Delaney, Apostolidis, Lachapelle, and Fortinsky (2011, p. 285) conducted a comparative descriptive study to examine “home care nurses’ knowledge of evidence-based education topics for management of heart failure.” The following excerpts from this study demonstrate the flow from research problem and purpose to research questions.

Research Problem

“Heart failure (HF), a chronic and disabling syndrome affecting adults of all ages and particularly older adults, is a major public health problem. An estimated 5.7 million Americans are currently affected by HF, and this figure is expected to double over the next 25 years, primarily because of the aging of the population and decreased mortality from other cardiovascular conditions (Hodges, 2009). … HF is characterized by poor posthospital discharge outcomes [problem significance]. … Home care agencies are currently being challenged by Centers for Medicare and Medicaid Services (CMS) to improve outcomes in HF management. … Home care nurses play key roles in the delivery of education to patients and their families [problem background]. However, home care nurses face unique challenges compared with nurses at other sites of care in providing comprehensive education on managing HF. These challenges include a lack of access to detailed patient information (Bowles, Pham, O’Connor, & Horowitz, 2010), a focus on generalist rather than specialist practice, and few opportunities for continuing education in specialized knowledge such as managing HF [problem statement].” (Delaney et al., 2011, p. 286)

Research Purpose

The purpose of this study was to examine “home care nurses’ knowledge of evidence-based HF education related to the disease process, its management, and patients’ self-management” (Delaney et al., 2011, p. 286).

Research Questions

Research questions included the following:

“(1) What is the level of knowledge of home care nurses regarding evidence-based education topics for patients with HF?…

(2) Were differences evident in nurses’ knowledge based on education and work experience?…

(3) What are home care nurses’ self-reported knowledge needs related to the care of patients with HF?” (Delaney et al., 2011, p. 287)

Question 1 focused on description of the home care nurses’ (population) knowledge about HF (variable). Question 2 focused on determining differences in the nurses’ knowledge on the basis of educational level and years of work experience (demographic variables). Question 3 focused on description of the nurses’ self-reported knowledge needs (variable) in managing patients with HF. Delaney et al. (2011) found that home care nurses were limited in their evidence-based knowledge for managing HF. There were no significance differences in the nurses’ knowledge and their educational level and years of experience. The researchers concluded that the home care nurses needed educational programs focused on HF patient management to improve the quality of patient education they could provide.

Formulating Questions in Qualitative Studies

The questions in qualitative studies are often limited in number, have a broad focus, and include variables or concepts that are more complex and abstract than those in quantitative studies. Marshall and Rossman (2011) noted that the questions in qualitative research either might be theoretical ones, which can be studied with different populations or in a variety of sites, or could be focused on a particular population or setting. Hudson et al. (2010) conducted an exploratory-descriptive qualitative study to examine the health-seeking challenges perceived by homeless young adults. The problem, purpose, and research questions used to direct this study are presented in the following excerpts.

Research Problem

“Adolescent homelessness is a distressing social problem. Approximately 1.5 to 2 million homeless adolescent persons live on the streets in the United States (Bucher, 2008); homelessness among young persons is more common than homelessness among older adults. … Homeless young adults are highly vulnerable to negative health consequences because of the realities of street life [problem significance]. … Homeless young persons are at risk for sexual and physical abuse. … Other negative health consequences experienced by homeless young adults include sexually transmitted infections, poorly controlled chronic mental illness, and lack of immunization for conditions, such as hepatitis A and hepatitis B (Hudson, Nyamathi, & Sweat, 2008). … Homeless persons are more likely to be admitted to the hospital and have increased durations of hospitalization than those of nonhomeless persons due to negative health consequences associated with street living. … Nearly half of all homeless young persons have no regular source of health care (Sneller et al., 2008) [problem background]. … The perceptions of how homeless persons view the health care system have not been well studied. … There is a growing assertion that improvements should be made with respect to the provision of quality care for the homeless young adults living in the United States. … One way to achieve high-quality programs designed to improve health care for homeless adults is to solicit these adults’ input in program development [problem statement].” (Hudson et al., 2010, pp. 212-213)

Research Purpose

“The purpose of this article was to gain a further understanding of the perceptions of homeless youth regarding their healthcare-seeking behaviors” (Hudson et al., 2010, p. 213).

