Transcript Research in Nursing - Denver School of Nursing

NSR 338: Research in Nursing
Dennis Ondrejka, Ph.D., R.N.
303-292-0015, ext. 3625 office
[email protected]
Fall, 2009
Is nursing a profession?
Q.#1: What are the criteria for a profession?
Nursing: Profession or
Technical Occupation?
Pavalko’s (1971) Continuum Model for a
Profession
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Theory
Relevance to social values
Education
Motivation
Autonomy
Commitment
Sense of community
Code of ethics
Explore the Meaning of a
Professional vs. Technical Practice
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Describe the similarities
or differences between
the chef at the Brown
Palace & the cook at
the Village Inn?
Cook
Chef
Professional vs. Technical
for all practice areas
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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
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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. Technical
Thinking and Valuing
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Professional thinking
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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
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Least is best
Specialization in depth
Experience is the primary
educator
Conserves energy beyond
the workday
Prefers others be
accountable
Enjoys consistency and
believes change is
disruptive
Is research important to the
profession?
Yes!! Research is important for
building a unique, systematic
body of knowledge about
a discipline
Nursing needs a systematic body of
knowledge to ...
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Promote Evidence-based practice
Give credibility to profession
Provide accountability for practice
Help document the cost-effectiveness of
care (Nieswiadomy, 2008)
What is Evidence Based
Nursing Practice?
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Knowledge from science & research
Knowledge from experts
Knowledge from patients
Knowledge arriving in many forms
Has levels of power and rigor
EBP IS NOT JUST FROM RESEARCH
Evidence Based Practice:
Definition
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“…the integration of current best evidence
with clinical expertise and patient values”
(Sackett et al., 2000)
“…a framework for clinical practice that
incorporates the best available scientific
evidence with the expertise of the clinician
and the patient’s preferences and values to
make decisions about health care.” (Levin,
2006)
What is Research?
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Process of searching for new
knowledge about phenomena
Validates and refines existing
knowledge (Burns & Grove, 2007)
Systematic process of inquiry or study
Builds new knowledge through the
dissemination of findings
Why Research???
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To Describe
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To identify and understand the nature of nursing
phenomena
What is the experience of growing up poor in
Manhattan?
To Explain
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Clarifies the relationship among phenomena,
and why certain events occur
What are the factors that supported DSN
graduates to pass NCLEX at 95% in 2009?
Why Research???
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To Predict
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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
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If we can predict, the next goal would be to
control or manipulate the situation to produce
the desired outcome.
We can reduce bed sores at all stages by
rotating patients every two hours maximum.
Ways We Acquire Knowledge
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Tradition
Authority
Borrowing
Trial and error
Personal experience
Role-modeling &
mentoring
Intuition
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Reasoning
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Inductive-gather
Deductive-divide
Rational-logic
Unstructured
Research
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Quantitative
Qualitative
Mixed / Other
Research Defined
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Research is a systematic, diligent inquiry
that is necessary to address:
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What needs to be known-what is the question,
hypothesis, or interest area
What research methods are needed to examine
this question or phenomena
What meaning can be extracted from the study
through data analysis to build our knowledge
base of that subject
Generate outcomes and disseminate new
knowledge
Ways to Study Research
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By its components (questions, rigors, sampling
method, measurement method, etc)
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Divided into two major types
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Qualitative
Quantitative
By the name of the method (experimental,
phenomenology, etc)
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By the philosophy it uses to inquire (positivistic,
naturalistic, both, neither)
Burns & Grove method:
Examine Your Text
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Table of Contents 7 Ch. 1
Ch. 2 = Quantitative Research
Ch. 3 = Qualitative Research
(philosophy discussed)
CH. 4 = tries to address both qualitative
and quantitative questions
Ch. 5, 6 = Lit review, Study
Frameworks & Theory
Examine Your Text
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Ch. 7 = ethics
Ch. 8 = Clarify Designs (quantitative)
Ch. 9 = Outcomes Research
Ch. 10 = Populations and Sampling for
quantitative and qualitative methods
Ch. 11 = Measurement of Data
quantitative and qualitative
Ch. 12 = Understanding Statistics
Examine Your Text
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Ch. 13 = Critiquing Research for
qualitative (five Standards) and
quantitative.
Ch. 14 = Building an Evidence Based
Practice
Ch. 14 Evidence Based Practice
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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
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Integrative Reviews (many types of designs)
Systematic Reviews (focused on a particular type of research
designs)
Meta-Analysis (has statistical evaluation of quantitative
designs).
Metasummaries & Metasynthesis (qualitative research)
Hierarchy of Evidence
Compare to Florczak article
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Level I: A systematic review or RCTs, metaanalysis of many randomized controlled trials
(RCTs)
Level II: Integrative Reviews of experimental
designs
Level III: from a well-designed controlled trial
without randomization
Level IV: From case-control or cohort studies
Hierarchy of Evidence
Compare to Florczak article
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Level V: From systematic reviews of
descriptive or qualitative studies,
metasummaries, metasynthesis,
Level VI: a single descriptive or qualitative
study
Level VII: It is an opinion from authorities on
that subject, or expert committee
Recent Changes in Nursing
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Page 500, second paragraph, Using ASA
81 mg. in at risk adults
Page 517, I.V. flush using 0.9% NS vs.
heparin. P & P on page 520.
Algorithms on page 524 for tx HTN.
I.V. skin prep using chlorhexidine vs.
Iodine products like providone-iodine
Strait cath urethra prep
Mydsn.org, NRS 338
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Evidence Based Research
www.cochrane.org/
www.guideline.gov
http://www.cebm.utoronto.ca/resources/w
ebsites.htm
www.ahcpr.gov/clinic/
http://www.crd.york.ac.uk/crdweb/
Research Philosophy Method:
Positivistic versus Naturalistic Inquiry
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This is a 100 year old debate
It is often correlated to research methodology
It is a philosophy on the way we think about
human phenomenon & inquiry (research)
We can integrate two different inquiry
methodologies, but philosophically they are
very different (mixed or blended design)
Our philosophy is the foundation for how we
design research
Positivistic Inquiry
Naturalistic Inquiry (Constructivism)
Quantitative
Triangulated
Solomon Design
-four group design
-pretest-treat-post test
Intervention Res
-pretest-no treat- post test
-no pre- no treat- post test
-random group
Quasi-Experimental
-validated tools
-two of three
Exp. controls
Blended Designs
- use quantitative
& qualitative
methods
Grounded Theory
-theory building
-Basic Social Process
Descriptive
- quantitative or
qualitative methods
Experimental Design
-random sample
-control group
-a treatment given
Outcome Research
Epidemiology (humans & Ds)
Analytic Epi
Descriptive Epi
Case Study
-single-double cases
-In-depth analysis
- comparative analysis
Action Research
Adequate time commitment
Collaborative effort
Openness to change
Quality of data collection and analysis
Impact on one’s practice
Qualitative
Post-modern
Phenomenology
- descriptive
- interpretive
- hermeneutic
