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Nursing and Midwifery Research: Methods and Appraisal for Evidence-Based Practice, 4th Edition

Nursing and Midwifery Research: Methods and Appraisal for Evidence-Based Practice, 4th Edition



Nursing and Midwifery Research: Methods and appraisal for evidence-based practice is the only local nursing and midwifery research textbook to span undergraduate and postgraduate research ...

Nursing and Midwifery Research: Methods and appraisal for evidence-based practice is the only local nursing and midwifery research textbook to span undergraduate and postgraduate research requirements.

Now in its fourth edition, the textbook continues to help nursing and midwifery students understand research data and processes, apply research findings in practice, conduct their own research and publish their findings.

Each edition of this highly regarded text has delivered an ever-stronger wealth of research examples within the context of Australia and New Zealand. This fourth edition is the most impressive yet, providing a solid research process-driven approach, with comprehensive coverage of research methodologies.

Nursing and Midwifery Research: Methods and appraisal for evidence-based practice, 4e has been significantly updated. It focuses on developing students' skills and confidence in critically searching for and appraising research literature and, importantly, using their research findings to inform their patient and client care.

Student learning tools include tutorial trigger boxes, evidence-based practice tips and multiple choice questions, and Elsevier's Evolve platform offers a range of online content to enhance the book's content.



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    Nursing and Midwifery Research: Methods and Appraisal for Evidence-Based Practice, 4th Edition Nursing and Midwifery Research: Methods and Appraisal for Evidence-Based Practice, 4th Edition Document Transcript

