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NSR 338: Research in Nursing
Dennis Ondrejka, Ph.D., R.N.
303-292-0015, ext. 3625 [email protected]
Fall, 2009
Is nursing a profession?
Q.#1: What are the criteria for a profession?
Nursing: Profession or Technical Occupation?
Pavalko’s (1971) Continuum Model for a Profession
Theory Relevance to social values Education Motivation Autonomy Commitment Sense of community Code of ethics
Explore the Meaning of a Professional vs. Technical
Practice
Describe the similarities or differences between the chef at the Brown Palace & the cook at the Village Inn?
Chef
Cook
Professional vs. Technicalfor all practice areas
Professional Practices Have a culture that
supports professional activities: frameworks, CE, research
Has a defined body of knowledge gained by formal education
Is a discipline with peer review and a code of ethics
Autonomy in practice with legislative and legal sanctions
Is an organized system of practice recognized by society
Technical Occupations Are more likely to have
more OJT than formal education.
Are skill focused Have trade journals or
technique trainings Do not focus on what
advances the practice Develop through
certifications Want less accountability
Professional vs. TechnicalThinking and Valuing
Professional thinking More is best Specialization in depth and
breadth Evidence-based education Invests energy beyond the
work-associations, research, reading
Expects self accountability Resilient with change and
believes change is valuable
Technical Thinking Least is best Specialization in depth Experience is the
primary educator Conserves energy
beyond the workday Prefers others be
accountable Enjoys consistency and
believes change is disruptive
Is research important to the profession?Yes!! Research is important for building a unique, systematic
body of knowledge about a discipline
Nursing needs a systematic body of knowledge to ...
Promote Evidence-based practice Give credibility to profession Provide accountability for practice Help document the cost-
effectiveness of care (Nieswiadomy, 2008)
What is Evidence Based Nursing Practice?
Knowledge from science & research
Knowledge from experts Knowledge from patients Knowledge arriving in many forms Has levels of power and rigor EBP IS NOT JUST FROM RESEARCH
Evidence Based Practice: Definition
“…the integration of current best evidence with clinical expertise and patient values” (Sackett et al., 2000)
“…a framework for clinical practice that incorporates the bestbest available scientific available scientific evidenceevidence with the expertise of the expertise of the clinicianclinician and the patient’s preferences patient’s preferences and valuesand values to make decisions about health care.” (Levin, 2006)
What is Research? Process of searching for new
knowledge about phenomena Validates and refines existing
knowledge (Burns & Grove, 2007)
Systematic process of inquiry or study
Builds new knowledge through the dissemination of findings
Why Research??? To Describe
To identify and understand the nature of nursing phenomena
What is the experience of growing up poor in Manhattan?
To Explain Clarifies the relationship among
phenomena, and why certain events occur What are the factors that supported DSN
graduates to pass NCLEX at 95% in 2009?
Why Research??? To Predict
This allows us to estimate the probability of a specific outcome in a given situation
There is a statistical difference in baseline patient glucose levels when using basilar method over sliding scale.
To Control or Manipulate If we can predict, the next goal would be to
control or manipulate the situation to produce the desired outcome.
We can reduce bed sores at all stages by rotating patients every two hours maximum.
Ways We Acquire Knowledge Tradition Authority Borrowing Trial and error Personal
experience Role-modeling &
mentoring Intuition
Reasoning Inductive-gather Deductive-divide Rational-logic Unstructured
Research Quantitative Qualitative Mixed / Other
Research Defined
Research is a systematic, diligent inquiry that is necessary to address: What needs to be known-what is the
question, hypothesis, or interest area What research methods are needed to
examine this question or phenomena What meaning can be extracted from the
study through data analysis to build our knowledge base of that subject
Generate outcomes and disseminate new knowledge
Ways to Study Research By its components (questions, rigors,
sampling method, measurement method, etc) Divided into two major types
Qualitative Quantitative
By the name of the method (experimental, phenomenology, etc)
By the philosophy it uses to inquire (positivistic, naturalistic, both, neither)
Burns & Grove method: Examine Your Text
Table of Contents 7 Ch. 1 Ch. 2 = Quantitative Research Ch. 3 = Qualitative Research
(philosophy discussed) CH. 4 = tries to address both
qualitative and quantitative questions
Ch. 5, 6 = Lit review, Study Frameworks & Theory
Examine Your Text Ch. 7 = ethics Ch. 8 = Clarify Designs (quantitative) Ch. 9 = Outcomes Research Ch. 10 = Populations and Sampling
for quantitative and qualitative methods
Ch. 11 = Measurement of Data quantitative and qualitative
Ch. 12 = Understanding Statistics
Examine Your Text Ch. 13 = Critiquing Research for
qualitative (five Standards) and quantitative.
Ch. 14 = Building an Evidence Based Practice
Ch. 14 Evidence Based Practice Research Utilization (RU) may have a lag time
for Practice up to 20 years Involves being a Change Agent. (DSN uses the
I2E2 model for change in third quarter) Best Evidence by research type
Integrative Reviews (many types of designs) Systematic Reviews (focused on a particular type of
research designs) Meta-Analysis (has statistical evaluation of
quantitative designs). Metasummaries & Metasynthesis (qualitative
research)
Hierarchy of EvidenceCompare to Florczak article
Level I: A systematic review or RCTs, meta-analysis of many randomized controlled trials (RCTs)
Level II: Integrative Reviews of experimental designs
Level III: from a well-designed controlled trial without randomization
Level IV: From case-control or cohort studies
Hierarchy of EvidenceCompare to Florczak article
Level V: From systematic reviews of descriptive or qualitative studies, metasummaries, metasynthesis,
Level VI: a single descriptive or qualitative study
Level VII: It is an opinion from authorities on that subject, or expert committee
Recent Changes in Nursing Page 500, second paragraph, Using
ASA 81 mg. in at risk adults Page 517, I.V. flush using 0.9% NS
vs. heparin. P & P on page 520. Algorithms on page 524 for tx HTN. I.V. skin prep using chlorhexidine vs.