Research Questions

This study included the following research questions:

“1. What are homeless young adults’ perspectives on facilitators and barriers to receiving health care?

2. How can existing homeless youth and young-adult-centered healthcare programs be improved?” (Hudson et al., 2010, 213)

The first study question focused on developing a description of the homeless young adults’ (population) perspectives on facilitators and barriers to receiving health care (research variables). The second question focused on identifying and describing how young-adult-centered healthcare programs can be improved (research variable). The study’s “identified themes were failing access to care based on perceived structural barriers (limited clinic sites, limited hours of operation, priority health conditions, and long wait times) and social barriers (perception of discrimination by uncaring professionals, law enforcement, and society in general…)” (Hudson et al., 2010, p. 212). The researchers also gained insights into the programmatic and agency resources that are needed to promote health-seeking behaviors by homeless young adults.

Formulating Hypotheses

A hypothesis is the formal statement of the expected relationship or relationships between two or more variables in a selected population. The hypothesis translates the problem and purpose into a clear explanation or prediction of the expected results or outcomes of the study (Shadish, Cook, & Campbell, 2002). This section describes the purpose, sources, and types of hypotheses that are commonly developed by researchers. In addition, the process for developing and testing hypotheses in nursing studies is described.

Purpose of Hypotheses

The purpose of a hypothesis is similar to that of research objectives and questions. A hypothesis (1) specifies the variables you will manipulate or measure, (2) identifies the population you will examine, (3) indicates the type of research, and (4) directs the conduct of your study. Hypotheses direct the conduct of a study by influencing the study design, sampling technique, data collection and analysis methods, and interpretation of findings. Hypotheses differ from objectives and questions by predicting the outcomes of a study. Study hypotheses are used to organize the results section of a study, and the results indicate support or nonsupport of each hypothesis. Hypothesis testing allows us to generate knowledge by testing theoretical statements or relationships that were identified in previous research, proposed by theorists, or observed in practice (Chinn & Kramer, 2008; Fawcett & Garity, 2009

Sources of Hypotheses

Research hypotheses can be generated by observing phenomena or problems in nursing practice, analyzing theory, and reviewing the research literature. Many hypotheses originate from real-life experiences. Clinicians and researchers observe events in practice and identify relationships among these events (theorizing), which are the bases for formulating hypotheses. For example, you may notice that the hospitalized patient who complains the most about pain receives the most pain medicine and other pain management strategies. The relationship identified is a prediction about events in clinical practice that has potential for empirical testing, because certain patients might not be receiving adequate pain management.

You could conduct a literature review to identify a theory that supports this relationship. For example, Fagerhaugh and Strauss (1977) developed a theory of pain management and identified the following relationship or proposition: As expressions of pain increase, pain management increases. The researchers developed this proposition through the use of grounded theory research. Additional testing is necessary to determine its usefulness in describing how patients express pain and how that pain is managed in a variety of practice situations. On the basis of theory and clinical observation, the following hypothesis might be formulated: The more frequently a hospitalized patient verbalizes perceptions of pain, the greater the administration of analgesic medications by healthcare providers.

