Chapter 24 Nursing Research and EvidenceBased Practice Sharon

Data Measurement § Researcher chooses the method of measuring variables § Measurement = assigning numbers to variables (counting, comparison, ranking) § Quantification of data allows for comparison of results using numbers. § Qualitative data uses narrative form and no numbers. Copyright © 2015. F. A. Davis Company

Measurement Levels § Why measurement is important: The level of measurement determines the statistical test used to measure data! § Nominal data is categorized. § The number of categories are counted and totaled as percentage or frequencies. § The numbers themselves have no value. § This is the lowest level of measurement. § Examples = gender, marital status Copyright © 2015. F. A. Davis Company

Measurement Levels (cont’d) § Ordinal data is ranked or categorized. § There are no differences between ranks unless it is specified. § The ranks indicate order, not quantity. § Examples = mild, moderate, severe; frequency distributions, percentages, and statistical tests Copyright © 2015. F. A. Davis Company

Measurement Levels (cont’d) § Interval data uses real numbers. It is categorized, ranked, and has rank-to-rank distances. § Examples = actual numbers on scale (thermometer) § Ratio data is categorized, ranked. It has rank-to-rank distances and natural zero point. § Examples = grades in book, money in account § It is the highest level of data. Copyright © 2015. F. A. Davis Company

Conversion of Data § Data can be changed from a higher level to a lower level, but not the other way. § Example: Temperature readings can be changed from numbers to categories such as high, moderate, or mild. § Should not be done because the data loses precision. Copyright © 2015. F. A. Davis Company

Collection Process § When colleting data, the researcher needs to answer these questions §

Data Collection § Elements that determine how the data variables are measured § The research questions or hypothesis § The design of the study § Types of variables § Data collection method § Questionnaires, interviews, attitude scales, observational methods § Sometimes several collection methods may be used for one study. Copyright © 2015. F. A. Davis Company

Types of Instruments § The type of instrument is determined by the research design. § Example: Observational design uses checklists, surveys, or questionnaires § Existing instruments that are copyrighted can be used. § Have established reliability and validity § Researcher-developed instruments may have problems with reliability and validity. § A pilot study is required to test new instruments. Copyright © 2015. F. A. Davis Company

Factors in Instrument Selection § Practicality of the instrument: includes cost, appropriateness, time, training required for use. § Reliability: needs to produce consistent results. § Use the correlation coefficient (− 1. 00 − +1. 00) − (r) magnitude between variable relationship to test the reliability of an instrument. § Reliable instruments have a positive relationship; above +. 70 is required for a reliable instrument. § More items in the instrument increases its reliability. § Reliability needs to be assessed periodically. Copyright © 2015. F. A. Davis Company

Instrument Reliability § Stability: the same results are obtained over time; use test-retest to measure it. § Equivalence: degree to which two different forms gather the same results. § This is particularly important with observational data. Copyright © 2015. F. A. Davis Company

Instrument Reliability (cont’d) § Interrater/interobserver: two or more observers using same tool are compared. § The degree to which the observers agree establishes the coefficient of equivalence. Copyright © 2015. F. A. Davis Company

Instrument Reliability (cont’d) § Internal consistency: shows that all the instrument’s items measure the same variable with only one concept. § Test used: split-half § The instrument’s items are divided in half and the scores compared (first to second, odd to even, etc. ) § The goal is to decrease the value of the (r). Copyright © 2015. F. A. Davis Company

Validity § The ability of the instrument to gather data that it is intended to collect. § Content is important. § It must be assessed periodically for effectiveness. Copyright © 2015. F. A. Davis Company

Types of Validity § Face validity: the researcher examines the instrument to see if it is measuring what it is supposed to be measuring. § Very superficial § Experts can be used § Never used as the sole measure of validity Copyright © 2015. F. A. Davis Company

Types of Validity (cont’d) § Content validity: looks at the instrument to determine if the number and type of items are adequate to measure variable. § No objective measure for determination of content validity. § Often uses a panel of experts. § The instrument blueprint is examined in light of the objectives and the knowledge level required (retention, recall). Copyright © 2015. F. A. Davis Company