-research self
-novel sounding
lacks theory
Ethnography
-living in the experience
-cultural immersion
Positivistic Inquiry
Quantitative
Naturalistic Inquiry (Constructivism)
Triangulated
Solomon Design
Qualitative
Blended Designs
Quasi-Experimental
Experimental Design
Grounded Theory
Constant Comparative
Analysis
Descriptive
Post-modern
Phenomenology
Case Study
Ethnography
Scientific Rigors by Design
Quantitative Research Rigor
Validity & Reliability (internal-external)
Conceptual Framework Developed
Statistical Inference
Generalizability
Temporality
Selection and Bias
Measurement validity / reliability
Controlling confounders
Appropriate study design for the questions
Qualitative Research Rigor
Descriptive Vividness
Methodological Congruence
Analytical Preciseness
Theoretical Connectedness
Heuristic Relevance
Trustworthiness, Credibility,
and Auditability
Confirmability, transferability
Stylistic & Personal
Relevance, Heuristic
Sample Size by Design
Positivistic Inquiry
Naturalistic Inquiry (Constructivism)
Quantitative
Triangulated
Solomon Design
Power Analysis
Quasi-Experimental
>40
Blended Designs
20-40
Grounded Theory
10-1000
Descriptive
1-12
Experimental Design
Power Analysis
Case Study
1-2
Action Research
?-100
Qualitative
Post-modern
1
Phenomenology
10+saturation (10-30)
Ethnography
1
Assumptions of Positivistic
Thinking
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Reality is singular,
tangible, & and can
be dissected
The researcher and
those being studied
are independent
Time and contextfree generalizations
are possible
Inquiry is value-free
value free
singular
reality
Positivistic
thinking
independent
variables
generalizable
Assumptions of Positivistic
Thinking
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There are real causes
or at least high
probability of a
relationship.
We believe we can
have independent
and dependent
variables as separate
entities
Validity of a design is
very critical to results
value free
singular
reality
Positivistic
cause & thinking
effect
independent
variables
generalizable
Assumptions of Positivistic
Thinking
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Reliability is based value-free
reliability
on how the design ishypothesis
singular
reproducible
testing
reality
Generalizability is
Positivistic
related to good
thinking
cause
validity
internal validity and
& effect
reliability with
generalizable
independent
comparable samplesvariable
Hypothesis testing
Assumptions of Naturalistic
Inquiry
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Realities are multiple,
multiple realities
pluralistic, and holistic
The researcher cannot
really be separated
from those being
naturalistic
studied and relationhypothesis
researcher inquiry
ships are explained
is a focus
& subject
area
connected
hypotheses are time
and context bound they are only working
statements
Assumptions of Naturalistic
Inquiry
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All entities are in a
state of mutual
simultaneous
shaping
Inquiry is valuebound
Validity is designed
into the process
Reliability &
general- izable are
not concepts of
value with this
multiple realities
inquiry is value bound
Naturalistic
inquiry
hypothesis
researcher thick
& subject description is a focus
area
connected
Differences in Scientific Rigor
positivistic
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Validity
Internal and external
reliability
Hypothesis testing
Statistical inferences
Independent and
dependent variables
Variable controls
Generalizability
naturalistic
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Descriptive Vividness
Methodological
Congruence
Analytical Preciseness
Theoretical
Connectedness
Heuristic Relevance
Others
Data Collection Difference
positivistic
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Tools
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naturalistic
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surveys, questionnaires
objective assessment &
identification
Measure the dependent 
variable
Convert to numeric
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symbols
Apply statistical
inferences to numbers
Large sample sizes help 
with confidence levels
Tool
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is the investigator by
interview, focus groups, &
observation
Data is subjective and
objective. It is collected &
not measured
Themes or clusters are
identified and data is
sorted in a theme analysis
The themes are supported
by participants or experts
Differences in Results
positivistic
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Statistical
significance for prepost treatment
Statistical
correlations &
relationships
identified
Probability of errors
& confidence
identified
Causal relationships
naturalistic
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The exploration &
description of a
phenomenon
Identification of
linkages, relationships,
or interpretations based
on theory connections
Results are themes,
clusters of ideas, or
theory constructs
Positivistic Discussion of
Results
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250 nurses were surveyed with an 80%
response rate or N=200. Questions were
rated using the Likert 5 scale. Question 1
had a mean of 4.2 with a S.D. of 0.5
suggesting the nurses had favorable opinions
about continuing education. Compared to a
1994 survey asking the same question, there
was a statistical difference that was less
favorable (mean 3.1, S.D. 0.7, p<.05)
Naturalistic Description
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I sat in the classroom as a peripheral member
staying as unobtrusive as possible. The
instructor came out from behind her desk,
sitting on the edge as she opened with a
question that brought all eyes in the room to
meet her own eyes. She paused - looked at
the eyes of the students.
The instructor displayed immediacy from the
moment she started the class.
Ethics and Research (Ch. 7)
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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:
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Fabrication of a study
Falsification or forging of data
Dishonest manipulation of the design or methods
Plagiarism
50% of the top 50 research institutions in US
have been investigated for research fraud
Ethical Problems in History
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Nazi medical experiments (19331945)
Tuskegee syphilis study by the
USPHS (1932-1972)
Willowbrook study (1950-1970)
Hepatitis study
Jewish Chronic Disease Hospital
study with live CA cells in 1960s
Ethical Problems in History
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University –Atomic Energy Government Exp.
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18 men and women injected with plutonium to
determine body distribution (at the time said to be
terminal) 1945-47
20 subjects ages 63-83 given doses of radioactive
radium and thorium inj. or oral. 1961-65
64 male inmates at Washington St. Prison had
testicular radiation to determine the smallest does
to makes someone sterile. 1963-70
125 retarded residents were fed radioactive ir9n
and calcium to see if a diet rich in cereal would
block the digestion of those two minerals. 1946-56
Nuremberg Code-1949
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Voluntary consent
Must yield fruitful results for society
Anticipated results justify the type of experiment
Avoids all unnecessary physical-mental injury
Cannot do studies that have a known injury or death
unless the exp. Physician is a subject
Risk does not out weight humanitarian benefit
Proper precautions to prevent injury, dis., death
Conducted by qualified persons
Subjects can always stop the study
Researcher must always be ready to stop the study
(risk)
Declaration of Helsinki-1964-84
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Differentiated therapeutic vs. non-therapeutic
research
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Clinical vs. Basic
Greater care to protect subjects in nontherapeutic research
There must be a strong, independent
justification for exposing a healthy vol. to
substantial risk
The investigator is to protect the health and life
of research subjects
The Belmont Report
Three Ethical Principles
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Principle of respect for persons
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Principle of Beneficence
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Do no harm to others
Principle of Justice
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Right to self determination and freedom to participate or not
Treat everyone fairly without discrimination
Led to USDHHS Code on Ethics
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Title 45, Part 46 (45 CFR 46)
Office of Human Subjects Research (OHSR) within NIH
http://helix.nih.gov:8001/ohsr
Institutional Review Board (IRB)
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Provides oversight on all ethical issues
related to someone doing research
Consent forms (voluntary subjects)
Disclosure forms
Confidentiality
Compensation disclosure
