Introduction to Nursing Research

Introduction to Nursing ResearchMid-Atlantic States Regional Nursing Competency

TOGETHER, WE CAN MAKETHE ORDINARY EXTRAORDINARY

Learning Objectives

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After completing this competency presentation, the nurse should be able to1. Know what research is and is not2. Determine required steps in the research process3. Distinguish quantitative from qualitative research4. Understand the process for research at KP5. Know what resources are available to support research6. Consider a draft research question and study purpose

What is needed to be a nurse researcher?

Knowledge – know how to do it

Competence – be able to do it

Experience – novice to expert

Now: Focus is on building knowledge base, process, and toolsFuture: Building research skills (competence) and program of research at KP (experience)

Novice to Expert: Benner’s model

Steps to build competence in any fieldAny new field or practice – novice level – need lots of guidanceBuild skills with experience, learning and mentorshipMost nurses are starting in research at the novice or advanced beginner levelPurpose of the competency is to provide basic knowledge and resources for gaining experience

Novice to expert: Research skills

Novice: Basic knowledge, limited skills, no experience

Advanced Beginner: Completed competency and beginning mentored research

Competent: Knows how to do research independently

Expert: Experienced at research, can use complex methods, Write grants, serve as a resource to nursing scientific community

Proficient: Leads research as PI and serve as mentor to others

Barriers to nurses doing research

• Complex language and mystery words – seems too hard to comprehend and illusive• Academic focus gets lost on clinicians in the real world• Lack of knowledge of how to do it or where to start• Lack of real training to do meaningful research• Few people are doing clinical research –difficult to control and messy!• Lack of mentors to learn how to do research• Misunderstanding about what research is and is not

Barriers

• Research seems to be kept behind a guarded door with secret language• “Club” of scholars, nerds, and geeks whose skills are unreachable – too complex for

people to learn• Secret society with a secret pass key to open the door

Debilitating and paralyzing vocabulary

Ways of knowing and learning things without research

Tradition “we’ve always done it that way”

Authority “because we told you so”

Borrowing “if it works in another field, it must be able to work in nursing”

Trial and error “let’s keep trying until we figure out the best way”

Personal experience “ My way is better because”

Definitions: Research

Root meaning – “search again” or “examine carefully”

Systematic process to do researchSearch – investigation, inquiry toProve – validate – “show me” andWhat we know (knowledge) and What we don’t know (generate new knowledge)

What it is… Definitions

• Seeks answers to questions in an orderly and systematic way• Method of problem solving – ask a question with a desire to answer it• Much like the nursing and scientific process:

Assess (what is known? What is in question?) Plan how to do the study (proposal includes steps); Implement study (follow the plan) ; Evaluate results (findings from the study, analysis)

• Most respected way to attain knowledge – for any professional discipline

Characteristics of research

• Attention to detail, accuracy in measurement, precision• Held to a higher degree of scrutiny and rigor• Study expected to add to the body of knowledge or science either to reinforce or

substantiate previous studies (replication) or to generate new information about a particular area. This is called “generalizable”. Most clinical research is conducted on how nursing is practiced (is one way better or equal to another), which contributes to outcomes of practice.

What is nursing science?

Started with Florence Nightingale in 1800s – examined practice, collected data and analyzed data

Body of knowledge unique to the discipline of nursing

ANA (2003) Definition of Nursing: the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations

Nursing studies should focus on understanding human needs and use of nursing interventions to promote health and manage illness; holistic

Types of nursing research

Clinical practice – impact of nursing interventions, patient responses to care, quality of care, testing results of initiatives, nursing sensitive outcomes, body of science including how nursing is practiced

Education – impact of nursing education on knowledge, practice, outcomes – which strategies promote nursing understanding and practice?

Administration – impact of nursing leadership on operations, costs of care, retention, work environment, leadership sensitive outcomes

Definition:

Research is systematic inquiry that uses disciplined methods to answer questions or solve problems (Polit and Beck, 2008).

Ultimate goal in nursing: provide care that has evidence to back it up and produces quality outcomes for patients, families, and system

What it isn’t

• Going to the library or internet looking for information• Doing a performance improvement project • Unplanned study without using research process and IRB approvals

Why is nursing research important?