Types of Validity (cont’d) § Criterion validity: the ability of an instrument to determine present responses and predict future responses. § Concurrent validity: compares an instrument’s ability to obtain a measurement by comparing it to another similar instrument. § Predictive validity: the instrument can predict responses in the future. Copyright © 2015. F. A. Davis Company

Types of Validity (cont’d) § Construct validity: the most difficult to measure; it is the degree to which an instrument measures the construct of the research design. § Requires the measurement of a variable that is not observable but is an abstraction derived from observable behavior. § It measures theory that explains the construct. § Tests used to determine construct validity § Know-groups procedure: tool given to two groups whose response is expected to differ on the variables. § Factor analysis: method to identify clusters of related items on tool. Copyright © 2015. F. A. Davis Company

Reliability Versus Validity § Reliability must be the first priority. § It is necessary for validity. § If an instrument is unreliable, it cannot have validity. § However, an instrument can be very reliable and have low validity. Copyright © 2015. F. A. Davis Company

Reliability Versus Validity (cont’d) § Order of priority for types of validity § First: construct validity § Second: face validity § Third: content validity § When talking about validity it is best to use terms like supported, assessed, evidence has shown, instead of established. Copyright © 2015. F. A. Davis Company

Elements That Cause Data Collection Error § Instrument inadequacies § Confusing items § Unclear instructions § Excessive length § Instrument administration biases § Used in different ways for different populations § Different researchers use it differently Copyright © 2015. F. A. Davis Company

Elements That Cause Data Collection Error (cont’d) § Environmental variations during collecting process § Different locations for testing § High noise levels § Uncomfortable room temperatures Copyright © 2015. F. A. Davis Company

Elements That Cause Data Collection Error (cont’d) § Variable subject characteristics during administration §

Questionnaires § Questionnaires are self-reporting instruments. § The appearance affects the responses. § Complicated, “crowded” questionnaires reduce response rate. § Reading level should be at the 6 th-grade level. § Language should be appropriate for the audience. Copyright © 2015. F. A. Davis Company

Questionnaires (cont’d) § Length of any individual question should be less than 20 words. § Question wording should be affirmative. § Avoid ambiguous questions. § Avoid double-negative questions. § Avoid sexist or politically incorrect terms. § Avoid double-barreled questions. Copyright © 2015. F. A. Davis Company

Question Type § Demographic: asks about the attribute variables of the study sample (age, occupation, etc. ). § Open-ended: Respondent cannot answer with a yes or no: requires thought and insight. Copyright © 2015. F. A. Davis Company

Question Type (cont’d) § Closed-ended § Should be collectively exhaustive (includes all possible answers). § Should be mutually exclusive (no overlapping with other answers). Copyright © 2015. F. A. Davis Company

Question Type (cont’d) § Contingency: answers to one question rely on how other questions were answered. § Example: “If you answered “yes” to #4, complete #5 -7. ” § Filler: used as a distraction from the main thrust of the questionnaire. § Has no direct effect on the results. Copyright © 2015. F. A. Davis Company

Questionnaires (cont’d) § Questions should be grouped together by focus. § Cover letter should explain why the research is being done. § Instructions should be clear and concise. § Advantages of questionnaires § Quick, cheap, easy to test for reliability and validity, cover a wide area, anonymous, honest answers Copyright © 2015. F. A. Davis Company

Questionnaires (cont’d) § Disadvantages of questionnaires § Mailing costly, response rate low, social answers, fail to answer all items, no clarification, must be able to read, not useful for physically handicapped, may not be representative of population Copyright © 2015. F. A. Davis Company

Interviews § Obtain responses from subject in a face-to-face encounter or over the phone. § Used for descriptive, qualitative, and experimental studies. § Types of interviews § Unstructured interview: used in exploratory/qualitative studies; no writing of questions in advance; probes, prompting subject; used to measure beliefs and attitudes. Copyright © 2015. F. A. Davis Company

Interviews (cont’d) § Types of interviews (cont’d) § Structured interview: identical questions are repeated; factual information is obtained; produces data that can be compared. § Semi-structured interview: asks predetermined questions but also probes; uses open and closed questions; must compare results to all subjects. § Instrument used § Determine interview schedule § May use tape/video recordings § Telephone Copyright © 2015. F. A. Davis Company

Interviews (cont’d) § Interviewer training; guidelines for interviewer § Timing/setting must be determined §

