance of being selected. This in turn means that there are no systematic biases in the makeup of the sample. Men and women have an equal chance of being selected, for example. Similarly, if participants are allocated at random to groups that will be compared (e.g., a special intervention and “usual care” group), then there is no systematic biases in the groups’ composition. Randomness is a compelling method of controlling confounding variables and reducing bias.

Another bias-reducing strategy is called blinding (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. For example, if study participants are aware of whether they are getting an experimental drug or a sham drug (a placebo), then their outcomes could be influenced by their expectations of the new drug’s efficacy. Blinding involves disguising or withholding information about participants’ status in the study (e.g., whether they are in a certain group) or about the study hypotheses.

Example of randomness and blinding Da Silva and colleagues (2015) studied the effect of foot reflexology on tissue integrity and impairment of the feet among people with type 2 diabetes mellitus. Their sample of 45 people with diabetes was randomly assigned to one of two groups —one group received guidelines on foot care plus 12 sessions of foot reflexology, and the other group received the guidelines only. The person who assessed foot impairment was blinded to which group the participants were in.

Qualitative researchers do not consider randomness or blinding desirable tools for understanding phenomena. A researcher’s judgment is viewed as an indispensable vehicle for uncovering the complexities of the phenomena of interest.

Reflexivity Qualitative researchers are also interested in discovering the truth about human experience. Qualitative researchers often rely on reflexivity to guard against personal bias. Reflexivity is the process of reflecting critically on the self and of analyzing and noting personal values that could affect data collection and interpretation. Qualitative 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.

Example of reflexivity Sanon and colleagues (2016) examined the role of transnationalism (maintenance of

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relationships and activities that transcend borders across countries) among Haitian immigrants in terms of hypertension self-management. By means of reflexivity, the primary researcher “considered her historical, social, and political context and position as they influenced her reflections, and the meanings she ascribed to the participants’ accounts” (p. 150). The researcher also reflected on the inequality in power relationship between the participants and herself.

TIP Reflexivity can be a useful tool in quantitative as well as qualitative research—self-awareness and introspection can enhance the quality of any study.

Generalizability and Transferability Nurses increasingly rely on evidence from disciplined research as a guide in their clinical practice. EBP is based on the assumption that study findings are not unique to the people, places, or circumstances of the original research.

As noted in Chapter 1, generalizability is the criterion used in quantitative studies to assess the extent to which the findings can be applied to other groups and settings. How do researchers enhance the generalizability of a study? First and foremost, they must design studies strong in reliability and validity. There is little point in wondering whether results are generalizable if they are not accurate or valid. In selecting participants, researchers must also give thought to the types of people to whom results might be generalized—and then select subjects accordingly. If a study is intended to have implications for male and female patients, then men and women should be included as participants.

Qualitative researchers do not specifically aim for generalizability, but they do want to generate knowledge that might be useful in other situations. Lincoln and Guba (1985), in their influential book on naturalistic inquiry, discuss the concept of transferability, the extent to which qualitative findings can be transferred to other settings, as another aspect of trustworthiness. An important mechanism for promoting transferability is the amount of rich descriptive information qualitative researchers provide about study contexts.

Abstracts for a quantitative and a qualitative nursing study are presented in the following sections. Read the abstracts for Examples 1 and 2 and then answer the critical thinking questions that follow. Examples 1 and 2 are featured on the interactive Critical Thinking Activity on website. The critical thinking questions for Examples 3 and 4 are based on the studies that appear in their entirety in Appendices A and B of this book. Our comments for these

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exercises are in the Student Resources section on .

EXAMPLE 1: QUANTITATIVE RESEARCH Study: Relationships among daytime napping and fatigue, sleep quality, and quality of life in cancer patients (Sun & Lin, 2016)

Background: The relationships among napping and sleep quality, fatigue, and quality of life (QOL) in cancer patients are not clearly understood.

Objective: The aim of the study was to determine whether daytime napping is associated with nighttime sleep, fatigue, and QOL in cancer patients.

Methods: In total, 187 cancer patients were recruited. Daytime napping, nighttime self-reported sleep, fatigue, and QOL were assessed using a questionnaire. Objective sleep parameters were collected using a wrist actigraph.

