Nursing Research: 63-377 Dr. Wally J. Bartfay

1. Nursing Research: 63-377Dr. Wally J. Bartfay “When you make the finding yourself – even if you’re the last person on Earth to see the light- you never forget it.” Carl Sagan

2. Review Quiz: True or False? • 1. Schools of nursing began introducing research into the curriculum during the 1940’s? • 2. The goal of nursing research is to describe, explain, control and predict phenomenon of interest to nursing? • 3. John Snow (1850s) performed the 1st clinical trail on the British Navy’s ship Salisbury to test his hypothesis regarding the cause and Rx. of scurvy (low citric acid levels)? • 4. Quantitative research helps develop theory and is considered inductive in nature? • 5. Nightingale’s (1850-1910) use of qualitative research methods demonstrated that mortality for hospitalized soldiers were significantly higher than those in the battlefield?

3. Elements of a good design • (1) Appropriate to the purpose of the investigation • (2) Appropriate to answer the research question(s) • (3) Feasible given realistic constraints • (4) Effective in reducing threats to validity

4. Controlling Equivalence of Subjects & Groups • When comparisons are made, it is assumed that individual units being compared are equivalent, EXCEPT for the variables being examined • Don’t want to compare “apple & oranges” (both are fruit per se but have very different compositions) • To establish “equivalence”, researcher defines inclusion & exclusion criteria • Deviations from these criteria are threats to validity • Note: Although random sampling is effective strategy for achieving equivalence, it does not guarantee equivalence (still need to check criteria)

5. Controlling the treatment • Ist step is to make a detailed description of the treatment(s) • 2nd step is to use strategies to ensure consistency in implementing treatment (e.g., same nurse does dressing, use same equipment, time, intensity, sequencing, staff skill etc) • Note: variations in treatment reduce effect size & internal validity is reduced

6. Carry-over Effect & Counter-balancing • Certain studies, each subject receives several treatments (e.g., relaxation, distraction or visual imagery) or various levels of the same treatment (e.g., different doses of med) • Occasionally, application of one treatment can affect response to later treatments – known as “carry-over” (e.g., effects of a cardiac med) • “Counter-balancing” is used to balance this by administering treatments in random order rather than being administered in same sequence

7. Controlling Extraneous Variables • (1) Random sampling: increases probability that subjects with various levels of an extraneous variable are included & are randomly dispersed throughout study • (2) Random assignment: Enhances probability that subjects with various levels of extraneous variables are equally dispersed in treatment & control groups

8. Controlling Extraneous Variables • (3) Homogeneity: more extreme form of equivalence in which researcher limits subjects to only one level of an extraneous variable to reduce its impact on study findings (e.g., only menopausal females, males aged 40 to 50) • (4) Heterogeneity: no rambling sampling used here, but researcher attempts to obtain subjects with “wide-range” of characteristics to reduce risk of biases (e.g., various occupations, SES, income levels) • (5) Blocking: Researcher includes subjects with various levels of an extraneous variable in the sample, but controls the number of subjects at each level & their random assignment to groups within the study (e.g., randomly assign equal numbers of subjects into 3 separate age categories)

9. Controlling Extraneous Variables • (6) Stratification: involves distribution of subjects through-out the sample, using sampling techniques similar to blocking, but purpose is “even distribution” throughout sample • (7) Matching: used when subjects in exp. Group is randomly selected & then a similar subject in relation to extraneous variable is randomly selected for control group (e.g., matched for HF, menstrual status, occupation, fitness level) • (8) Statistical control: Data analysis procedures that have capacity to remove (partial-out) the variance explained by extraneous variables before analysis of differences or relationships between or among variables of interest are examined

10. Triangulation strategies • (1) Data triangulation: involves collection of data from multiple sources for same study (multi-site study, note longitudinal studies are not a form b/c their purpose is to identify change) • (2) Investigator: 2 or more investigators with diverse research training backgrounds examine same phenomenon • (3) Theoretical: is use of all theoretical interpretations that could conceivably be applied to a given area • (4) Methodological: is use of 2 or more research methods in a single study (most common type, e.g., use different instruments to examine same phenomenon like QOL) • (5) Analysis: same data set is analyzed with 2 or more differing analyses techniques (purpose is to provide a means to cross-validate findings)

