CHAPTER 9. Research in nursing
concepts and processes
John Daly, Doug Elliott and Esther Chang
LEARNING OBJECTIVES
• an understanding of the role of research in the development of contemporary nursing
• an appreciation of the need for a range of approaches to research in nursing
• basic knowledge and understanding of research processes in nursing
• an appreciation of the contribution of research to the development of knowledge and clinical practice standards in nursing, and
• a beginning understanding of research critique and research dissemination processes in nursing.
RESEARCH IN NURSING
This chapter introduces you to basic concepts and processes of research in nursing. research has assumed a position of significance in australian nursing, and there continue to be advances in knowledge development and the sophistication of research approaches.
The concept of research in nursing is not new in the western world (D’Antonio, 1997 and Mulhall, 1995). in britain, florence nightingale was active in research in nursing in the nineteenth century, though it was not until 1940 that further progress occurred and it was 1963 before the first government-funded post to facilitate research in nursing was established in the ministry of health (mulhall 1995). nursing research and educational centres were established in some universities in the 1970s. in the united states, government support for research in nursing was initiated in the 1950s (d’antonio 1997). by that time, many universities had nursing degree courses at undergraduate and postgraduate level, as well as a significant number of nurse researchers with doctorates who were able to provide research leadership for the profession.
In australia and new zealand, it was in the late 1980s when nursing was established as an academic discipline with a significant presence in universities. there continues to be growth in appropriately prepared nurse researchers who can provide research leadership, disciplinary scholarship and contribute to the ongoing professionalisation of nursing throughout australasia. the discipline of nursing, through various professional bodies, has highlighted the important role of research in the continued development of nursing as a practice discipline with a research-based body of knowledge (e.g. australian nursing and midwifery council 2006, council of deans of nursing and midwifery (anz), royal college of nursing australia 2003). the australian nursing and midwifery council (anmc) competency standards for the registered nurse (australian nursing and midwifery council 2006) clearly identify the importance of research to the registered nurse role. this is given expression in competency standards 3.1 to 3.4 in particular:
3.1 Identifies the relevance of research to improving individual/group health outcomes,
3.2 Uses best available evidence, nursing expertise and respect for the values and beliefs of individuals/groups in the provision of care,
3.3 Demonstrates analytical skills in accessing and evaluating health information and research evidence, and
3.4 Supports and contributes to nursing and health care research (australian nursing and midwifery council 2006:4).
WHAT IS RESEARCH?
Research is a rigorous process of inquiry designed to provide answers to questions about phenomena of concern within an academic discipline or profession. It is defined as ‘the systematic study of materials and sources to establish facts and reach new conclusions’ (Compact Oxford English Dictionary 2004:1). Research is a complex subject and field comprised of a number of well-established but diverse traditions. In a chapter such as this, it is possible to present only broad brushstrokes to familiarise the reader with key underpinnings of research processes in nursing. To develop in-depth knowledge and understanding of any one or a range of research traditions, processes and/or methods, further study and reading from a variety of sources will be necessary.
Research traditions can be investigated in relation to their philosophical underpinnings, and in the course of your reading of research you will encounter a number of essentially different paradigms. A research paradigm is an overarching framework that is based on values, beliefs and assumptions (Parse 1987). This framework contains theory about the nature of reality and guidelines for the methods to be used in carrying out research using (or within) the paradigm (Parse 2001). In addition, the ideas within the paradigm have implications for the type of knowledge being sought in a research study, the way in which the study will be carried out and the way in which outcomes from the work will be used.
As nursing is a complex field, researchers access a range of approaches, including positivist, feminist and interpretive paradigms. Quality research is labour, skill and resource intensive; therefore, a number of important decisions need to be made before embarking upon a research project. Not least, all research must be ethical, requiring adherence to strict guidelines (National Health and Medical Research Council 2007) and obtaining the necessary approval from institutional human research ethics committees.
Research has the potential to serve a number of purposes in a practice-based discipline such as nursing. Research is necessary to:
• test commonly held knowledge or assumptions
• widen understanding of a subject
• stimulate self-action/study
• develop best practice (i.e. research-based practice)
• explain behaviours
• allow predictions, and
• assist in the formation of a body of nursing knowledge.