Iodine products like providone-iodine
Strait cath urethra prep
Mydsn.org, NRS 338 Evidence Based Research
www.cochrane.org/www.guideline.govhttp://www.cebm.utoronto.ca/resources/websites.htm
www.ahcpr.gov/clinic/ http://www.crd.york.ac.uk/crdweb/
Research Philosophy Method:Positivistic versus Naturalistic
Inquiry This is a 100 year old debate It is often correlated to research
methodology It is a philosophy on the way we think about
human phenomenon & inquiry (research) We can integrate two different inquiry
methodologies, but philosophically they are very different (mixed or blended design)
Our philosophy is the foundation for how we design research
Positivistic Inquiry Naturalistic Inquiry (Constructivism)
Quantitative Triangulated Qualitative
Solomon Design Blended Designs Post-modern -four group design - use quantitative -pretest-treat-post test Intervention Res & qualitative -research self -pretest-no treat- post test methods -novel sounding -no pre- no treat- post test lacks theory -random group Quasi-Experimental Grounded Theory Phenomenology -validated tools -two of three -theory building - descriptive
Exp. controls -Basic Social Process - interpretive - hermeneutic Descriptive
Experimental Design - quantitative or Ethnography -random sample qualitative methods -living in the experience -control group -cultural
immersion -a treatment given Outcome Research
Case Study Epidemiology (humans & Ds) -single-double cases Analytic Epi -In-depth analysis Descriptive Epi - comparative analysis
Action ResearchAdequate time commitmentCollaborative effortOpenness to changeQuality of data collection and analysis Impact on one’s practice
Positivistic Inquiry Naturalistic Inquiry (Constructivism)
Quantitative Triangulated Qualitative
Solomon Design Blended Designs Post-modern Quasi-Experimental Grounded Theory Phenomenology
Constant Comparative Analysis
Descriptive Experimental Design Ethnography
Case Study
Scientific Rigors by DesignQuantitative Research RigorValidity & Reliability (internal-external) Qualitative Research Rigor Conceptual Framework Developed Descriptive Vividness Statistical Inference Methodological CongruenceGeneralizability Analytical PrecisenessTemporality Theoretical Connectedness Selection and Bias Heuristic RelevanceMeasurement validity / reliability Trustworthiness, Credibility, Controlling confounders and AuditabilityAppropriate study design for the questions Confirmability, transferabilityStylistic & Personal
Relevance, Heuristic
Sample Size by DesignPositivistic Inquiry Naturalistic Inquiry (Constructivism)
Quantitative Triangulated Qualitative
Solomon Design Blended Designs Post-modern Power Analysis 20-40 1 Quasi-Experimental Grounded Theory Phenomenology
>40 10-1000 10+saturation (10-30) Descriptive
Experimental Design 1-12 Ethnography
Power Analysis 1
Case Study 1-2
Action Research ?-100
Assumptions of Positivistic Thinking Reality is singular,
tangible, & and can be dissected
The researcher and those being studied are independent
Time and context-free generalizations are possible
Inquiry is value-free
value free singular reality
Positivistic thinking
generalizableindependentvariables
Assumptions of Positivistic Thinking There are real
causes or at least high probability of a relationship.
We believe we can have independent and dependent variables as separate entities
Validity of a design is very critical to results
value free
singular reality
validity
Positivistic thinking
generalizable
cause &effectindependentvariables
Assumptions of Positivistic Thinking
Reliability is based on how the design is reproducible
Generalizability is related to good internal validity and reliability with comparable samples
Hypothesis testing
generalizable
value-free
Positivistic thinking
validity
singularreality
hypothesistesting
reliability
cause & effectindependentvariable
Assumptions of Naturalistic Inquiry Realities are multiple,
pluralistic, and holistic The researcher cannot
really be separated from those being studied and relation-ships are explained
hypotheses are time and context bound - they are only working statements
researcher& subjectconnected
hypothesis is a focus area
multiple realities
naturalisticinquiry
Assumptions of Naturalistic Inquiry All entities are in a
state of mutual simultaneous shaping
Inquiry is value-bound
Validity is designed into the process
Reliability & general- izable are not concepts of value with this thinking
researcher& subject connected
hypothesisis a focusarea
Naturalistic inquiry
thick description
multiple realities inquiry is value bound
Differences in Scientific Rigorpositivistic naturalistic Validity Internal and external
reliability Hypothesis testing Statistical inferences Independent and
dependent variables Variable controls Generalizability
Descriptive Vividness Methodological
Congruence Analytical
Preciseness Theoretical
Connectedness Heuristic Relevance Others
Data Collection Differencepositivistic naturalistic Tools
surveys, questionnaires objective assessment &
identification Measure the dependent
variable Convert to numeric
symbols Apply statistical
inferences to numbers Large sample sizes help
with confidence levels
Tool is the investigator by
interview, focus groups, & observation
Data is subjective and objective. It is collected & not measured
Themes or clusters are identified and data is sorted in a theme analysis
The themes are supported by participants or experts
Differences in Results positivistic naturalistic Statistical
significance for pre-post treatment
Statistical correlations & relationships identified
Probability of errors & confidence identified
Causal relationships
The exploration & description of a phenomenon
Identification of linkages, relationships, or interpretations based on theory connections
Results are themes, clusters of ideas, or theory constructs
Positivistic Discussion of Results 250 nurses were surveyed with an 80%
response rate or N=200. Questions were rated using the Likert 5 scale. Question 1 had a mean of 4.2 with a S.D. of 0.5 suggesting the nurses had favorable opinions about continuing education. Compared to a 1994 survey asking the same question, there was a statistical difference that was less favorable (mean 3.1, S.D. 0.7, p<.05)
Naturalistic Description I sat in the classroom as a peripheral
member staying as unobtrusive as possible. The instructor came out from behind her desk, sitting on the edge as she opened with a question that brought all eyes in the room to meet her own eyes. She paused - looked at the eyes of the students.
