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Unit1nursingresearch 160829140315
Unit1nursingresearch 160829140315
Review:
Problem solving and
scientific method.
Research –definition, characteristics, purposes, types of
research, Basic research terms, Scope of nursing
research, Overview of Research process, Significance
of research in nursing, Historical Evolution of nursing
research.
Future trends in nursing research.
Problems and challenges in nursing research, health
and social research.
Priorities for nursing research.
Evidence based practice.
Ethics in research
Looking for new knowledge, doing something
new ??
Looking for facts
Measuring phenomenon, health states,
including health and disease
Developing new – materials, products
including drugs, processes, designs….
New models of delivery of health services
Organised investigation of a problem
French word - re- cerche “ to search again”
A careful investigation or inquiry
A systematic and objective analysis and
recording of controlled observation that may
lead to the development of generalisation of
principles, theories, resulting in prediction
and possible ultimate control of events
J. W. BEST
It is a careful inquiry or examination seeking
facts or principles , a diligent investigation to
ascertain something
CLIFFORD WOODY
It is an attempt to gain solutions to problems;
more precisely it is the collection of data in a
rigorously controlled situation for the
purpose of prediction or explanation
TREECE AND TREECE
• Discovery – finding what existed
• Inventions – new produce development that
did not exist in nature
• Innovation – new ways to solve old problems
• Development – after invention to useful
products and services
• Testing new and old products/drugs and
services
• Evaluation of programs – wider outcomes
and impacts, including unintended outcomes.
Generation of knowledge
Problem solving
Originality
Empirical
Logical
Replicable
Appropriate methodology
Good tools
Choosing alternatives
if unsuccessful or till Defining
successful
Collecting relevant
information
Verifying validity
Formulation of
Evaluation of
hypothesis / solutions
hypothesis
1. Basic and applied research
Exploration
Explanation
Development of clinical
interventions
Promotes EBN
Document cost effectiveness
Nursing education
Nursing administration
Nursing informatics
Influences current and future practices
Adequately trained nurses can conduct
quality clinical research
Leads to EBN practice
Provide description, explanation, prediction
and control of nursing situations in nursing
practice
Identifies cost effective practices
Problem solving
WORLD VIEW/ GENERAL PERSPECTIVE OF THE
COMPLEXITIES OF REAL WORLD
BASIC PHILOSOPHICAL QUESTIONS
◦ Ontologic –what is the nature of reality?
◦ Epistemologic- what is the relationship with the
inquirer and that being studied?
◦ Axiologic- what is the role of values in inquiry?
◦ Methodologic – how should the inquirer obtain
knowledge?
Intellectual pluralism
A beautiful thing about
learning is that nobody
can take it away from
you
Future trends
• Heightened focus on EBP
• Development of stronger
evidence base
• Emphasis on SR
• Expanded local research in
health care settings
Patient
preferences and
circumstances
Improved Best
Individual
clinical
expertise
patient available
clinical
evidence
outcomes
Awareness of
clinical setting
& resource
EBP
constraints
Future trends
Strengthening of multidisciplinary
collaboration
Expanded dissemination of
research findings
Increasing visibility of nursing
research
Increased focus on cultural issues
and health disparities
Inadequate knowledge
Lack of qualified guide
Difficulty in controlling external variables
Lack of time
Lack of standardized tools
Reliability of disciplined research
Studying many variables
Ethical problems
Lack of support from administrative set up
Financial constraints
Fallibility of disciplined research
Handling multiple variables
Difficulty in control of external variables
Minimal possibility of lab research
lack of standardized tools
Measuring qualitative phenomenon through
quantitative means
Lack of interest among the nurses and other
health personnel
Ethical constraints
Health promotion and disease prevention
Promotion of health of vulnerable and
marginalized communities
Patient safety and quality of health care
Development of EBP and translational
research
Promotion of health of older people
Patient centered care and care co ordination
Palliation and end of life care
Care implications of genetic testing and
therapeutics
Capacity development of nurse researchers
Nurses working environment
STTI 2005
• Evidence is materials and observations collected to
demonstrate “truth” or what works
• What looks apparent and obvious may not be true – sun
moving around the earth !!
• Evidence is systematically collected information
(measurement ) to support or disprove a hypothesis or
theory
• Two types of evidence ‐ direct evidence and circumstantial
evidence
• Observations lead to theory – theory leads to observations or
experimentation to confirm theory
• Experimentation provides strongest
evidence
Sources
◦ Tradition and authority
◦ Clinical experience, trial and error and intuition
◦ Logical reasoning
◦ Assembled information
◦ Disciplined research
“Evidence‐based medicine (EBM) or
evidence‐based practice (EBP) aims to apply
the best available evidence gained from the
scientific method to clinical decision making.
