polit chapter 1

Foundationsof NursingResearch

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NURSING RESEARCH INPERSPECT IVE

It is an excitingand challengingtime to be anurse. Nurses are managing their clinical responsi-bilities at a time when the nursing profession and thelarger health care system require an extraordinaryrange of skills and talents of them. Nurses areexpected to deliver the highest possible quality ofcare in a compassionate manner, while also beingmindful of costs. To accomplish these diverse (andsometimes conflicting) goals, nurses must accessand evaluate extensive clinical information, andincorporate it into their clinical decision-making. Intodays world, nurses must become lifelong learners,capable of reflecting on, evaluating, and modifyingtheir clinical practice based on new knowledge. And,nurses are increasingly expected to become producersof new knowledge through nursing research.

What Is Nursing Research?

Research is systematic inquiry that uses disciplinedmethods to answer questions or solve problems.The ultimate goal of research is to develop, refine,and expand a body of knowledge.

Nurses are increasingly engaged in disciplinedstudies that benefit the profession and its patients,

Introduction to Nursing Research

and that contribute to improvements in the entirehealth care system. Nursing research is systematicinquiry designed to develop knowledge aboutissues of importance to the nursing profession,including nursing practice, education, administra-tion, and informatics. In this book, we emphasizeclinical nursing research, that is, researchdesigned to generate knowledge to guide nursingpractice and to improve the health and quality oflife of nurses clients.

Nursing research has experienced remarkablegrowth in the past three decades, providing nurseswith an increasingly sound base of knowledge fromwhich to practice. Yet as we proceed into the 21stcentury, many questions endure and much remainsto be done to incorporate research-based knowl-edge into nursing practice.

Examples of nursing research questions:

What are the factors that determine the length of stay of patients in the intensive care unitundergoing coronary artery bypass graft surgery (Doering, Esmailian, Imperial-Perez,& Monsein, 2001)?

How do adults with acquired brain injury per-ceive their social interactions and relationships(Paterson & Stewart, 2002)?

The Importance of Research in Nursing

Nurses increasingly are expected to adopt anevidence-based practice (EBP), which is broadlydefined as the use of the best clinical evidence inmaking patient care decisions. Although there isnot a consensus about what types of evidenceare appropriate for EBP (Goode, 2000), there isgeneral agreement that research findings fromrigorous studies constitute the best type of evi-dence for informing nurses decisions, actions,and interactions with clients. Nurses are accept-ing the need to base specific nursing actions anddecisions on evidence indicating that the actionsare clinically appropriate, cost-effective, andresult in positive outcomes for clients. Nurseswho incorporate high-quality research evidenceinto their clinical decisions and advice are beingprofessionally accountable to their clients. Theyare also reinforcing the identity of nursing as aprofession.

Another reason for nurses to engage in anduse research involves the spiraling costs of healthcare and the cost-containment practices beinginstituted in health care facilities. Now, more thanever, nurses need to document the social relevanceand effectiveness of their practice, not only to theprofession but to nursing care consumers, healthcare administrators, third-party payers (e.g., insur-ance companies), and government agencies. Someresearch findings will help eliminate nursingactions that do not achieve desired outcomes.Other findings will help nurses identify practicesthat improve health care outcomes and containcosts as well.

Nursing research is essential if nurses are tounderstand the varied dimensions of their profes-sion. Research enables nurses to describe the char-acteristics of a particular nursing situation aboutwhich little is known; to explain phenomena thatmust be considered in planning nursing care; topredict the probable outcomes of certain nursingdecisions; to control the occurrence of undesiredoutcomes; and to initiate activities to promotedesired client behavior.

Example of an EBP project:

The Association of Womens Health, Obstetric,and Neonatal Nurses (AWHONN) is onenursing organization that has demonstrated astrong commitment to evidence-based nursingpractice. For example, AWHONN undertook aproject that developed and tested an evidence-based protocol for urinary incontinence inwomen, and then designed procedures tofacilitate the protocols implementation intoclinical practice (Samselle et al., 2000a, 2000b).More recently, AWHONN and the NationalAssociation of Neonatal Nurses designed andtested an evidence-based protocol for neonatalskin care, and also instituted procedures forimplementing it (Lund, Kuller, Lane, Lott,Raines, & Thomas, 2001; Lund, Osborne,Kuller, Lane, Lott, & Raines, 2001).

The ConsumerProducer Continuum in Nursing Research

With the current emphasis on EBP, it has becomeevery nurses responsibility to engage in one or moreroles along a continuum of research participation. Atone end of the continuum are those nurses whoseinvolvement in research is indirect. Consumers ofnursing research read research reports to developnew skills and to keep up to date on relevant findingsthat may affect their practice. Nurses increasingly areexpected to maintain this level of involvement withresearch, at a minimum. Research utilizationtheuse of research findings in a practice settingdepends on intelligent nursing research consumers.

At the other end of the continuum are the pro-ducers of nursing research: nurses who activelyparticipate in designing and implementing researchstudies. At one time, most nurse researchers wereacademics who taught in schools of nursing, butresearch is increasingly being conducted by prac-ticing nurses who want to find what works best fortheir patients.

Between these two end points on the continuumlie a rich variety of research activities in whichnurses engage as a way of improving their effec-

4 PART 1 Foundations of Nursing Research

publication, Notes on Nursing (1859), describes herearly interest in environmental factors that promotephysical and emotional well-beingan interest thatcontinues among nurses nearly 150 years later.Nightingales most widely known research contri-bution involved her data collection and analysisrelating to factors affecting soldier mortality andmorbidity during the Crimean War. Based on herskillful analyses and presentations, she was suc-cessful in effecting some changes in nursing careand, more generally, in public health.

For many years after Nightingales work, thenursing literature contained little research. Someattribute this absence to the apprenticeship nature ofnursing. The pattern of nursing research that even-tually emerged at the turn of the century was closelyaligned to the problems confronting nurses. Moststudies conducted between 1900 and 1940 con-cerned nurses education. For example, in 1923, agroup called the Committee for the Study ofNursing Education studied the educational prepara-tion of nurse teachers, administrators, and publichealth nurses and the clinical experiences of nursingstudents. The committee issued what has becomeknown as the Goldmark Report, which identifiedmany inadequacies in the educational backgroundsof the groups studied and concluded that advancededucational preparation was essential. As morenurses received university-based education, studiesconcerning nursing studentstheir differentialcharacteristics, problems, and satisfactionsbecame more numerous.

During the 1940s, studies concerning nursingeducation continued, spurred on by the unprece-dented demand for nursing personnel that resulted from World War II. For example, Brown (1948)reassessed nursing education in a study initiated atthe request of the National Nursing Council for WarService. The findings from the study, like those ofthe Goldmark Report, revealed numerous inadequa-cies in nursing education. Brown recommended thatthe education of nurses occur in collegiate settings.Many subsequent research investigations concerningthe functions performed by nurses, nurses roles andattitudes, hospital environments, and nursepatientinteractions stemmed from the Brown report.

tiveness and enhancing their professional lives.These activities include the following:

Participating in a journal club in a practice set-ting, which involves regular meetings amongnurses to discuss and critique research articles

Attending research presentations at professionalconferences

Discussing the implications and relevance ofresearch findings with clients

Giving clients information and advice aboutparticipation in studies

Assisting in the collection of research informa-tion (e.g., distributing questionnaires to patients)

Reviewing a proposed research plan withrespect to its feasibility in a clinical setting andoffering clinical expertise to improve the plan

Collaborating in the development of an idea fora clinical research project

Participating on an institutional committee thatreviews the ethical aspects of proposed researchbefore it is undertaken

Evaluating completed research for its possibleuse in practice, and using it when appropriate

In all these activities, nurses with someresearch skills are in a better position than thosewithout them to make a contribution to nursingknowledge. An understanding of nursing researchcan improve the depth and breadth of every nursesprofessional practice.

NURSING RESEARCH:PAST, PRESENT, ANDFUTURE

Although nursing research has not always had theprominence and importance it enjoys today, its longand interesting history portends a distinguishedfuture. Table 1-1 summarizes some of the key eventsin the historical evolution of nursing research.