The instructor displayed immediacy from the moment she started the class.
Ethics and Research (Ch. 7)
Starts with the study purpose, design, methods of measurement, and subjects
Guidelines for all of these It is still a concern today More recent ethical issues are:
Fabrication of a study Falsification or forging of data Dishonest manipulation of the design or methods Plagiarism
50% of the top 50 research institutions in US have been investigated for research fraud
Ethical Problems in History
Nazi medical experiments (1933-1945)
Tuskegee syphilis study by the USPHS (1932-1972)
Willowbrook study (1950-1970) Hepatitis study
Jewish Chronic Disease Hospital study with live CA cells in 1960s
Ethical Problems in History University –Atomic Energy Government Exp.
18 men and women injected with plutonium to determine body distribution (at the time said to be terminal) 1945-47
20 subjects ages 63-83 given doses of radioactive radium and thorium inj. or oral. 1961-65
64 male inmates at Washington St. Prison had testicular radiation to determine the smallest does to makes someone sterile. 1963-70
125 retarded residents were fed radioactive ir9n and calcium to see if a diet rich in cereal would block the digestion of those two minerals. 1946-56
Nuremberg Code-1949 Voluntary consent Must yield fruitful results for society Anticipated results justify the type of experiment Avoids all unnecessary physical-mental injury Cannot do studies that have a known injury or
death unless the exp. Physician is a subject Risk does not out weight humanitarian benefit Proper precautions to prevent injury, dis., death Conducted by qualified persons Subjects can always stop the study Researcher must always be ready to stop the
study (risk)
Declaration of Helsinki-1964-84
Differentiated therapeutic vs. non-therapeutic research
Clinical vs. Basic Greater care to protect subjects in non-
therapeutic research There must be a strong, independent
justification for exposing a healthy vol. to substantial risk
The investigator is to protect the health and life of research subjects
The Belmont ReportThree Ethical Principles
Principle of respect for persons Right to self determination and freedom to participate or
not Principle of Beneficence
Do no harm to others Principle of Justice
Treat everyone fairly without discrimination Led to USDHHS Code on Ethics
Title 45, Part 46 (45 CFR 46) Office of Human Subjects Research (OHSR) within NIH http://helix.nih.gov:8001/ohsr
Institutional Review Board (IRB) Provides oversight on all ethical
issues related to someone doing research
Consent forms (voluntary subjects) Disclosure forms Confidentiality Compensation disclosure Ethics documented in the research Accountability to rules, regulations, and
legal entities Protects at risk populations
The Literature Review Primary Sources Secondary Sources Theoretical literature Empirical (Research) literature Evidence Based Research Sites
www.cochrane.org/www.guideline.govhttp://www.cebm.utoronto.ca/resources/websites.htm www.ahcpr.gov/clinic/ http://www.crd.york.ac.uk/crdweb/
Definition of a Literature Review (Ch. 5)
A systematic and explicit approach to the identification, retrieval, and bibliographical management of independent studies … locating information … synthesizing … developing guidelines …
Purposes of the Lit. Review Facilitate development of the Conceptual
Framework by summarizing knowledge Clarify the research topic Clarify the research problem Verify the significance of the research
problem Specify the purpose of the study Describe relevant studies or theories Develop definitions of major variables Select a research design, data measurement,
data collection & analysis, & interpret findings
Literature Searches Ebscohost with CINAHL:
http://search.ebscohost.com Log in: DSN Password: evidence Mydsn.org
NRS 338 Data bases
Understanding Research Designs Can have confusing terms Research Methodology
The entire process from question to analysis Research Design
Clearly defined structures within which the study is implemented
Is a large blueprint, but must be tailored to the study and then mapped out in detail
Quantitative Designs (Ch. 2)
What are the four types ofQuantitative Designs?
Quantitative Designs Experimental Quasi-experimental Descriptive Correlational
Aim to describe, compare, and predict in order to understand or control phenomena
Quantitative Designs
What characterizes true Experimental Research
Designs?
True Experimental Research Designs
Are characterized by: Random assignment of subjects to
groups
Comparison of treatment group(s) with a
Control or “business as usual” group
True Experimental Research Designs (cont.)