The use of research knowledge in practice is the most common contact professional and student nurses have with research. This contact will be through reading, reviewing and critiquing research studies published in the literature. Constructing a review of the relevant literature is often called ‘secondary research’, while developing and conducting an original study is called ‘primary research’. Levels of research use and understanding can be described by the ‘4 As of research’ (Crookes & Davies 2004:xiii). These are:
1. Awareness of and access to the research literature
2. Appreciation or the ability to understand and critique the language of research
3. Application of research findings to local practice settings, and
4. Ability to conduct original (primary) research independently or in a team.
The aim of the first three As of research is not to produce research workers, but to cultivate and nurture nurses to:
• accept research as a normal and integral aspect of nursing practice
• read and understand research reports
• apply research findings to clinical practice (i.e. evidence-based practice)
• influence colleagues on the use of research data, and
• accept responsibility for their own professional development (Crookes & Davies 2004:xii).
That is, not all nurses need to undertake research, but all nurses should use research in their practice. Some nurses will also undertake original research (the fourth ‘A’).
WHERE DO WE FIND RESEARCH?
Literally hundreds of research journals, dissertations, reports and books are published each year. One of the most important steps in the research process is conducting a thorough literature review. Students are often faced with the dilemma of how extensive a review is necessary. There is no formula to determine that 20 or 120 articles will provide the necessary background for the study. The number of references will depend on how familiar you are with the area under investigation, and the scope of the review will depend on how much research is available for that topic. Checking the reference list at the end of recent articles can often assist in the process. Experienced researchers know that maintaining an up-to-date review of the literature is an ongoing process throughout any research activity.
To begin with, it is important to differentiate between primary and secondary sources (this is equivalent to primary and secondary research approaches). A primary source is a report written by the study author/s themselves. A primary source includes information on the rationale of the study, its participants, design, methods of collecting data, procedure, results, outcomes, limitations, recommendations and references. Most research articles published in professional journals are primary sources. A secondary source is one that summarises information from primary sources presented by other authors (see Table 9.1). When an author cites a previous study in the review of literature section, it is a secondary source.
| Term | Meaning |
|---|---|
| Construct validity | The extent to which a measuring instrument measures a theoretical construct or characteristic |
| Descriptive statistics | Description of characteristics (e.g. frequency, percentages), but no inference of relationships between variables |
| Exclusion criteria | A list of characteristics that exclude an individual from being in a study (e.g. less than 24 hours admission in hospital, presence of other illnesses that may influence patient outcomes) |
| Explanatory variable | Independent variable; the intervention being manipulated to exhibit a change in the outcome variable |
| Inclusion criteria | A list of the characteristics required for a subject to be included in a study (e.g. patients admitted for cardiac surgery, 16 years or older, English language skills (reading and writing) sufficient to complete the study questionnaires) |
| Inferential statistics | Statistical procedures used to test an hypothesis about the relationships between two or more variables (e.g. t-tests, analysis of variance, regression modelling) and the application of study findings to the population being studied (generalisability) |
| Integrative review | A style of literature review that combines findings from quantitative and qualitative studies, theoretical and methodological literature using narrative analysis |
| Measuring instrument | The tool used to measure the concept of interest (e.g. questionnaire, biochemical test) |
| Normal distribution | Distribution of scores for a particular variable follow a bell-shape pattern around the mean score for the sample; required to use inferential statistics |
| Outcome variable | Dependent variable; measurement of the concept being studied |
| Primary research | Original research conducted with participants (e.g. patients, health professionals, students) |
| Primary source | A report of original research written by the study author/s that includes information on the study rationale, participants, design, methods of collecting data, procedure, findings, discussion, limitations, and recommendations for practice and further research |
| Reliability | The consistency or stability of a measure or instrument on repeated uses |
| Responsiveness | The ability of a measuring instrument to detect small but important differences of a dynamic characteristic |
| Sample | A selected group of participants who have similar characteristics to the population from which they were drawn (i.e. representative); allows for generalisation of results from the study sample to the wider population |
| Secondary research | A process where data from previous primary research studies are reinvestigated (e.g. literature review, systematic review) |
| Secondary source | A source of literature that summarises information from original research (primary source) presented by other authors |
| Systematic review | A style of literature review combining findings from quantitative studies with similar hypotheses and methods, to inform research and practice using narrative and/or statistical analysis |
Both primary and secondary sources are important in different circumstances. Secondary sources such as systematic reviews (SRs) are becoming increasingly common as the best available evidence when reviewing clinical practice issues. However, secondary sources should be limited when undertaking your own secondary research (i.e. a literature review), while every effort to obtain relevant primary sources should be an aim of the activity.