It seeks to assess the strength of the
evidence of risks and benefits of treatments
and diagnostic tests. This helps clinicians
understand whether or not a treatment will
do more good than harm.”
How evidence grows: No evidence, to some
evidence, substantial evidence, review of
evidence, meta‐analysis, overall
recommendation.
Authority based policies and programs – vs.
evidence based policies and programs.
Systematic evaluation of evidence is new
science – but clinical trials are not new – first
trial was done by James Lind 1747 on 12
sailors on board a ship to see effect of limes
and oranges on Scurvy (bleeding gums)
Observations – basis of most clinical science developments –
disease and syndromes defined by observed symptoms and signs –
systematic observations on series of similar cases
• Observations during epidemics ‐ John Snow on Cholera…
• Trials Randomized
Conceptual Phase
Reviewing the related
literature
Undertaking clinical
fieldwork
Developing conceptual
framework
Formulating
hypotheses
Phase II
Design and planning phase
Selecting Specifying
a Designing the methods to
research sampling plan measure
design research
variables
Developing Identifying
intervention the Developing
protocols population methods to Finalizing
safe guard the
subjects research
plan
Phase III
Empirical phase
Collecting the
data
Preparing the
data for
analysis
Phase IV
Analytic phase
Analyzing the
data
Interpreting
the results
Phase V
Dissemination phase
Utilizing the
Communicating
findings in
the findings
practice
Planning
Contd..
Sulfanilamide was then given to these
prisoners to determine the effectiveness
of this drug. Some subjects died and
others suffered serious injury. Many
nurses participated in these unethical
experiments.
(Bonifazi 2004)
Between June and September 1944,
photographs and body measurements
were taken of 112 Jewish prisoners.
Then they were killed, and their
skeletons were defleshed.
Contd..
One purpose of this study was to
determine if photographs from live
human being could be used to predict
skeletal size. The skeleton collection
was to be displayed at the Reich
University of Strasbourg.
Contd..
Exploding gas gangrene bombs next
to prisoners tied to stakes.
(Hayter, 1979)
In July 1963, doctors at the Jewish
Chronic Disease Hospital in Brooklyn,
New York, injected live cancer cells into
22 elderly patients. The study was
designed to measure patients’ ability to
reject foreign cells. The patients were
told that they were being given skin
tests.
(Katz, 1972)
In 2005, it was revealed that
government-funded researchers tested
experimental AIDS drugs on hundreds
of foster children.
(Solomon, 2005)
Ethics is the science that deals with
rightness and wrongness of actions.
(Aiken, 2004)
A right is defined as “ a valid, legally
recognized claim or entitlement,
encompassing both freedom from
government interference or
discriminatory treatment and an
entitlement to a benefit of service”.
contd…
Researcher must try to avoid
injury to research subjects
Researcher must be qualified to
conduct research
Subjects or the researcher can
stop the study if problems occur.
Based on the preliminary efforts of the Council
for International Organisations of Medical
Sciences (CIOMS) in 1964 at Helsinki, the
World Medical Association formulated general
principles and specific guidelines on use of
human subjects in medical research, known
as the Helsinki Declaration
National Commission for the Protection of
Human Subjects of Biomedical and Behavioral
Research.
The Belmont Report summarizes ethical
principles and guidelines for research involving
human subjects.
Three core principles
◦ respect for persons
◦ Beneficence
◦ justice.
Three primary areas of application
◦ informed consent
◦ assessment of risks and benefits
◦ selection of subjects.
Respect for person
Beneficence
Justice
Belmont principles
Requires investigators to treat
subjects as autonomous individuals
and obtain their informed consent
Research subjects must be regarded
not as passive sources of data, but
as individuals whose welfare and
rights must be respected.
requires investigators to design
protocols that will provide valid
and generalisable knowledge
ensure that the benefits of the
research are proportionate to the
risks assumed by the subjects.
wellbeing of the subjects must be
protected.
Level1: No anticipated effects: no positive
or negative effects for the subjects
Level
2: Temporary discomfort considered
minimal risk studies
Level
4: Risk of permanent damage,
potential for subject to suffer permanent
damage
Level5: Certain permanent damage; no
experiment should be conducted where
there is an a priori reason to believe that
death or disabling injury will occur...
requires that the benefits and burden
of research be distributed fairly .
Research participants assume some
risk in order to benefit the society as
a whole.
Therefore no single group, especially
not disadvantaged, vulnerable or
minority groups should be asked to
bear a disproportionate share of risk.
Beneficence ‐ a practitioner/researcher should act
in the best interest of the patient/participant
Non‐maleficence ‐ "first, do no harm”
Autonomy ‐ the participant has the right to refuse
the intervention or opt out from the research
study
Justice ‐ concerns the distribution of scarce
health resources and the decision of who gets
what treatment
Dignity ‐ the patient/participant (and the person
treating the patient) have the right to dignity.