Also characterized by …
Strict control of extraneous variables to obtain true representation of “cause and effect” Note: use “causality” language with
caution!!! (there is always a P-value) Ex: Smoking and cancer
Randomized Controlled Clinical Trials (RCT)
True Experimental Design
Large N (# of subjects) Draw subjects from reference population Randomly assign subjects to treatment/experimental or control group Examine for baseline equivalence Multiple sites used for generalizability
Quasi-Experimental Research Designs
Are characterized by:
Treatment or intervention Comparison of treatment group(s) with a control or “business as usual” group Non-equivalence of groups--not randomly
assigned; group assignment often evolves naturally “convenience” sampling)
Ex: Pts. on one unit compared to pts. on another
Quasi-Experimental Research Designs (cont.)
Also are characterized by…
Aiming to represent “cause and effect” in situations where less control over variables exists
Most frequently used design in nursing
Correlational Designs Descriptive correlational designs
Used to describe variables and to examine relationships between or among variables
Predictive correlational designs Used to predict value of one variable based
on values obtained for another variable Independent variable used to “predict”
Dependent variable Regression Model-testing design
Looks at relationships among a # of variables
Correlational Designs Descriptive correlational designs
Used to describe variables and to examine relationships between or among variables
Predictive correlational designs Used to predict value of one variable
based on values obtained for another variable
Independent variable used to “predict” Dependent variable
Quantitative Design Concerns
Primary purpose (check question) Is there a treatment (intervention) Will the treatment be controlled Is there a control (untreated) group Is there a pre or post test (or both) Is sample random Will sample be a single group or divided
into several groups
Quantitative Design Concerns-2
How many groups will there be What is the size of each group Will groups be randomly assigned Will there be repeated measurements over
time or will the data be collected cross-sectionally at one or two points in time
Have extraneous variables been identified and controlled for
What strategies are being used to compare variables or groups
Research Question Considerations Ethics Significance Motivation Qualifications Feasibility
Hypotheses and Research Qs Hypotheses: Intelligent guesses
about predicted relationships
Problem statement what the issue/concern/problem is and why it should be addressed
Research Qs: “Burning question”
What are Criteria for Hypotheses? (Ch. 4)
Declarative Written in present tense Include population Identify variables Reflect the problem/concern Are empirically testable
Independent & Dependent Variables
Independent (IV) The treatment The intervention That which is manipulated
Dependent (DV) Outcome What is being measured The difference
Types of Hypotheses: Simple & Complex
Simple One Independent Variable (IV) and
one Dependent Variable (DV)
Complex Two or more IVs, two or more DVs, or both, being investigated at same
time
Hypothesis: #1 Average length of gestation is
shorter for infants of mothers who use cocaine than among mothers who use alcohol during the last six months of pregnancy.
Population? IV? DV?
Simple or complex?
Hypothesis: #2 The greater the degree of
sleep deprivation, the higher the anxiety levels of intensive care unit patients.
Population? IV? DV?
Simple or complex?
Hypothesis: #3 The total wt. loss of overweight
elementary students who follow a reduced calorie diet and exercise 20 minutes four times a week will be greater than those students who do not follow a reduced calorie diet and do not exercise 20 minutes four times a week.
Population? IV? DV?
Simple or complex?
Hypothesis: #4 The degree of stress reported by
flight-for-life nurses is greater than the degree of stress reported by ICU nurses.
Population? IV? DV?
Simple or complex?
Name that Hypothesis: #5 More domestic violence and levels
of anger are reported by veterans who served in the military in Iraq compared to those in the military who served in Afghanistan.
Population? IV? DV?
Simple or complex?
Sample of Research Topic & Questions
Topic: Adolescent sexuality Problem statement: (e.g., pregnancy rates in US
are much higher compared to most Western countries)
Research Question: Will high school adolescent males report higher levels
of comfort with their own sexuality than will females? Hypothesis:
Adolescent males in grades 9 – 12 will report statistically higher levels of comfort with their own sexuality than will females in the same grades.
Quantitative Design Concerns
Primary purpose (check question) Is there a treatment (intervention) Will the treatment be controlled Is there a control group (untreated) Is there a pre or post test (or both) Is the sample a random sample Will the sample be a single group or
divided into several groups
Quantitative Design Concerns-2
How many groups will there be What is the size of each group Will groups be randomly assigned Will there be repeated measurements Will the data be collected cross-sectionally
or over time Have extraneous variables been identified
and controlled for What strategies are being used for
comparison of variables or groups
Components of Study Validity
Definition: It is an examination of the approximation of truth or falsity of the propositions Statistical Validity (right stats used) Internal Validity (sample represents the
population being studied) Construct Validity (concept & Operational
def. of variable match, & instrument accuratly measures theoretical constructs it purports to measure.
External Validity (methods allow for generalizability)
(Cook and Campbell, 1979)
Statistical Validity Errors Violate assumptions about the data
Nominal, ordinal, interval, ratio data Type I and Type II errors Need for Power Analysis
Predicts the necessary N value Inappropriate use of certain statistics
for the various types of data Random irrelevancies in setting Random heterogeneity of respondents
Statistical Conclusion ValidityType I and Type II Errors
Accept the Null Hypothesis Reject the Null Hypothesis Reality is: Type I ErrorNo Desired There is no differencedifference caused by fishing
Reality is: Type II Error, there is There is a difference often caused Desired Difference by a low N value
Internal Validity Definition:
*It is the extent to which the effects detected in the study are a true reflection of reality rather than the result of extraneous variables;
* The independent variable did have an impact on the dependent variable and it was not by random chance (p value)
Threats to Internal Validity History: Natural events over time impacting
the subjects Maturation: A person’s growth in any area
impacting his/her response Testing effect caused by subjects
remembering previous testing Instrument reliability of treatment Selection process (randomized) Mortality threat Interaction with subjects No equalization of treatment
External Validity Definition:
To provide development of the design that allows it to be generalized beyond the sample used in the study.