The Early Years: From Nightingale tothe 1950s

Most people would agree that research in nursingbegan with Florence Nightingale. Her landmark

CHAPTER 1 Introduction to Nursing Research 5

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YEAR EVENT

1859 Nightingales Notes on Nursing published1900 American Nursing Journal begins publication1923 Columbia University establishes first doctoral program for nurses

Goldmark Report with recommendations for nursing education published1930s American Journal of Nursing publishes clinical cases studies1948 Brown publishes report on inadequacies of nursing education1952 The journal Nursing Research begins publication1955 Inception of the American Nurses Foundation to sponsor nursing research1957 Establishment of nursing research center at Walter Reed Army Institute of Research1963 International Journal of Nursing Studies begins publication1965 American Nurses Association (ANA) begins sponsoring nursing research conferences1966 Nursing history archive established at Mugar Library, Boston University1968 Canadian Journal of Nursing Research begins publication1971 ANA establishes a Commission on Research1972 ANA establishes its Council of Nurse Researchers1976 Stetler and Marram publish guidelines on assessing research for use in practice1978 The journals Research in Nursing & Health and Advances in Nursing Science begin publication1979 Western Journal of Nursing Research begins publication1982 The Conduct and Utilization of Research in Nursing (CURN) project publishes report1983 Annual Review of Nursing Research begins publication1985 ANA Cabinet on Nursing Research establishes research priorities1986 National Center for Nursing Research (NCNR) established within U.S. National Institutes of Health1987 The journal Scholarly Inquiry for Nursing Practice begins publication1988 The journals Applied Nursing Research and Nursing Science Quarterly begin publication

Conference on Research Priorities (CORP #1) in convened by NCNR1989 U.S. Agency for Health Care Policy and Research (AHCPR) is established1992 The journal Clinical Nursing Research begins publication1993 NCNR becomes a full institute, the National Institute of Nursing Research (NINR)

CORP #2 is convened to establish priorities for 19951999The Cochrane Collaboration is establishedThe journal Journal of Nursing Measurement begins publication

1994 The journal Qualitative Health Research begins publication1997 Canadian Health Services Research Foundation is established with federal funding1999 AHCPR is renamed Agency for Healthcare Research and Quality (AHRQ)2000 NINR issues funding priorities for 20002004; annual funding exceeds $100 million

The Canadian Institute of Health Research is launchedThe journal Biological Research for Nursing begins publication

TABLE 1.1 Historical Landmarks Affecting Nursing Research

for the educational preparation of nurses and,increasingly, for nursing research.

Nursing research began to advance worldwidein the 1960s. The International Journal of NursingStudies began publication in 1963, and theCanadian Journal of Nursing Research was firstpublished in 1968.

Example of nursing research break-throughs in the 1960s:

Jeanne Quint Benoliel began a program ofresearch that had a major impact on medicine,medical sociology, and nursing. Quint exploredthe subjective experiences of patients after diag-nosis with a life-threatening illness (1967). Ofparticular note, physicians in the early 1960susually did not advise women that they hadbreast cancer, even after a mastectomy. Quints(1962, 1963) seminal study of the personalexperiences of women after radical mastectomycontributed to changes in communication andinformation control by physicians and nurses.

Nursing Research in the 1970s

By the 1970s, the growing number of nurses con-ducting research studies and the discussions of the-oretical and contextual issues surrounding nursingresearch created the need for additional communi-cation outlets. Several additional journals that focuson nursing research were established in the 1970s,including Advances in Nursing Science, Research inNursing & Health, the Western Journal of NursingResearch, and the Journal of Advanced Nursing.

In the 1970s, there was a decided change inemphasis in nursing research from areas such asteaching, curriculum, and nurses themselves to theimprovement of client caresignifying a growingawareness by nurses of the need for a scientific basefrom which to practice. Nursing leaders stronglyendorsed this direction for nursing studies.Lindeman (1975), for example, conducted a study toascertain the views of nursing leaders concerning thefocus of nursing studies; clinical problems wereidentified as the highest priorities. Nurses also beganto pay attention to the utilization of research findings

A number of forces combined during the 1950sto put nursing research on a rapidly acceleratingupswing. An increase in the number of nurses withadvanced educational degrees, the establishment ofa nursing research center at the Walter Reed ArmyInstitute of Research, an increase in the availabilityof funds from the government and private founda-tions, and the inception of the American NursesFoundationwhich is devoted exclusively to thepromotion of nursing researchwere forces provid-ing impetus to nursing research during this period.

Until the 1950s, nurse researchers had fewoutlets for reporting their studies to the nursingcommunity. The American Journal of Nursing, firstpublished in 1900, began on a limited basis topublish some studies in the 1930s. The increasingnumber of studies being conducted during the1950s, however, created the need for a journal inwhich findings could be published; thus, NursingResearch came into being in 1952.

Nursing research took a twist in the 1950s notexperienced by research in other professions, atleast not to the same extent as in nursing. Nursesstudied themselves: Who is the nurse? What doesthe nurse do? Why do individuals choose to enternursing? What are the characteristics of the idealnurse? How do other groups perceive the nurse?


Knowledge development through research in nurs-ing began in earnest only about 40 years ago, in the1960s. Nursing leaders began to express concernabout the lack of research in nursing practice.Several professional nursing organizations, such asthe Western Interstate Council for Higher Educationin Nursing, established priorities for research inves-tigations during this period. Practice-orientedresearch on various clinical topics began to emergein the literature.

The 1960s was the period during which termssuch as conceptual framework, conceptual model,nursing process, and theoretical base of nursingpractice began to appear in the literature and toinfluence views about the role of theory in nursingresearch. Funding continued to be available both


in nursing practice. A seminal article by Stetler andMarram (1976) offered guidance on assessingresearch for application in practice settings.

In the United States, research skills amongnurses continued to improve in the 1970s. Thecadre of nurses with earned doctorates steadilyincreased, especially during the later 1970s. Theavailability of both predoctoral and postdoctoralresearch fellowships facilitated the development ofadvanced research skills.


Kathryn Barnards research led to break-throughs in the area of neonatal and young childdevelopment. Her research program focused onthe identification and assessment of children atrisk of developmental and health problems,such as abused and neglected children andfailure-to-thrive children (Barnard, 1973, 1976;Barnard & Collar, 1973; Barnard, Wenner,Weber, Gray, & Peterson, 1977). Her researchcontributed to work on early interventions forchildren with disabilities, and also to the field ofdevelopmental psychology.


The 1980s brought nursing research to a new level ofdevelopment. An increase in the number of qualifiednurse researchers, the widespread availability ofcomputers for the collection and analysis of informa-tion, and an ever-growing recognition that research isan integral part of professional nursing led nursingleaders to raise new issues and concerns. More atten-tion was paid to the types of questions being asked,the methods of collecting and analyzing informationbeing used, the linking of research to theory, and theutilization of research findings in practice.

Several events provided impetus for nursingresearch in this decade. For example, the firstvolume of the Annual Review of Nursing Researchwas published in 1983. These annual reviewsinclude summaries of current research knowledgeon selected areas of research practice and encourageutilization of research findings.

Of particular importance in the United Stateswas the establishment in 1986 of the NationalCenter for Nursing Research (NCNR) at theNational Institutes of Health (NIH) by congres-sional mandate, despite a presidential veto that wasoverridden largely as a result of nurse-scientistssuccessful lobbying efforts. The purpose of NCNRwas to promoteand financially supportresearch training and research projects relating topatient care. In addition, the Center for Researchfor Nursing was created in 1983 by the AmericanNurses Association. The Centers mission is todevelop and coordinate a research program to serveas the source of national information for the profes-sion. Meanwhile, funding for nursing researchbecame available in Canada in the 1980s through theNational Health Research Development Program(NHRDP).