Interviews (cont’d) § Advantages: wide range of subjects, response rate high, data usable, in-depth responses, nonverbal and mannerisms observed § Disadvantages: training, time consuming, social answers, anxious about recording, influenced, nonverbal behavior decreased Copyright © 2015. F. A. Davis Company

Observation § Collecting of data through visual observation § Plan for observation should include

Observation (cont’d) § Who observes? § Training, reliability § What procedure is used? § Structured: prior knowledge (checklist) § Unstructured (describes behaviors ) § Event/time sampling; entire event versus during only specific times Copyright © 2015. F. A. Davis Company

Observation (cont’d) § What is the observer’s relationship to the subject? § Nonparticipant observer, overt: discloses that research is being conducted and identifies data being collected. § Nonparticipant observer, covert: does not disclose that research is being conducted. Copyright © 2015. F. A. Davis Company

Observation (cont’d) § What is the observer’s relationship to the subject? (cont’d) § Participant observer, overt: involvement with the subjects; produces qualitative data only. § Participant observer, covert: participates but without the knowledge of the subjects. Copyright © 2015. F. A. Davis Company

Physiological Data § Physiological measures: collection of physical data. § Data is very accurate and objective. § Need for more physiological studies and multiple data-collection instruments in nursing to produce more valid data. Copyright © 2015. F. A. Davis Company

Attitude Scales § They are instruments that report attitudes or feelings on a continuum. § Related items are given a score when totaled. § Types of attitude scales § Likert scale: strongly agree to disagree; forced to select answers that are incorrect § Semantic differential scale: attitude along continuum between two phases; responses in semantic space Copyright © 2015. F. A. Davis Company

Psychological Scales § Personality inventories: measures differences in traits, needs, or values of individuals; compared to average results; usually produces honest answers. § Projective techniques: uses items that are written to have no meaning. § Examples = Rorschach inkblot test; thematic apperception test Copyright © 2015. F. A. Davis Company

Data Collection Methods § Q Sort: subjects sort statements into categories according to attitudes of the statement. § Left to right in piles; positive to negative § Delphi technique: uses several rounds of questions to seek a consensus on topic from experts without face-to-face meeting. § Often used to get opinions, beliefs, or future predictions from experts. Copyright © 2015. F. A. Davis Company

Data Collection Methods (cont’d) § Visual analog scale: a line is presented with words that represent a concept; subjects mark on the line at the point that describes their feeling. § Pre-existing data: uses charts, records, documents, or journals as data source. Copyright © 2015. F. A. Davis Company

Analysis of Data § Quantitative: best type of data § Qualitative: changed to symbols or numbers § Statistical consultant can be used to help with data analysis. § Coding data gives it numerical values. Copyright © 2015. F. A. Davis Company

Critiquing Data Collection § Data § What data was collected? § Who collected the data? § When, how, and where was data collected? § What is the level of measurement of variables? § How are the instruments described? § New? Used before? Standardized? § Reliability/validity of instruments? § What validity type(s) does the instrument have? § Was a pilot study done? Copyright © 2015. F. A. Davis Company

Critiquing Data Collection (cont’d) § Questions to ask § § § § § Are the methods appropriate? How many methods were used? What method was used to determine validity? Is the questionnaire good quality? What was the response rate to the questionnaire? Are there any sampling biases? How is anonymity/confidentiality maintained? How much time for the interview was allowed? What was the training for interviewers? Copyright © 2015. F. A. Davis Company

Study Findings § How the study’s data is analyzed § Results should be presented in the past tense. § The study findings are the presentation of the RESULTS in the form of empirical data or FACTS. § This is not the place for the researcher to express opinions or reactions to the data. Copyright © 2015. F. A. Davis Company

Presentation of Findings § Findings should be presented in narrative forms and tables. § Table and narrative should “stand alone. ” § Reader should be able to obtain results in both narrative and table form. Copyright © 2015. F. A. Davis Company

Presentation of Findings (cont’d) § As much attention should be paid to data that FAIL to support hypothesis as to those that DO. § In qualitative research, hypotheses are rarely tested and therefore do not require statistics. Copyright © 2015. F. A. Davis Company

Presentation of Findings (cont’d) § Qualitative data § Narrative presentation frequently contains many direct quotes made by participants. § The researcher then presents a summary of findings by discussing § THEMES and PATTERNS identified § CATEGORIES of responses Copyright © 2015. F. A. Davis Company