Most serious threat is that the results can only be said of the group being studied
Threats to External Validity Small N No randomization when it is needed Poor sample representation either
by type, geography, or some other characteristic
Cannot be replicated for some extraneous variable
Factors Influencing Sample Size
Effect Size The degree to which the phenomenon
is present in the population or to which the null hypothesis is false.
It is hard to detect an effect from an intervention if the sample is small
Type of study conducted Case study, phenomenology,
experimental, Descriptive
Factors Influencing Sample Size
The number of variables This requires a power analysis to
determine the necessary N Measurement Sensitivity
The ability of the measurement to find what it thinks it is finding.
Data Analysis Techniques The various statistics can impact the
number of subjects needed.
Types of Probability Sampling Simple Random Sampling (select those
with specific characteristics)
Stratified Random Sampling (2 or more strata of population)
Cluster Sampling (all states, cities) Systematic Sampling (every nth) Random Assignment to Groups
(Treatment and Control)
Types of Non-probability Sampling
Convenience (Accidental) Sampling
Quota Sampling Purposive Sampling Network Sampling Theoretical Sampling
Non-Probability Sampling
Purposive Sampling (Non-Randomized)
Theoretical Sampling
Convenience Sampling
Quota
Network
Caution Areas on Data You see what you look for You look for what you know Appropriate statistical strategies
for certain types of numbers If you are a hammer, the world
looks like a nail
Dealing With Data (ch. 11)
Developing Data Collection Forms Planning Data Collection Process Planning he Organization of Data Planning Data Analysis Planning Interpretation &
Communication of Findings Evaluation of the Plan
Data Collection Tasks Recruiting Subjects Maintaining Consistency Maintaining Controls Protecting Study Integrity Problem-Solving
Physiological Measures:Reliability and Validity
Accuracy measurement that has the most precise identifiers
for the level of measurement sought Selectivity
the ability to identify that which is really want to sometimes called specificity
Precision the amount of reproducibility in measurement
Sensitivity The amount of a changed parameter that can be
detected Sources of Error
Data Collection Problems People Problems Researcher Problems Institutional Problems Event Problems Measurement Validity Measurement Reliability
Computer Support for Data Data Input Data Storage Data Retrieval Statistical Analysis
Numbers and Use of Numbers Nominal (subjective)
A Named category given a number for convenience, e.g. males are 1 and females are 2
Ordinal (subjective) A scale that is subjective but shows a direction, e.g.
pain scale, cancer staging, all Likert scales Interval (objective)
Numbers where the interval between them is meaningful, and there is no absolute zero but an arbitrary zero, e. g. a temperature. These numbers can be less than zero.
Ratio (objective) Numbers where there is an absolute zero which
means it is absent or there is a denominator that allows for comparison of meaning and . e. g. number of cases or infections per 100 hospital days, stage 2 skin breakdown per 100 patients.
Bivariate Data AnalysisIndependent Groups
Nominal Data Chi squared (Two or more samples) Phi (Two samples) Cramer’s V (Two samples) Contingency Coefficient (Two
samples) Lambda (Two samples)
Bivariate Data AnalysisIndependent Groups
Ordinal Data Mann-Whitney U Kolmogorov-Smirnov (two-sample test) Wald-Wolfowitz Run Test Spearman Rank-Order Correlation Kendall’s Tau Kruskal-Wallis One-Way Analysis of
Variance by Rank (three or > samples)
Bivariate Data AnalysisIndependent Groups
Interval or Ratio Data t Test for independent samples Pearson’s Correlation Analysis of Variance (Two or more
samples) ANOVA Simple Regression Multiple Regression Analysis (two or
more samples)
Bivariate Data AnalysisDependent Groups
Nominal Data McNemar Test Cochran Q Test (three or more samples)
Ordinal Data Sign Test Wilcoxon Matched-pairs, Signed-Ranks Friedman Two-Way Analysis of Variance
by Ranks (for three or more samples)
Bivariate Data Analysis Dependent Groups
Interval or Ratio Data t Test for Related Samples Analysis of Covariance (for three or
more samples) ANCOVA
Multivariate Data Analysis
Interval or Ratio Data Multiple Regression Analysis Factorial Analysis of Variance Analysis of Covariance Factor Analysis Discriminate Analysis Canonical Correlation Structural Equation Modeling Time-Series Analysis
Working with Descriptive Data:A Toolkit for Health Care Professionals Using Descriptive Statistics
Correlational DescriptivePredictive Descriptive
Model Testing Descriptive
Statistics vs. Tools Inferential Statistic Analysis
Statistics (regression, correlation, t-test, F-test, Multivariate testing etc.)