Several nursing groups developed priorities fornursing research during the 1980s. For example, in1985, the American Nurses Association Cabineton Nursing Research established priorities thathelped focus research more precisely on aspects ofnursing practice. Also in the 1980s, nurses began toconduct formal projects designed to increaseresearch utilization. Finally, specialty journals suchas Heart & Lung and Cancer Nursing began toexpand their coverage of research reports, and sev-eral new research-related journals were estab-lished: Applied Nursing Research, ScholarlyInquiry for Nursing Practice, and Nursing ScienceQuarterly. The journal Applied Nursing Researchis notable for its intended audience: it includesresearch reports on studies of special relevance topracticing nurses.

Several forces outside of the nursing profes-sion in the late 1980s helped to shape todays nurs-ing research landscape. A group from theMcMaster Medical School in Canada designed aclinical learning strategy that was called evidence-based medicine (EBM). EBM, which promulgatedthe view that scientific research findings were farsuperior to the opinions of authorities as a basis forclinical decisions, constituted a profound shift formedical education and practice, and has had amajor effect on all health care professions.


the Canadian Health Services Research Foundationwas established in 1997 with an endowment fromfederal funds, and plans for the Canadian Institutefor Health Research were underway.

Several research journals were establishedduring the 1990s, including Qualitative HealthResearch, Clinical Nursing Research, ClinicalEffectiveness, and Outcomes Management forNursing Practice. These journals emerged inresponse to the growth in clinically oriented and in-depth research among nurses, and interest in EBP.Another major contribution to EBP was inauguratedin 1993: the Cochrane Collaboration, an interna-tional network of institutions and individuals,maintains and updates systematic reviews of hun-dreds of clinical interventions to facilitate EBP.

Some current nursing research is guided by pri-orities established by prominent nurse researchersin the 1990s, who were brought together by NCNRfor two Conferences on Research Priorities(CORP). The priorities established by the firstCORP for research through 1994 included low birthweight, human immunodeficiency virus (HIV)infection, long-term care, symptom management,nursing informatics, health promotion, and techno-logy dependence.

In 1993, the second CORP established thefollowing research emphases for a portion ofNINRs funding from 1995 through 1999: develop-ing and testing community-based nursing models;assessing the effectiveness of nursing interventionsin HIV/AIDS; developing and testing approaches toremediating cognitive impairment; testing interven-tions for coping with chronic illness; and identifyingbiobehavioral factors and testing interventions topromote immunocompetence.


Many studies that Donaldson (2000) identifiedas breakthroughs in nursing research were con-ducted in the 1990s. This reflects, in part, thegrowth of research programs in which teams ofresearchers engage in a series of related researchon important topics, rather than discrete andunconnected studies. As but one example,

In 1989, the U.S. government established theAgency for Health Care Policy and Research(AHCPR). AHCPR (which was renamed the Agencyfor Healthcare Research and Quality, or AHRQ, in1999) is the federal agency that has been chargedwith supporting research specifically designed toimprove the quality of health care, reduce healthcosts, and enhance patient safety, and thus plays apivotal role in the promulgation of EBP.


A team of researchers headed by DorothyBrooten engaged in studies that led to the devel-opment and testing of a model of site transitionalcare. Brooten and her colleagues (1986, 1988,1989), for example, conducted studies of nursespecialistmanaged home follow-up servicesfor very-low-birth-weight infants who were dis-charged early from the hospital, and laterexpanded to other high-risk patients (1994). Thesite transitional care model, which was devel-oped in anticipation of government cost-cuttingmeasures of the 1980s, has been used as aframework for patients who are at health risk asa result of early discharge from hospitals, andhas been recognized by numerous health caredisciplines.


Nursing science came into its maturity during the1990s. As but one example, nursing research wasstrengthened and given more national visibility inthe United States when NCNR was promoted to fullinstitute status within the NIH: in 1993, theNational Institute of Nursing Research (NINR)was born. The birth of NINR helps put nursingresearch more into the mainstream of researchactivities enjoyed by other health disciplines.Funding for nursing research has also grown. In1986, the NCNR had a budget of $16.2 million,whereas 16 years later in fiscal year 2002, the bud-get for NINR was over $120 million. Fundingopportunities for nursing research expanded in othercountries as well during the 1990s. For example,


several nurse researchers had breakthroughsduring the 1990s in the area of psychoneuroim-munology, which has been adopted as the modelof mindbody interactions. Barbara Swansonand Janice Zeller, for example, conducted severalstudies relating to HIV infection and neuropsy-chological function (Swanson, Cronin-Stubbs,Zeller, Kessler, & Bielauskas, 1993; Swanson,Zeller, & Spear, 1998) that have led to discoveriesin environmental management as a means ofimproving immune system status.

Future Directions for Nursing Research

Nursing research continues to develop at a rapidpace and will undoubtedly flourish in the 21st cen-tury. Broadly speaking, the priority for nursingresearch in the future will be the promotion ofexcellence in nursing science. Toward this end,nurse researchers and practicing nurses will besharpening their research skills, and using thoseskills to address emerging issues of importance tothe profession and its clientele.

Certain trends for the beginning of the 21stcentury are evident from developments takingshape in the 1990s:

Increased focus on outcomes research.Outcomes research is designed to assess anddocument the effectiveness of health care ser-vices. The increasing number of studies that canbe characterized as outcomes research has beenstimulated by the need for cost-effective carethat achieves positive outcomes without com-promising quality. Nurses are increasinglyengaging in outcomes research focused both onpatients and on the overall delivery system.

Increased focus on biophysiologic research.Nurse researchers have begun increasingly tostudy biologic and physiologic phenomena aspart of the effort to develop better clinical evi-dence. Consistent with this trend, a new journalcalled Biological Research for Nursing waslaunched in 2000.

Promotion of evidence-based practice.Concerted efforts to translate research findings

into practice will continue and nurses at alllevels will be encouraged to engage in evidence-based patient care. In turn, improvements willbe needed both in the quality of nursing studiesand in nurses skills in understanding, critiquing,and using study results.

Development of a stronger knowledge basethrough multiple, confirmatory strategies.Practicing nurses cannot be expected to changea procedure or adopt an innovation on the basisof a single, isolated study. Confirmation is usu-ally needed through the deliberate replication(i.e., the repeating) of studies with differentclients, in different clinical settings, and at dif-ferent times to ensure that the findings arerobust. Replication in different settings is espe-cially important now because the primary set-ting for health care delivery is shifting frominpatient hospitals to ambulatory settings, thecommunity, and homes. Another confirmatorystrategy is the conduct of multiple-site investi-gations by researchers in several locations.

Strengthening of multidisciplinary collabora-tion. Interdisciplinary collaboration of nurseswith researchers in related fields (as well asintradisciplinary collaboration among nurseresearchers) is likely to continue to expand inthe 21st century as researchers address funda-mental problems at the biobehavioral and psy-chobiologic interface. As one example, there arelikely to be vast opportunities for nurses andother health care researchers to integrate break-throughs in human genetics into lifestyle andhealth care interventions. In turn, such collabo-rative efforts could lead to nurse researchersplaying a more prominent role in national andinternational health care policies.

Expanded dissemination of research findings. TheInternet and other electronic communication havea big impact on the dissemination of researchinformation, which in turn may help to promoteEBP. Through such technological advances as on-line publishing (e.g., the Online Journal ofKnowledge Synthesis for Nursing, the OnlineJournal of Clinical Innovation); on-line resourcessuch as Lippincotts NursingCenter.com; elec-


Responding to compelling public health con-cerns (e.g., reducing health disparities in cancerscreening; end-of-life/palliative care)

SOURCES OF EVIDENCEFOR NURSING PRACTICE

Nursing students are taught how best to practicenursing, and best-practice learning continuesthroughout nurses careers. Some of what studentsand nurses learn is based on systematic research,but much of it is not. In fact, Millenson (1997) esti-mated that 85% of health care practice has not beenscientifically validated.

Clinical nursing practice relies on a collage ofinformation sources that vary in dependability andvalidity. Increasingly there are discussions of evi-dence hierarchies that acknowledge that certaintypes of evidence and knowledge are superior toothers. A brief discussion of some alternativesources of evidence shows how research-basedinformation is different.