• Find out best ways to provide care for patients from a nursing perspective• Allows a way to answer questions or solve nursing problems that come up every day• Way to evaluate the outcomes or effectiveness• Provides evidence behind what we do and more confidence for why we’re doing what

we’re doing• Opportunity for professional advancement• Elevates nursing to a science and profession rather than a job• Definition of a professional is that they control their own practice• Builds a scientific and knowledge base for nursing practice beyond experience and

tradition

Limitations with research

• Cannot answer all questions – i.e. moral or ethical issues• All things are not measurable or good tools not available• Statistics may show significance, but in the real world may not really be important (clinical

significance)• Studies are done many different ways, it’s hard to repeat them to confirm and verify

results – one study rarely tells the whole story

General Steps

1. General idea about a topic or question for the study2. Review of the literature – what is known about your question3. Purpose and aims of the study – what do you want to do?4. Research question – specific and measurable5. Methods – how will you go about answering your question6. Subjects – who and what to include (data) and exclude7. Protection of human subjects and informed consent8. Procedures of the study – what exactly will be done and when9. Analysis of results – how will you test and summarize your findings10. Recommendations for future research11. Dissemination

Start with a question or idea

Usually generated by clinical observationsWhy does this happen?Are there things that cause things to happen?What would happen if we did something different?

Can come from questions raised from other studies – recommendations for further study

Jump Starters for research ideas

What interventions do you do in practice?Things nurses do every day

Hemodynamic monitoringVS measurementPreventing complications Procedures

What is the knowledge base for the practices? Sacred cow or evidence-based?Policy based?Book from school? How we were taught or do it here?

How can research improve/influence these interventions?

Developing a Research Question (RQ)

It is essential to develop a research question that you're interested in or care about!A solid research question is like a lifeline that keeps you anchored during your search.The question should not be too broad or too narrow.Once you've drafted a research question to the best of your ability and knowledge, then a

good way to refine your research question is to put it out to peer review or to work one-on-one with a librarian or a mentor colleague.

Research Question Checklist

• Is my RQ something that I am curious about and that others might care about? Does it present an issue on which I can take a stand?

• Does my RQ put a new spin on an old issue, or does it try to solve a problem?• Is my RQ too broad, too narrow, or OK?• Is my RQ researchable…

– within the time frame available?– given the resources available at my location?

• Is my RQ measurable? What type of information do I need? Can I find actual data to support or contradict a position?

• What resources will I have? (journals, books, internet resources, government documents, interviews with people).

Review of Literature (ROL)

This is a common problem area for new researchers because you may not have received the training to develop skills in computer based searching.

ROL – getting beyond the fear

Many misunderstand the process of literature review …may seem easy but takes time to do it wellIt is a skill that can be learned by anyone with practiceHelp is here! Online KP librarianshttp://kpmd.org/forms/librarian.php

What kind of approach would you use to assess the literature for your topic?

Going to research studies that have been published to see what is known about a topic/question

Allows to further refine your research question after you learn from what is out there already

Prepares you for the background and significance part of the research protocol

ROL – Getting started - Resources

• Looking specifically for research studies dealing with your question or topic – focused area to review

• Can be electronic or paper – eLibraries and university libraries• Work with a librarian- Ask a Librarian (KP resource);

http://kpmd.org/forms/librarian.php• Look at references list on papers found – many can be found there – and shows if

one keeps showing up or referenced over and over

ROL - Content

• Review first for any published guidelines, systematic reviews of research, meta-analysis – may have already answered your question or get you up to speed with the latest and greatest

• Research on your question specifically• Research on your topic that is related• Consider time period – latest and greatest (keep showing up in the references) and any

really important work done in the past

Organizing the Literature Review

2 Key Skills•Information seeking

Make a written plan for how you are going to searchStart broad and then focus downCritique – is it a good study? – also requires certain knowledge and skills – may need help/consultation and practice

•Summarizing the literature related to your topicThemes – what kind of things keep coming upTrends – are there similar things happening over time?