Presentation of Findings (cont’d) § Figures: any type of visual presentation other than a table. § Graphs, diagrams, scales, and/or photos § Discussion of findings § More subjective than narrative presentation. § Allows for interpretations of findings. § Limitations may be revisited. Copyright © 2015. F. A. Davis Company

Discussion of Findings § This part of the paper is more interpretive. § It allows the researcher to describe and discuss interpretations of findings. § Supported and unsupported § No literature cited. § Limitations may be discussed. Copyright © 2015. F. A. Davis Company

Hypotheses Discussion: Possible Results § Null hypothesis is not rejected. § Negative results are important. § Attempt some explanation for results obtained. § Null hypothesis is rejected and research hypothesis is supported. § Data provides the support for the research hypothesis. § Must state with certainty results are not due to chance. § Null hypothesis is rejected and results are in the opposite direction from the prediction of the research hypothesis. Copyright © 2015. F. A. Davis Company

Statistical Significance § Statistical significance: null hypothesis is rejected and differences found are not

Clinical Significance § Clinical significance: findings may be useful in the clinical setting with clients. § As size of sample increases, the correlation to reach significance decreases. § Statistically significant correlation means that you are reasonably sure that the actual correlation between variables is greater than zero. Copyright © 2015. F. A. Davis Company

Conclusions § Knowledge or understanding that has been obtained from the study should answer these questions. § Is the problem and purpose answered? § Is the hypothesis and framework supported? § What is the sample size and population from which the sample is taken? Was it adequate? § Is it possible to generalize the results to other populations? Copyright © 2015. F. A. Davis Company

Implications § The implication section of the study is creative. § Includes changes that you have thought about earlier. § Includes shoulds or should nots of the study. § Determines if more research on this topic is required. § Should be at least one idea for future research. § How can educators, clinicians, researchers, theorists use this information? Copyright © 2015. F. A. Davis Company

Recommendations § Different study methods, sample size, setting, instrument changes § Future research based on study findings, framework § Partial replication when studies are changed § Study limitations: sample, instrument, variable control, methodology changes Copyright © 2015. F. A. Davis Company

Ethical Issues in Research § Confidentiality § Make certain no participants are identified. § The name of the agency in which the study took place is never mentioned and it cannot be identified. Copyright © 2015. F. A. Davis Company

Critiquing the Research Study § Questions to ask § Are the findings clear and concise? § Are the findings presented in an objective manner? § Is the study hypothesis/questions addressed? § Are limitations listed and discussed? § Is the statistical/clinical significance discussed? § Are the conclusions clearly stated? § Can generalizations be made based on the data? § Were findings over-generalized? § What are the implications and recommendations? Copyright © 2015. F. A. Davis Company

Research Report § A written or verbal communication of findings of the study § Findings should be presented in the order of the research process. § Research reports may be presented in § Lecture or talk § Journal article § Poster presentation § Thesis/dissertation Copyright © 2015. F. A. Davis Company

Publishing Research § Research is generally published in a journal. § Refereed journals use acknowledged experts to review manuscripts. § Non-refereed journals use editorial staff or consultants to review manuscripts. § Peer review process involves review of manuscript by professional colleagues. Copyright © 2015. F. A. Davis Company

Publishing Research (cont’d) § Before submitting an article, send a query letter to determine the editor’s interest. § Letters may go to several journals, but the actual manuscript MUST NEVER be sent to more than one journal at a time. Copyright © 2015. F. A. Davis Company

Publishing Research (cont’d) § Two to twelve months from the time the manuscript is submitted to the time it is published. § Author will receive galley proofs for approval. Copyright © 2015. F. A. Davis Company

Funding for Study § If funding was received for a study, the researcher is expected to provide a final report at completion of project. § Report may be brief or lengthy § Lets the funding agency know that the submitted plan (which initiated the funds for study) was complied and the actual research was completed Copyright © 2015. F. A. Davis Company

Theses and Dissertations § A thesis is completed as part of the requirements for a master’s degree. § A dissertation is completed as part of the requirements for a doctoral degree. § These are capstone projects. § They are written and then defended orally before a panel of experts. Copyright © 2015. F. A. Davis Company