Descriptive Statistic Analysis Tools to display information
Critical Path Process (p. 524)
1. Select the process2. Define the process3. Form a team4. Create the critical path5. Make the path a working
document
Critical Pathway for Complaints of Chest Pain in
ED
O 2 , IV ,B lo od s , E K G
N o p re v io ussym p to m s
G o od H e a lthM in . R isk fa c to rs
O 2 , IV , B lo od s , E K GA S A , N itro g lyce rn
P re v io ussym p to m s
H a s so m e riskfa c to rs
O 2 , IV , A S A , B e ta ,B lo cker, M o rp h in e ,C a rd ia c C a th L ab
C C U
P re v io u s C A Dm a n y risk
fa c to rs
E D P atie n tsc /o ch es t p a in
Force Field Analysis
Driving Forces(support efforts)
Comparable to Other Schools
Recent drop in NCLEX ratesFaculty requests
Restraining Forces(conflict with efforts)
Significant Change in Policy
More students would failDSN had 90-94% NCLEX
rates with 72%
Driving Issues for Moving Minimum Grade at DSN From 72% to 74%
Indicators to be Used in Hospitals
Quantitative measures Related to one or more dimensions
of performance Help provide data that (when
analyzed) give information about quality
Direct attention to potential problems
Types of Indicators Sentinel-event indicators
Serious injury or death indicator
Aggregate-data indicators Rating for med errors and patient complaints
Continuous-variable indicators Number of new bed sores per day
Rate-based indicators Infections per 1000 patient days
Run Charts Probably most
familiar/used tool Used to identify
trends/patterns in a process over time
Helps track if target level has been attained/maintained
Run Chart – Trend ChartUsed for Self Comparison
0
20
40
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Unit XUnit X
Quarterly report of new bed sores for Unit X 2008
Comparison Run Charts – Trend Charts-(Dangerous because these are not ratio numbers)
0
10
20
30
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Unit XUnit A
Unit B
Unit XUnit AUnit B
Quarterly report of new bed sores for Units A, B, & X for 2008
Histograms
Bar charts that display: Patterns of variation The way measurement data are
distributed Snapshot in time
May be more complex to establish; consult statistics textbook if needed
Comparison Run Charts – Trend Charts-(Dangerous because these are not ratio numbers)
0
5
10
15
20
25
30
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Unit XUnit AUnit B
Quarterly report of new bed sores for Units A, B, & X for 2008
Comparison Run Charts – Trend Charts for Delta Hospital (can be compared equally)
0
2
4
6
8
10
12
14
16
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Unit XUnit AUnit B
Quarterly report of new bed sores per 1000 patientdays for Units A, B, & X for 2008.
Control Chart
Max.
Min.
Std.
0.005 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
x x x
x x x x x
0.003 x x x
x
0.000
This is the control chart for infections from I.V.s on Unit XWith 3 case per 1000 patient days as the standard (std)for 2008.
Pie Charts Descriptive data Shows a distribution by category Compared to the Whole
Pie Distribution of new bed sores for hospitalized patients at Delta Hospital
Unit XUnit AUnit B
Total of 140 new bed sores reported in 2008
43
37
36
Scatter Diagrams
Graphs that show statistical correlation between 2 variables
Used when group wants to: Test a theory Analyze raw data Monitor an action taken
Scatter Diagram Process
Min. Program Passing rates in %
NCLEX Scores by %
72
74
76
100%
Surveys
Survey’s can carry a risk to them. Also know what Likert Scale you are using and why (1-4, 1-5, 1-10 most common).
These are Ordinal Numbers
Naturalistic Inquiry— (Ch. 3) Qualitative Research Methods
Phenomenology Ethnography Auto-ethnography Grounded Theory Descriptive Qualitative Historical ?
Non-Probability Sampling
Purposive Sampling (Non-Randomized)
Theoretical Sampling
Convenience Sampling
Quota
Network
Observational Measurement
Unstructured Structured
Category Systems Checklists Rating Scales
Emic (from within) Etic (from external view point)
Phenomenology Research:“The Lived Experience”
Phenomenology is a science whose purpose is to describe the appearance of things as a lived experience.
It allows nursing to interpret the nature of consciousness in the world.
It can be descriptive or interpretive (hermeneutic).
It is a philosophy, an method, and an inductive logic strategy
Design Characteristics Purposive samples of 7-20 usually going
for saturation. Instrument is the researcher Data collection is by interview of groups
or individual that are verbatim, taped, and field notes.
Data collection is directly tied to analysis, that eventually is coded or structured into themes.
Unique Features of Phenomenology
Most of the literature review is conducted at the end of the data collection. It is believed the CF biases the data collection and analysis. Like Grounded Theory but without a BSP or
bias already in mind. It is conducted by gathering interview
data from others. It is never quantitative, but some would
prefer to try and keep it objective.
Five Steps of the Method Shared Experience is presented Transform the lived experience into an
experience the subject would agree with Code the data Put it into written form and create
confirmation of the data texts. Create a complete integration of all of
these for a research document NOTE: In come cases, researchers need
to have Bracketing to control an over-riding bias or emotional response
Qualitative Research RigorsThe Five Standards (Ch. 13)
Descriptive Vividness Methodological Congruence Theoretical Connectedness Analytical Preciseness Heuristic Relevance
Defining Naturalistic RigorStandards 1 and 2 Descriptive vividness
narratives are texturized, thick, and full of details
the writer shows connections and level of membership
Methodological congruence details of exactly how the data is
gathered with ethical rigor. Does the method match the design?
Defining Naturalistic RigorStandards 3, 4 and 5
Analytical preciseness the data is transformed across several
levels of abstraction moving raw data to clusters,
interpretations, or theory Theoretical connectedness
ensuring the theoretical schema is clear and related to the data being collected and a lens for analysis
Heuristic relevance readers must recognize the phenomenon as
applicable, meaningful, & recognizable
Other Types of Rigor Using Trustworthiness
Trustworthy questions Trustworthy approach Trustworthy in analysis Trustworthy and authenticity of data
Ethnography Research
Defined as: “Learning from People”
By Spradley
Four Types of Ethnography Classical
Years in the field, constantly observing and making sense of actions. Includes description and behavior. Attempts to describe everything bout the culture.
