nursing-research-and-statistics.pdf

c h a p t e r 1 Introduction to Nursing Research OBJECTIVES Upon completion of this chapter the learner will be able to: Identify the types of knowledge used by nurses in their practice Discuss the historical developments of nursing research Explain the meaning and definition of research Differentiate between research in nursing and nursing research Differentiate between problem-solving, scientific method, and research Explain basic and applied research Identify the characteristics of nursing research and researcher Discuss the significance of nursing research Explain research utilization Differentiate between research utilization and evidence-based practice Discuss various aspects of evidence-based practice Define evidence-based research NURSING RESEARCH: A PERSPECTIVE Managing clinical responsibility is a challenge for nurses and nursing profession. Nurses require extraordinary range of knowledge, skills, and talents to provide quality care to their patients. Historically, nurses’ practices were based on certain types of knowledge. The mechanisms that nurses usually used to provide patient care were as follows: traditions and customs, common sense, authority, experience, intuition, logical reasoning, and assembled knowledge. Carper stated that there are four types of knowledge that nurses use to base their practice, namely empirics, aesthetics, ethics, and personal knowledge. Park had described three types of knowledge. They are representational knowledge (to describe, explain or understand a phenomenon), relational knowledge (knowing a person both affectively and cognitively), and reflective knowledge (bringing changes by ref lecting on agreeing to the values, which inform the world in which we live). Whatever may be the type of knowledge, it gets outdated quickly in today’s scientific world. The half-life of scientific knowledge is getting shorter than before. Nurses must access and evaluate extensive clinical information and incorporate it into their clinical decision-making to provide quality care in a compassionate manner. This is possible only through the efficient use of research findings. This can be achieved by purposeful reading of research reports and research summaries in the practice area and by conducting or participating in research studies to develop new knowledge. Nursing research generates new knowledge that boosts scientific practices and is the only valid knowledge that nurses can rely upon in their practice. So, nurses need to be cognizant and proficient in the research process. 2 | Chapter 1 HISTORICAL DEVELOPMENT OF NURSING RESEARCH The need ofresearch was emphasized in modern nursing practice fromitsinception. Florence Nightingale established her system of nursing and nursing education over a hundred years ago. However, she envisioned the development of nursing as a scholarly human and scientific discipline. She used the research process and records to formulate ideas for improving nursing and health care. This incidence directs the need of observation and documentation in the practice of nursing. This may be the reason why she is still remembered by the statisticians as a pioneer in statistics. Florence Nightingale focused on the importance of a healthy environment for patients. She used aspects of research such as ventilation, cleanliness, purity of water, and healthy diet. She began her research during the Crimean War (1853–1856) and collected data based on her observations. She used statistics and graphs to present results. She had based her nursing care on research findings. Her most important findings were that mortality rate decreased from 42 per cent to 2 per cent for wounded or ill soldiers after the environment was cleaned. Although Florence Nightingale paved way for scientific basis for nursing practice, nurse’s education was mainly based on apprenticeship training model in early period. During this period, the primary emphasis was on the availability of student’s services in patient care rather than on developing knowledge base for the nursing profession. Nursing Research Development in USA The historical background on the development of nursing research in the USA shows that from 1900 to 1950 most leaders in nursing had advanced preparation in the field of education. As a result, many research studies focused on education rather than practice and that improved the educational system of nursing. During 1900–1950s, many articles on nursing care of patients with communicable diseases, hygiene, sanitation, asepsis, infant mortality, and maternal mortality were seen in nursing literature. This shows nurses’ awareness towards research. The American Journal of Nursing was first published in 1900. In 1920, the journal published its first case study, which was used as a teaching tool for students at that time. Even now, case studies are found to be one of the best teaching tools for nursing. In 1920s, the first graduate programme in nursing was started in the USA. The 1930s witnessed the evaluation of the effectiveness of nursing procedures and distinguished nursing orders from medical orders. During 1930–1940s, nursing leaders conducted studies on the status of nursing students and the findings helped to relieve excess nursing duties from students to fully benefit from educational programmes. After World War II, a broader concept of nursing care related to public health nursing was developed. The importance of including social sciences and humanities into nursing education was emphasized during this period. Social sciences and humanities helped nurses to have a broader concept of family-centred care. This promoted nurses with research background to conduct studies on the sociological and psychological aspects of illness. The research resulted in the fundamental paradigm shift of nursing care from patient-centred care to family-centred care. In 1950, graduatelevel programmes were started in nursing. The aim was to prepare nurses for leadership positions, advance practice and research. In 1950, the American Nurses Association (ANA) initiated a five-year study on nursing functions and activities. 1952 was a landmark year in the history of nursing research with the publication of the Nursing Research Journal. This helped to communicate the growing body of knowledge to professionals in nursing. In 1953, the Institute for Research and Service in Nursing Education was established by Teacher’s College, Columbia. In 1955, the ANA established the American Nurses Foundation to support and promote research activities. In 1956, the articles that appeared in journals show reflections on the ideas about conceptual development of nursing as a science and a profession. Introduction to Nursing Research | 3 During 1955–1965, researchers focused their work on the characteristics of students for selection, retention, and educational processes. Articles focusing on quality of patient care, chronic heart diseases, cancer, stroke, and so on were also published at that time. Hospitals began to report experiences with intensive care unit and automation. In 1963, the publication of International Journal of Nursing Studies was started. Sigma Theta Tau first published Image (now The Journal of Nursing Scholarship) in 1967. Prior to 1970, the Nursing Research Journal was the only major publication. However, by 1970, the number of publications increased, which included Western Journal of Nursing Research, Advances in Nursing Sciences, Nursing Science Quarterly and Scholarly inquiry for Nursing Practice. In 1970, the ANA funded the formulation of a national commission for the study of nursing and nursing education. During this period, some private sources also published independent investigations of the quality of nursing in USA. Five