Results: According to waking-after-sleep-onset measurements, patients who napped during the day experienced poorer nighttime sleep than did patients who did not (t = −2.44, p = .02). Daytime napping duration was significantly negatively correlated with QOL. Patients who napped after 4 pm had poorer sleep quality (t = −1.93, p = .05) and a poorer Short-Form Health Survey mental component score (t = 2.06, p = .04) than did patients who did not. Fatigue, daytime napping duration, and sleep quality were significant predictors of the mental component score and physical component score, accounting for 45.7% and 39.3% of the variance, respectively.

Conclusions: Daytime napping duration was negatively associated with QOL. Napping should be avoided after 4 pm.

Implications for Practice: Daytime napping affects the QOL of cancer patients. Future research can determine the role of napping in the sleep hygiene of cancer patients.

Critical Thinking Exercises 1. Consider the following targeted questions:

a. What were the independent and dependent variables in this study? What are the PICO components?

b. Is this study experimental or nonexperimental? c. How, if at all, was randomness used in this study? d. How, if at all, was blinding used in this study? e. Did the researchers use any statistical tests? If yes, were any of the

results statistically significant? 2. If the results of this study are valid and generalizable, what might be some

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of the uses to which the findings could be put in clinical practice?

EXAMPLE 2: QUALITATIVE RESEARCH Study: Adolescents’ lived experiences while hospitalized after surgery for ulcerative colitis (Olsen et al., 2016)

Abstract: Adolescents are in a transitional phase of life characterized by major physical, emotional, and psychological challenges. Living with ulcerative colitis is experienced as a reduction of their life quality. Initial treatment of ulcerative colitis is medical, but surgery may be necessary when medical treatment ceases to have an effect. No research-based studies of adolescents’ experience of the hospital period after surgery for ulcerative colitis exist. The objective of the study was to identify and describe adolescents’ lived experiences while hospitalized after surgery for ulcerative colitis. This qualitative study was based on interviews with eight adolescents. Analysis and interpretation were based on a hermeneutic interpretation of meaning. Three themes were identified: Body: Out of order, Seen and understood, and Where are all the others? The adolescents experience a postoperative period characterized by physical and mental impairment. Being mentally unprepared for such challenges, they shun communication and interaction. The findings demonstrate the importance of individualized nursing care on the basis of the adolescent’s age, maturity, and individual needs. Further study of adolescent patients’ hospital stay, focusing on the implications of being young and ill at the same time, is needed.

Critical Thinking Exercises 1. Consider the following targeted questions:

a. On which qualitative research tradition, if any, was this study based? b. Is this study experimental or nonexperimental? c. How, if at all, was randomness used in this study? d. Is there any indication in the abstract that triangulation was used?

Reflexivity ? 2. If the results of this study are trustworthy and transferable, what might be

some of the uses to which the findings could be put in clinical practice? 3. Compare the two abstracts in Examples 1 and 2. The first is structured,

with specific headings, whereas the second is a more “traditional” format consisting of a single paragraph. Which do you prefer? Why?

EXAMPLE 3: QUANTITATIVE RESEARCH IN APPENDIX A • Read the introduction and methods section of Swenson and colleagues’

(2016) study (“Parents’ use of praise and criticism in a sample of young

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children seeking mental health services”) in Appendix A of this book.

Critical Thinking Exercises 1. Answer the following targeted questions:

a. Did this article follow a traditional IMRAD format? Where does the introduction to this article begin and end?

b. How, if at all, was randomness used in this study? c. How, if at all, was blinding used? d. Comment on the possible generalizability of the study findings.

EXAMPLE 4: QUALITATIVE RESEARCH IN APPENDIX B • Read the abstract of Beck and Watson’s (2010) study (“Subsequent

childbirth after a previous traumatic birth”) in Appendix B of this book.

Critical Thinking Exercises 1. Answer the following targeted questions, which may assist you in

assessing aspects of the study’s merit: a. Where does the introduction to this article begin and end? b. How, if at all, was randomness used in this study? c. Is there any indication in the abstract that triangulation was used?

Reflexivity ? d. Comment on the possible transferability of the study findings.

WANT TO KNOW MORE? A wide variety of resources to enhance your learning and understanding of this chapter are available on .

• Interactive Critical Thinking Activity • Chapter Supplement on Guides to Overall Critiques of Research Reports • Answers to the Critical Thinking Exercises for Examples 3 and 4 • Internet Resources with useful websites for Chapter 4 • A Wolters Kluwer journal article in its entirety—the study described as

Example 1 on p. 73.