Systematic Defines the structure of a culture.
Interpretive (hermeneutic) To study the culture through inference and analysis
looking for “why” behaviors exist. Critical
Relies on critical theory. Power differentials, who gains and who loses, what supports the status quo.
Historical Roots Early 1900s had several introductions Herodotus wrote about travel in Persia Malinowski’s Study of Trobriand Islanders Hans Stade wrote about his being in
captivity by the wild tribes of Eastern Brazil The School of Sociology in Chicago, where
the city was a laboratory from all the immigrants (dancers, muggers, case studies)
Observation Methods Emic
From within the research itself as a member or participant of some type.
Etic From the outside looking in like a
camera. It can be a peripheral issue or external observer member.
Fundamental Constructs Is usually “etic” on the outside like a camera Sometimes they are “emic”, on the inside as
one of the actors (more in sociology) Researcher is the instrument Fieldwork is where the work occurs Focus is on culture Involves cultural immersion There is a tension and reflexivity between
the researcher as a member or researcher as researcher
Stages of Ethnography Participant observation (gain access,
rapport, trust) Descriptive observation (9) (space, actors,
activities, objects, act, event, time, goal, and feelings)
Ethnographic record (field notes, verbatim, old records, amalgamate the information)
Domain analysis Focused observation (what is now critical)
Stages in Ethnography-2 Taxonomic analyzing (categorize) Componential analysis
(components of the selected areas)
Discover cultural themes Take a cultural inventory Write up the ethnography
Rigors for Ethnography Plausibility
It is very easy to accept as truth Credibility
Not exactly self evident, so you look at sources of evidence
Thick Description Writing in such detail as to know exactly what is
going on. We could also use the Five Standards
Sources of Errors Personal reactivity False inferences Gaps in writing, remembering, and
interpreting Going Native
Grounded Theory Research
Started by Glaser and Strauss in 1967 Used extensively in nursing research Takes into account the concepts of
George Herbert Mead (1934) regarding symbolic interaction theory- how we give meaning to situations, words, objects, symbols
Is very individualistic in meaning Most often used to study areas which
previous research exists
Steps in Grounded Theory are conducted
simultaneously Observation Collection of data Organization of data Review of additional literature Forming theory from the data Using Constant Comparative
Analysis
Data Collection Methods Have qualitative and quantitative
properties
Interviews (one on one, groups) Observation Records (retrospective analysis) Surveys (quantitative) Questionnaires (could be
quantitative) Demographic data
Constructs of Grounded Theory Conceptual framework comes from the
data rather than the literature review There is always an over-riding social
issues being addressed called the Basic Social Process (BSP)
Researcher focuses on dominate processes rather than describing the setting, or unit
You compare all data with all other data
Constructs of Grounded Theory You may change data collection
methods in mid stream to be more appropriate to what has already been discovered
The researcher is to be doing most sequential tasks all at the same time
Constant Comparative Analysis Get data, look at it, look at the
literature, look at previous data, go get more data, look at more literature, look at all the data, etc.
Revise the question, collection method, and keep collecting data, look at literature, compare to old data, etc.
Sampling Methods Called Theoretical Sampling
Based on the current question Add new groups to the sample based
on what it is you have learned (may need more men in the sample, or more people over the age of 70, etc.)
The sample being used moves as the theory develops
Coding the data Look for positive AND negative
cases related to your social process Step One: read, describe, and
interpret Step Two: constant comparison and
clustering Step Three: reduce it to a BSP
Conducting Grounded Theory
Be aware of the social life of the participants Make less assumptions in the beginning Sensitizing to the literature, Bracket if needed Layers of reality are explored, assess your
own energy to go further Spend enough time with participants and data Be observant to how the participants are
doing Learn the symbols being used to create this
reality Sample across time
Case Studiesfrom Stake (2000) and Yin (1994)
These are OBJECT or METHOD issues Object: Has to do with what you want to
study not an approach to how to study it Method: Can be quantitative or
qualitative method (analytically, vs. holistically)
Questions are aimed at “How” or “Why”(rarely “What”)
Single or multiple cases-usually1or 2
Purpose of Case Studies Seeks the unique features (particular) while also
describing the common by describing: The nature of the case The case’s history and background The physical setting Other contexts (economics, political, legal, aesthetic
issues) Other cases through which this case is recognized Through the informants by which the case is known
Examine changes across time (multiple case) Same group of different group
Case Study Rigor Yin (1994) treats this as a positivistic
activity, therefore: Construct, Internal, and external validity Reliability This is not just a pilot study for quasi- or full
experimental designs. It is different. Stake (2000) treats it more naturalistic
Thick description is key Auditability (can it be followed by the reader)
Observational Measurement Could Use all of These
Unstructured Structured
Category Systems Checklists Rating Scales
Emic (from within) Etic (from external view point)
Interview Data Collection
Unstructured Structured
Describing interview questions Pretesting the interview protocol Training interviewers Preparing for an interview Probing Recording interview data
Coding methods
Problem Revisions I am curious about the
standardized treatment protocols for circumcision of a new borne.
NEXT REVISION NEXT REVISION NEXT REVISION NEXT REVISION
Problem Statements-Questions dictates the design
What is experience of police officers who were wounded in the line of duty related to their ability to return to work?