hundred US nurses earned doctoral degrees in the 1970s, which is considered as a landmark achievement in the development of nursing research. In 1970, the Commission on Nursing Research was formulated in the USA to advance research activities. In 1972, the Council of Nurse Researchers was established. In 1973, the National Commission for Nurses in the USA concluded that nursing is a science and an art. Advances in Nursing Science and Research in Nursing were first published in that year, followed by Western Journal of Nursing Research (1979). During 1977–1986, 720 journal articles related to nursing research were published with 95 per cent nurses as first authors. During 1976–1981 and in 1985, the ANA developed the statement of priority on nursing research. In 1986, the National Center for Nursing Research was established in the USA with Dr Ada Sue Hinshaw as the first director. In 1993, the National Center for Nursing Research became the National Institute for Nursing Research. The current work of this institution is related to expansion in clinical practice, ethical practice and protection of human subjects. Another area of concern is the use and evaluation of nursing theories. The Qualitative Research Journal was first published in 1994. 1997 witnessed the foundation of Canadian Health Services. In 2004, world view on Evidence Based Nursing Journal was started. History of Nursing Research in Europe In Europe, especially in the UK, the United Kingdom Central Council for Nursing (UKCC) and the National Institutes of Health (NIH) also took up nursing research as a main agenda for nursing fraternity to improve evidence-based nursing practice. In the 1950s, sociologists and psychologists were more involved in researching nursing and nurses. Marjorie Simpson started a self-help group for nurse researchers in 1959 called the Research Discussion Group. This later became the Research Society of the Royal College of Nursing. By 1980s, nurses in the UK obtained doctoral degrees from various universities. They obtained research qualification even after a baccalaureate programme. Tierney identified the UK, Finland and Denmark as having developed in a similar way over 30 years, with Estonia, Lithuania, and Slovenia developing their research activities only in the past 10 years. Nursing Research in India The first attempt at nursing research in India dates back to Florence Nightingale’s report on unsanitary conditions in Indian military men’s living areas. In 1946, the Bhore Committee in its report recommended improvement in various aspects of nursing, including the need for higher education. Following these recommendations, nurses from India were sent to Columbia University to acquire research qualifications. Ms Edith Buchanan of Rajkumari Amrit Kaur College of Nursing (RAKCON) was the first nurse in India to obtain a doctoral degree in education with the sponsorship of the World Health Organization (WHO). In 1955, Ms Margaretta Craig attended the International Council of Nurses meet and presented a paper on the need for nursing research in India. 4 | Chapter 1 From 1960 onwards, postgraduate nursing students started progressively involving themselves in research at RAKCON, Delhi, and College of Nursing, Christian Medical College, Vellore. In 1963, the Indian Nursing Council (INC) conducted a study on the health services of India to revise General Nursing and Midwifery (GNM) syllabus. Dr Marie Ferguson of RAKCON along with other nurse leaders conducted an activity study to define nursing and non-nursing functions of nurses in selected health institutes of India. The Trained Nurses Association of India conducted a study on nurses’ time utilization with the assistance of Ms Anna Gupta, under the guidance of Dr Sulochana Krishnan. Ms Margaretta Craig was the chairperson. Dr Aparna Bhaduri and Dr Marie Farrel had authored Health Research: A Community Based Approach, which was published by WHO. They conducted a series of seminars in various parts of the country to create awareness about nursing research among nursing educators. The first nursing research conference was organized at College of Nursing, Bengaluru, in 1982. The title of the conference was ‘Nursing Research in India: Prospect and Retrospect’. This conference had made the following recommendations: 1. Each nursing college should have a research cell. 2. The faculty at a nursing college should encourage students and provide time for conducting research. 3. The college of nursing should foster research attitude among nursing students. 4. The central and state governments and private institutions should include budget for nursing research. 5. Opportunity should be provided for faculty to visit foreign countries on short-term basis to learn about nursing research. 6. Efforts should be taken to establish collaborative areas of research and scholastic interactions with nursing colleges in other countries. In 1984, the University Grants Commission sponsored a conference at Bengaluru titled ‘Teaching Nursing Research to Nursing College Teachers’ for all teachers of nursing colleges in India. The first M. Phil. programme for nurses started at RAK in 1986 followed by MAHE, Manipal, in 1992; doctoral programmes are now offered by many universities in India for nurses as well as other disciplines such as psychology, education and other humanities. The INC now offers Doctor of Philosophy in Nursing (PhD) programme in collaboration with WHO at Rajiv Gandhi University, Bengaluru. Other prestigious universities that offer PhD programme in India are MAHE, Manipal; JNU, New Delhi; SNDT, Mumbai; University of Kerala; University of Calicut; MG University; Kottayam; The Tamilnadu Dr MGR Medical University, Chennai and Devi Ahilya Vishwavidyalaya Indore and many other universities, Indore. As far as research articles are concerned, the Nursing Journal of India (NJI) gives preference for research articles. From 1978 to 1980, Dr Aparna Badhuri and Dr Marie Farrel wrote on nursing research in a series of articles in NJI. Many Indian nurses were sponsored by the Rockefeller Foundation to achieve their doctoral degree from Columbia University during 1950–1970s. In 1998, the National Institute of Mental Health and Neurosciences Bangalore (NIMHANS) organized a nursing research interest section. In 2002, INC revised the GNM syllabus and included nursing research in the curriculum. Another landmark achievement in nursing research in India was the establishment of the Nursing Research Society of India (NRSI) in 1986, with Dr Inderjit Walia as the founder president and Mrs Uma Handa as the first secretary. The work of NRSI has helped in creating awareness on research among nurses. Every year, the society organizes conferences for nurses on current issues in the nursing field pertinent to nursing in the country. NRSI now has zone-wise activities, as India is a vast country and it may not be able to cater to the needs of all nurses in this diversified country. Introduction to Nursing Research | 5 NRSI has provided a portal for the dissertations conducted in the country as a curricular requirement by postgraduate students (). Now, there are many indexed journals that are published for dissemination of nursing research articles; examples of such journals are Nursing and Midwifery Research Journal, Nightingale’s Nursing Times, Journal of Nursing and Midwifery, Journal of Nursing Research Society of India, Indian Journal of Nursing Studies, Journal of Nursing Education, and Kerala Nurses’Forum. PhD Consortium and Its Role in Research Development The INC in collaboration with Rajiv Gandhi University of Health Sciences and WHO has initiated a doctoral programme in nursing under the Faculty of Nursing to promote doctoral education in various fields of nursing (). Currently, there are six study centres (College of Nursing, NIMHANS, Bengaluru; R.A.K. College of Nursing, New Delhi; C.M.C. College of Nursing, Vellore; C.M.C. College of Nursing, Ludhiana; Government College of Nursing, Thiruvananthapuram and Government College of Nursing, Hyderabad). These centres are connected by video conferencing facilities. Currently, the seventh batch of students is doing the doctoral research under the PhD consortium. The consortium can be contacted at . Indira Gandhi National Open University had also started PhD in nursing in the year 2010. The current enrolment is fixed for postgraduate nurses who have completed five years of experience after postgraduate qualification. DEFINITION AND MEANING In today’s world, nurses must be lifelong learners capable of evaluating and modifying their clinical practice based on new knowledge. Nurses are increasingly expected to become producers of new knowledge through nursing research. The term research in Latin means ‘to know’. The word ‘research’ is derived from the French language and its literal meaning is ‘investigate thoroughly’. It is a new way of experiencing reality. Research is to search again or to examine carefully. It is the process of collecting, analysing and interpreting data to understand a phenomenon. Specifically, research is diligent, systematic enquiry, or investigation to validate and refine existing knowledge and generate new knowledge. Research in its broadest sense is an attempt to gain solutions to problems; more precisely, it is the collection of data in a rigorously controlled situation for the purpose of prediction or explanation. ANA defines nursing research as the development of knowledge about health and the promotion of health over the full life span, care of persons with health problems and disabilities, and nursing actions to enhance the ability of individuals to respond effectively to actual or potential health problems. According to ANA, nurses use research to provide evidence-based care that promotes quality health outcomes for individuals, families, communities, and health care systems. Nursing research is a systematic approach to examine the phenomena that are important to nursing and nurses. Nursing research is the systematic enquiry designed to develop trustworthy evidence about issues of importance to the nursing profession, including nursing practice, education, administration, and informatics. NURSING RESEARCH VERSUS RESEARCH IN NURSING Nursing research focuses on the practice of nursing. Research in nursing studies the nursing profession and the characteristics of the nurse. Nursing research is mainly concerned with clinical problems. Research in nursing is the broader study of the nursing profession and includes historical, ethical 6 | Chapter 1 and political studies. Nursing research includes all studies concerning nursing practice, education, and administration. Studies concerning nurses themselves also can be included in nursing research. It provides objective and reliable nursing knowledge to improve the quality of nursing practice. It is important for every nurse to know that studies related to patient care or promoting wellness are usually termed ‘clinical nursing research’. SCIENTIFIC METHOD AND RESEARCH PROCESS Scientific method is the basis of scientific investigation. It involves experiments on samples or specimens. In scientific method, the scientist poses a question and formulates hypotheses. The hypothesis stays as the potential explanation or answer to the question. Here, the researcher with empirical evidence and rigorous control attempts to answer the question under consideration. So, it is a process that starts with a question. It is a systematic and objective method of enquiry. Scientific method helps a researcher to develop new knowledge, expand and validate existing knowledge, and reaffirm previous knowledge. The rigorous control is the core of scientific method. Hence a specific problem is studied in a systematic and objective way by keeping rigorous control and holding conditions constant which permit only variation to phenomena comes under study. It also focuses on the structure and control to establish cause and effect relationship between variables by supporting or rejecting the hypothesis. The scientific problem-solving helps in theory testing and not theory developing. This method helps to test fractions of theory rather than a whole theory. That is, a fraction of the theory can be tested while specific problems are investigated because it is structured. Theory generation is possible only when a loosely structured research method is used, as it helps to depict the totality or wholeness of the human experience under study. Research process covers all branches of research with a whole lot of methodology and not only the scientific method of experimentation. Research uses non-experimental observations for gathering information. In a historical research, the researcher may collect data on experiences of people in a retrospective perspective. However, in scientific the method, the researcher performs the observation as a by-product of some intervention. Research process refers to the actual gathering of information. This can be observation, interview or even gathering information on the Internet. In the scientific method, rules and answers are derived through several steps and it ends with a conclusion as proving or disproving, or accepting or rejecting, the hypothesis posed. Research is a step in the knowledge quest. Research today has a wide spectrum from researching a book and writing a review to locating best evidence from different sources to answer a burning clinical question in the context of nursing research. When research is used in the context of science, it is a step of scientific method. Scientific method is specific and often uses the following steps: 1. State a hypothesis—a tentative prediction of relationship between variables. 2. Design an experimental procedure to test the hypothesis and construct equipment and tools necessary for testing. 3. Conduct experiment. 4. Analyse data collected from experiment. 5. Refine or correct hypothesis and continue the experiment if necessary. The scientific method has many limitations compared with other research methods in nursing. Because nursing uses human beings as subjects, it poses moral and ethical issues. The complexity of human behaviour will not allow rigorous control, and the measurement of behaviour poses difficulty due to influence of external variables. Keeping conditions constant is a difficult task. Introduction to Nursing Research | 7 NURSING RESEARCH AND PROBLEM-SOLVING A problem is a situation that can be quantitative or qualitative, confronts an individual or a group of individuals, and requires resolution. Problem-solving is a powerful human activity. It is a process, an activity, whereby the best value is determined for an unknown, subject to a specific set of conditions. It is a means by which an individual uses previously acquired knowledge, skills, and understanding to satisfy the demands of an unfamiliar situation. It is impossible to teach specific facts that will always lead to a solution. The ability to solve a problem comes from doing it. Many things must pull together to solve a problem. Problem-solving is a skill necessitating a combination of experience, knowledge, process, and art. The problem-solving process is a series of logical steps, which when followed produce an optimal solution, given time, and resources as two constraints. There are different steps involved in problem-solving and different experts give several types of steps. However, all these experts agree on the following steps: 1. Specify the Problem: This involves evaluating the present state and determining how it differs from the stated goals. 