Ethics documented in the research
Accountability to rules, regulations, and
legal entities
Protects at risk populations
The Literature Review
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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/
Definition of a
Literature Review (Ch. 5)
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A systematic and explicit approach
to the identification, retrieval, and
bibliographical management of
independent studies … locating
information … synthesizing …
developing guidelines …
Purposes of the Lit. Review
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Facilitate development of the Conceptual
Framework by summarizing knowledge
Clarify the research topic
Clarify the research problem
Verify the significance of the research problem
Specify the purpose of the study
Describe relevant studies or theories
Develop definitions of major variables
Select a research design, data measurement,
data collection & analysis, & interpret findings
Literature Searches
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Ebscohost with CINAHL:
http://search.ebscohost.com
Log in: DSN
Password: evidence
Mydsn.org
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NRS 338
Data bases
Understanding Research Designs
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Can have confusing terms
Research Methodology
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The entire process from question to analysis
Research Design
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Clearly defined structures within which the
study is implemented
Is a large blueprint, but must be tailored to the
study and then mapped out in detail
Quantitative Designs (Ch. 2)
What are the four types of
Quantitative Designs?
Quantitative Designs
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Experimental
Quasi-experimental
Descriptive
Correlational
Aim to describe, compare, and predict in
order to understand or control
phenomena
Quantitative Designs
What characterizes true
Experimental Research
Designs?
True Experimental Research
Designs
Are characterized by:
 Random assignment of subjects to groups
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Comparison of treatment group(s) with a
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Control or “business as usual” group
True Experimental Research
Designs (cont.)
Also characterized by …
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Strict control of extraneous variables
to obtain true representation of “cause
and effect”
Note: use “causality” language with
caution!!! (there is always a P-value)
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Ex: Smoking and cancer
Randomized Controlled Clinical
Trials (RCT)
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True Experimental Design
Large N (# of subjects)
 Draw subjects from reference population
 Randomly assign subjects to
treatment/experimental or control group
 Examine for baseline equivalence
 Multiple sites used for generalizability
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Quasi-Experimental
Research Designs
Are characterized by:
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Treatment or intervention
Comparison of treatment group(s) with a
control or “business as usual” group
Non-equivalence of groups--not randomly
assigned; group assignment often evolves
naturally “convenience” sampling)
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Ex: Pts. on one unit compared to pts. on another
Quasi-Experimental
Research Designs (cont.)
Also are characterized by…
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Aiming to represent “cause and effect”
in situations where less control over
variables exists
Most frequently used design in nursing
Correlational Designs
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Descriptive correlational designs
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Used to describe variables and to examine
relationships between or among variables
Predictive correlational designs
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Used to predict value of one variable based
on values obtained for another variable
Independent variable used to “predict”
Dependent variable  Regression
Model-testing design
Looks at relationships among a # of variables
Correlational Designs
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Descriptive correlational designs
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Used to describe variables and to examine
relationships between or among variables
Predictive correlational designs
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Used to predict value of one variable based
on values obtained for another variable
Independent variable used to “predict”
Dependent variable
Quantitative Design Concerns
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Primary purpose (check question)
Is there a treatment (intervention)
Will the treatment be controlled
Is there a control (untreated) group
Is there a pre or post test (or both)
Is sample random
Will sample be a single group or divided into
several groups
Quantitative Design Concerns-2
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How many groups will there be
What is the size of each group
Will groups be randomly assigned
Will there be repeated measurements over
time or will the data be collected crosssectionally at one or two points in time
Have extraneous variables been identified
and controlled for
What strategies are being used to compare
variables or groups
Research Question
Considerations
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Ethics
Significance
Motivation
Qualifications
Feasibility
Hypotheses and Research Qs
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Hypotheses: Intelligent guesses about
predicted relationships
Problem statement  what the
issue/concern/problem is and why it
should be addressed
Research Qs: “Burning question”
What are Criteria for
Hypotheses? (Ch. 4)
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Declarative
Written in present tense
Include population
Identify variables
Reflect the problem/concern
Are empirically testable
Independent & Dependent
Variables
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Independent (IV)
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The treatment
The intervention
That which is manipulated
Dependent (DV)
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Outcome
What is being measured
The difference
Types of Hypotheses:
Simple & Complex
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Simple
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One Independent Variable (IV) and one
Dependent Variable (DV)
Complex
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Two or more IVs, two or more DVs, or
both, being investigated at same time
Hypothesis: #1
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Average length of gestation is
shorter for infants of mothers who
use cocaine than among mothers
who use alcohol during the last six
months of pregnancy.
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Population? IV?
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Simple or complex?
DV?
Hypothesis: #2
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The greater the degree of sleep
deprivation, the higher the anxiety
levels of intensive care unit
patients.
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Population? IV?
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Simple or complex?
DV?
Hypothesis: #3
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The total wt. loss of overweight elementary
students who follow a reduced calorie diet
and exercise 20 minutes four times a week
will be greater than those students who do
not follow a reduced calorie diet and do not
exercise 20 minutes four times a week.
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Population? IV?
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Simple or complex?
DV?
Hypothesis: #4
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The degree of stress reported by flightfor-life nurses is greater than the
degree of stress reported by ICU
nurses.
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Population? IV?
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Simple or complex?
DV?
Name that Hypothesis: #5
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More domestic violence and levels of
anger are reported by veterans who
served in the military in Iraq compared
to those in the military who served in
Afghanistan.
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Population? IV?
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Simple or complex?
DV?
Sample of Research Topic &
Questions
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Topic: Adolescent sexuality
Problem statement: (e.g., pregnancy rates in US are
much higher compared to most Western countries)
Research Question:
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Will high school adolescent males report higher levels of
comfort with their own sexuality than will females?
Hypothesis:

