All effective research follows a series of predetermined, highly specific steps. Each step builds on the previous one and provides the foundation for the eventual discussion of findings. It is important to understand basic research princi- ples in order to effectively implement EBP. Alone or in col- laboration with others, community health nurses use the fol- lowing nine steps to complete a research project:
1. Identify an area of interest.
2. Formulate a research question or statement.
3. Review the literature.
4. Select a conceptual model.
5. Choose a research design.
6. Obtain Institutional Review Board or Human Sub- jects Committee approval.
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7. Collect and analyze data.
8. Interpret results.
9. Communicate findings.
Clear research questions, thorough review of the litera- ture, human subjects protection, and a sound research design are factors to consider when evaluating the results of studies for incorporation into your practice.
Identify an Area of Interest
Identifying the problem or area of interest is frequently one of the most difficult tasks in the research process. The prob- lem needs specificity (i.e., it must be specific enough to direct the formulation of a research question). For example, concern about child safety is too broad a problem; instead, the focus could be on a narrower subject, such as the use of child restraints and car seat availability and use in a particular community.
The problem must also be feasible. Feasibility concerns whether the area of interest can be examined, given available resources. For example, a statewide study of the needs of pregnant adolescents might not be practical if time or funding is limited, but a study of the same group in a given school district could be more easily accomplished.
The meaning of the project and its relevance to nursing must also be considered, such as exploring the implications for nursing practice in the study of pregnant adolescents.
Areas for study often evolve from personal interests, clinical experience, or philosophical beliefs. The nurse’s specialty influences the selection of a problem for study and also the particular perspective or approaches used. The community health nurse functions within a context that emphasizes dis- ease prevention, wellness, and the active involvement of clients in the services they receive. Clients’ physical and social environments, as well as their biopsychosocial and spiritual domains, are of major concern. Community health nurses think in terms of the broader community; their research efforts are developed with the needs of the com- munity or specific populations in mind.
Problems recently identified and studied within com- munity health nursing include:
◆ Cardiovascular health promotion in aging women:
validating a population health approach (Sawatzky
& Naimark, 2005)
◆ Childhood immunization refusal: provider and parent perceptions (Fredrickson, Davis, Arnould, Kennen, Hurniston, Cross, & Bocchini, 2004)
◆ Process evaluation of a nurse-delivered smoking relapse prevention program for new mothers (Groner, French, Ahijevych, & Wewers, 2005)
◆ The impact of just-in-time e-mail “reminders” on patient outcomes in home health care (Feldman, Murtaugh, Pezzin, McDonald, & Peng, 2005)
◆ Mothers’ ranking of clinical intervention strategies used to promote infant health (Gaffney & Altieri, 2001)
◆ Racial differences in parenting dimensions and adolescent condom use at sexual debut (Cox, 2006)
◆ The volunteer potential of inactive nurses for disas- ter preparedness (Fothergill, Palumbo, Rambur, Reinier, & McIntosh, 2005)
◆ Public health nursing practice change and recom- mendations for improvement (Zahner & Gredig, 2005)
Each of these problem areas provides direction for the formulation of related research questions.
Formulate a Research Question or Statement
The research question or statement reflects the kind of infor- mation desired and provides a foundation for the remainder of the project. The manner in which the question or statement is phrased suggests the research design for the project. For example, the question “What are nurses’ attitudes toward pregnant women who use methamphetamine?” determines that the design will be simple, nonexperimental, and exploratory (see later discussion). In contrast, the question
“What is the effect of an educational program on nurses’
attitudes toward drug-abusing pregnant women?” suggests an experiment that will evaluate changes in nurses’ attitudes toward pregnant women who abuse drugs after receiving an educational intervention. The first research question sug- gests a broad, open-ended conversation with nurse partici- pants, asking them to discuss their attitudes toward pregnant women who abuse drugs, such as methamphetamine. From the data obtained, general themes and patterns will emerge, leading the researcher to some overall conclusions. The sec- ond question examines the effects that an educational pro- gram may have on nurses’ attitudes about pregnant women who abuse crack cocaine, for instance. This is most likely a quantitative, evaluative study that may involve pretesting to determine the nurses’ attitudes, conducting one or more classes, and then posttesting to determine whether any change occurred in attitude or beliefs.
Well-formulated research questions identify the popu- lation of interest, the variable or variables to be measured, and the interventions (if any). It is very important when for- mulating research questions that specific terms be used to clearly represent the variables being studied. For example, if
“stress’’ is identified as the variable measured in the research question, then it is important to note how stress is being defined. The researcher who wants to measure stress experi- enced by clients waiting for HIV test results must be careful not to measure other related variables, such as trait anxiety (a general personality trait) or depression. Consistency of terms used is crucial to the success of a project, so investi- gators must formulate the research question carefully. One must be clear about the variable and what is being measured to ensure validity of the results.
Formulation of a PICO question (patient problem, intervention, comparison, outcome), related to EBP, is a similar process, especially in its specificity. Good examples of research questions addressed recently by community health nurses include:
◆ Are there differences in how rural and urban fami- lies [ population of interest] view death and end-of- life care [variables] for their elderly family mem- bers with dementia residing in nursing homes (Gessert, Elliott, & McAlpine, 2006)?