2. Analyse the Problem: Analysing the problem involves learning as much as you can about it. 3. Formulate Possible Solutions: Identify a wide range of possible solutions. 4. Evaluate Possible Solutions: Weigh the advantages and disadvantages of each solution. 5. Choose a Solution: Consider three factors: compatibility with your priorities, amount of risk, and practicality. 6. Implement the solution. 7. Evaluate and revise if necessary. Both nursing research and problem-solving use abstract critical thinking and complex reasoning to identify new information. However, research process needs to be distinguished from problem-solving. Problem-solving targets a single problem of a patient or an organization, for example, a patient complaining that a particular nurse behaves absent-mindedly while providing care. This may be a problem related to that particular nurse; the reasons for such behaviour need to be analysed and solutions are to be determined to change the behaviour of that particular nurse. Research process, on the other hand, contributes to the profession of nursing by validating, predicting, explaining, and controlling phenomena of interest to nursing with the help of statistics. For example, a study can be conducted to find the level of satisfaction among patients receiving chemotherapy in the day care centre. The knowledge derived from this study can be used to change the practice. The study can be replicated in another place for further validation of findings. A solution derived for a problem cannot be replicated as the problem may not be the same for another situation or place. Research involves an explicit process of informed consent for subjects of the study, which is not customary in a problem-solving scenario. In the example of the absent-minded nurse, she can be called and questioned about the reasons of absent mindedness, whereas the patients participating in the study on the level of satisfaction need to give informed consent expressing their willingness of participation. Research is subjected to external and peer review and replication to ascertain validity and ethical principles. A problem of absent mindedness of a particular nurse is an isolated problem and a solution is necessitated for that situation. However, the level of satisfaction of patients is related to multiple factors that are not only related to the nurse’s behaviour. It needs a thorough exploration of the structure, process and output in the health care organization. The factors may be similar in different organizations and need 8 | Chapter 1 TABLE 1.1 Differences between Research and Problem-solving S. No. Research Problem-solving 1. Start with selection of a research topic. Target a single problem. 2. Perform the rigorous process of collecting and analysing data using statistical methods. No statistical analysis is used. 3. Controlthe extraneous and confounding variables. No control is imposed. 4. Informed consent of participantsis necessary. No informed consent is needed. 5. Findings of the research study can be generalized. No generalization is needed. 6. Replication of the study is possible. No replication is possible and issituation based. replication to identify best evidence. Table 1.1 summarizes the differences between research and problem-solving: NEED AND IMPORTANCE OF NURSING RESEARCH The most important purpose of nursing research is to develop a scientific knowledge base for nursing practice. Practitioners of human care and treatment throughout history have been viewed with respect, and their services were unquestioned compared with those in other professions. However, these differences are diminishing. Now, nurses must account for what they do, why they do, what they produce and how much it costs. So, nursing is accountable to society for providing cost-effective state-of-the-art quality care, and nurses are accountable to their patients. A solid research base will provide evidence of the nursing action that is effective in promoting positive patient outcomes in terms of positive aspects of health including survival rates, states of physiological, physical and emotional health, and satisfaction with health care services. The classic definition of outcome of medical treatment of death, disease, disability, discomfort, and dissatisfaction (5 Ds) need not be the outcome of nursing research. So, the care given must be routinely assessed and remedial measures must be taken to decide the outcome of nursing practice. Nurses need to seek ways to improve nursing care through research. Research results create a strong scientific base for nursing practice, especially when deliberately and carefully evaluated for application to specific clinical topics. During the career of a nurse, many practice issues and clinical questions will be raised, which require research to answer such queries confidently. Pursuing research in such areas will help nurses to acquire valid and reliable information that would enable them to provide quality care. Findings of nursing research not only aim at affecting the direct provision of nursing and health care to recipients of nursing care but also need to generate knowledge in areas that affect nursing care processes indirectly. Burns and Groove stated that research within the realms of nursing education, nursing administration, health services, characteristics of nurses and nursing roles provides evidence for effectively changing these supporting areas of nursing knowledge. Validates Nursing as a Profession Nursing like other professions has educational standards, autonomy, socialization, an established knowledge base, licensure, formal entry examinations, code of ethics, technical expertise, professional standards, altruistic service, and public trust. These are the main characteristics of a profession. The knowledge base of nursing is updated through the same rigorous process of research similar to other scientific professions. Nursing practice activities are substantiated to produce reliable outcomes by a number ofresearches. Introduction to Nursing Research | 9 Critics assert that nursing is a borrowed knowledge, and hence, there is a challenge for nurses to identify those elements that are unique to nursing and build scientific knowledge base unique to nursing. Nursing practice activities can be substantiated as predicting valid and reliable outcomes for patients only after a body of knowledge has been established and confirmed by substantial amount of research. The total body of knowledge called nursing is composed of many facts, concepts, principles, and theories. Much of this knowledge is borrowed from the medical, biological, and social sciences. So, it is imperative for nurses to develop their own body of knowledge in nursing that describes and explains nursing problems and nursing care. Thus, research is essential to develop scientific principles and theories specific to nursing. Researchers in nursing are now conducting research that applies scientific principles from general sciences to nursing care problems to aid in developing scientific base for the profession. Nursing research confirms and expands the body of knowledge to validate the profession with its own knowledge base. For example, if a study on patient comfort suggests that a relationship exists between high level of stress and noise level in patient care unit, the nurse can very well adopt a practice of keeping a lower level of noise in the unit, promoting comfort. These findings can be incorporated into practice and can be suggested as a scientific base for validating nursing interventions related to stress reduction strategies. There it forms a part of nursing knowledge base. New knowledge obtained through research needs