Adolescent males in grades 9 – 12 will report statistically
higher levels of comfort with their own sexuality than will
females in the same grades.
Quantitative Design Concerns







Primary purpose (check question)
Is there a treatment (intervention)
Will the treatment be controlled
Is there a control group (untreated)
Is there a pre or post test (or both)
Is the sample a random sample
Will the sample be a single group or
divided into several groups
Quantitative Design Concerns-2







How many groups will there be
What is the size of each group
Will groups be randomly assigned
Will there be repeated measurements
Will the data be collected cross-sectionally
or over time
Have extraneous variables been identified
and controlled for
What strategies are being used for
comparison of variables or groups
Components of Study Validity

Definition: It is an examination of the
approximation of truth or falsity of the
propositions




Statistical Validity (right stats used)
Internal Validity (sample represents the
population being studied)
Construct Validity (concept & Operational def.
of variable match, & instrument accuratly
measures theoretical constructs it purports to
measure.
External Validity (methods allow for
generalizability)

(Cook and Campbell, 1979)
Statistical Validity Errors

Violate assumptions about the data



Type I and Type II errors
Need for Power Analysis




Nominal, ordinal, interval, ratio data
Predicts the necessary N value
Inappropriate use of certain statistics for the
various types of data
Random irrelevancies in setting
Random heterogeneity of respondents
Statistical Conclusion Validity
Type I and Type II Errors
Accept the Null Hypothesis Reject the Null Hypothesis
Reality is:
Type I Error
No
Desired
There is no difference
difference
caused by fishing
Reality is:
There is a
Difference
Type II Error, there is
difference often caused
by a low N value
Desired
Internal Validity

Definition:
*It is the extent to which the effects
detected in the study are a true
reflection of reality rather than the
result of extraneous variables;
* The independent variable did have an
impact on the dependent variable and it
was not by random chance (p value)
Threats to Internal Validity








History: Natural events over time impacting
the subjects
Maturation: A person’s growth in any area
impacting his/her response
Testing effect caused by subjects
remembering previous testing
Instrument reliability of treatment
Selection process (randomized)
Mortality threat
Interaction with subjects
No equalization of treatment
External Validity

Definition:
To provide development of the
design that allows it to be
generalized beyond the sample
used in the study.
Most serious threat is that the results
can only be said of the group being
studied
Threats to External Validity




Small N
No randomization when it is needed
Poor sample representation either by
type, geography, or some other
characteristic
Cannot be replicated for some
extraneous variable
Factors Influencing
Sample Size