Tradition

Many questions are answered and problems solvedbased on inherited customs or tradition. Withineach culture, certain truths are accepted as given.For example, as citizens of democratic societies,most of us accept, without proof, that democracy isthe highest form of government. This type ofknowledge often is so much a part of our heritagethat few of us seek verification.

Tradition offers some advantages. It is efficientas an information source: each individual is notrequired to begin anew in an attempt to understandthe world or certain aspects of it. Tradition or customalso facilitates communication by providing a com-mon foundation of accepted truth. Nevertheless, tra-dition poses some problems because many traditionshave never been evaluated for their validity. Indeed,by their nature, traditions may interfere with theability to perceive alternatives. Walkers (1967)research on ritualistic practices in nursing suggeststhat some traditional nursing practices, such as theroutine taking of a patients temperature, pulse, and

tronic document retrieval and delivery; e-mail; and electronic mailing lists, informationabout innovations can be communicated morewidely and more quickly than ever before.

Increasing the visibility of nursing research.The 21st century is likely to witness efforts toincrease the visibility of nursing research, theonus for which will fall on the shoulders ofnurse researchers themselves. Most people areunaware that nurses are scholars andresearchers. Nurse researchers must marketthemselves and their research to professionalorganizations, consumer organizations, and thecorporate world to increase support for theirresearch. They also need to educate upper-levelmanagers and corporate executives about theimportance of clinical outcomes research. AsBaldwin and Nail (2000) have noted, nurseresearchers are one of the best-qualified groupsto meet the need in todays world for clinicaloutcomes research, but they are not recognizedfor their expertise.

Priorities and goals for the future are also underdiscussion. NINR has established scientific goalsand objectives for the 5-year period of 2000 to2004. The four broad goals are: (1) to identify andsupport research opportunities that will achieve sci-entific distinction and produce significant contribu-tions to health; (2) to identify and support futureareas of opportunity to advance research on highquality, cost-effective care and to contribute to thescientific base for nursing practice; (3) to communi-cate and disseminate research findings resultingfrom NINR-funded research; and (4) to enhance thedevelopment of nurse researchers through trainingand career development opportunities. For the years2000, 2001, and 2002, topics identified by NINR asspecial areas of research opportunity included:

Chronic illnesses or conditions (e.g., managementof chronic pain; care of children with asthma;adherence to diabetes self-management)

Behavioral changes and interventions (e.g.,research in informal caregiving; disparities ofinfant mortality; effective sleep in health andillness)


respirations, may be dysfunctional. The Walkerstudy illustrates the potential value of criticalappraisal of custom and tradition before acceptingthem as truth. There is growing concern that manynursing interventions are based on tradition, cus-toms, and unit culture rather than on sound evi-dence (e.g., French, 1999).

Authority

In our complex society, there are authoritiespeoplewith specialized expertisein every field. We areconstantly faced with making decisions about mat-ters with which we have had no direct experience;therefore, it seems natural to place our trust in thejudgment of people who are authoritative on an issueby virtue of specialized training or experience. As asource of understanding, however, authority hasshortcomings. Authorities are not infallible, particu-larly if their expertise is based primarily on personalexperience; yet, like tradition, their knowledge oftengoes unchallenged. Although nursing practice wouldflounder if every piece of advice from nursingeducators were challenged by students, nursing edu-cation would be incomplete if students never hadoccasion to pose such questions as: How does theauthority (the instructor) know? What evidence isthere that what I am learning is valid?

Clinical Experience, Trial and Error,and Intuition

Our own clinical experiences represent a familiarand functional source of knowledge. The ability togeneralize, to recognize regularities, and to makepredictions based on observations is an importantcharacteristic of the human mind. Despite the obvi-ous value of clinical expertise, it has limitations asa type of evidence. First, each individuals experi-ence is fairly restricted. A nurse may notice, forexample, that two or three cardiac patients followsimilar postoperative sleep patterns. This observa-tion may lead to some interesting discoveries withimplications for nursing interventions, but does onenurses observations justify broad changes innursing care? A second limitation of experience is

that the same objective event is usually experiencedor perceived differently by two individuals.

Related to clinical experience is the method oftrial and error. In this approach, alternatives aretried successively until a solution to a problem isfound. We likely have all used trial and error in ourlives, including in our professional work. For exam-ple, many patients dislike the taste of potassium chlo-ride solution. Nurses try to disguise the taste of themedication in various ways until one method meetswith the approval of the patient. Trial and error mayoffer a practical means of securing knowledge, butit is fallible. This method is haphazard, and theknowledge obtained is often unrecorded and, hence,inaccessible in subsequent clinical situations.

Finally, intuition is a type of knowledge thatcannot be explained on the basis of reasoning or priorinstruction. Although intuition and hunches undoubt-edly play a role in nursing practiceas they do in theconduct of researchit is difficult to develop policiesand practices for nurses on the basis of intuition.

Logical Reasoning

Solutions to many perplexing problems are devel-oped by logical thought processes. Logical reason-ing as a method of knowing combines experience,intellectual faculties, and formal systems ofthought. Inductive reasoning is the process ofdeveloping generalizations from specific observa-tions. For example, a nurse may observe the anxiousbehavior of (specific) hospitalized children and con-clude that (in general) childrens separation fromtheir parents is stressful. Deductive reasoning isthe process of developing specific predictions fromgeneral principles. For example, if we assume thatseparation anxiety occurs in hospitalized children(in general), then we might predict that (specific)children in Memorial Hospital whose parents do notroom-in will manifest symptoms of stress.

Both systems of reasoning are useful as a meansof understanding and organizing phenomena, andboth play a role in nursing research. However, rea-soning in and of itself is limited because the validityof reasoning depends on the accuracy of the infor-mation (or premises) with which one starts, and


PARADIGMS FORNURSING RESEARCH

A paradigm is a world view, a general perspectiveon the complexities of the real world. Paradigmsfor human inquiry are often characterized in termsof the ways in which they respond to basic philo-sophical questions:

Ontologic: What is the nature of reality? Epistemologic: What is the relationship between

the inquirer and that being studied? Axiologic: What is the role of values in the inquiry? Methodologic: How should the inquirer obtain

knowledge?

Disciplined inquiry in the field of nursing isbeing conducted mainly within two broad paradigms,both of which have legitimacy for nursing research.This section describes the two alternative paradigmsand outlines their associated methodologies.

The Positivist Paradigm

One paradigm for nursing research is known as pos-itivism. Positivism is rooted in 19th centurythought, guided by such philosophers as Comte,Mill, Newton, and Locke. Positivism is a reflectionof a broader cultural phenomenon that, in thehumanities, is referred to as modernism, whichemphasizes the rational and the scientific. Althoughstrict positivist thinkingsometimes referred to aslogical positivismhas been challenged andundermined, a modified positivist position remainsa dominant force in scientific research.

The fundamental ontologic assumption of pos-itivists is that there is a reality out there that can bestudied and known (an assumption refers to abasic principle that is believed to be true withoutproof or verification). Adherents of the positivistapproach assume that nature is basically orderedand regular and that an objective reality exists inde-pendent of human observation. In other words, theworld is assumed not to be merely a creation of thehuman mind. The related assumption of determin-ism refers to the belief that phenomena are not hap-hazard or random events but rather have antecedentcauses. If a person has a cerebrovascular accident,

reasoning may be an insufficient basis for evaluatingaccuracy.

Assembled Information

In making clinical decisions, health care profes-sionals also rely on information that has beenassembled for a variety of purposes. For example,local, national, and international bench-markingdata provide information on such issues as therates of using various procedures (e.g., rates ofcesarean deliveries) or rates of infection (e.g.,nosocomial pneumonia rates), and can serve as aguide in evaluating clinical practices. Cost datathat is, information on the costs associated withcertain procedures, policies, or practicesaresometimes used as a factor in clinical decision-making. Quality improvement and risk data,such as medication error reports and evidence onthe incidence and prevalence of skin breakdown,can be used to assess practices and determine theneed for practice changes.