Additional study aids, including eight journal articles and related questions, are also available in Study Guide for Essentials of Nursing Research, 9e.

Summary

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Points

Both quantitative and qualitative researchers disseminate their findings, most often by publishing reports of their research as journal articles, which concisely describe what researcher did and what they found.

Journal articles often consist of an abstract (a synopsis of the study) and four major sections that often follow the IMRAD format: an Introduction (the research problem and its context); Method section (the strategies used to answer research questions); Results (study findings); and Discussion (interpretation and implications of the findings).

Research reports are often difficult to read because they are dense, concise, and contain jargon. Quantitative research reports may be intimidating at first because, compared to qualitative reports, they are more impersonal and report on statistical tests.

Statistical tests are used to test hypotheses and to evaluate the reliability of the findings. Findings that are statistically significant have a high probability of being “real.”

A goal of this book is to help students to prepare a research critique, which is a critical appraisal of the strengths and limitations of a study, often to assess the worth of the evidence for nursing practice.

Researchers face numerous challenges, the solutions to which must be considered in critiquing a study because they affect the inferences that can be made.

An inference is a conclusion drawn from the study evidence, taking into account the methods used to generate that evidence. Researchers strive to have their inferences correspond to the truth.

Reliability (a key challenge in quantitative research) refers to the accuracy of information obtained in a study. Validity broadly concerns the soundness of the study’s evidence—that is, whether the findings are convincing and well grounded.

Trustworthiness in qualitative research encompasses several different dimensions, including credibility, dependability, confirmability, transferability, and authenticity.

Credibility is achieved to the extent that the methods engender confidence in the truth of the data and in the researchers’ interpretations. Triangulation, the use of multiple sources to draw conclusions about the truth, is one approach to enhancing credibility.

A bias is an influence that produces a distortion in the study results. In quantitative studies, research control is an approach to addressing bias. Research control is used to hold constant outside influences on the dependent variable so that the relationship between the independent and dependent variables can be better

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understood. Researchers seek to control confounding (or extraneous) variables—variables

that are extraneous to the purpose of a specific study. For quantitative researchers, randomness—having certain features of the study

established by chance—is a powerful tool to eliminate bias. Blinding (or masking) is sometimes used to avoid biases stemming from

participants’ or research agents’ awareness of study hypotheses or research status. Reflexivity, the process of reflecting critically on the self and of scrutinizing

personal values that could affect data collection and interpretation, is an important tool in qualitative research.

Generalizability in a quantitative study concerns the extent to which the findings can be applied to other groups and settings.

A similar concept in qualitative studies is transferability, the extent to which qualitative findings can be transferred to other settings. One mechanism for promoting transferability is a rich and thorough description of the research context so that others can make inferences about contextual similarities.

REFERENCES FOR CHAPTER 4 Choquette, A., Rennick, J., & Lee, V. (2015). Back to school after cancer treatment: Making sense of the

adolescent experience. Cancer Nursing. Advance online publication. *da Silva, N., Chaves, É., de Carvalho, E., Carvalho, L., & Iunes, D. (2015). Foot reflexology in feet impairment of

people with type 2 diabetes mellitus: Randomized trial. Revista Latino-Americana de Enfermagem, 23, 603– 610.

Larimer, K., Durmus, J., & Florez, E. (2015). Experiences of young adults with pacemakers and/or implantable cardioverter defibrillators. Journal of Cardiovascular Nursing. Advance online publication.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage. Montreuil, M., Butler, K., Stachura, M., & Pugnaire-Gros, C. (2015). Exploring helpful nursing care in pediatric

mental health settings: The perceptions of children with suicide risk factors and their parents. Issues in Mental Health Nursing, 36, 849–859.

Olsen, I., Jensen, S., Larsen, L., & Sørensen, E. (2016). Adolescents’ lived experiences while hospitalized after surgery for ulcerative colitis. Gastroenterology Nursing, 39, 287–296.

Park, H., Chun, Y., & Gang, M. (2015). Effects of the Patient-Centered Environment Program on behavioral and emotional problems in home-dwelling patients with dementia. Journal of Gerontological Nursing, 41, 40–48.

Sanon, M. A., Spigner, C., & McCullagh, M. C. (2016). Transnationalism and hypertension self-management among Haitian immigrants. Journal of Transcultural Nursing, 27, 147–156.