Effect Size



The degree to which the phenomenon is
present in the population or to which the
null hypothesis is false.
It is hard to detect an effect from an
intervention if the sample is small
Type of study conducted

Case study, phenomenology,
experimental, Descriptive
Factors Influencing
Sample Size

The number of variables


Measurement Sensitivity


This requires a power analysis to determine the
necessary N
The ability of the measurement to find what it
thinks it is finding.
Data Analysis Techniques

The various statistics can impact the number of
subjects needed.
Types of Probability Sampling

Simple Random Sampling
(select those with
specific characteristics)

Stratified Random Sampling
(2 or more strata
of population)



Cluster Sampling (all states, cities)
Systematic Sampling (every nth)
Random Assignment to Groups
and Control)
(Treatment
Types of Non-probability
Sampling





Convenience (Accidental) Sampling
Quota Sampling
Purposive Sampling
Network Sampling
Theoretical Sampling
Non-Probability Sampling
Theoretical Sampling
Quota
Purposive Sampling (Non-Randomized)
Convenience Sampling
Network
Caution Areas on Data




You see what you look for
You look for what you know
Appropriate statistical strategies for
certain types of numbers
If you are a hammer, the world looks
like a nail
Dealing With Data (ch. 11)






Developing Data Collection Forms
Planning Data Collection Process
Planning he Organization of Data
Planning Data Analysis
Planning Interpretation &
Communication of Findings
Evaluation of the Plan
Data Collection Tasks





Recruiting Subjects
Maintaining Consistency
Maintaining Controls
Protecting Study Integrity
Problem-Solving
Physiological Measures:
Reliability and Validity

Accuracy


Selectivity


the amount of reproducibility in measurement
Sensitivity


the ability to identify that which is really want to
sometimes called specificity
Precision


measurement that has the most precise identifiers for the
level of measurement sought
The amount of a changed parameter that can be detected
Sources of Error
Data Collection Problems






People Problems
Researcher Problems
Institutional Problems
Event Problems
Measurement Validity
Measurement Reliability
Computer Support for Data




Data Input
Data Storage
Data Retrieval
Statistical Analysis
Numbers and Use of Numbers

Nominal (subjective)


Ordinal (subjective)


A scale that is subjective but shows a direction, e.g. pain
scale, cancer staging, all Likert scales
Interval (objective)


A Named category given a number for convenience, e.g.
males are 1 and females are 2
Numbers where the interval between them is meaningful,
and there is no absolute zero but an arbitrary zero, e. g. a
temperature. These numbers can be less than zero.
Ratio (objective)

Numbers where there is an absolute zero which means it
is absent or there is a denominator that allows for
comparison of meaning and . e. g. number of cases or
infections per 100 hospital days, stage 2 skin breakdown
per 100 patients.
Bivariate Data Analysis
Independent Groups

Nominal Data





Chi squared (Two or more samples)
Phi (Two samples)
Cramer’s V (Two samples)
Contingency Coefficient (Two samples)
Lambda (Two samples)
Bivariate Data Analysis
Independent Groups

Ordinal Data






Mann-Whitney U
Kolmogorov-Smirnov (two-sample test)
Wald-Wolfowitz Run Test
Spearman Rank-Order Correlation
Kendall’s Tau
Kruskal-Wallis One-Way Analysis of
Variance by Rank (three or > samples)
Bivariate Data Analysis
Independent Groups

Interval or Ratio Data





t Test for independent samples
Pearson’s Correlation
Analysis of Variance (Two or more
samples) ANOVA
Simple Regression
Multiple Regression Analysis (two or more
samples)
Bivariate Data Analysis
Dependent Groups

Nominal Data



McNemar Test
Cochran Q Test (three or more samples)
Ordinal Data



Sign Test
Wilcoxon Matched-pairs, Signed-Ranks
Friedman Two-Way Analysis of Variance
by Ranks (for three or more samples)
Bivariate Data Analysis
Dependent Groups

Interval or Ratio Data


t Test for Related Samples
Analysis of Covariance (for three or more
samples) ANCOVA
Multivariate Data Analysis

Interval or Ratio Data








Multiple Regression Analysis
Factorial Analysis of Variance
Analysis of Covariance
Factor Analysis
Discriminate Analysis
Canonical Correlation
Structural Equation Modeling
Time-Series Analysis
Working with Descriptive Data:
A Toolkit for Health Care Professionals
Using Descriptive Statistics
Correlational Descriptive
Predictive Descriptive
Model Testing Descriptive
Statistics vs. Tools

Inferential Statistic Analysis


Statistics (regression, correlation, t-test, Ftest, Multivariate testing etc.)
Descriptive Statistic Analysis

Tools to display information
Critical Path Process (p. 524)
1.
2.
3.
4.
5.
Select the process
Define the process
Form a team
Create the critical path
Make the path a working document
Critical Pathway for
Complaints of Chest Pain in ED
ED Patients
c/o chest pain
No previous
symptoms
Good Health
Min. Risk factors
Previous
symptoms
Has some risk
factors
Previous CAD
many risk
factors
O2, IV,
Bloods, EKG
O2, IV, Bloods, EKG
ASA, Nitroglycern
O2, IV, ASA, Beta,
Blocker, Morphine,
Cardiac Cath Lab
CCU
Force Field Analysis
Driving Issues for Moving Minimum Grade at DSN
From 72% to 74%
Driving Forces
(support efforts)
Restraining Forces
(conflict with efforts)
Comparable to Other Schools
Recent drop in NCLEX rates
Faculty requests
Significant Change in Policy
More students would fail
DSN had 90-94% NCLEX
rates with 72%