◆ What is the effect of rural residence [variable] on unmet dental care [variable] for children with special 66
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health care needs [ population of interest] (Skinner, Slifkin, & Mayer, 2006)?
◆ What is the lived experience [variable] of adults being diagnosed with Lyme disease [ population of interest] (Drew & Hewitt, 2006)?
◆ Are parents of low-income Ohio toddlers [ popula- tion of interest] receiving information on lead poi- soning prevention [variable], and how would they prefer to receive this information [variable]
(Polivka, 2006)?
◆ Can father’s clubs [intervention variable] improve the health of rural Haitian children [ population of interest] (Sloand & Gebrian, 2006)?
Review the Literature
A review of the literature consists of two phases. The first phase consists of a cursory examination of available publi- cations related to the area of interest. Although several nurs- ing research journals publish studies reflecting all areas of nursing practice, most specialty areas have dedicated journals.
Public Health Nursing, Family and Community Health, Journal of Community Health Nursing, American Journal of Public Health, Journal of School Health, Nursing and Health Sciences, and Journal of School Nursing are some of the journals that publish studies of particular interest to community health nurses. In this phase, the investigator develops knowledge about the area of interest that is some- what superficial but sufficient to make a decision about the value of pursuing a given topic. If considerable research has already been conducted in the area, the investigator may decide to ask a different question or to pursue another area of interest.
The second phase of the literature review involves an in-depth, critically evaluated search of all publications rele- vant to the topic of interest. The goal of this phase is to nar- row the focus and increase depth of knowledge. Journal arti- cles describing research conducted on the topic of interest provide the most important kind of information, followed by clinical opinion articles (information on the topic described by experts in the field) and books. Journal articles provide more up-to-date information than do books, and systematic investigations provide a foundation for other studies. Prior research that has already been done on the topic of interest provides a solid foundation for later replication studies.
Criteria for compiling a good review of the literature include (a) using articles that closely relate to the topic of interest (relevancy); (b) using current articles that provide up-to-date and recent information—usually within the past 5 years (although earlier articles may be included based on their importance to the area of interest); and (c) using both primary and secondary sources. A primary source is a pub- lication that appears in its original form. A secondary source is an article in which one author writes about another author’s work; reviews fall into this category. Pri- mary sources historically were preferred over secondary sources because they afford the investigator a more accurate and first-hand account of the study from which personal conclusions can be drawn. Secondary sources, however, are now seen as more helpful in guiding practice decisions, as integrative reviews of current research are a critical element of EBP.
A major component of a review of literature is the investigator’s critical evaluation of the information col- lected. The conceptual base and research methods of studies must be critically assessed regarding the appropriateness of the methods used and the conclusions drawn, as well as how carefully the research was conducted.
After a careful, critical, and comprehensive review of the literature, the investigator writes a clear description of the information related to the area of interest, including con- flicting findings and referencing each study or article. This review provides the basis for the proposed study or the clin- ical decision to be made. The conclusions from the literature review become the basis for the new study’s assumptions and methodology. Rather than making a “leap of knowl- edge,” the hypothesis or research question must be created by basing assumptions on previous research studies.
Select a Conceptual Model
In relation to research, a conceptual model is a framework of ideas for explaining and studying a phenomenon of inter- est. A conceptual model conveys a particular perception of the world; it organizes the researcher’s thinking and provides structure and direction for research activities. Models are like a framework on which to “hang’’ concepts or variables, and they should be used to guide the design and methods for collecting research data.
All fields of study identify their major areas of concerns or boundaries. Nursing, since the early work of Florence Nightingale, is concerned with the interaction between humans and the environment in relation to health (Blais, Hayes, Kozier, & Erb, 2006). Widely used classic nursing conceptual models such as Orem’s (1985) self-care model or King’s (1989) open systems model reflect the boundaries and major concerns of nursing as a profession. Although nurse investigators frequently and successfully use conceptual models developed within other fields, the advantage of using nursing models is that they provide an understanding of the world in terms of nursing’s major concerns (see Chapter 14).
The investigator can become familiar with various con- ceptual models by reviewing the literature in the area of inter- est and by reading any of the many texts available on concep- tual models. A thorough understanding of the major concepts of a potential model and their relationships is necessary before one attempts to use a model as a framework for a study.
Choose a Research Design
The design of a research project represents the overall plan for carrying out the study. This overall plan guides the conduct of the study and, depending on its effectiveness, can influence investigators’ confidence in their results. A major considera- tion in selecting a particular design is to try to control as much as possible those factors that are not included in the study but can influence the results. For example, in a classic study by Douglas and co-workers (1999), researchers wanted to dis- cover the percentage of homes with functioning smoke alarms. They initially conducted a telephone survey, a com- monly used method of survey research in community health, and found that 71% of households reported functioning smoke alarms. Concerned that this might be an inflated num- ber, they conducted an on-site survey to confirm the results.