Such sources, although offering some infor-mation that can be used in practice, provide nomechanism for determining whether improvementsin patient outcomes result from their use.

Disciplined Research

Research conducted within a disciplined format isthe most sophisticated method of acquiring evi-dence that humans have developed. Nursingresearch combines aspects of logical reasoningwith other features to create evidence that,although fallible, tends to be more reliable thanother methods of knowledge acquisition.

The current emphasis on evidence-based healthcare requires nurses to base their clinical practice tothe greatest extent possible on research-based find-ings rather than on tradition, authority, intuition, orpersonal experience. Findings from rigorousresearch investigations are considered to be at thepinnacle of the evidence hierarchy for establishingan EBP. As we discuss next, disciplined research innursing is richly diverse with regard to questionsasked and methods used.


the scientist in a positivist tradition assumes thatthere must be one or more reasons that can bepotentially identified and understood. Much of theactivity in which a researcher in a positivist para-digm is engaged is directed at understanding theunderlying causes of natural phenomena.

Because of their fundamental belief in an objec-tive reality, positivists seek to be as objective as pos-sible in their pursuit of knowledge. Positivists attemptto hold their personal beliefs and biases in checkinsofar as possible during their research to avoid con-taminating the phenomena under investigation. Thepositivists scientific approach involves the use oforderly, disciplined procedures that are designed totest researchers hunches about the nature of phenom-ena being studied and relationships among them.

The Naturalistic Paradigm

The naturalistic paradigm began as a counter-movement to positivism with writers such as Weberand Kant. Just as positivism reflects the culturalphenomenon of modernism that burgeoned in thewake of the industrial revolution, naturalism is anoutgrowth of the pervasive cultural transformationthat is usually referred to as postmodernism.Postmodern thinking emphasizes the value ofdeconstructionthat is, of taking apart old ideasand structuresand reconstructionthat is,putting ideas and structures together in new ways.The naturalistic paradigm represents a major alter-native system for conducting disciplined researchin nursing. Table 1-2 compares the major assump-tions of the positivist and naturalistic paradigms.


ASSUMPTION POSITIVIST PARADIGM NATURALISTIC PARADIGM

Ontologic (What is Reality exists; there is a real Reality is multiple and subjective,the nature of reality?) world driven by real natural mentally constructed by individuals.

causes.

Epistemologic (How is The inquirer is independent The inquirer interacts with thosethe inquirer related to from those being researched; being researched; findings arethose being researched?) findings are not influenced by the creation of the interactive

the researcher. process.

Axiologic (What is the role Values and biases are to be Subjectivity and values areof values in the inquiry?) held in check; objectivity inevitable and desirable.

is sought.

Methodologic (How is Deductive processes Inductive processesknowledge obtained?) Emphasis on discrete, specific Emphasis on entirety of some

concepts phenomenon, holisticVerification of researchers Emerging interpretations grounded

hunches in participants experiencesFixed design Flexible designTight controls over context Context-boundEmphasis on measured, Emphasis on narrative information;

quantitative information; qualitative analysisstatistical analysis

Seeks generalizations Seeks patterns

TABLE 1.2 Major Assumptions of the Positivist and Naturalistic Paradigms

For the naturalistic inquirer, reality is not afixed entity but rather a construction of the individ-uals participating in the research; reality existswithin a context, and many constructions are possi-ble. Naturalists thus take the position of relativism:if there are always multiple interpretations of real-ity that exist in peoples minds, then there is noprocess by which the ultimate truth or falsity of theconstructions can be determined.

Epistemologically, the naturalistic paradigmassumes that knowledge is maximized when thedistance between the inquirer and the participantsin the study is minimized. The voices and interpre-tations of those under study are crucial to under-standing the phenomenon of interest, and subjectiveinteractions are the primary way to access them.The findings from a naturalistic inquiry are theproduct of the interaction between the inquirer andthe participants.

Paradigms and Methods: Quantitativeand Qualitative Research

Broadly speaking, research methods are the tech-niques used by researchers to structure a study and togather and analyze information relevant to theresearch question. The two alternative paradigmshave strong implications for the research methods tobe used. The methodologic distinction typicallyfocuses on differences between quantitativeresearch, which is most closely allied with the posi-tivist tradition, and qualitative research, which ismost often associated with naturalistic inquiryalthough positivists sometimes engage in qualitativestudies, and naturalistic researchers sometimes col-lect quantitative information. This section providesan overview of the methods associated with the twoalternative paradigms. Note that this discussionaccentuates differences in methods as a heuristicdevice; in reality, there is often greater overlap ofmethods than this introductory discussion implies.

The Scientific Method and Quantitative ResearchThe traditional, positivist scientific methodrefers to a general set of orderly, disciplined proce-dures used to acquire information. Quantitative


researchers use deductive reasoning to generatehunches that are tested in the real world. They typ-ically move in an orderly and systematic fashionfrom the definition of a problem and the selectionof concepts on which to focus, through the designof the study and collection of information, to thesolution of the problem. By systematic, we meanthat the investigator progresses logically through aseries of steps, according to a prespecified plan ofaction.

Quantitative researchers use mechanismsdesigned to control the study. Control involvesimposing conditions on the research situation sothat biases are minimized and precision and validityare maximized. The problems that are of interest tonurse researchersfor example, obesity, compli-ance with a regimen, or painare highly complicatedphenomena, often representing the effects of vari-ous forces. In trying to isolate relationshipsbetween phenomena, quantitative researchersattempt to control factors that are not under directinvestigation. For example, if a scientist is interestedin exploring the relationship between diet and heartdisease, steps are usually taken to control otherpotential contributors to coronary disorders, suchas stress and cigarette smoking, as well as addi-tional factors that might be relevant, such as apersons age and gender. Control mechanisms arediscussed at length in this book.

Quantitative researchers gather empiricalevidenceevidence that is rooted in objectivereality and gathered directly or indirectly throughthe senses. Empirical evidence, then, consists ofobservations gathered through sight, hearing,taste, touch, or smell. Observations of the pres-ence or absence of skin inflammation, the heartrate of a patient, or the weight of a newborn infantare all examples of empirical observations. Therequirement to use empirical evidence as the basisfor knowledge means that findings are groundedin reality rather than in researchers personalbeliefs.

Evidence for a study in the positivist paradigmis gathered according to a specified plan, using for-mal instruments to collect needed information.Usually (but not always) the information gatheredin such a study is quantitativethat is, numeric

information that results from some type of formalmeasurement and that is analyzed with statisticalprocedures.

An important goal of a traditional scientificstudy is to understand phenomena, not in isolatedcircumstances, but in a broad, general sense. Forexample, quantitative researchers are typically notas interested in understanding why Ann Jones hascervical cancer as in understanding what generalfactors lead to this carcinoma in Ann and others.The desire to go beyond the specifics of the situa-tion is an important feature of the traditional scien-tific approach. In fact, the degree to which researchfindings can be generalized to individuals otherthan those who participated in the study (referredto as the generalizability of the research) is awidely used criterion for assessing the quality ofquantitative studies.

The traditional scientific approach used byquantitative researchers has enjoyed considerablestature as a method of inquiry, and it has been usedproductively by nurse researchers studying a widerange of nursing problems. This is not to say, how-ever, that this approach can solve all nursing prob-lems. One important limitationcommon to bothquantitative and qualitative researchis thatresearch methods cannot be used to answer moral orethical questions. Many of our most persistent andintriguing questions about the human experience fallinto this areaquestions such as whether euthanasiashould be practiced or abortion should be legal.Given the many moral issues that are linked to healthcare, it is inevitable that the nursing process willnever rely exclusively on scientific information.

The traditional research approach also mustcontend with problems of measurement. To study aphenomenon, quantitative researchers attempt tomeasure it. For example, if the phenomenon ofinterest is patient morale, researchers might want toassess if morale is high or low, or higher under cer-tain conditions than under others. Although thereare reasonably accurate measures of physiologicphenomena, such as blood pressure and body tem-perature, comparably accurate measures of suchpsychological phenomena as patient morale, pain,or self-image have not been developed.