11. Clinical Trials • Are studies designed to examine effectiveness of clinical treatments (e.g., meds, nursing procedures, therapies) • Phase I: Used to determine issues around safety & desirable outcomes (e.g., dose of med)- {No control or randomization} • Phase II: Seeks preliminary evidence of efficacy & side effects/ outcomes- {No control or randomization} • Phase III: Experiment to compare effect of new treatment/ procedure or med with current “gold standard” (e.g., Compare deferiprone with desferal)- also called “full-scale definitive trials” or “randomized clinical trails” (RCTs)

12. Primary prevention & Health Promotion Studies • Involve applying treatment of primary prevention (the cause) & then attempts to measure effect (which would not occur if treatment was effective) • Try to measure things that do not happen (e.g., development of heart disease, diabetes in a community) • Hence, design involves examining changes in community, & variables are called “indicators” • A change in the indicator is inferred to be a consequence of effectiveness of the prevention program (treatment) (e.g., TV based healthy eating campaign over a defined period of time)

13. Outcomes Research: A brief history • Sir William Petty (1623-1687) 1st to question effectiveness of health care services (considered to be father of economics & epidemiology) • French physician Louis (1787-1872) developed statistical methods demonstrated often harmful & lethal effects of blood-letting • Semmelweiss (18th century) showed that women in labor assisted by midwives had lower mortality than those attended by physicians in hospital wards (hand-washing) • Florence Nightingale (1812-1910) developed 1st uniform hospital discharge data set & used data to link mortality with Dx & Rx’s & disseminated her findings to those who formulated health policy (she enraged military & civilian med. Establishment of her day)

14. Outcomes Research • Designed to examine effectiveness of health care services • Strategies used from traditional scientific endeavours & incorporate evaluative research, epidemiology & economic theory perspectives • Nurses are taking the lead in conducting studies to examine the outcomes of programs designed to protect or improve health of the community • Goal is the evaluation of outcomes (time dependent) & attribution (requires assigning place & degree of responsibility for outcomes observed) {e.g., providers, patient compliance, insurers, resources, etc} • Standard of care is norm on which quality of care is judged

15. Methodologic Research • Studies which address the development, testing, validation & evaluation of research instruments (tools) or methods • May be descriptive, non-experimental or experimental (e.g., evaluate SF-36 QOL instruments with young children-most studies done only on adults)

16. Survey Research • Done to obtain global information about the prevalence, distribution & interrelations of variables within a defined population (e.g., Canada Census Survey) • Very flexible & broad in scope • Can be applied to many populations & cover a wide range of topics • However, info obtained is rather superficial • May appear in several formats (e.g., telephone, paper & pencil), big problem with compliance & validity here

17. Phases in Qualitative Research Designs/ Approaches • Phase I: Orientation & overview -determines what is salient about the phenomenon of interest) (e.g., how decision making occurs with treatment options for pt’s with prostate CA) • Phase II: Focused exploration –more focused exploration & in-depth exploration (e.g., information given about Rx choices for prostate CA & expected outcomes) • Phase III: Confirmation & Closure – helps to establish that findings are correct & trustworthy (e.g., go back & discuss what researcher head subject say about Rx. Choices & expected outcomes for prostate CA & how decisions were arrived at alone or in combination)

18. Qualitative Approach & Nursing

19. Qualitative Approach & Nursing Note: The researcher is the “instrument” here

20. Qualitative Research Methods • (1) Phenomenological: is a process of learning & constructing the “meaning of human experiences” through intensive dialogue with subjects who are living the experiences (e.g., women with breast CA) • (2) Grounded Theory Method: Inductive approach that uses a systematic set of procedures to arrive at theory about basic social processes (e.g., organizational characteristics of self-help groups for parents with special needs children)

21. Qualitative Research Methods • (3) Ethnographic method: derived from Greek term “ethnos” meaning people, race or cultural group- it focuses on the scientific description & interpretation of cultural or social groups & systems (Aboriginal health) • (4) Case-study method: Study of a selected phenomenon that provides an in-depth description of its dimensions & processes (e.g., selenium-deficient induced cardiomyopathy in nutritionally deprived run-away child)

22. Bonus assignment due Sept.29 • Have a great week…