to be tested in practice. Nursing care should also generate new areas for research. Thus, research helps in validating the profession. The highest goal of nursing research is the establishment of nursing theories and principles to provide sound bases for practice that validate the profession. While providing nursing care, the choice of nursing intervention is determined from the body of nursing knowledge and factual information about the patient. So, certain standard principles of practice appropriate to particular situation are selected from the body of knowledge. A time should come when it can be said that the scientific base for a particular nursing intervention has arrived from a knowledge base from nursing itself. This will be possible only by developing scientific basis for the profession through research. Refines Existing Knowledge on Nursing Practice Research helps in the discovery of new knowledge and refines existing knowledge. The knowledge generated can be used to improve clinical practice, nursing education, nursing administration, and different nursing roles. For example, diagnosis of type 2 diabetes was made previously with fasting blood sugar 160 mg/dl and GTT (Glucose Tolerance Test) as criteria. The new criteria are FBS (Fasting Blood Sugar)  126 mg/dl—two separate occasions, symptoms, and positive 2-hour GTT—and HbA1C  6.5. This is an example of refining existing knowledge. Researches in the area of care of newborns have identified that keeping infants in the supine position is better than the prone (face down) position to prevent sudden infant death syndrome (SIDS). Previously, newborns and infants were kept face down to drain secretions; this resulted in the suffocation of infants, leading to SIDS. For example, a child sleeping face down may move his or her face into such a position that the nose and mouth are completely obstructed. This may alter the levels of oxygen or carbon dioxide in the infant’s blood. Protective responses to stressful stimuli may be defective in infants who are vulnerable to SIDS. Furthermore, it is identified that items in a baby’s crib and his or her sleeping position can combine with a baby’s physical problems to increase the risk of SIDS. Babies who are placed on their stomachs or sides to sleep may have more difficulty breathing than those placed on their backs. Lying face down on a fluffy comforter or a waterbed can block an infant’s airway. Draping a blanket over a baby’s head is also risky. This is not the only reason for SIDS, but these findings definitely helped nurses to refine existing knowledge on care of infants to reduce the incidence of SIDS. 10 | Chapter 1 Provides Scientific Basis and Demonstrates Accountability to Profession The scientific knowledge of nursing is derived from the focus or unique perspective of the discipline and provides an organizing framework for nursing practice. The knowledge obtained through research helps nurses to substantiate and justify their actions by referring to research findings. Research results create a strong scientific base for nursing practice, especially when deliberately and carefully evaluated for application to specific clinical topics. In this era of accountability, nurses are accepting the challenge to document outcomes of care. Nursing research had progressed to account for nursing practices and potential effects and document their worth to hospital administration and policy-makers. Thus, nurses can prove the benefit of their appointment over others for providing cost-effective quality care, especially in the current scenario of economic crisis. Research is essential to validate nursing actions, which in turn provide justification for the cost of nurses versus unlicensed assistive workers. Through research, the scientific basis for our actionsis being challenged constantly. Nursing research equipsthe nurses for description, explanation, prediction, and control of nursing phenomena in their clinical practice. Description is done through identifying and understanding the nature and attributes of nursing phenomena and sometimes the relationships among these phenomena. Through research, nurses are able to do the following: 1. Describe what exists in nursing practice 2. Discover new information 3. Promote understanding of situation 4. Classify information for use in the discipline A study conducted to find out the stressors of leukaemic children and their coping mechanisms towards hospitalization provided an insight into the common stressors and described the same in terms of children and their parents. The factors identified as most stressful by parents were not even considered stressful by nurses and doctors. This provided new information regarding different perspective on stressors. Hence, research that concentrates on description is an essential groundwork for studies that will provide explanation, prediction, and control of nursing phenomena. Explanation, according to Burns and Groove, is concerned with the clarification of relationship among and between phenomena. This helpsto identify the reasons why certain events occur. Explanation helps to the organization of concepts and derivation of concepts and principles. Quite often description follows explanation. When enough facts exist, explanation of relation between such facts is necessary. The explanation of phenomena helps to predict the occurrence of certain events. Through research, prediction on the chance of occurrence of certain events can be estimated and precautionary measures can be taken. The probability of occurrence of certain events can be possible only through scientific research using inferential statistics. For example, the Meteorological Survey of India gives prediction on climate or weather changes for each day and gives red alert to fishermen to take precautions by not going to sea on certain days when there is a possibility of a hurricane or heavy tides. These weather reports are obtained through research and monitoring. Here, the people can take precautions, as there is an anticipated risk of turbulent sea. In a similar manner, in nursing, the use of Norton’s scale for bedsore risk assessment help nurses to predict the anticipated risk of developing bedsore in certain hospitalized patients. This example explains that the probability of developing certain conditions or complications is there if certain situations or risk factors are present. Hence, nursing research helps nurses to promote wellness through preventing the occurrence of risk factors. As mentioned earlier, once the outcome of phenomena is predicted through research, the control can be exercised through manipulation of the situation or risk factors. Wiedenbach described control as the ability to write a prescription to produce Introduction to Nursing Research | 11 the desired results. For example, if a patient is found to be prone to develop bedsore, the nurse can very well prescribe to the patient a water mattress, which would control the occurrence of pressure ulcer in that patient. Estimating and anticipating the outcome in a particular situation is thus possible through research. In a nut shell, nursing research does the following for nursing as a profession: 1. Validates nursing as a profession (by providing distinguishing criteria to consider nursing as a profession, a service, occupation) 2. Provides scientific basis for practice by explaining, describing, predicting, and controlling phenomena important to nursing and nurses 3. Helps in formulating theories 4. Helps in formulating models and frameworks for practice 5. Helps in testing the proposed theory 6. Helps in testing models for practice 7. Helps in developing cost-effective quality nursing interventions CHARACTERISTICS OF A GOOD RESEARCH 1. Research is a systematic process that identifies variables and tests the relationship between them. 2. It is logical and so it can be duplicated by others. 