Another issue is that nursing research tends to focus on human beings, who are inherentlycomplex and diverse. Traditional quantitativemethods typically focus on a relatively small por-tion of the human experience (e.g., weight gain,depression, chemical dependency) in a singlestudy. Complexities tend to be controlled and, ifpossible, eliminated, rather than studied directly,and this narrowness of focus can sometimesobscure insights.

Finally and relatedly, quantitative research con-ducted in the positivist paradigm has sometimesbeen accused of a narrowness and inflexibility ofvision, a problem that has been called a sedimentedview of the world that does not fully capture thereality of human experience.

Naturalistic Methods and Qualitative ResearchNaturalistic methods of inquiry attempt to deal withthe issue of human complexity by exploring itdirectly. Researchers in the naturalistic traditionemphasize the inherent complexity of humans, theirability to shape and create their own experiences,and the idea that truth is a composite of realities.Consequently, naturalistic investigations place aheavy emphasis on understanding the human expe-rience as it is lived, usually through the careful col-lection and analysis of qualitative materials that arenarrative and subjective.

Researchers who reject the traditional scien-tific method believe that a major limitation of theclassical model is that it is reductionistthat is, itreduces human experience to only the few conceptsunder investigation, and those concepts are definedin advance by the researcher rather than emergingfrom the experiences of those under study.Naturalistic researchers tend to emphasize thedynamic, holistic, and individual aspects of humanexperience and attempt to capture those aspects intheir entirety, within the context of those who areexperiencing them.

Flexible, evolving procedures are used to capi-talize on findings that emerge in the course of thestudy. Naturalistic inquiry always takes place in thefield (i.e., in naturalistic settings), often over anextended period of time, while quantitative research


desirable trend in the pursuit of new evidence forpractice. Although researchers world view may beparadigmatic, knowledge itself is not. Nursingknowledge would be thin, indeed, if there were nota rich array of methods available within the twoparadigmsmethods that are often complementaryin their strengths and limitations. We believe thatintellectual pluralism should be encouraged andfostered.

Thus far, we have emphasized differencesbetween the two paradigms and their associatedmethods so that their distinctions would be easy tounderstand. Subsequent chapters of this book willfurther elaborate on differences in terminology,methods, and research products. It is equallyimportant, however, to note that these two para-digms have many features in common, only someof which are mentioned here:

Ultimate goals. The ultimate aim of disciplinedinquiry, regardless of the underlying paradigm,is to gain understanding about phenomena. Bothquantitative and qualitative researchers seek tocapture the truth with regard to an aspect of theworld in which they are interested, and bothgroups can make significant contributions tonursing knowledge. Moreover, qualitative stud-ies often serve as a crucial starting point formore controlled quantitative studies.

External evidence. Although the word empiri-cism has come to be allied with the traditionalscientific approach, it is nevertheless the casethat researchers in both traditions gather andanalyze external evidence that is collectedthrough their senses. Neither qualitative norquantitative researchers are armchair analysts,relying on their own beliefs and views of theworld for their conclusions. Information is gath-ered from others in a deliberate fashion.

Reliance on human cooperation. Because evi-dence for nursing research comes primarily fromhuman participants, the need for human cooper-ation is inevitable. To understand peoples char-acteristics and experiences, researchers mustpersuade them to participate in the investigationand to act and speak candidly. For certain

takes place both in natural as well as in contrivedlaboratory settings. In naturalistic research, the col-lection of information and its analysis typicallyprogress concurrently; as researchers sift throughinformation, insights are gained, new questionsemerge, and further evidence is sought to amplify orconfirm the insights. Through an inductive process,researchers integrate information to develop a theoryor description that helps explicate processes underobservation.

Naturalistic studies result in rich, in-depthinformation that has the potential to elucidate varieddimensions of a complicated phenomenon. Becauseof this featureand the relative ease with whichqualitative findings can be communicated to layaudiencesit has been argued that qualitative meth-ods will play a more prominent role in health carepolicy and development in the future (Carey, 1997).

The findings from in-depth qualitativeresearch are rarely superficial, but there are severallimitations of the approach. Human beings are useddirectly as the instrument through which informa-tion is gathered, and humans are extremely intelli-gent and sensitivebut fallibletools. The subjec-tivity that enriches the analytic insights of skillfulresearchers can yield trivial findings among lesscompetent inquirers.

The subjective nature of naturalistic inquirysometimes causes concerns about the idiosyncraticnature of the conclusions. Would two naturalisticresearchers studying the same phenomenon in thesame setting arrive at the same results? The situa-tion is further complicated by the fact that mostnaturalistic studies involve a relatively small groupof people under study. Questions about the gener-alizability of findings from naturalistic inquiriessometimes arise.

Multiple Paradigms and NursingResearch

Paradigms should be viewed as lenses that help tosharpen our focus on a phenomenon of interest, notas blinders that limit intellectual curiosity. Theemergence of alternative paradigms for the study ofnursing problems is, in our view, a healthy and


topics, the need for candor and cooperation is achallenging requirementfor researchers ineither tradition.

Ethical constraints. Research with human beingsis guided by ethical principles that sometimesinterfere with research goals. For example, ifresearchers want to test a potentially beneficialintervention, is it ethical to withhold the treat-ment from some people to see what happens? Asdiscussed later in the book (see Chapter 7),ethical dilemmas often confront researchers,regardless of their paradigmatic orientation.

Fallibility of disciplined research. Virtually allstudiesin either paradigmhave some limi-tations. Every research question can beaddressed in many different ways, andinevitably there are tradeoffs. Financial con-straints are universal, but limitations existeven when resources are abundant. This doesnot mean that small, simple studies have novalue. It means that no single study can everdefinitively answer a research question. Eachcompleted study adds to a body of accumulatedknowledge. If several researchers pose thesame question and if each obtains the same orsimilar results, increased confidence can beplaced in the answer to the question. The fal-libility of any single study makes it importantto understand the tradeoffs and decisions thatinvestigators make when evaluating the ade-quacy of those decisions.

Thus, despite philosophic and methodologicdifferences, researchers using the traditional quan-titative approach or naturalistic methods oftenshare overall goals and face many similar con-straints and challenges. The selection of an appro-priate method depends on researchers personaltaste and philosophy, and also on the research ques-tion. If a researcher asks, What are the effects ofsurgery on circadian rhythms (biologic cycles)?the researcher really needs to express the effectsthrough the careful quantitative measurement ofvarious bodily properties subject to rhythmic vari-ation. On the other hand, if a researcher asks,What is the process by which parents learn tocope with the death of a child? the researcher

would be hard pressed to quantify such a process.Personal world views of researchers help to shapetheir questions.

In reading about the alternative paradigms fornursing research, you likely were more attracted toone of the two paradigmsthe one that corre-sponds most closely to your view of the world andof reality. It is important, however, to learn aboutand respect both approaches to disciplined inquiry,and to recognize their respective strengths and lim-itations. In this textbook, we describe methodsassociated with both qualitative and quantitativeresearch.

THE PURPOSES OFNURSING RESEARCH

The general purpose of nursing research is toanswer questions or solve problems of relevanceto the nursing profession. Sometimes a distinc-tion is made between basic and applied research.As traditionally defined, basic research is under-taken to extend the base of knowledge in a disci-pline, or to formulate or refine a theory. Forexample, a researcher may perform an in-depthstudy to better understand normal grievingprocesses, without having explicit nursing appli-cations in mind. Applied research focuses onfinding solutions to existing problems. For exam-ple, a study to determine the effectiveness of anursing intervention to ease grieving would beapplied research. Basic research is appropriatefor discovering general principles of humanbehavior and biophysiologic processes; appliedresearch is designed to indicate how these princi-ples can be used to solve problems in nursingpractice. In nursing, the findings from appliedresearch may pose questions for basic research,and the results of basic research often suggestclinical applications.