**Sun, J. L., & Lin, C. C. (2016). Relationships among daytime napping and fatigue, sleep quality, and quality of life in cancer patients. Cancer Nursing. Advance online publication.

*A link to this open-access article is provided in the Internet Resources section on website.

**This journal article is available on for this chapter.

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5 Ethics in Research

Learning Objectives On completing this chapter, you will be able to:

Discuss the historical background that led to the creation of various codes of ethics Understand the potential for ethical dilemmas stemming from conflicts between ethics

and research demands Identify the three primary ethical principles articulated in the Belmont Report and the

important dimensions encompassed by each Identify procedures for adhering to ethical principles and protecting study participants Given sufficient information, evaluate the ethical dimensions of a research report Define new terms in the chapter

Key Terms Anonymity Assent Belmont Report Beneficence Certificate of Confidentiality Code of ethics Confidentiality Consent form Debriefing Ethical dilemma Full disclosure Informed consent Institutional Review Board (IRB) Minimal risk Risk/benefit assessment Stipend Vulnerable group

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ETHICS AND RESEARCH In any research with human beings or animals, researchers must address ethical issues. Ethical concerns are especially prominent in nursing research because the line between what constitutes the expected practice of nursing and the collection of research data sometimes gets blurred. This chapter discusses ethical principles that should be kept in mind when reading a study.

Historical Background We might like to think that violations of moral principles among researchers occurred centuries ago rather than recently, but this is not the case. The Nazi medical experiments of the 1930s and 1940s are the most famous example of recent disregard for ethical conduct. The Nazi program of research involved using prisoners of war and “racial enemies” in medical experiments. The studies were unethical not only because they exposed people to harm but also because subjects could not refuse participation.

There are more recent examples. For instance, between 1932 and 1972, the Tuskegee Syphilis Study, sponsored by the U.S. Public Health Service, investigated the effects of syphilis among 400 poor African American men. Medical treatment was deliberately withheld to study the course of the untreated disease. It was revealed in 1993 that U.S. federal agencies had sponsored radiation experiments since the 1940s on hundreds of people, many of them prisoners or elderly hospital patients. And, in 2010, it was revealed that a U.S. doctor who worked on the Tuskegee study inoculated prisoners in Guatemala with syphilis in the 1940s. Other examples of studies with ethical transgressions have emerged to give ethical concerns the high visibility they have today.

Codes of Ethics In response to human rights violations, various codes of ethics have been developed. The ethical standards known as the Nuremberg Code were developed in 1949 in response to the Nazi atrocities. Several other international standards have been developed, including the Declaration of Helsinki, which was adopted in 1964 by the World Medical Association and was most recently revised in 2013.

Most disciplines, such as medicine and nursing, have established their own code of ethics. In the United States, the American Nurses Association (ANA) issued Ethical Guidelines in the Conduct, Dissemination, and Implementation of Nursing Research in 1995 (Silva, 1995). The ANA, which declared 2015 the Year of Ethics, published a revised Code of Ethics for Nurses with Interpretive Statements, a document that not only covers ethical issues for practicing nurses primarily but also includes principles that apply to nurse researchers. In Canada, the Canadian Nurses Association published the third edition of its Ethical Research Guidelines for Registered Nurses in 2002. And, the International Council of Nurses (ICN) developed the ICN Code of Ethics for Nurses, which was updated in 2012.

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TIP Many useful websites are devoted to ethics and research, links to some of which are listed in the Internet Resources for this chapter on website.

Government Regulations for Protecting Study Participants Governments throughout the world fund research and establish rules for adhering to ethical principles. In the United States, an important code of ethics was adopted by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The commission issued a report in 1978, known as the Belmont Report, which provided a model for many guidelines adopted by disciplinary organizations in the United States. The Belmont Report also served as the basis for regulations affecting research sponsored by the U.S. government, including studies supported by the National Institute of Nursing Research (NINR). The U.S. ethical regulations have been codified at Title 45 Part 46 of the Code of Federal Regulations and were revised most recently in 2005.