3. It has clearly defined purposes. 4. It exerts control over situations or extraneous variables and the variables under study. 5. It is reductive, as it investigates a small sample and findings can be generalized to a larger population. 6. It creates empirical evidences as decisions are based on the data collected. 7. It produces reliable results that can be replicated as others may find the same results. 8. It produces valid findings that are reproducible. 9. It maintains accuracy in all steps. 10. It maintains originality. 11. It meets ethical principles. 12. The informed consent is obtained from the participants. 13. It tests a whole theory or the parts of a theory. 14. It develops theory. 15. It uses logical reasoning in generation of knowledge both deductively and inductively. 16. The findings can be used for description, prediction, and explanation of phenomenon of interest Attributes of a Researcher A researcher should have certain characteristics to effectively conduct the research. They are as follows: 1. A researcher should be a subject expert; they should have qualities such as endurance, commitment and a sensitive mind and should be purpose oriented. 2. The researcher should also have scientific temper with a spirit of enquiry and rational approach. 3. The researcher must be objective and avoid sentiments and emotional interpretations of facts. 12 | Chapter 1 TYPES OF RESEARCH Nursing research activities may be classified into two types. Purpose Basic Research It is the fundamental or pure research for establishing new knowledge with the development and refinement of theories. The findings are not immediately applicable to practical problems, but they provide scope for further research to expand the body of knowledge. In basic research, a specific purpose is not delineated by the researcher like that of applied research, but it stimulates new ways of thinking about divergence that have the potential to change and improve how practitioners deal with a problem. Major aims of basic research are as follows: 1. Gather and generate information. 2. Expand the body of knowledge of the particular discipline in which the study is conducted. 3. Refute or support theories. 4. Refine existing knowledge or theories and principles. Example: A researcher conducts a study on adolescents’ attitude towards hero worship. Here, the researcher observesthat the adolescents believe in positive role modelling rather than hero worship. So, a theory can be evolved on the benefits of role modelling in developing positive attitude among adolescents. Applied Research This type of research also helps in generating new knowledge but can be applied to practical setting without undue delay. It has functional purposes and practical use. Applied research is done to find a solution to a problem that requires an impending solution. It is action oriented and involves collection and analysis of data to arrive at a solution for existing problems in any organization or practice area. So, applied research attempts to solve problems in the organization, make decision, evaluate programmes, and develop new strategies for pursuing change in existing practice. Example: A researcher might have seen that there is a wide variation in oxygen saturation of patients receiving different modes of oxygen delivery after giving the same amount of oxygen. So, the researcher may conduct a study to identify the reasons and the best method of oxygen delivery to improve saturation within a prescribed period of oxygen delivery. Table 1.2 provides a comparison of the basic and applied researches. TABLE 1.2 Comparison of Basic and Applied Research S. No. Basic Research Applied Research 1. Basic research is the pure or fundamental research. It is used in the field of practice to solve a problem. 2. It is done to study a general phenomenon, a process. It is targeted at solving a specific problem for a utilitarian purpose. 3. It is abstract or theoretical. Atheoryorpartofthe theory istested tofindtheutility. 4. It is knowledge for the sake of knowledge and is believed as a starting point in knowledge expansion. It is useful in creating evidences. Introduction to Nursing Research | 13 Approach to Research The following are the various approaches to research: 1. Descriptive research: (a) Classified as surveys (b) Qualitative strategies 2. Experimental research: (a) Purely experimental (b) Quasi-experimental 3. Historical (documentary) In the historical approach, the researcher does the systematic collection and critical evaluation of data related to past occurrences. It examines what has already occurred. The investigator has no control over manipulating the independent variables. Experimental approach is future oriented and predicts what will occur. In this approach, the investigator has control in the manipulations of the independent variables in the experimental settings, and the subjects are randomly arranged (each individual is assigned a place in a group based on chance alone) to the treatment (experiment) condition specified in the study. Quasi-experimental research refers to modification of the experimental approach. The investigator may have control in manipulating the independent variables, although the subjects are not randomly arranged to the treatment condition. The type of research used by a researcher depends on the objectives and framework of the study, kind of data and nature of problems to be solved. The researcher’s skills, background and academic preparation, and areas of competence will influence the selection of the type of research that they do. Difference between research approaches is determined by their time orientation and the extent to which the investigator has control over manipulating the independent variables and the type of philosophy a researcher holds. The philosophy of the researcher influences what type of research they perform. A person holding positivist philosophy may propagate quantitative experimental studies to develop empirical evidences. Naturalistic philosophical perspective advocates qualitative researches. They hold the view that whatever be the control exercised by the researcher, there will be a researcher influence in any experiment. A person believing in critical social theory may propagate yet another approach or mixed methodology. RESEARCH UTILIZATION Research utilization (RU) is the use of research findings in practice to improve the quality of care provided to patients. It is the use of findings of a particular study and is different from evidence-based practice (EBP). RU involves critical analysis and evaluation of research findings and then determines how they fit into clinical practice. Incorporating the findings into practice helps to close the gap between research and practice. More recently, RU efforts in nursing have been replaced by EBP. EVIDENCE-BASED PRACTICE Though RU and EBP are used synonymously by many people, there are differences between these two. RU uses the available research findings to guide the nursing practice and the efforts of the nurses to improve patient outcomes, whereas EBP is the conscientious use of current best evidence in making decisions about patient care. EBP is a problem-solving approach to clinical practice that integrates a systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question. This includes patient data and research data, one’s own clinical practice and patient preferences, 14 | Chapter 1 and values. ‘EBP de-emphasizes ritual, isolated and clinical experiences, ungrounded opinion and tradition as a basis for nursing practices—and stresses instead the use of research findings and, as appropriate, quality improvement data, other operational and evaluation data, the consensus of recognized experts, and affirmed experience to substantiate practice.’ Table 1.3 lists the differences between RU and EBP. TABLE 1.3 Differences between Research Utilization and Evidence-based Practice Research Utilization (RU) Evidence-based Practice (EBP) RU is the use of knowledge typically based on a single study. EBP takes into consideration the findings based on a series ofstudies and the expertise of the practitioner as well asthe patient preferences and values. In RU, we use the results of studies often conveniently selected as supported for nursing care. EBP • is far more rigorous: Here the nurse selects all research that has been done • in an area. Then the research results are analysed together and synthesized, coming up with a through integrative • review. The results are then put into the context of clinical expertise and the value system of the patient and particular protocols of the best practices that are developed. EBP encompasses multiple types of evidence such as research findings, research reviews and evidence-based theory and the integration of that evidence with clinical expertise, and patient preferences and values. Findings are usually applied at the organization level. Findings are usually applied in the bedside and are tailored to individual patient care needs. It follows the steps of RU. It synthesizes all the evidences and integrates with expert opinion, patient preferences and values. EBP is positioned to become a major driving force in the disciplinary life of clinicians, students, educators, administrators, and policy-makers. Extensive work is being done on the best ways to translate research into practice, generating a new area of health care science called translation science. Eventually, the promise of translation science is to provide evidence on the best waysto incorporate best evidence into health care, including nursing practice. Importance of Evidence-based Practice in Nursing Nursing is a practice profession; it is important that clinical practice be based on scientific knowledge. Evidence generated by nursing research provides support for the quality and cost-effectiveness of nursing interventions. It has been observed that EBP improves patient care. A meta-analysis of 84 studies conducted showed that 72 per cent of patients receiving EBP had 28 per cent better outcomes than the control group. The Committee on Quality of Health Care in America, Institute of Medicine, named EBP as Rule 5 of the 10 Rules for Health Care in Crossing the Quality Chasm as a means of quality improvement. It has been seen that only a small percentage (21%) of health care providers are incorporating research Introduction to Nursing Research | 15 findings into patient care decisions. The use of EBP in practice may improve use of research findings. Balas and Boren identified that it takes approximately 17 yearsto translate research findings into practice. EBP improves nurses and other health care professional’s job satisfaction and reduces employee turnover. It has seen that hospitals that had incorporated EBP in nursing practice had less turnover compared with other hospitals. Hospitals with magnet accreditation used EBP in nursing and witnessed fewer turnovers among nurses. This is attributed to job satisfaction among nurses who use EBP. Without current best evidence, practice rapidly gets outdated. Health care providers need to judiciously find the best evidence to make informed care decisions as there are now innumerable amount of information on drugs, health care products, emerging information on risks and benefits of products, alternative medicine approaches, and so on. EBP is a problem-solving approach to clinical practice that incorporates the best evidence from welldesigned studies, patient values, and patient preferences. In EBP, questions are generated in a different manner from research questions. The widely used model is the PICO acronym. PICO stands for the following: P: Patient population I: Intervention of interest C: Comparison intervention or status O: Outcome of interest The following example illustrates the use of PICO format for a clinically burning question. With hypertensive patients (BP 150/80), what is the effect of giving patients choice versus no choice in the selection of their food items on their weight maintenance or blood pressure? P: Patient population (patients with BP 150/80) I: Intervention (choice—patient selects his own food) C: Comparison intervention (no choice group) O: Outcome (maintenance of weight or BP) Patient Population—Questions to Ask: On what patient group is the information required. Starting with your patient, ask how you would describe a group of patients similar to yours. Intervention (Exposure): This is the second part of the question. It can be an action to make a change in a situation or a nursing care on which you want to study the effect. On what medical or nursing intervention do you want to study the effect? What is key intervention that you want to consider? Comparison: Here the comparison of usual intervention to another mode of intervention to find the effect. In the given example, the patients’ choice of food selection rather than a prescribed food menu is compared. What is it compared with? Is it better or worse than no intervention at all or than another intervention? What is the main alternative to compare with the intervention? Outcome: It is the fourth component of PICO. What do we anticipate as an outcome? Until now, we have learned how to formulate a burning question for finding evidence; patient population or patient condition needs to be carefully delineated so that the search for evidence provides relevant information. In the same way, intervention of interest requires similar delineation. The comparison of interest can be a comparison with another intervention similar to the one stated in the given example or the standard of care. The outcome of interest is the desired accomplishment, measurement, or improvement as a result of selected intervention. After formulating a burning clinical question for finding evidence, it is very important to locate the answer to the clinical question formulated. It requires understanding of the information sources. There are many resources available. If the first source is not of help, go for the next, then again the next, and so on. Research studies and clinical trials published in the journal literature 16 | Chapter 1 form the foundation of scientific evidence. However, not all research meets the highest standards of quality. So, those who practice EBP should do systematic reviews or meta-analysis. Determining Best Evidence The most accepted way of finding evidence is through a systematic review. ‘A systematic review is a summary of evidences on a particular topic, typically by an expert or expert panel that uses a rigorous process for identifying, appraising, and synthesizing studies to answer a specific clinical question.’ Conclusions are drawn about the data gathered through this process. Many systematic reviews summarize results from multiple studies. They are called meta-analysis. Systematic reviews or meta-analysis and evidence-based clinical practice guidelines are regarded as the strongest level of evidence on which practice decisions are based. If one research study or clinical trial provides good evidence, several studies with similar findings give even stronger evidence or negate previous findings. This logic is applied by researchers to systematically identify, appraise, and synthesize evidence from individual studies on a particular topic. Here comes the use of meta-analysis of several studies with statistical analyses. These processes translate into the literature as systematic reviews and summaries of evidence. The key to knowing whether the significant and relevant evidence have been found is through further evaluation of the selected studies from a successfully executed search. This evaluation method is called the critical appraisal of the evidence. After completing searches in the appropriate information resources, critically analyse the retrieved documents for validity, reliability, and applicability to the following factors: 1. A defined clinical situation 2. The original clinical question 3. The individual patient needs 4. Do the findings apply to this clinical setting and patient population? 