    • Nursing andMidwiferyResearchmethods and appraisal for evidence-based practice 4th edition Zevia Schneider Dean Whitehead Geri LoBiondo-Wood Judith Haber sample proofs © Elsevier Australia
    • Nursing andMidwiferyResearchmethods and appraisal for evidence-based practice 4th edition Zevia SCHNEIDER PhD, MPsychEd, MAppSc, MEd (TESOL), BEd, BA, FACN, RN, RM Dean WHITEHEAD PhD, MSc, BEd, RN Geri LoBiondo-Wood PhD, RN, FAAN Judith Haber PhD, APRN, BC, FAAN Sydney Edinburgh London New York Philadelphia St Louis Toronto sample proofs © Elsevier Australia
    • Mosby is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067This edition © 2013 Elsevier Australia3rd edition 2007. 2nd edition 2003. 1st edition 1999. All editions © Elsevier Australia.This edition is an adaptation of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice byGeri LoBiondo-Wood, PhD, RN, FAAN and Judith Haber, PhD, APRN, BC, FAAN.Copyright © 2010, 2006, 2002, 1998, 1994, 1990, 1986, by Mosby, Inc., an affiliate of Elsevier Inc.This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the CopyrightAmendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrievalsystem or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording orotherwise) without prior written permission from the publisher.Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have beenpossible. The publisher apologises for any accidental infringement and would welcome any information to redressthe situation.This publication has been carefully reviewed and checked to ensure that the content is as accurate and current aspossible at time of publication. We would recommend, however, that the reader verify any procedures, treatments,drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisherassume any liability for injury and/or damage to persons or property arising from any error in or omission fromthis publication.National Library of Australia Cataloguing-in-Publication DataSchneider, Zevia.Nursing and midwifery research: methods and appraisal for evidence-based practice / Zevia Schneider;Dean Whitehead.4th ed.9780729541374 (pbk.)Includes index.Nursing–Research.Midwifery–Research.Whitehead, Dean.610.73072Publishers: Libby Houston and Melinda McEvoyDevelopmental Editor: Elizabeth CoadyProject Coordinators: Natalie Hamad and Karthikeyan MurthyEdited by Forsyth Publishing ServicesProofread by Tim LearnerIndex by Robert SwansonCover and internal design by Lisa PetroffTypeset by Toppan Best-set Premedia LimitedPrinted in China by China Translation and Printing Servicesiv sample proofs © Elsevier Australia
    • CONTENTSForeword viii Chapter 3 Searching and reviewing thePreface ix research literature 35Editors xi Dean WhiteheadContributors xi Types of research literature resources 36 Conducting a search of the researchUS Contributors xiv literature 43Reviewers xvi Reviewing the research literature 47Acknowledgments xviii Summary 53Section One Research awareness 1 Chapter 4 Identifying research ideas,Chapter 1 The significance of nursing and questions, statements and hypotheses 57midwifery research 3 Zevia Schneider and Dean WhiteheadZevia Schneider Developing and refining a research idea 58 Background to evidence-based nursing and Defining a specific problem area 59 evidence-based midwifery 5 The significance of research problem Research awareness and consumerism — how statements to nursing or midwifery 60 this book accommodates these 6 Reviewing relevant literature 64 What is evidence? 6 Operational definition 68 Linking theory, education and practice to Hypothesis testing 68 nursing research 7 Summary 73 International and Australasian nursing research — a brief history 8 Chapter 5 Ethical and legal issues in Professional organisations in Australia and the research 77 Asia-Pacific region 10 Martin Woods and Zevia Schneider International, Australian and New Zealand Ethical and legal considerations in research: journals 11 an historical perspective 78 Educational preparation for conducting Summary 94 research 11 Clinical programs of research 12 Section Two Research appreciation Promoting nursing and midwifery research 12 and application 101 Other important factors in facilitating Chapter 6 Common qualitative methods 103 effective nursing and midwifery research 13 Dean Whitehead Collaborative research teams 13 Why is qualitative research useful? 104 Clinical governance and clinical audit 14 The main approaches to qualitative research 105 Future directions for nursing and midwifery ‘Traditional’ approaches to qualitative research 14 research 107 Summary 15 Grounded theory 111 Ethnography 114Chapter 2 An overview of research theory Other ‘common’ qualitative methods 115and process 20 Keeping up with qualitative developments 116Dean Whitehead Summary 117 Research theories, philosophies and paradigms 21 Chapter 7 Sampling data and data Choosing a paradigm 25 collection in qualitative research 123 Theoretical and conceptual frameworks 28 Violeta Lopez and Dean Whitehead Research process and research design 28 Sampling techniques and procedures in Summary 31 qualitative research 124 v sample proofs © Elsevier Australia
    • Data collection in qualitative research 127 Establishing evidence about the content of When have enough data been collected? 136 a measure 227 Summary 136 Establishing evidence of relationships between the measure and otherChapter 8 Analysing data in qualitative variables 227research 141 Responsiveness 229Thomas Harding and Dean Whitehead Developing a measuring instrument 230 Key issues regarding analysis of Assessing instruments 232 qualitative data 142 Summary 233 Conducting qualitative analysis: general principles 143 Chapter 13 Analysing data in quantitative Managing data analysis 147 research 237 Writing up data analysis 148 Murray Fisher and Zevia Schneider Styles of data analysis 148 Descriptive statistics 238 Other styles of analysing qualitative data 151 Levels of measurement 238 Qualitative meta-synthesis 152 Normal distribution 244 Trustworthiness 153 Inferential statistics 248 Reporting and disseminating qualitative Probability and the level of significance 249 data findings 155 Meta-analysis 258 Summary 156 Structural equation modelling techniques 258 Summary 259Chapter 9 Common quantitative methods 161Linda Shields and Roger Watson Chapter 14 Mixed-methods research 263 Concepts underpinning quantitative Dean Whitehead and Zevia Schneider research 162 What is mixed-methods research? 