Ten Questions That Will Help You Get Through Any Research Report

What is the research question?What is the basis for this research question?Why is this research question important?How was this research question studied? Does the study method make sense?Were the correct subjects selected for the study?Was the research question answered?Does the answer make sense?Does it matter?What is next?

What a Literature Review is Not

•Not a list of as many articles as possible•Not just a summary of what you read•It is – a careful choice of articles, studies, guidelines, etc that best helps describe background for your research

Refining the topic/key words to start

Look at the question and pick words that are clearly related to the question; setting; population; type of literature (research, guidelines, systematic review)

What discipline might have answers: Nursing, Medicine, education – point to what journals they might go to

Example: Research question: What is the impact of follow-up calls to assess compliance of hypertensive patients taking prescribed medications on BP control? Key words: medication compliance, hypertension

Final “ROL”

• Starts with small summaries (abstracts) of studies• Choose ones appropriate to review and relevant to your study• Should include what is not known and recommendations for other studies

Approaches to answer the research question – methods and design

If your question sounds like “What is going on here?” “How many patients have X?” This is a probably a descriptive study (most beginners should start here).

If your question is “when this happens, is there something else that tends to happen too? Do they go together?” Is diabetes associated with obesity? This may be a correlational study.

If your question sounds like “What is the effect of one thing on another? “What are the outcomes of patients who get a standard intervention vs a new treatment?” Or can you predict who would experience something? These are experimental studies.

True experiments test what happens without the intervention (control) and with the interventions(s) being experimented.

Randomized selects who is in the test and non-test groups in a random way to reduce “bias” in selecting who gets or doesn’t get in the test group.

Timing and Studies

Retrospective – go back and look at what happened over a particular period of time (often easier for beginners - easier to do, less labor intensive)

Before and after – Measure what you had before and then what you have after an intervention or change

Prospective (forward as you go), randomized (pick at random who gets the standard treatment and new treatment(s), controlled (with a control group who would represent not receiving treatment)

Longitudinal – studies over time periods

Types of Research

Quantitative: Numbers

Qualitative: Quality or Meaning

Types of Research Designs

Quantitative – will you count something? Measure something? Do any kinds of statistics, even averages?

Qualitative – will you interview, get narrative deep information on a subject? Observation of “what is going on here”

Gives richer details about a specific phenomenon Seen often in nursing studies – “experience of X group”Often done before quantitative studies to gain more information about things that are not

known well

Mixed Methods – use some of both

Qualitative ResearchSeeks to find meaning behind thingsExplorative and can lead to quantitative studies

Phenomenological Research“Lived experience”

Grounded Theory ResearchGenerate theory

Ethnographic ResearchParticipant observationKey informants

Historical ResearchDocuments

Descriptive Research

WhoWhat

WhereWhenHow

Correlational Research

Explains things beyond “what is”Discovers Relationships

Quasi/Experimental Research

Test interventionsPredict outcomes

Variables

What is to be studied?Value can varyExamples:

GenderHeight and weightScore on a testAmount of painSeverity of injury

Measuring the Variable

Conducting the experiment

Reliability & Validity

Validity = instrument measures what it is supposed to measure

Reliability = CONSISTENCY of measurement

Proposal Steps

Background – summarizes information behind the question Complete Literature Review Determine Theoretical Framework Determine Objectives, Questions, Hypotheses

What do you want to find out in this study?What are the research questions you ask?If experiment, what do you think will occur? - hypothesis

Identify Study VariablesWhat you want to studyMust be MEASURABLE

• Determine Assumptions:Conditions considered to be true

Examples

Objectives or purpose of the study: To identify dietary compliance of diabetic patients with two education interventions To compare and contrast nutritionist one-to-one teaching versus group teaching To compare and contrast Hgba1c based on type of education

VariablesWhat is to be studied?Independent vs. dependent (experimental)The findings are dependent on somethingIndependent – happen as they occur

Hypothesis

What you think could happen- this is your educated guess or guess based on prior research

Steps in Quantitative Research

Population & SampleWho or what do you want to study?How are you going to get a “representative” group?Is your sample and population from a big database, i.e. infection control? Core

measures?