Barriers to Utilization of Research § Nurses’ lack of knowledge of research and the findings § Nurses’ negative attitudes toward nursing research § Inadequate skills in disseminating research findings Copyright © 2015. F. A. Davis Company

Barriers to Utilization of Research (cont’d) § Lack of institutional support for research by nurses § Study findings that are not ready for use in nursing practice Copyright © 2015. F. A. Davis Company

Evidence-Based Practice § The movement to achieve cost-effective, highquality care based on scientific inquiry generates the drive for evidence-based practice (EBP). § Because of the volume of literature being published by all health-care professions, including nursing, it is important to develop critical discernment skills. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Critical discernment requires the nurse to understand the research process and to sift through and carefully assess all available and credible research findings. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Nurses should use traditional critiquing methods before determining that research results are ready for practice. § Nurses must also evaluate research findings for applicability to their specific clinical setting. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Most new procedures must go through a policy and procedure committee. § Procedure must be approved prior to use. § Procedure is then standardized for use by all appropriate personnel. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § The current use of EBP in nursing requires a transition from nursing care that is based on opinions, past practices, and precedent to decisions that are based on scientific research and proven evidence. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Goal of EBP: to obtain the best information available and to integrate it into nursing practice. § Ultimate outcome: improved quality of care based on the best practices from research. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Evidence reports § Provide a scientific basis for a disease or a nursing practice. § Integrate the data into actions used in practice. § Synthesize previous and current knowledge related to the topic. § Review the information for quality and documentation. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § The reviews in evidence reports § More detailed than a typical literature review § Include broad-based information translated into specific approaches to client care Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Key elements in evidence reports § Part 1 should include a structured summary statement of the problem, practice, or disease that describes what is in the evidence report. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Part 2 should have a lengthy and detailed analysis of the published and unpublished data, including § § Reviews of articles and reports The populations included in the studies The nature of the nursing actions investigated The ranking or grading of the quality of the evidence Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Level of quality of the evidence § Also called “level of recommendation for use. ” § Answers the nurse’s question, “Should I value this information and use it in my practice? ” § Evidence reports provide both the type of evidence included and the strengths and consistencies of the information. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Types of evidence used § Five types of evidence can be present in an evidence report, ranked from I (strongest) to V (weakest). § Type I: meta-analysis of multiple well-designed, controlled studies that examines and synthesizes many studies to find similar results. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Types of evidence used (cont’d) § Type II: at least one well-designed experimental study with a random sample, control group, and intervention. § Type III: well-designed, quasi-experimental studies, such as nonrandomized controlled, single-group pretest or post-test, cohort studies, or time series studies. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Types of evidence used (cont’d) § Type IV: well-designed nonexperimental studies, such as comparative and correlational descriptive studies and controlled case studies. § Type V: Case reports and clinical examples. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Strength and consistency of evidence are ranked on a 5 -point scale. § A (best) to E (poorest) § In general, a “B” or higher should be present before a nurse integrates the data into EBP. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Strength and consistency § Type I evidence: consistent findings from multiple studies of types II, III, or IV. § Type II, III, or IV evidence: findings are generally consistent. § Type II, III, or IV evidence: findings are inconsistent. § Type V evidence: little or no evidence. § Panel consensus: practice recommendations are based on the opinions of experts in the field. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Evaluating an evidence report § Is this the best available evidence? § Peer-reviewed journals § Reports no more than 3 to 5 years old § Will the recommendations work for my practice given the client population and problems? Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Evaluating an evidence report (cont’d) § Do the recommendations fit well with the preferences and values of the clients I commonly work with? § If the values of the nurse’s primary group vary greatly from those of the study group, it is likely the recommendations may not work well. Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Sources § Clinical journals § Evidence-Based Nursing § Online Journal of Clinical Innovations § Reformatted STTI Online § Journal for Knowledge Synthesis in Nursing Copyright © 2015. F. A. Davis Company

Evidence-Based Practice (cont’d) § Other sources § National Guideline Clearinghouse (U. S. Agency for Healthcare Research and Quality): a repository for clinical practice guidelines § The Cochrane Collaboration (international): develops and maintains systematic reviews § State University of New York (SUNY) website: lists the best sites for information Copyright © 2015. F. A. Davis Company