The specific purposes of nursing researchinclude identification, description, exploration,explanation, prediction, and control. Within eachpurpose, various types of question are addressed bynurse researchers; certain questions are moreamenable to qualitative than to quantitative inquiry,and vice versa.


quantitative research, by contrast, the researcherbegins with a phenomenon that has been previouslystudied or definedsometimes in a qualitativestudy. Thus, in quantitative research, identificationtypically precedes the inquiry.

Qualitative example of identification:Weiss and Hutchinson (2000) investigated

people with diabetes and hypertension to discoverthe basic social problem that affects their adherence

Identification and Description

Qualitative researchers sometimes study phenomenaabout which little is known. In some cases, so littleis known that the phenomenon has yet to be clearlyidentified or named or has been inadequately definedor conceptualized. The in-depth, probing nature ofqualitative research is well suited to the task ofanswering such questions as, What is this phenom-enon? and What is its name? (Table 1-3). In


TYPES OF QUESTIONS: TYPES OF QUESTIONS:PURPOSE QUANTITATIVE RESEARCH QUALITATIVE RESEARCH

Identification What is this phenomenon?What is its name?

Description How prevalent is the phenomenon? What are the dimensions of theHow often does the phenomenon occur? phenomenon?What are the characteristics of the What variations exist?

phenomenon? What is important about the phenomenon?

Exploration What factors are related to the What is the full nature of the phenomenon?phenomenon? What is really going on here?

What are the antecedents of the What is the process by which thephenomenon? phenomenon evolves or is experienced?

Explanation What are the measurable associations How does the phenomenon work?between phenomena? Why does the phenomenon exist?

What factors cause the phenomenon? What is the meaning of the phenomenon?Does the theory explain the How did the phenomenon occur?

phenomenon?

Prediction What will happen if we alter a phenomenon or introduce an intervention?

If phenomenon X occurs, will phenomenon Y follow?

Control How can we make the phenomenon ,happen or alter its nature or prevalence?

Can the occurrence of the phenomenonbe prevented or controlled?

TABLE 1.3 Research Purposes and Research Questions

to health care directives. Through in-depth inter-views with 21 clients, the researchers identified thatwarnings of vulnerability was the basic problemundermining adherence.

Description of phenomena is another impor-tant purpose of research. In a descriptive study,researchers observe, count, delineate, and classify.Nurse researchers have described a wide variety ofphenomena. Examples include patients stress andcoping, pain management, adaptation processes,health beliefs, rehabilitation success, and timepatterns of temperature readings.

Description can be a major purpose for bothqualitative and quantitative researchers. Quantitativedescription focuses on the prevalence, incidence,size, and measurable attributes of phenomena.Qualitative researchers, on the other hand, use in-depth methods to describe the dimensions, varia-tions, and importance of phenomena. Table 1-3compares descriptive questions posed by quantita-tive and qualitative researchers.

Quantitative example of description:Bohachick, Taylor, Sereika, Reeder, and

Anton (2002) conducted a study to describe quan-titative changes in psychological well-being andpsychological resources 6 months after a hearttransplantation.

Qualitative example of description:Bournes and Mitchell (2002) undertook an

in-depth study to describe the experience of wait-ing in a critical care waiting room.

Exploration

Like descriptive research, exploratory research beginswith a phenomenon of interest; but rather than simplyobserving and describing it, exploratory researchinvestigates the full nature of the phenomenon, themanner in which it is manifested, and the other factorsto which it is related. For example, a descriptive quan-titative study of patients preoperative stress mightseek to document the degree of stress patients experi-ence before surgery and the percentage of patientswho actually experience it. An exploratory studymight ask the following: What factors diminish or

increase a patients stress? Is a patients stress relatedto behaviors of the nursing staff? Is stress related tothe patients cultural backgrounds?

Qualitative methods are especially useful forexploring the full nature of a little-understood phe-nomenon. Exploratory qualitative research isdesigned to shed light on the various ways in whicha phenomenon is manifested and on underlyingprocesses.

Quantitative example of exploration:Reynolds and Neidig (2002) studied the

incidence and severity of nausea accompanyingcombinative antiretroviral therapies among HIV-infected patients, and explored patterns of nauseain relation to patient characteristics.

Qualitative example of exploration:Through in-depth interviews, Sadala and

Mendes (2000) explored the experiences of 18 nurseswho cared for patients who had been pronouncedbrain dead but kept alive to serve as organ donors.

Explanation

The goals of explanatory research are to understandthe underpinnings of specific natural phenomena,and to explain systematic relationships among phe-nomena. Explanatory research is often linked to the-ories, which represent a method of deriving, organiz-ing, and integrating ideas about the manner in whichphenomena are interrelated. Whereas descriptiveresearch provides new information, and exploratoryresearch provides promising insights, explanatoryresearch attempts to offer understanding of theunderlying causes or full nature of a phenomenon.

In quantitative research, theories or prior find-ings are used deductively as the basis for generat-ing explanations that are then tested empirically.That is, based on a previously developed theory orbody of evidence, researchers make specificpredictions that, if upheld by the findings, addcredibility to the explanation. In qualitative studies,researchers may search for explanations about howor why a phenomenon exists or what a phenomenonmeans as a basis for developing a theory that isgrounded in rich, in-depth, experiential evidence.



the study emphasized in the chapter. A review ofthe full journal article likely would prove useful.

Research Example of a Quantitative Study

McDonald, Freeland, Thomas, and Moore (2001)conducted a study to determine the effectiveness of apreoperative pain management intervention for reliev-ing pain among elders undergoing surgery. Theirreport appeared in the journal Research in Nursing &Health.

McDonald (who had conducted earlier researchon the topic of pain and pain management) and hercolleagues developed a preoperative intervention thattaught pain management and pain communicationskills. The content was specifically geared to olderadults undergoing surgery. Forty elders, all older thanage 65 years, were recruited to participate in thestudy. Half of these elders were assigned, at random,to participate in the special intervention; the remain-ing half got usual preoperative care. Postoperativepain was measured for both groups on the evening ofthe surgery, on postoperative day 1, and on postoper-ative day 2. The results supported the researchers pre-dictions that (a) pain in both groups would declineover time; and (b) those receiving the special inter-vention would experience greater decreases in painover time.

The researchers noted that further research isneeded to determine whether the interventions effectresulted from instruction in pain management or inpain communication skills (and, indeed, McDonaldreported being in the process of conducting such astudy). They also noted that the study was based onelders undergoing certain types of surgery at a singlesite, acknowledging that the findings need confirmationin other settings and contexts. Nevertheless, this studyoffers evidence that pain responses of elderly surgicalpatients can be lowered through a nursing intervention.The strength of this evidence lies in several factorsseveral of which you will appreciate more as youbecome familiar with research methods. Most impor-tant, this study was quite rigorous. The interventionitself was based on a formal theory of communicationaccommodation, which addresses how people adjustcommunication to their own needs. The researcherstook care to ensure that the two groups being com-pared were equivalent in terms of background and

Quantitative example of explanation:Resnick, Orwig, Maganizer, and Wynne

(2002) tested a model to explain exercise behavioramong older adults on the basis of social support,age, and self-efficacy expectations.

Qualitative example of explanation:Hupcey (2000) undertook a study that

involved the development of a model explainingthe psychosocial needs of patients in the intensivecare unit. Feeling safe was the overwhelming needof patients in the intensive care unit.

Prediction and Control

Many phenomena defy explanation. Yet it is fre-quently possible to make predictions and to controlphenomena based on research findings, even in theabsence of complete understanding. For example,research has shown that the incidence of Down syn-drome in infants increases with the age of the mother.We can predict that a woman aged 40 years is athigher risk of bearing a child with Down syndromethan is a woman aged 25 years. We can partially con-trol the outcome by educating women about the risksand offering amniocentesis to women older than 35years of age. Note, however, that the ability to predictand control in this example does not depend on anexplanation of why older women are at a higher riskof having an abnormal child. In many examples ofnursing and health-related studiestypically, quanti-tative onesprediction and control are key objec-tives. Studies designed to test the efficacy of a nurs-ing intervention are ultimately concerned withcontrolling patient outcomes or the costs of care.