What are the unique features of Hospitals that have NP conducting all surgical admission assessments?
There is (is no) statistically significant difference in iatrogenic diseases between nurse to patient ratios of 1:5 vs 1:8 on General Medical Units.
Does the birthing center philosophy show a relationship to the type of care provided and if so, what is the relationship.
How did the July 08 BSN cohort at DSN obtain a 99% NCLEX pass rate?
Special Research Designs Triangulated, Mixed, Blended Historical Research Action Research Outcome Research Intervention Research
TriangulationBlended Designs
First used by Campbell and Fiske in 1959. Denzin in 1989 identified four different
types. Data Triangulation Investigator triangulation Theoretical triangulation Methodological Triangulation
Kimchi, Polivka, and Stevenson (1991) have suggested a fifth type Multiple Triangulation
Data Triangulation Collection of data from multiple
sources Intent is to obtain diverse views of
the same phenomenon. (Longitudinal is different and is looking for change)
Validate data by seeing if it occurs from different sources
Investigator Triangulation Two or more investigators with
different research backgrounds examining the same phenomenon
Clarifies disciplinary bias Adds to validity of data
Theoretical Triangulation Using all the theoretical
interpretations that could conceivably be applied to a given area
Each view is critically examined for utility and power
Increased the confidence of the hypothesis
Can lead to even greater T. F. beliefs
Methodological Triangulation
The use of two or more research methods in a single study Design level Data collection level
Two major types Within-method (all are one
philosophy) Across-method (across philosophies)
Pros and Cons of Triangulation Very trendy in the 90’s Can be used with smaller N Combined methods may just be
the rise of a new method There are philosophical risks Complex designs and therefore
complex analysis
Action Research: AKA clinical research, clinical inquiry,
A systematic investigation conducted by practitioners involving the use of scientific techniques in order to improve their performance.
Kurt Lewin (1946).
Advantages of Action Research:
The reflective practitioner Contributes to the knowledge base of
teaching practice-self awareness Supports the professional development
of practitioners –more competent in research issues
Builds a collegial network Identifies problems and seeks solutions
in a systematic fashion It can be used at all levels and in all
areas of education
Examples of Action Research Pick a topic Define the problem Select a design Select subjects Collect the data Analyze the data Application of results WHAT MAKES IT ACTION RESEARCH
What Makes it Action Research Invested in rigorously empirical
(positivistic), and reflective and interpretive (naturalistic)
Engages people who have traditionally been called “subjects” who are active in the research process.
Results have a practical outcome related to lives or work of participants.
Outcome Research p.272-317Came from evaluation research of the 70’s and
80’s
Focuses on the end result of patient care and linked to the process that caused the outcome
Momentum is from policy makers, insurers, and the public
Level of concern: 1. Care by clinician, 2. Amenities, 3. Care by the patient, 4. Care received by community
More complex that it may appear
Evaluation of Outcome Research Process Evaluation
Involves Standards of Care Involves Practice Styles Involves Cost of Care
Structure Evaluation Elements of the Structure Philosophies of Management & Decision
Making Process Evaluate Structure Issues and their impact
on the care provided Lacks a set methodology
Indicators of Outcome Research Many Descriptive Indicators for
Nursing Care: NDNQI, Picker, Stage all bed sores on patients at
admission vs. during stay and at discharge.
There must be a clear link between outcome and process
We see practice based web sites: AHRQ, APRNet, PBRN group,
Sampling in Outcome Research Large heterogeneous samples, but not
randomized. They want a full spectrum of the population.
However, they want samples who were treated and those who were not treated to compare differences in outcomes.
Risks, no random sample, small sample sizes are often used putting all their inferential statistics at risk for error.
Intervention Research It is used to give “Causal
Explanations” for what is being seen
Uses quantitative and qualitative methods
It is more than a single research event, but it deals with multiple issues over time
Intervention Research Process Extensive search of what information is
available Heavy emphasis on the intervention and
refining its use Field tested to see if it will work It will involve a host of studies over time Has a host of informants who explain
the local culture and what it will take to get data
Intervention Research Methods
Integrative lit. reviews Consumer publications Standards/ guidelines Meta-analysis Health policy analysis Personal exp.
Reflections Consensus conferences Retrospective chart
reviews Descriptive-
Correlational studies
Observation Case study Focus groups Qual. Studies Concept analysis New media Position Papers Delphi studies Outcome studies
Risk for Use of Intervention Research Risk is asking the wrong question Inadequately trained interveners Poorly defined intervention Many confounding variables that can show
up Too complex to manage and integrate Long time can change many factors: i.e.
who is doing it, where can you still collect data, level of commitment by locations, etc.
Criteria for Intervention Research Design: The intervention is---
Effective Replicable Simple to use Practical Generalizability Compatible with local customs and
values
Historical Research Thought of as qualitative because it
lacks sampling, treating, and controls. Uses Quantitative language, i.e. validity
and reliability of data—best primary sources of data.
Looks at external criticism of data (where, when, by whom), and internal criticism of data (reliability, authentic, biased lens of writer)
Process of Historical ResearchNo Visible Rigor from Qualitative or Quantitative
Research Outline Watch for cross-referencing Be prepared to spend months to years
collecting the data Careful attention to note taking for all
data collection A synthesis of all the data collected and
may need an interpretive strategy Develop a writing outline Write your Historiography
“The beautiful thing about learning is that nobody can take it away from you.”
--BB King US jazz
musician