Some hypotheses are initially generated from relationships expressed in a theory, when the intent of the researcher is to test a theory. Usually, middle-range theories are tested in research, and a proposition or relationship from the theory provides the basis for the generation of one or more study hypotheses (Fawcett & Garity, 2009; Smith & Liehr, 2008). For example, Rungruangsiripan, Sitthimongkol, Maneesriwongul, Talley, and Vorapongsathorn (2011) tested the relationships in the Common-Sense Model of Illness Representation (Diefenbach & Leventhal, 1996) to examine the factors affecting medication adherence in individuals with schizophrenia. Figure 8-1 contains the framework model for this study based on the Common-Sense Model of Illness Representation, which has three stages: sources of information, illness representation, and coping. “Sources of information included social support variable, therapeutic alliance variable, and experience of medication side effects variable. Coping consisted of intention to change adherence behavior and adherence behavior” (Runguangsiripan et al., 2011, p. 272). This model shows the direct and indirect relationships among the concepts that provide a basis for the study hypotheses. A direct relationship is when one concept links to another concept without an intervening concept. For example, the concept of social support is linked directly to illness representation. In an indirect relationship, one concept is linked to another concept through an intervening third concept. For example, the concept experience with medication side effects is indirectly linked to the concept intention to change adherence behavior through the concept of illness representation (see Figure 8-1). The Rungruangsiripan et al. (2011) study set the following hypotheses:

Figure 8-1 Hypothesized medication adherence model. (From Rungruangsiripan, M., Sitthimongkol, Y., Maneesriwongul, W., Talley, S., & Vorapongsathorn, T. (2011). Mediating role of illness representation among social support, therapeutic alliance, experience of medication side effects, and medication adherence in persons with schizophrenia. *Archives of Psychiatric Nursing, 25*(4), 273.)

“(a) Social support and therapeutic alliance would have a positive direct effect on illness representation and adherence behavior in individuals with schizophrenia;

(b) Experience of medication side effects would have a negative direct effect on illness representation and adherence behavior in individuals with schizophrenia;

(d) Social support, therapeutic alliance, and experience of medication side effects would have an indirect effect on intention to change adherence behavior and adherence behavior through illness representation; and

(e) Illness representation would have a positive direct effect on intention to change adherence behavior and adherence behavior as well as an indirect effect on adherence behavior via intention to change adherence behavior.” (Rungruangsiripan et al., 2011, p. 272)

These hypotheses were formulated to test the propositions or relationships from the Common-Sense Model of Illness Representation (see Figure 8-1). The researchers found that “therapeutic alliance and the experience of medication side-effects enhanced illness representation, which in turn led to an intention to change adherence behavior. Social support did not alter illness representation or adherence behavior” (Rungruangsiripan et al., 2011, p. 269). Illness representation is the patients’ perception of their schizophrenia and their ability to cope with the illness. Patients with a clear perception of their schizophrenia have strong intentions to change their adherence behaviors. Thus, mental health nurses need to promote the patients’ understanding of their schizophrenia illness to enhance their adherence to their medications.

Reviewing the research literature and synthesizing findings from different studies can also be used to generate hypotheses. For example, Ross, Sawatphanit, Mizuno, and Takeo (2011) synthesized the findings from studies to identify the factors that predict depressive symptoms in postpartum women who are HIV-positive. They developed a conceptual framework for their study that is presented in Figure 8-2. The researchers “hypothesized that depressive symptoms are negatively related to self-esteem, emotional support, and infant health status but positively associated with physical symptoms” (Ross et al., 2011, p. 37).

Figure 8-2 Conceptual framework of the study. (From Ross, R., Sawatphanit, W., Mizuno, M., & Takeo, K. (2011). Depressive symptoms among HIV-positive postpartum women in Thailand. *Achieves of Psychiatric Nursing, 25*(1), 37.)

Ross et al. (2011) found that self-esteem and infant health status were significant predictors of postpartum women’s depressive symptoms but physical symptoms and emotional support were not. The study results indicated that 74.1% of the HIV-positive postpartum women had symptoms of depression, and the researchers encouraged nurses to examine the self-esteem and infant health status of such women to increase identification of episodes of depression. The researchers also recommended further research to identify additional factors that might be predictive of depression in HIV-positive postpartum women. Thus, two relationships, those of self-esteem and infant health status to depressive symptoms, were supported in the framework model (see Figure 8-2). However, the other relationships, those of emotional support and physical symptoms to depressive symptoms, were not supported in this study. Additional research is needed to increase understanding of the factors that might be predictive of depression in postpartum women who are HIV-positive.