NSR 338: Research in Nursing Dennis Ondrejka, Ph.D., R.N.

1. NSR 338: Research in NursingDennis Ondrejka, Ph.D., R.N. 303-292-0015, ext. 3625 office d.ondrejka@denverschoolofnursing.edu Fall, 2009

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

3. 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

4. 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? Cook Chef

5. 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. Technicalfor all practice areas

6. 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 Professional vs. TechnicalThinking and Valuing

7. Is research important to the profession? Yes!! Research is important for building a unique, systematic body of knowledge about a discipline

8. 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)

9. 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

10. Evidence Based Practice: Definition • “…the integration of current bestevidence with clinical expertise and patient values” (Sackett et al., 2000) • “…a framework for clinical practice that incorporates the bestavailable scientific evidence with the expertise of the clinician and the patient’s preferences and values to make decisions about health care.” (Levin, 2006)

11. What is Research? Process of searching for newknowledge about phenomena Validates and refines existingknowledge(Burns & Grove, 2007) Systematic process of inquiry or study Builds new knowledge through the dissemination of findings

12. 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?

13. 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.

14. 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 Ways We Acquire Knowledge

15. 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

16. 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)

17. 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

18. 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

19. Examine Your Text • Ch. 13 = Critiquing Research for qualitative (five Standards) and quantitative. • Ch. 14 = Building an Evidence Based Practice

20. 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)

21. 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

22. 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

23. 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

24. Mydsn.org, NRS 338 • Evidence Based Research www.cochrane.org/ www.guideline.gov http://www.cebm.utoronto.ca/resources/websites.htm www.ahcpr.gov/clinic/ http://www.crd.york.ac.uk/crdweb/

25. Research Philosophy Method:Positivistic versus Naturalistic Inquiry • This is a 100 yearold 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

26. Positivistic Inquiry Naturalistic Inquiry (Constructivism)Quantitative Triangulated QualitativeSolomon Design Blended DesignsPost-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-ExperimentalGrounded Theory Phenomenology -validated tools -two of three -theory building - descriptiveExp. controls -Basic Social Process - interpretive - hermeneuticDescriptiveExperimental Design - quantitative orEthnography -random sample qualitative methods -living in the experience -control group -cultural immersion -a treatment given Outcome Research Case StudyEpidemiology (humans & Ds) -single-double cases Analytic Epi -In-depth analysis Descriptive Epi - comparative analysisAction ResearchAdequate time commitment Collaborative effort Openness to change Quality of data collection and analysis Impact on one’s practice

27. Positivistic Inquiry Naturalistic Inquiry (Constructivism)Quantitative Triangulated QualitativeSolomon DesignBlended DesignsPost-modernQuasi-ExperimentalGrounded Theory PhenomenologyConstant Comparative AnalysisDescriptiveExperimental DesignEthnographyCase StudyScientific Rigors by DesignQuantitative Research RigorValidity & Reliability (internal-external) Qualitative Research RigorConceptual 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, transferability Stylistic & Personal Relevance, Heuristic

28. Sample Size by DesignPositivistic Inquiry Naturalistic Inquiry (Constructivism)Quantitative Triangulated QualitativeSolomon DesignBlended DesignsPost-modern Power Analysis 20-40 1 Quasi-ExperimentalGrounded Theory Phenomenology >40 10-1000 10+saturation (10-30) DescriptiveExperimental Design1-12Ethnography Power Analysis 1Case Study1-2Action Research?-100

29. 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 singular reality value free Positivistic thinking independent variables generalizable

30. 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 singular reality value free Positivistic thinking cause & effect validity independent variables generalizable

31. 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 value-free reliability hypothesis testing singular reality Positivistic thinking cause & effect validity generalizable independent variable

32. 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 multiple realities naturalistic inquiry hypothesis is a focus area researcher & subject connected

33. 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 multiple realities inquiry is value bound Naturalistic inquiry hypothesis is a focus area researcher & subject connected thick description

34. 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 Differences in Scientific Rigorpositivistic naturalistic

35. Tools surveys, questionnaires objective assessment & identification Measure the dependent variable Convert to numeric symbols Apply statistical inferences to numbers Large sample sizes help withconfidence 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 Data Collection Differencepositivistic naturalistic

36. 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 Differences in Results positivistic naturalistic

37. 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)

38. 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.

39. 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

40. 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

41. 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

42. 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)

43. 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

44. 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

45. 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

46. The Literature Review • Primary Sources • Secondary Sources • Theoretical literature • Empirical (Research) literature • Evidence Based Research Sites www.cochrane.org/ www.guideline.gov http://www.cebm.utoronto.ca/resources/websites.htm www.ahcpr.gov/clinic/ http://www.crd.york.ac.uk/crdweb/

47. 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 …

48. 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

49. Literature Searches • Ebscohost with CINAHL:http://search.ebscohost.com • Log in: DSN • Password: evidence • Mydsn.org • NRS 338 • Data bases

50. 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