Ethical Dilemmas in Conducting Research Research that violates ethical principles typically occurs because a researcher believes that knowledge is potentially beneficial in the long run. For research problems, participants’ rights and study quality are put in direct conflict, posing ethical dilemmas for researchers. Here are examples of research problems in which the desire for rigor conflicts with ethical considerations:

1. Research question: Does a new medication prolong life in patients with AIDS? Ethical dilemma: The best way to test the effectiveness of an intervention is to administer the intervention to some participants but withhold it from others to see if the groups have different outcomes. However, if the intervention is untested (e.g., a new drug), the group receiving the intervention may be exposed to potentially hazardous side effects. On the other hand, the group not receiving the drug may be denied a beneficial treatment.

2. Research question: Are nurses equally empathic in their treatment of male and female patients in the intensive care unit (ICU)? Ethical dilemma: Ethics require that participants be aware of their role in a study. Yet, if the researcher informs nurse participants that their empathy in treating male and female ICU patients will be scrutinized, will their behavior be “normal”? If the nurses’ usual behavior is altered because of the known presence of research observers, then the findings will be inaccurate.

3. Research question: How do parents cope when their children have a terminal illness?

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Ethical dilemma: To answer this question, the researcher may need to probe into parents’ psychological state at a vulnerable time, yet knowledge of the parents’ coping mechanisms might help to design effective ways of addressing parents’ grief and stress.

4. Research question: What is the process by which adult children adapt to the day-to- day stress of caring for a parent with Alzheimer’s disease? Ethical dilemma: Sometimes, especially in qualitative studies, a researcher may get so close to participants that they become willing to share “secrets” and privileged information. Interviews can become confessions—sometimes of unseemly or illegal behavior. In this example, suppose a woman admitted to physically abusing her mother—how does the researcher respond to that information without undermining a pledge of confidentiality? And, if the researcher divulges the information to authorities, how can a pledge of confidentiality be given in good faith to other participants?

As these examples suggest, researchers are sometimes in a bind. Their goal is to develop high-quality evidence for practice, but they must also adhere to rules for protecting human rights. Another type of dilemma may arise if nurse researchers face conflict-of-interest situations, in which their expected behavior as nurses conflicts with standard research behavior (e.g., deviating from a research protocol to assist a patient). It is precisely because of such dilemmas that codes of ethics are needed to guide researchers’ efforts.

ETHICAL PRINCIPLES FOR PROTECTING STUDY PARTICIPANTS The Belmont Report articulated three primary ethical principles on which standards of ethical research conduct are based: beneficence, respect for human dignity, and justice. We briefly discuss these principles and then describe methods researchers use to comply with them.

Beneficence Beneficence imposes a duty on researchers to minimize harm and maximize benefits. Human research should be intended to produce benefits for participants or, more typically, for others. This principle covers multiple aspects.

The Right to Freedom From Harm and Discomfort Researchers have an obligation to prevent or minimize harm in studies with humans. Participants must not be subjected to unnecessary risks of harm or discomfort, and their participation in research must be necessary for achieving societally important aims. In research with humans, harm and discomfort can be physical (e.g., injury), emotional

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(e.g., stress), social (e.g., loss of social support), or financial (e.g., loss of wages). Ethical researchers must use strategies to minimize all types of harms and discomforts, even ones that are temporary.

Protecting human beings from physical harm is often straightforward, but it may be more difficult to address psychological issues. For example, participants may be asked questions about their personal lives. Such queries might lead people to reveal deeply personal information. The need for sensitivity may be greater in qualitative studies, which often involve in-depth exploration into highly personal areas. Researchers need to be aware of the nature of the intrusion on people’s psyches.

The Right to Protection From Exploitation Involvement in a study should not place participants at a disadvantage. Participants need to be assured that their participation, or information they provide, will not be used against them. For example, people describing their economic situation should not risk loss of public health benefits; people reporting drug abuse should not fear being reported for a crime.

Study participants enter into a special relationship with researchers, and this relationship should not be exploited. Because nurse researchers may have a nurse– patient (in addition to a researcher–participant) relationship, special care may be needed to avoid exploiting that bond. Patients’ consent to participate in a study may result from their understanding of the researcher’s role as nurse, not as researcher.

In qualitative research, psychological distance between researchers and participants often declines as the study progresses. The emergence of a pseudotherapeutic relationship is not uncommon, which could create additional risks that exploitation could inadvertently occur. On the other hand, qualitative researchers often are in a better position than quantitative researchers to do good, rather than just to avoid doing harm, because of the close relationships they develop with participants.