Indicators to be Used in Hospitals




Quantitative measures
Related to one or more dimensions of
performance
Help provide data that (when analyzed)
give information about quality
Direct attention to potential problems
Types of Indicators

Sentinel-event indicators


Aggregate-data indicators


Rating for med errors and patient complaints
Continuous-variable indicators


Serious injury or death indicator
Number of new bed sores per day
Rate-based indicators

Infections per 1000 patient days
Run Charts



Probably most
familiar/used tool
Used to identify
trends/patterns in a
process over time
Helps track if target
level has been
attained/maintained
Run Chart – Trend Chart
Used for Self Comparison
Quarterly report of new bed sores for Unit X 2008
40
20
0
1st Qtr
Unit X
2nd Qtr
3rd Qtr
4th Qtr
Unit X
Comparison Run Charts – Trend
Charts-(Dangerous because these
are not ratio numbers)
Quarterly report of new bed sores for Units
A, B, & X for 2008
30
20
Unit B
Unit A
Unit X
10
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Unit X
Unit A
Unit B
Histograms

Bar charts that display:




Patterns of variation
The way measurement data are distributed
Snapshot in time
May be more complex to establish;
consult statistics textbook if needed
Comparison Run Charts – Trend
Charts-(Dangerous because these
are not ratio numbers)
Quarterly report of new bed sores for Units
A, B, & X for 2008
30
25
20
Unit X
Unit A
Unit B
15
10
5
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Comparison Run Charts – Trend
Charts for Delta Hospital (can be
compared equally)
Quarterly report of new bed sores per 1000 patient
days for Units A, B, & X for 2008.
16
14
12
10
Unit X
Unit A
Unit B
8
6
4
2
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Control Chart
This is the control chart for infections from I.V.s on Unit X
With 3 case per 1000 patient days as the standard (std)
for 2008.
0.005
Max.
Std.
0.003
0.000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
x
x
x
x
x
x
x
x
x
Min.
x
x
x
Pie Charts



Descriptive data
Shows a distribution by category
Compared to the Whole
Pie Distribution of new bed sores for
hospitalized patients at Delta Hospital
Total of 140 new bed sores reported in 2008
36
43
37
Unit X
Unit A
Unit B
Scatter Diagrams


Graphs that show statistical correlation
between 2 variables
Used when group wants to:



Test a theory
Analyze raw data
Monitor an action taken
Scatter Diagram Process
Min. Program Passing rates in %
76
74
72
NCLEX Scores by %
100%
Surveys
Survey’s can carry a risk to them. Also know what Likert
Scale you are using and why (1-4, 1-5, 1-10 most common).
These are Ordinal Numbers
Naturalistic Inquiry— (Ch. 3)
Qualitative Research Methods






Phenomenology
Ethnography
Auto-ethnography
Grounded Theory
Descriptive Qualitative
Historical ?
Non-Probability Sampling
Theoretical Sampling
Quota
Purposive Sampling (Non-Randomized)
Convenience Sampling
Network
Observational Measurement


Unstructured
Structured





Category Systems
Checklists
Rating Scales
Emic (from within)
Etic (from external view point)
Phenomenology Research:
“The Lived Experience”




Phenomenology is a science whose purpose
is to describe the appearance of things as a
lived experience.
It allows nursing to interpret the nature of
consciousness in the world.
It can be descriptive or interpretive
(hermeneutic).
It is a philosophy, an method, and an
inductive logic strategy
Design Characteristics




Purposive samples of 7-20 usually going for
saturation.
Instrument is the researcher
Data collection is by interview of groups or
individual that are verbatim, taped, and
field notes.
Data collection is directly tied to analysis,
that eventually is coded or structured into
themes.
Unique Features of
Phenomenology

Most of the literature review is conducted at
the end of the data collection. It is believed
the CF biases the data collection and
analysis.



Like Grounded Theory but without a BSP or bias
already in mind.
It is conducted by gathering interview data
from others.
It is never quantitative, but some would
prefer to try and keep it objective.
Five Steps of the Method






Shared Experience is presented
Transform the lived experience into an
experience the subject would agree with
Code the data
Put it into written form and create
confirmation of the data texts.
Create a complete integration of all of these
for a research document
NOTE: In come cases, researchers need to
have Bracketing to control an over-riding
bias or emotional response
Qualitative Research Rigors
The Five Standards (Ch. 13)





Descriptive Vividness
Methodological Congruence
Theoretical Connectedness
Analytical Preciseness
Heuristic Relevance
Defining Naturalistic Rigor
Standards 1 and 2


Descriptive vividness
 narratives are texturized, thick, and full of
details
 the writer shows connections and level of
membership
Methodological congruence
 details of exactly how the data is gathered
with ethical rigor. Does the method match
the design?
Defining Naturalistic Rigor
Standards 3, 4 and 5



Analytical preciseness
 the data is transformed across several levels of
abstraction
 moving raw data to clusters, interpretations, or
theory
Theoretical connectedness
 ensuring the theoretical schema is clear and
related to the data being collected and a lens for
analysis
Heuristic relevance
 readers must recognize the phenomenon as
applicable, meaningful, & recognizable
Other Types of Rigor Using
Trustworthiness




Trustworthy questions
Trustworthy approach
Trustworthy in analysis
Trustworthy and authenticity of data
Ethnography Research
Defined as:
“Learning from People”
By Spradley
Four Types of Ethnography

Classical


Systematic


Defines the structure of a culture.
Interpretive (hermeneutic)


Years in the field, constantly observing and making sense of
actions. Includes description and behavior. Attempts to describe
everything bout the culture.
To study the culture through inference and analysis looking for
“why” behaviors exist.
Critical