Methods of MeasurementHow you are going to “measure” the variables

Quantitative Research Steps

Data Collection & AnalysisHow are you going to collect data?

Step-by-step; detailed

Should be so detailed that someone else could replicate it

When determining what to measure…

• Must have a clear sense of WHAT is to be measured and WHY• Be reasonable about what data are required • Data integrity is required for data to be trusted – some are more accurate than others –

know the limitations of your data sources – reliability and validity• Are tools already out there to measure this that have been studied and validated for their

ability to measure something?• Retrospective data difficult to capture everything; Prospective is better

Quantitative Research Steps

Research OutcomesWhat are your findings?Are they statistically significant?Are they clinically significant?

Communication of FindingsResearch presentationsAbstractsPeer-reviewed publicationsThe LAST step—must be done!

Generate implications for practice

Generate implications for future research

Building a Proposal to do the Study

• Title of the study – should represent what you are doing simply

• Background and Significance – Summarize information known and why it is important to have this burning question answered

• Purpose of the study – why are you doing this? What are you hoping to achieve?

• Research Question(s) – What is the impact of X on patient outcomes after myocardial infarction?

• Methods and Design – Subjects, consent

• Analysis of findings plan

Are there any possible risks in doing your study?

Find out the standard of care

Are you going to change the standard of care? If so, is it within your licensure and practice scope to change that care?

What risks to the patient could occur as a result of a new intervention: emotional, physical? Information breach?

If it’s greater than minimal risk, requires consent

Informed Consent

Must consider if the patient should consent for the studyRetrospective studies – can’t getIf you don’t think you need consent, must complete a “waiver of consent” form and explain

why notMust be given by the investigators – cannot delegate

Other considerations

• Will this impact the work of the nurses or patient care in the area you are studying? If so, you must get administrative approval from that area and from nursing

• Will it cost money for the study to the patient or facility?

• Will you “de-identify” patient identifiers to avoid risk of divulging information?

Requirements: Process for nursing studies at Kaiser Permanente

Discuss research idea with your manager and directorDevelop basic research proposalComplete two forms required by the KP Research Department

Meet with Director of Research or designee for KP-MAS

Microsoft Word Document

Microsoft Word Document

Resources for Research

Nurse Practice Leaders

KP Librarian and eLibrary

Advanced Practice Nurses

Nurses who have done research

Nurses in master’s or doctoral programs

Professional contacts within specialty

Physicians

KP Research Department

Review

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Based on the information presented in this competency presentation, answer the following review questions:

1. There is no difference in data collected for qualitative versus quantitative research

A. TrueB. False

2. Informed consent is not needed to collect data on patients at KP.A. TrueB. False

Review

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Based on the information presented in this competency presentation, answer the following review questions:

1. All of the following statements are correct about research except:A. Does not resemble the nursing processB. Systematic and preciseC. Provides data for analysisD. Seeks to answer questions of the profession

2. The steps in research includeA. Research questionB. Review of literatureC. Decision about study variables and data collectionsD. All of the above

Review

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Based on the information presented in this competency presentation, answer the following review questions:

1. Validity refers to the consistency of measurementA. TrueB. False

2. All of the following resources are available to support research (Circle all that apply):

A. Online librarianB. MAS Research DepartmentC. Nurse Practice LeadersD. Online access to prior research

Conclusion

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After completing the Introduction to Research competency:1. The nurse is able to state the steps in the research process.2. The nurse is able to distinguish the difference in quantitative versus qualitative

research.3. The nurse is able to identify the resources within KP to get help with research.4. The nurse is able to understand the process for research approval at KP.5. The nurse is able to write a research question and draft proposal with support.

References

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American Nurses Association. (2003). Definition of Nursing.

Benner, P. (1984). From Novice to Expert, Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley Publishing Co.

Penoyer, D., Warrington, W., Miller, H., & Loerzel, V.(2009).Nursing research basics: Part 1. Professional Nursing Academy, Orlando Healthcare.

Polit, D. & Beck, C. (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice, 8th Edition. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.