Example of therapeutic research experiences Beck et al. (2015) found that some participants in their study on secondary traumatic stress among certified nurse-midwives told the researchers that writing about the traumatic births they had attended was therapeutic for them. One participant wrote, “I think it’s fascinating how little respect our patients and coworkers give to the traumatic experiences we suffer. It is healing to be able to write out my experiences in this study and actually have researchers interested in studying this topic.”

Respect for Human Dignity Respect for human dignity is the second ethical principle in the Belmont Report. This principle includes the right to self-determination and the right to full disclosure.

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The Right to Self-Determination The principle of self-determination means that prospective participants have the right to decide voluntarily whether to participate in a study, without risking prejudicial treatment. It also means that people have the right to ask questions, refuse answering questions, and drop out of the study.

A person’s right to self-determination includes freedom from coercion. Coercion involves explicit or implicit threats of penalty from failing to participate in a study or excessive rewards from agreeing to participate. The issue of coercion requires careful thought when researchers are in a position of authority or influence over potential participants, as might be the case in a nurse–patient relationship. Coercion can be subtle. For example, a generous monetary incentive (or stipend) to encourage the participation of a low-income group (e.g., the homeless) might be considered mildly coercive because such incentives may be seen as a form of pressure.

The Right to Full Disclosure Respect for human dignity encompasses people’s right to make informed decisions about study participation, which requires full disclosure. Full disclosure means that the researcher has fully described the study, the person’s right to refuse participation, and potential risks and benefits. The right to self-determination and the right to full disclosure are the two elements on which informed consent (discussed later in this chapter) is based.

Full disclosure is not always straightforward because it can create biases and sample recruitment problems. Suppose we were testing the hypothesis that high school students with a high absentee rate are more likely to be substance abusers than students with good attendance. If we approached potential participants and fully explained the study’s purpose, some students might refuse to participate, and nonparticipation would be selective; students who are substance abusers—the group of primary interest—might be least likely to participate. Moreover, by knowing the study purpose, those who participate might not give candid responses. In such a situation, full disclosure could undermine the study.

In such situations, researchers sometimes use covert data collection (concealment), which is collecting data without participants’ knowledge and thus without their consent. This might happen if a researcher wanted to observe people’s behavior and was worried that doing so openly would change the behavior of interest. Researchers might choose to obtain needed information through concealed methods, such as observing while pretending to be engaged in other activities.

A more controversial technique is the use of deception, which can involve deliberately withholding information about the study or providing participants with false information. For example, in studying high school students’ use of drugs, we might describe the research as a study of students’ health practices, which is a mild form of misinformation.

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Deception and concealment are problematic ethically because they interfere with people’s right to make truly informed decisions about personal costs and benefits of participation. Some people think that deception is never justified, but others believe that if the study involves minimal risk yet offers benefits to society, then deception may be acceptable.

Full disclosure has emerged as a concern in connection with data collected over the Internet (e.g., analyzing the content of messages posted to blogs or social media sites). The issue is whether such messages can be used as data without the authors’ consent. Some researchers believe that anything posted electronically is in the public domain, but others feel that the same ethical standards must apply in cyberspace research and that researchers must carefully protect the rights of individuals who are participants in “virtual” communities.

Justice The third principle articulated in the Belmont Report concerns justice, which includes participants’ right to fair treatment and their right to privacy.

The Right to Fair Treatment One aspect of justice concerns the equitable distribution of benefits and burdens of research. The selection of participants should be based on research requirements and not on people’s vulnerabilities. For example, groups with lower social standing (e.g., prisoners) have sometimes been selected as study participants, raising ethical concerns.

Potential discrimination is another aspect of distributive justice. During the 1990s, it was found that women and minorities were being excluded from many clinical studies. In the United States, this led to regulations requiring that researchers who seek funding from the National Institutes of Health (including NINR) include women and minorities as study participants.

The right to fair treatment encompasses other obligations. For example, researchers must treat people who decline to participate in a study in a nonprejudicial manner, they must honor all agreements made with participants, they must show respect for the beliefs of people from different backgrounds, and they must treat participants courteously and tactfully at all times.

The Right to Privacy Research with humans involves intrusions into people’s lives. Researchers should ensure that their research is not more intrusive than it needs to be and that privacy is maintained. Participants have the right to expect thatny data they provide will be kept in strict confidence.