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After face-to-face interviews, they found that only 66% of householders reported having functioning alarms. However, when researchers actually tested the smoke alarms in those homes, only 49% were fully functioning. By having researchers actually test the smoke alarms, this design con- trolled for inflated results of the more commonly conducted, convenient, and economical telephone survey. Is self-report always unreliable? A small study of working middle-aged women revealed that self-reported weekly physical activity was strongly associated with pedometer data, indicating that, in this case, self-report yielded reasonably reliable data (Speck & Looney, 2006). This is evidence that the community health nurse must determine the most efficacious method of obtaining necessary data.
In another example, researchers themselves controlled the variables to ensure true results. Kerr and colleagues (2001) knew from their review of the literature that posters encourag- ing exercise at the point of choice between stairs and escala- tors in public shopping areas could be effective in promoting greater use of stairs. They incorporated this fact into the design of their study. They used a control site and a study site (both shopping malls) and collected baseline data and a first observation 2 weeks after placing posters. Then, they followed up with stair-riser banners containing multiple messages placed on alternate stairs. Both sites were equal at baseline and the first observation; however, at the second observation time (at 4 weeks), there was a 6.7% increase in use of the stairs at the site with stair-riser banners. This simple yet novel approach motivated more people to use the stairs.
Complete descriptions of various research designs and specific methodologies are available in basic nursing research texts. For the purposes of this chapter, a few important con- siderations underlying design selection are described. First, quantitative approaches use two major categories of research design: experimental and nonexperimental (or descriptive).
Experimental designrequires that the investigators institute an intervention and then measure its consequences.
Investigators hypothesize that a change will occur as a result of their intervention, and then they attempt to test whether their hypothesis was accurate. Experimental design requires investigators to randomly assign subjects to an experimen- tal group(those receiving the intervention) and a control group(those not receiving the intervention). This process, called randomization, is the systematic selection of research subjects, so that each one has an equal probability of selection.
Another important distinction made within the experi- mental category of research is between true experiments and quasi-experiments. True experiments are characterized by instituting an intervention or change, assigning subjects to groups in a specific manner (randomization), and comparing the group of subjects who experience the manipulation to the control group (those not receiving the intervention).
Randomized control trials (RCTs)are generally consid- ered the gold standard of experimental research—they are commonly used to determine the safety and efficacy of new medications or to test the effectiveness of one intervention over another, and they are a foundation of EBP (Melnyk &
Fineout-Overholt, 2005). Quasi-experiments lack one of these elements, such as the randomization of subjects. Com- munity health nurses conduct quasi-experiments more often than true experiments because it is often difficult (and some-
times impossible) to use randomization. For instance, a nurse may conduct a nutrition education intervention with fifth grade students at a particular school. Although the nurse can have one classroom participate in the intervention and another remain the control group, he or she cannot ran- domly assign the children to classrooms (i.e., intervention or control). Therefore, this research would be characterized as quasi-experimental in nature.
Nonexperimental designs (also called descriptive designs) are used in research to describe and explain phe- nomena or examine relationships among phenomena. Exam- ples of this approach include examining the relationship between gender and smoking behaviors among adolescents, describing the emotional needs of families of clients with Alzheimer disease, and determining the attitudes of parents in a given community toward sex education in the schools.
In each of these instances, the focus of the research is on the relationships observed or the description of what exists.
Such nonexperimental designs are often the precursors of experiments. Once such an intervention is developed, further research can evaluate its appropriateness and, ultimately, its effectiveness. Other lines of clinically based research can also be designed. The choice of research design influences the ability to generalize the results, and the attention given to the details of the study affects the value of the knowledge derived. Research done with larger numbers of participants drawn from a geographically diverse area is more complete than small scale, exploratory studies done in an isolated area with a small, homogeneous sample. Valid tools or instruments and appropriately applied statistical methods lead to greater confidence in the results of the study.
Obtain Institutional Review Board or Human Subjects Committee Approval
Whenever research is to be conducted that involves human subjects, prior approval must be gained from either an Insti- tutional Review Board or a Human Subjects Committee.
The reason for this approval is to safeguard the rights of prospective study participants. Each health department should have a committee or a gatekeeper, such as the health officer, who understands the federal guidelines for protecting subjects involved in research studies.
One of the most egregious examples of exploitation of human subjects was a study carried out by the U. S. Public Health Service. The Tuskegee study, begun in 1932 and ended in 1972, sought to learn more about syphilis and to justify treatment services for Blacks in Alabama (Centers for Disease Control and Prevention [CDC], 2008). The 399 men with syphilis who participated in the study had agreed to be examined and treated. However, they were misled about the exact purpose of the study and were not given all of the facts; therefore, they were unable to give truly informed consent. Even after penicillin became the drug of choice for treatment of syphilis in 1947, the researchers failed to offer this treatment to the infected participants.
Because of this experiment and earlier Nazi atrocities, the Nuremberg Code and the Declaration of Helsinki were adopted by the world scientific community, then revised in 1975, as a means of assuring ethical research practices (Blais, Hayes, Kozier, & Erb, 2006; CDC, 2003) (see Evi- dence-Based Practice: Ethics in Action).
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