Quantitative example of prediction:Lindeke, Stanley, Else, and Mills (2002)

used neonatal data to predict academic perfor-mance and the need for special services amongschool-aged children who had been in a level 3neonatal intensive care unit.

RESEARCH EXAMPLES

Each chapter of this book presents brief descrip-tions of actual studies conducted by nurseresearchers. The descriptions focus on aspects of

medical characteristics, so that group differences inpain responses reflected the intervention and not somespurious factor. The research team members who mea-sured pain responses were not aware of whether theelders were in the intervention group, so as not to biasthe measurements. Finally, the findings are more per-suasive because the team of researchers who conduct-ed the study have developed a solid program ofresearch on pain, and their research has contributedincrementally to understanding pain responses andappropriate nursing interventions.

Research Example of a Qualitative Study

Cheek and Ballantyne (2001) undertook a study todescribe the search and selection process for an agedcare facility after discharge of a family member fromacute hospital settings in Australia, and to explore theeffects the process had on the individuals and theirfamilies. Twelve residents and 20 of their sponsors(the primary contact person responsible for the resi-dent) participated in the study. Face-to-face in-depthinterviews were conducted with residents in the agedcare facilities and with family members in theirhomes. They were all asked to talk about their per-sonal experiences of the search and selection processand its effect on their well-being.

These interviews were audiotaped and then tran-scribed. Analysis of the interview transcripts revealedfive themes. One theme, for example, was labeleddealing with the systemcutting through the maze.Dealing with the system was perceived as being in themiddle of a war zone. This sense of battle was relatedto confusion, lack of control, and the feeling of beingat the systems mercy. Contributing to this perception of being at war with the system was the stress of having to deal with multiple aged care facilities on anindividual basis. A second major theme was labeledUrgencymoving them on and in. Sponsors felt asense of urgency in finding a suitable facility to havetheir family member transferred to from the acutesetting. Sponsors felt pressured to make on-the-spotdecisions to accept or reject a place in a facility onceit had become available.

This thorough and careful study provides a first-hand perspective on the experiences of people goingthrough the process of selecting an appropriate long-term care facility for aging family members. One of

the central implications for practice of this study con-cerns the need to revise the search and selectionprocess to make it more efficient in terms of time andeffort of the sponsors and residents. In addition, thestudy suggests that increased communicationfromthe acute setting to the aged care facilities being con-sideredcould play an important role in decreasingthe stress of this guilt-ridden experience. The clinicalimplications of the study are strengthened by the factthat the researchers took steps to ensure its rigor. Forexample, the transcripts of these interviews were readby at least two members of the research team whoindividually identified themes from each interview.The researchers then compared and discussed thethemes from all the interviews until consensus wasreached. Moreover, the researchers took steps toweigh their evidence for their thematic conclusionsagainst potentially competing explanations of thedata.

SUMMARY POINTS

Nursing research is systematic inquiry todevelop knowledge about issues of importanceto nurses.

Nurses in various settings are adopting anevidence-based practice that incorporatesresearch findings into their decisions and theirinteractions with clients.

Knowledge of nursing research enhances theprofessional practice of all nursesincludingboth consumers of research (who read andevaluate studies) and producers of research(who design and undertake research studies).

Nursing research began with FlorenceNightingale but developed slowly until its rapidacceleration in the 1950s. Since the 1970s, nurs-ing research has focused on problems relating toclinical practice.

The National Institute of Nursing Research(NINR), established at the U.S. NationalInstitutes of Health in 1993, affirms the statureof nursing research in the United States.

Future emphases of nursing research are likelyto include outcomes research, research utiliza-tion projects, replications of research, multisitestudies, and expanded dissemination efforts.



STUDY ACTIVIT IES

Chapter 1 of the Study Guide to Accompany NursingResearch: Principles and Methods, 7th edition, offersvarious exercises and study suggestions for reinforc-ing the concepts presented in this chapter. In addition,the following study questions can be addressed:

1. What are some of the current changes occur-ring in the health care delivery system, andhow could these changes influence nursingresearch?

2. Is your world view closer to the positivist orthe naturalistic paradigm? Explore the aspectsof the two paradigms that are especially con-sistent with your world view.

3. How does the assumption of scientific determin-ism conflict with or coincide with superstitiousthinking? Take, as an example, the superstitionassociated with four-leaf clovers or a rabbitsfoot.

4. How does the ability to predict phenomenaoffer the possibility of their control?

SUGGESTED READINGS

Methodologic and TheoreticalReferences

American Nurses Association Cabinet on NursingResearch. (1985). Directions for nursing research:Toward the twenty-first century. Kansas City, MO:American Nurses Association.

Baldwin, K. M., & Nail, L. M. (2000). Opportunities andchallenges in clinical nursing research. Journal ofNursing Scholarship, 32, 163166.

Brown, E. L. (1948). Nursing for the future. New York:Russell Sage.

Carey, M. A. (1997). Qualitative research in policy devel-opment. In J. M. Morse (Ed). Completing a qualitativeproject: Details and dialogue (pp. 345354).Thousand Oaks, CA: Sage.

DAntonio, P. (1997). Toward a history of research innursing. Nursing Research, 46, 105110.

Donaldson, S. K. (2000). Breakthroughs in scientificresearch: The discipline of nursing, 19601999. AnnualReview of Nursing Research, 18, 247311.

French, P. (1999). The development of evidence-basednursing. Journal of Advanced Nursing, 29, 7278.

Disciplined research stands in contrast to othersources of evidence for nursing practice, such astradition, voices of authority, personal experi-ence, trial and error, intuition, and logical rea-soning; rigorous research is at the pinnacle ofthe evidence hierarchy as a basis for makingclinical decisions.

Disciplined inquiry in nursing is conductedwithin two broad paradigmsworld viewswith underlying assumptions about the com-plexities of reality: the positivist paradigm andthe naturalistic paradigm.

In the positivist paradigm, it is assumed thatthere is an objective reality and that natural phe-nomena are regular and orderly. The relatedassumption of determinism refers to the beliefthat phenomena are the result of prior causesand are not haphazard.

In the naturalistic paradigm, it is assumedthat reality is not a fixed entity but is rather aconstruction of human mindsand thus truthis a composite of multiple constructions ofreality.

The positivist paradigm is associated with quan-titative researchthe collection and analysis ofnumeric information. Quantitative research istypically conducted within the traditionalscientific method, which is a systematic andcontrolled process. Quantitative researchers basetheir findings on empirical evidence (evidencecollected by way of the human senses) and strivefor generalizability of their findings beyond asingle setting or situation.

Researchers within the naturalistic paradigmemphasize understanding the human experienceas it is lived through the collection and analysisof subjective, narrative materials using flexibleprocedures that evolve in the field; this para-digm is associated with qualitative research.

Basic research is designed to extend the base ofinformation for the sake of knowledge. Appliedresearch focuses on discovering solutions toimmediate problems.

Research purposes for nursing research includeidentification, description, exploration, explana-tion, prediction, and control.


Goode, C. J. (2000). What constitutes evidence inevidence-based practice? Applied Nursing Research,13, 222225.

Guba, E. G. (Ed.). (1990). The paradigm dialog.Newbury Park, CA: Sage.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalisticinquiry. Beverly Hills, CA: Sage.

Lindeman, C. A. (1975). Delphi survey of priorities inclinical nursing research. Nursing Research, 24,434441.

Millenson, M. L. (1997). Demanding medical evidence.Chicago: University of Chicago Press.

Nightingale, F. (1859). Notes on nursing: What it is, andwhat it is not. Philadelphia: J. B. Lippincott.

Stetler, C. B., & Marram, G. (1976). Evaluating researchfindings for applicability in practice. NursingOutlook, 24, 559563.

Walker, V. H. (1967). Nursing and ritualistic practice.New York: Macmillan.

Studies Cited in Chapter 1

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