264 Observational designs 166 Methodological triangulation/pluralism 265 Quasi-experimental designs 172 The value of mixed-methods research 268 Experimental designs 175 Limitations associated with mixed-methods Randomised controlled trials 177 research 269 Summary 179 Action research 269 Delphi technique 275Chapter 10 Sampling data in quantitative Case study approach 277research 184 Q methodology 278Zevia Schneider and Murray Fisher Summary 279 Sampling concepts 185 Summary 197 Chapter 15 Critically reviewing research studies 285Chapter 11 Quantitative data collection Zevia Schneiderand study validity 200 Critical reading 286Sonya Osborne and Zevia Schneider Critical review of qualitative research studies 290 Measuring a variable of interest 201 Critical review of quantitative research Conceptual and operational definitions 201 studies 302 Types of data collection 202 Summary 313 Study validity 210 Summary 213 Chapter 16 Applying research knowledge: evidence-based practice, practiceChapter 12 Assessing measuring development and knowledge translation 316instruments 218 Bridie Kent and Brendan McCormackBrigid Gillespie and Wendy Chaboyer Why change practice? 317 Measurement error 219 Different approaches to practice change 318 Performance characteristics of an instrument 221 Being informed by evidence 321vi sample proofs © Elsevier Australia
    • Important factors for evidence Managing research participants 359 implementation 324 Managing the study data 363 Knowledge translation in practice 326 Managing the budget 366 Summary 327 Managing a multi-national project 366 Trials registries 367Section Three Conducting primary Writing project reports and publications 367research 333 Completing the study 368Chapter 17 Writing proposals and grant Summary 368applications 335Zevia Schneider Chapter 19 Writing and presenting What is a research proposal? 336 research findings for dissemination 372 Planning a project 336 Dean Whitehead and Zevia Schneider Writing a proposal 339 The importance of disseminating research Ethical considerations 344 findings: ‘publish or perish’ 373 Dissemination of findings 346 Barriers to publishing 376 Budget 346 Overcoming the barriers towards Submitting a proposal for review 348 publication 377 Research committee review and HREC review 348 The process and structure of writing for Funding sources 348 peer-reviewed publication 381 Summary 349 Other forums for research dissemination 385 Summary 386Chapter 18 Managing a research project 354Ruth Endacott and Dean Whitehead Becoming involved in a research team 355 Glossary 391 Managing a research team 356 Index 401 vii sample proofs © Elsevier Australia
    • FOREWORDI am pleased to introduce the fourth edition of Nursing and Midwifery Research: methods and appraisalfor evidence-based practice. As with previous editions, this version of the text provides a benchmark fornursing and midwifery research, particularly in its emphasis on research-informed and evidence-basedpractice. The book responds to a noble agenda; that of inspiring current and future generations ofnurses and midwives to value the development and extension of our rapidly evolving knowledge base.Examples throughout the book illustrate how far we have come in our short history by identifyingsignificant practice changes that would have been impossible without the research evidence thatallows us to defend and sometimes challenge existing practices. These examples provide importantindicators of professionalisation, and each entrenches the expectation of continuous, ongoingdevelopment. This fourth version of the book has a number of new authors, each with substantialexpertise in their field, lending unique perspectives and ideas to the major topics. All authors providenovel insights into research processes and practices without compromising the standard set inprevious editions. For practitioners the book is an invaluable asset, an essential compilation of what,why and how we generate and use research for practice development and, ultimately, to improve thehealth of populations. This book has a number of remarkable strengths that make it useful for teaching across bothundergraduate and postgraduate programs, particularly the emphasis on practice development asthe ultimate goal of research. The chapters also reflect contemporary trends in the global researchliterature, such as the appreciation of mixed-methods research as a way to generate a comprehensiveperspective on practice where this may be more persuasive in informing practice change than single-method studies. Another feature is that studies cited throughout the chapters illustrate the manycontexts of healthcare, which gives students and practitioners a sense of where research can be appliedto their particular area of interest. Yet another strength lies in the authors’ attention to detail inrelation to searching and analysing the vast body of literature that can seem daunting to the noviceresearcher. It is also helpful to see that the chapters retain the learning prompts that proved so helpfulin the previous edition; the ‘Research in brief ’, ‘Points to ponder’ and ‘Evidence-based practice tips’.And, as with previous editions, this book is written in accessible language, which is often a challengefor students simultaneously learning the language of research and the language of nursing and/ormidwifery. This book proudly presents a plethora of Australian and New Zealand research that linksus to the global advancement of professional knowledge. I trust that you will find it both informativeand engaging. Professor Anne McMurray,Emeritus Professor of Nursing, School of Nursing and Midwifery, Adjunct Professor, Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Queensland Emeritus Professor of Nursing, School of Nursing and Midwifery, Murdoch University, Perth, Western Australiaviii sample proofs © Elsevier Australia