Relies on critical theory. Power differentials, who gains and who
loses, what supports the status quo.
Historical Roots





Early 1900s had several introductions
Herodotus wrote about travel in Persia
Malinowski’s Study of Trobriand Islanders
Hans Stade wrote about his being in captivity
by the wild tribes of Eastern Brazil
The School of Sociology in Chicago, where
the city was a laboratory from all the
immigrants (dancers, muggers, case studies)
Observation Methods

Emic


From within the research itself as a
member or participant of some type.
Etic

From the outside looking in like a camera.
It can be a peripheral issue or external
observer member.
Fundamental Constructs







Is usually “etic” on the outside like a
camera
Sometimes they are “emic”, on the inside as
one of the actors (more in sociology)
Researcher is the instrument
Fieldwork is where the work occurs
Focus is on culture
Involves cultural immersion
There is a tension and reflexivity between
the researcher as a member or researcher
as researcher
Stages of Ethnography





Participant observation (gain access,
rapport, trust)
Descriptive observation (9) (space, actors,
activities, objects, act, event, time, goal,
and feelings)
Ethnographic record (field notes, verbatim,
old records, amalgamate the information)
Domain analysis
Focused observation (what is now critical)
Stages in Ethnography-2





Taxonomic analyzing (categorize)
Componential analysis (components
of the selected areas)
Discover cultural themes
Take a cultural inventory
Write up the ethnography
Rigors for Ethnography

Plausibility


Credibility


Not exactly self evident, so you look at sources
of evidence
Thick Description


It is very easy to accept as truth
Writing in such detail as to know exactly what is
going on.
We could also use the Five Standards
Sources of Errors




Personal reactivity
False inferences
Gaps in writing, remembering, and
interpreting
Going Native
Grounded Theory Research





Started by Glaser and Strauss in 1967
Used extensively in nursing research
Takes into account the concepts of George
Herbert Mead (1934) regarding symbolic
interaction theory- how we give meaning to
situations, words, objects, symbols
Is very individualistic in meaning
Most often used to study areas which
previous research exists
Steps in Grounded Theory are
conducted simultaneously






Observation
Collection of data
Organization of data
Review of additional literature
Forming theory from the data
Using Constant Comparative
Analysis
Data Collection Methods Have qualitative
and quantitative properties






Interviews (one on one, groups)
Observation
Records (retrospective analysis)
Surveys (quantitative)
Questionnaires (could be quantitative)
Demographic data
Constructs of Grounded Theory




Conceptual framework comes from the data
rather than the literature review
There is always an over-riding social issues
being addressed called the Basic Social
Process (BSP)
Researcher focuses on dominate processes
rather than describing the setting, or unit
You compare all data with all other data
Constructs of Grounded Theory


You may change data collection methods in
mid stream to be more appropriate to what
has already been discovered
The researcher is to be doing most
sequential tasks all at the same time
Constant Comparative Analysis


Get data, look at it, look at the
literature, look at previous data, go
get more data, look at more literature,
look at all the data, etc.
Revise the question, collection
method, and keep collecting data,
look at literature, compare to old data,
etc.
Sampling Methods


Called Theoretical Sampling
 Based on the current question
 Add new groups to the sample based on
what it is you have learned (may need
more men in the sample, or more people
over the age of 70, etc.)
The sample being used moves as the theory
develops
Coding the data




Look for positive AND negative cases
related to your social process
Step One: read, describe, and
interpret
Step Two: constant comparison and
clustering
Step Three: reduce it to a BSP
Conducting Grounded Theory








Be aware of the social life of the participants
Make less assumptions in the beginning
Sensitizing to the literature, Bracket if needed
Layers of reality are explored, assess your own
energy to go further
Spend enough time with participants and data
Be observant to how the participants are doing
Learn the symbols being used to create this
reality
Sample across time
Case Studies
from Stake (2000) and Yin (1994)

These are OBJECT or METHOD issues




Object: Has to do with what you want to
study not an approach to how to study it
Method: Can be quantitative or
qualitative method (analytically, vs.
holistically)
Questions are aimed at “How” or
“Why”(rarely “What”)
Single or multiple cases-usually1or 2
Purpose of Case Studies

Seeks the unique features (particular) while also
describing the common by describing:







The nature of the case
The case’s history and background
The physical setting
Other contexts (economics, political, legal, aesthetic
issues)
Other cases through which this case is recognized
Through the informants by which the case is known
Examine changes across time (multiple case)

Same group of different group
Case Study Rigor

Yin (1994) treats this as a positivistic
activity, therefore:




Construct, Internal, and external validity
Reliability
This is not just a pilot study for quasi- or full
experimental designs. It is different.
Stake (2000) treats it more naturalistic


Thick description is key
Auditability (can it be followed by the reader)
Observational Measurement
Could Use all of These


Unstructured
Structured





Category Systems
Checklists
Rating Scales
Emic (from within)
Etic (from external view point)
Interview Data Collection


Unstructured
Structured







Describing interview questions
Pretesting the interview protocol
Training interviewers
Preparing for an interview
Probing
Recording interview data
Coding methods
Problem Revisions





I am curious about the standardized
treatment protocols for circumcision of
a new borne.
NEXT REVISION
NEXT REVISION
NEXT REVISION
NEXT REVISION
Problem Statements-Questions
dictates the design





What is experience of police officers who were
wounded in the line of duty related to their ability to
return to work?
What are the unique features of Hospitals that have
NP conducting all surgical admission assessments?
There is (is no) statistically significant difference in
iatrogenic diseases between nurse to patient ratios of
1:5 vs 1:8 on General Medical Units.
Does the birthing center philosophy show a
relationship to the type of care provided and if so,
what is the relationship.
How did the July 08 BSN cohort at DSN obtain a 99%
NCLEX pass rate?
Special Research Designs





Triangulated, Mixed, Blended
Historical Research
Action Research
Outcome Research
Intervention Research
Triangulation
Blended Designs


First used by Campbell and Fiske in 1959.
Denzin in 1989 identified four different
types.