Truthfulness and honesty ‐ the concept of
informed consent has increased in importance
since the historical events of the Nuremberg
trials and Tuskegee Syphilis Study
Abstract of a SR in the field of Non
communicable disease
Research priorities by ICN,INC, KUHS
Mention instances that you have noticed
which violated the principles of ethics.
Describe the process of INFORMED CONSENT
Means that participants have adequate
information about the research, comprehend
that information and have the ability to
consent to or decline participation voluntarily.
contd..
Necessary information
Informed consent
◦ The nature of research project
◦ Procedures of the study
◦ The potential risks & benefits of the
study
Assurances that participation is
voluntary
Protection of confidentiality
Questions about the study
Plagiarism
Fabrication & falsification
Non publication of data
Faulty data gathering
procedure
Poor data storage and
retention
Misleading authorship
Sneaky publication practices
Guidelines for Nurses
Advocacy
Privacy
Confidentiality
Debriefing
Anonymity
An independent review board comprises
medical/scientific and non‐medical
/nonscientific members
9‐15 members
Review every research proposal on human
subjects
IT IS MANDATORY THAT ALL PROPOSALS ON
BIOMEDICAL RESEARCH INVOLVING HUMAN
SUBJECTS SHOULD BE CLEARED BY AN
APPROPRIATELY CONSTITUTED
INSTITUTIONAL ETHICS COMMITTEE
How essential is the research?
Informed consent‐ voluntariness
Non exploitation of vulnerable population
Privacy and confidentiality ( HIV/AIDS)
Minimal risks and dangers for subjects
Reasonable risk ‐ benefit ratio
Professional competence of
investigator/researcher
Accountability and transparency
Institutional arrangements/adequate clinical
monitoring to ensure safety
Emergency care provision
Totality of responsibility
Compliance of GCP (Good Clinical Practice)
Informed consent document‐ contents
Critiquing the Ethical Aspects
i) Was the study approved by an
Institutional Review Board (IRB)?
ii) Was informed consent obtained
from the subjects?
iii) Is there information about
provisions for anonymity or
confidentiality?
contd…
iv) Were vulnerable subjects used?
v) Does it appear that subjects
might have been coerced into
acting as subjects?
vi) Is it evident that the benefits
of participation in the study
outweighed the risks involved?
vii)Were subjects provided the
opportunity to ask questions
about the study and told how to
contact the researcher if other
questions arose?
viii) Were subjects told how they
could get the results of the
study?
Conducting research ethically
requires protection of human
rights of subjects. Human rights
that require protection in research
include - self determination,
privacy, anonymity &
confidentiality and fair treatment.
Research need to be conducted
with ethical guidelines.
Evidence Based Nursing and prepare notes..
Burns and Grove 5 th edition 2005
Polit and Beck 8th edition 2012
Wood and Haber 6th edition 2006
Schmidt and Brown 2009
LITERATURE REVIEW
Scientific knowledge grows day by day
Multiplication of research information
Studies are undertaken with the context of an
existing base of knowledge
Researcher’s work to be built on the work of others
(Kaplan,1964)
Consists of all written sources relevant to
the selected topic
Empirical literature
It consists of concept analysis, models, theories
& conceptual frameworks that support a selected
research problem and purpose
It reflects the current understanding of the
research problem
Theoretical literature can be found in the serials,
periodicals & monographs
Comprises of relevant studies in journals & books
as well as unpublished theses
Secondary sources
A primary source is written by a person who is
responsible for originating or generating the ideas
published
Problems
- Interpretation is influenced by the author’s
perception & may be biased
- Possibility of errors
- Fails to provide the details of study
DEPTH AND BREADTH OF REVIEW
Researcher’s background
- new investigator & experienced investigator
Complexity of research project
- numerous variables & complex methodologies
Availability of sources
- articles, journals & books
TIME FRAME FOR LITERATURE REVIEW
Identify new
Document search
references,
decisions and actions
leads
Abstract, Analyse
Prepare
encode Critique, integrate
synthesis
information evaluate the information,
/critical
from the studies search for
summary
studies themes
Searching the literature
Data bases
- Printed form
- Electronic data base
CINAHL (Cumulative Index to Nursing and Allied Health
Literature) Pubmed
MEDLINE (Medical Literature Online)
ISI (Institute for Scientific Information Web of Knowledge)
British Nursing Index- Nursing and Allied Health Source
(ProQuest)
Cochrane Database of Systematic Reviews
HaPI (Health and Psychological Instruments Database)
Dissertation Abstracts Online
Contains citations of nursing literature published after 1955
Referred as “Red Books” by nursing scholars
Covers English language, Nursing and Allied Health journals,
books, book chapters, dissertations & selected conference
proceedings
Electronic version contains database from 1982 to the
present (more than one million records)