5. Is the evidence strong enough to warrant a change in practice Apply: Once the evidence has been gathered, it is time to apply. Before applying, evaluate whether the intervention should be accepted, rejected, or modified for clinical practice. Think about your own clinical expertise and patients’ preferences and values. Educate the Staff About Its Importance: Solicit staff input so that they will more readily get into the recommended practice. Determine who should be involved in the approval process for the practice change. If costs are likely to increase as a result of the practice change, provide rationale or decide how to handle it. Conduct a trial implementation by focusing on one area where practice change can be carried out easily. Critical Appraising Knowledge for Clinical Decision-Making: Each clinical decision made or action taken is based on the nurse’s knowledge, as described earlier in this chapter. Knowledge is derived from a variety of sources: experience, tradition, trial and error, authority, logical thinking, research, and theories. Grading the strength of the evidence should incorporate the following three domains: 1. Quality 2. Quantity 3. Consistency Introduction to Nursing Research | 17 Integrating the Evidence Evidences that had been critically appraised may be integrated into practice. The common evidences the nurse integrate into clinical practice in order are as follows: 1. Evidence from the literature search 2. Health care provider’s expertise 3. Clinical assessment of the patient 4. Available health care resources 5. Patient preferences and values Evaluating the Effectiveness The effectiveness of the evidence-based intervention is evaluated in terms of how the treatment worked or how effective the clinical decision was with a particular patient or practice setting. This type of evaluation is essential in determining whether the change based on evidence resulted in the expected outcome. If the treatment did not produce the expected effect or the outcome, the analysis should include the formulation of all possible alternative explanations for the findings. A short list of broad strategies that apply regardless of the setting is as follows: 1. Assessment of barriers to EBP 2. Correction of misperceptions about EBP goals and processes 3. Questioning of current clinical practices Evidence-based research is used to describe a type of research where the researcher is aware of certain evidence before exploring the subject. Precisely, the researcher does not enter the project unbiased. They are aware of a theory derived from the evidence and use research to test its validity. KEY POINTS  Traditionally, nurses use different ways of knowledge in their practice.  Assembled knowledge is obtained through thought process and scientific way.  The four types of knowledge used by nurses are empirics, aesthetics, ethics, and personal knowledge.  Nurses also use representational knowledge, relational knowledge, and reflective knowledge.  Research in nursing studies the nursing profession and the characteristics of the professional, whereas nursing research is concerned with practice issues.  The main goal of nursing research is to create and maintain scientific basis for professional practice and validate nursing as a profession.  Nursing research helps nurses in describing, explaining, predicting and controlling the nursing phenomenon of interest.  The two major types of research are basic and applied research.  Nurses need to know the historical development of nursing research to appreciate the previous works and present development to move further.  Much of the nursing research is based on positivism, naturalism, or social critical theory.  Research process and problem-solving use abstract critical thinking and complex reasoning to identify new information, but both are distinct in the characteristics of bringing new information. 18 | Chapter 1  The scientific method has many limitations compared with nursing research process. The complexity of human behaviour will not allow rigorous control. Research process covers all branches of research with different approaches, contrary to the scientific method of experimentation.  RU in nursing is the use of knowledge typically based on a single study, whereas EBP uses findings of many studies, expertise of practices, patient preferences and values.  EBP includes many steps, with formulating a clinical question as the first step. PICO is a tip for nurses to formulate a burning clinical question.  The evidences derived need to be critically analysed before being applied in practice. QUESTIONS I. Essay-type Question 1. How will you substantiate the importance of nursing research to nursing profession? II. Short Notes 1. What are the types of knowledge nurses use in their professional practice? 2. How will you differentiate nursing research from research in nursing? 3. How will you differentiate scientific method from research process? 4. How will you differentiate problem-solving from research process? 5. What are characteristics of a nursing research? 6. What is EBP? 7. How will you differentiate RU from EBP? 8. Why it is important for nurses to use EBP in nursing? III. Multiple-choice Questions Circle the alphabet before the correct answer 1. A problem-solving method that uses experience, intellectual faculties and thought process with both inductive and deductive reasoning is (a) logical reasoning (b) scientific thinking (c) experiential knowledge (d) positivist thoughts 2. The scientific knowledge derived through testing theories by objective approach is (a) intuition (b) empirics (c) aesthetics (d) ethics 3. The chance of occurrence of certain events estimated is called (a) description (b) explanation (c) prediction (d) recapitulation 4. Apositivist philosophy in research proposesis (a) qualitative study (b) quantitative study (c) mixed methodology (d) experiential research 5. The use of a research finding in practice to improve the quality of care provided to patients is (a) EBP (b) RU (c) translation science (d) experiential knowledge Introduction to Nursing Research | 19 6. A new area of health science that translates research findings to practice is (a) EBP (b) RU (c) reflective knowledge (d) translational science 7. Ms Smitha would like to conduct a study on the professional aspects of nursing. You will categorize her study into (a) research in nursing (b) nursing research (c) clinical research (d) qualitative research 8. If a research finding helps nurses to change existing practices for better patient care outcome, it is (a) validating practice (b) providing scientific basis for practice (c) refining existing practice (d) testing theory 9. Fundamental or pure research is called (a) basic research (b) applied research (c) interventional research (d) quantitative research 10. Which of the following is the central core of scientific method? (a) objectivity (b) control (c) systematic (d) replicable 11. NRSI was established in the year (a) 1976 (b) 1986 (c) 1996 (d) 200 Answer Keys 1. (b) 2. (b) 3. (c) 4. (b) 5. (b) 6. (d) 7. (a) 8. (c) 9. (a) 10. (b) 11. (b)