Data Triangulation
Investigator triangulation
Theoretical triangulation
Methodological Triangulation
Kimchi, Polivka, and Stevenson (1991) have
suggested a fifth type

Multiple Triangulation
Data Triangulation



Collection of data from multiple
sources
Intent is to obtain diverse views of the
same phenomenon. (Longitudinal is
different and is looking for change)
Validate data by seeing if it occurs
from different sources
Investigator Triangulation



Two or more investigators with
different research backgrounds
examining the same phenomenon
Clarifies disciplinary bias
Adds to validity of data
Theoretical Triangulation
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Using all the theoretical
interpretations that could conceivably
be applied to a given area
Each view is critically examined for
utility and power
Increased the confidence of the
hypothesis
Can lead to even greater T. F. beliefs
Methodological Triangulation
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The use of two or more research
methods in a single study
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Design level
Data collection level
Two major types
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Within-method (all are one philosophy)
Across-method (across philosophies)
Pros and Cons of Triangulation
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Very trendy in the 90’s
Can be used with smaller N
Combined methods may just be the
rise of a new method
There are philosophical risks
Complex designs and therefore
complex analysis
Action Research: AKA clinical
research, clinical inquiry,
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A systematic investigation conducted by
practitioners involving the use of
scientific techniques in order to improve
their performance.
Kurt Lewin (1946).
Advantages of Action Research:
The reflective practitioner
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Contributes to the knowledge base of
teaching practice-self awareness
Supports the professional development of
practitioners –more competent in research
issues
Builds a collegial network
Identifies problems and seeks solutions in a
systematic fashion
It can be used at all levels and in all areas of
education
Examples of Action Research
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Pick a topic
Define the problem
Select a design
Select subjects
Collect the data
Analyze the data
Application of results
WHAT MAKES IT ACTION RESEARCH
What Makes it Action Research
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Invested in rigorously empirical
(positivistic), and reflective and
interpretive (naturalistic)
Engages people who have traditionally
been called “subjects” who are active in
the research process.
Results have a practical outcome
related to lives or work of participants.
Outcome Research
p.272-317
Came from evaluation research of the 70’s and 80’s
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Focuses on the end result of patient care and
linked to the process that caused the
outcome
Momentum is from policy makers, insurers,
and the public
Level of concern: 1. Care by clinician, 2.
Amenities, 3. Care by the patient, 4. Care
received by community
More complex that it may appear
Evaluation of Outcome Research
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Process Evaluation
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Structure Evaluation
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Involves Standards of Care
Involves Practice Styles
Involves Cost of Care
Elements of the Structure
Philosophies of Management & Decision Making
Process
Evaluate Structure Issues and their impact on the
care provided
Lacks a set methodology
Indicators of Outcome Research
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Many Descriptive Indicators for Nursing
Care: NDNQI, Picker,
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Stage all bed sores on patients at
admission vs. during stay and at discharge.
There must be a clear link between
outcome and process
We see practice based web sites:
AHRQ, APRNet, PBRN group,
Sampling in Outcome Research
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Large heterogeneous samples, but not
randomized. They want a full spectrum of the
population.
However, they want samples who were
treated and those who were not treated to
compare differences in outcomes.
Risks, no random sample, small sample sizes
are often used putting all their inferential
statistics at risk for error.
Intervention Research
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It is used to give “Causal Explanations”
for what is being seen
Uses quantitative and qualitative
methods
It is more than a single research event,
but it deals with multiple issues over
time
Intervention Research Process
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Extensive search of what information is
available
Heavy emphasis on the intervention and
refining its use
Field tested to see if it will work
It will involve a host of studies over time
Has a host of informants who explain the
local culture and what it will take to get data
Intervention Research Methods
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Integrative lit. reviews
Consumer publications
Standards/ guidelines
Meta-analysis
Health policy analysis
Personal exp. Reflections
Consensus conferences
Retrospective chart
reviews
Descriptive-Correlational
studies
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Observation
Case study
Focus groups
Qual. Studies
Concept analysis
New media
Position Papers
Delphi studies
Outcome studies
Risk for Use of Intervention
Research
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Risk is asking the wrong question
Inadequately trained interveners
Poorly defined intervention
Many confounding variables that can show up
Too complex to manage and integrate
Long time can change many factors: i.e. who
is doing it, where can you still collect data,
level of commitment by locations, etc.
Criteria for Intervention Research
Design: The intervention is--
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Effective
Replicable
Simple to use
Practical
Generalizability
Compatible with local customs and
values
Historical Research
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Thought of as qualitative because it lacks
sampling, treating, and controls.
Uses Quantitative language, i.e. validity and
reliability of data—best primary sources of
data.
Looks at external criticism of data (where,
when, by whom), and internal criticism of
data (reliability, authentic, biased lens of
writer)
Process of Historical Research
No Visible Rigor from Qualitative or Quantitative
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Research Outline
Watch for cross-referencing
Be prepared to spend months to years
collecting the data
Careful attention to note taking for all data
collection
A synthesis of all the data collected and may
need an interpretive strategy
Develop a writing outline
Write your Historiography
“The beautiful thing about
learning is that nobody can take
it away from you.”
--BB King
US jazz musician