Accessed online http://www.cinahl.com or by CD-ROM
Developed by US National Library of Medicine (NLM)
– Free access
Covers about 5000 Medical, Nursing and Health
journals
15 million records from mid 1960’s
From 1999, Abstracts of Cochrane collaboration
became available
Is an online database with free access through
PubMed web
www.ncbi.nlm.gov/entrez/query.fcgi
Maintains multidisciplinary resources called the
web of knowledge
Psych Info
Ovid sp
Science direct
Key words are the major concepts or variables that
must be included in your search
To determine the key words, identify concepts,
variables, population, interventions, measurement
methods or relevant outcomes
Subject headings and phrases can be used
Think of alternative terms (synonyms)
Note down the key words in the written search plan
Truncating words allow to locate more citations
related to the term
Do not truncate terms to less than four letters –
will give unwanted references
Pay attention to variant spellings
Frequently cited author’s name can be used to
perform search
Use a journal title in case of well known journal in
that particular topic/field
Name of databases used
Exclusion & inclusion criteria used
Date of performing search
Exact search strategy used
Key words used
Combining strategies used
Number of articles found
Percentage of relevant articles
Websites visited & links pursued
Authors contacted for further information
Develop a table of record and save it in the computer
As per the format used in the reference list
Often capitalized
OR is commonly used
AND- delimits the search
OR- expands the search
NOT- narrows the search
Truncation symbols
*- wom*n,
Pain 3,35,949
Pain AND Child* AND Nur 2054
Limit to English 1834
Limit to entries with abstracts 1430
Limit to nursing journals 794
Limit to 2001-2010 399
Limits
- vary with the data base
- limit the years of search
- limit within particular years & get
the hits
- depends on the time limit
- full text articles are better
Helps to avoid irrelevant & non useful material
Have more current information
Need to subscribe to online journals
Can access full text article
Articles are reviewed & published within 3 months
List of current electronic nursing journals are
available at
www.4nursingjournals.com
Unlikely to find relevant studies but may get
information relevant to background & significance
Advantage – information are current
Disadvantage – accuracy is questionable & no
screening process
Important to check the source
Identify the best search engine
Coding
Read, categorise, code key variables, record them
- Methodologic matrix
- Results matrix
- Evaluation matrix
TYPES OF REVIEW MATRIX
Authors
Publication year
Dependent variables
- pain perception
- use of analgesics
- Effect of nursing
intervention
Others – association & relationships
EVALUATION MATRIX
Authors
Publication years
Major strengths
Major weaknesses
Quality score
SUMMARY- SEARCHING THE
REVIEW
DEF
PURPOSES
STRATEGIES
APPROACHES
STEPS
STRATEGY DEVELOPING
SELECT DATABASE
SELECT KEYWORDS
CONTD
RECORD SEARCH- REF
MANAGEMENT SW
LOCATE RELEVANT LITERATURE
COMPLEX SEARCHES
LIMIITING SEARCHES
SEARCHING E JOURNALS AND
INTERNET
RECORDING MECHANISMS
◦ PROTOCOL
◦ MATRICES
Skimming resources
Comprehending resources
Analyzing resources
Synthesizing resources
Quickly reviewing a source to gain a broad
overview of its content
Read title, author’s name, abstract or introduction
& the major headings
Finally review the conclusion or summary
Helps to make a preliminary judgement about the
value of the source
Helps to determine whether it is primary or
secondary source
Requires complete reading of an article
carefully
Highlight the content you consider
important
Relevant categories are identified for
sorting & organizing sources
These categories serve as a guide for
writing the literature review
Can determine the value of a source for a particular
study
Checking references
Is challenging
Relevant sources
Organizing the review – meaningful
Structure in such a way that the presentation is
logical, demonstrates meaningful thematic
integration & leads to a conclusion about the state
of evidence on the topic
Major sections
Introduction
Summary
Definition of the topic of review
Context
Purpose / objectives
Scope
Structure
Include emerging themes, solutions, gaps,
point out recent trends, Divergent perspectives
Give structure or narrative thread
◦ Chronological; by themes; by sector / domains / sub-
groups; by development of ideas or along a process;
by themes)
Use sub-headings organized in proper layers
Signposting
Adduce evidence - citation
Quotes
Paraphrase
Style – detached narration, a dialogue with the
literature,
Use tables to compare two or more
perspectives, methods, profile of participants
Summarize major and most convincing
contributions of significant studies
Evaluate the current state of the evidence in
the field
Point out gaps
Point out issues pertinent to future study
Provide insight into the relationship between
the central topic review and a larger area of
study
Check for accuracy & completeness
Year of citation
Must be comprehensive & thorough incorporating
up to date references
Systematic
Reproducible
Absence of bias