Indexes, abstracts and databases
Most libraries now provide reference sources via computer databases to assist students in locating references on a specific topic and to undertake their own computer searches. A computer search will generate complete bibliographic citations, often including abstracts of many articles published in a particular area of interest. An abstract is a concise summary of a study. A variety of indexes and databases are available, providing bibliographic listings of articles, abstracts, conference proceedings and books. All indexes provide bibliography citations, giving the authors’ names, publication date, article title, journal volume and issue number, and pages. Each academic discipline has an index to its collection of journals.
A valuable index and database in the health science literature is the Cumulative Index to Nursing and Allied Health Literature (CINAHL), which has journals from nursing and allied health disciplines listed. Another important index and database is Medline, a bibliography of medical studies (Elliott 2007c). The related database, Pubmed, provides free public access to Medline studies (see www.ncbi.nlm.nih.gov/entrez). Other important abstract indexes that may be relevant to your topic are: Education Resources Information Centre (ERIC); Psychology Abstracts, Sociological Abstracts, Cancer Therapy Abstracts (CANCERLIT); and Dissertation Abstracts International.
Most indexes and databases use key words or medical subject (MeSH) headings. When a topic is not found in the subject headings, you can search key words that have been adopted by most of the journal publishers. Many journals also publish key words with an article. Most university libraries hold extensive collections of refereed journals across a range of disciplines. Many databases now provide full-text papers online, although this function may be restricted to journal subscribers (check with your professional library for access rights to journals).
Peer-reviewed journals
Peer-reviewed journals serve many important functions, including facilitation of expert review of manuscripts, reporting the findings of research studies or theoretical papers, dissemination of papers that have been approved for publication following peer review, and serving as a resource for scholars and researchers involved in compiling and/or developing knowledge in an area of nursing research or practice. Criteria that must be met before a paper is approved for publication in a refereed journal vary, but all editors will be concerned with maintaining a standard of excellence in regard to scientific merit and the literary standard of the work, and the relevance of the paper in terms of its potential to contribute to knowledge development in the topic area.
There are many peer-reviewed journals in nursing internationally. Each has its own aims, purposes and requirements, which must be followed by nurses wishing to submit their work for peer review with a view to being published in the journal. Most journals have a related website that provides further details for readers and authors.
DEVELOPING RESEARCH QUESTIONS
Research ideas come from many sources. Some ideas are derived from theoretical considerations, while others arise from the need to solve practical problems or to improve the quality of care. Having a good idea is often not enough—you need to translate that idea into research questions. This section briefly discusses how to develop research questions based on the amount of knowledge and/or theory about the topic, and describes the importance of a thorough review of the literature to identify relevant theory and research.
A research question is usually developed to direct a study. It needs to be a concise inquiring statement about a problem or issue that can be challenged to generate new knowledge. Although there are no specific rules and procedures for asking research questions, the way research questions are worded can have an effect on the research design and methods that follow.
When formulating a research question, it is important that you discuss your topic and question with your colleagues or experts in the field, as this will assist you with the development and refinement of the question. Often the initial research question is structured too broadly to provide a feasible project in terms of timeframe and resources. Consider the following example: Do undergraduate students taught in a supportive environment increase their learning capabilities as graduates? Before this can be answered, a number of issues have to be clarified. What exactly is a supportive environment? What does it mean to increase their learning capabilities? How do we measure learning capabilities? How do we determine learning capabilities in graduates? Until you can define the terms and determine how to measure the variables they represent, you cannot answer the original question. Frequently, researchers have to narrow the topic area or, in some cases, the types and number of settings or the number of participants they include in the study. This process of narrowing the topic ultimately must also be consistent with the research design and methods of the study.
Research questions can be classified based on the amount of knowledge and/or theory about the topic area. Questions may be exploratory and descriptive, through to testing or confirmatory. Once the question has been formulated, the type of study design becomes clear. Exploratory studies are used when there is little or no literature on either the topic or the population to be researched. Questions at this level are designed to explore the topic or a single population. For example, ‘What is …?’ or ‘What are …?’ the phenomena or concepts of interest.
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