    • PREFACE Write the vision, and make it plain upon tables, that he may run that readeth it. (Prophet Habbakuk)We have modified prophet Habakkuk’s dictum to make his message accessible to all. As the prophetdictates, we have written our vision, we have made it plain in this text — so that those who read it (thereader of this book) may then run with it (apply it in practice). In the third edition of this text, in 2007, we dedicated the book to all health professionals(particularly nurses and midwives), all consumers of research and all those conducting research. Ourdesire to reach out to the same audience remains unchanged. The revision of this book was guidedby constructive comments from those health professionals — our students, colleagues and friends inallied health professions. We gratefully acknowledge their contribution in making this edition moreinclusive and broader in scope while maintaining a detailed account of the variety of commonresearch approaches. This fourth edition is different from previous editions in many respects. The differences haveoccurred mainly due to our dynamic responses to the reviewers of the new edition, market eventsand feedback from the Australian and New Zealand readers of the previous edition. The impetus forbasing nursing and midwifery practice on evidence-based practice (EBP) continues. The outcomesfrom both disciplines’ research clearly highlights the importance of research-informed practice andthe relevance of including all nurses and midwives in the research process — either through raisingresearch awareness, the conduct of research or the implementation of findings into practice (researchconsumerism). Both nursing and midwifery have assured their places as distinct disciplines throughthe increasing numbers of quality research studies in Australia, New Zealand and worldwide.Research methods, be they quantitative or qualitative approaches or mixed-methods, are generic toboth nursing and midwifery — hence the development of a shared discipline book such as this one. Knowledge about research process and design is essential in today’s healthcare settings — especiallywhen aligned to the context of evidence-based practice and practice development (PD). Nurses andmidwives need to understand what the outcomes of research mean and their implications forchanging practice. This book, then, is directed in the first instance to those health professionals (theconsumers of research) who base their clinical decisions on how and when to use research findingsto change practice. In most cases this will usually be undergraduate and new graduate nursing andmidwifery students. However, postgraduate students are also targeted where they are still ‘learning’research and, where they are more confident, are directed to the later chapters on conductingresearch. Such students should find the chapters on writing a research proposal, disseminatingresearch findings and managing a research project useful. This edition has been restructured into three sections and 19 chapters. Research is a logical andsequential ‘start to finish’ process as set out in this book. However, each chapter is also a ‘self-contained’ account of the title topic — referring back and forward to other chapters where thereis related content. Section 1, Research awareness, sets the scene for the importance of nursing andmidwifery research and provides an overview of research theory and its underpinning processes. Italso includes chapters on critically searching for and reviewing the research literature and ethical andlegal research issues, focussing on Australia and New Zealand. Section 2, Research appreciation andapplication, provides a detailed discussion of qualitative, quantitative and mixed-methods researchapproaches with many useful examples from the clinical area. Chapters are devoted to criticalevaluation, implementation, sampling, collecting and analysing data in qualitative and quantitativeapproaches. Evidence-based practice, practice development, knowledge transfer and changing practice ix sample proofs © Elsevier Australia
    • through research are also discussed towards the end of this section. Section 3, Conducting primaryresearch, is designed to enhance the previous two sections by supporting both undergraduate andpostgraduate students in their research endeavours. Writing research proposals may be a requirementfor undergraduates in their research program and postgraduates will find the information useful fordeveloping an ethics proposal or applying for university or external funding. Research projectmanagement and useful advice on how to present research findings (especially through the process ofpublication) are detailed in the final two chapters. There has been another relatively recent development in Australasian nursing and midwiferypractice that has also shaped this revised edition; that is, the increasing internationalisation of theworkforce. International nurses and nursing students — mainly from Vietnam, China, Japan, Korea,the Philippines and South America — are a now familiar feature of healthcare. Many of thesepractitioners are enrolling in undergraduate, post-graduate and specialised clinical programs. TheseLOTE (‘language other than English’) students and clinicians present challenges which the nursingand midwifery fraternities should strive to address in order to assist them with their learning,development and integration into, and adjustment to, a new culture, a new education system and anew workforce. A major undertaking in this text, where possible, has been to make the ‘language’ ofresearch and evidence as accessible as possible. A word of explanation is needed about the tutorial triggers, research in brief boxes, points to ponderand the learning activities. The research in brief boxes contain, in most cases, a brief summary ofresearch articles which were considered relevant to the chapter and serve as additional examples. Theauthors are identified both in the ‘box’ and in the reference list and therefore can be accessed by thereader should they wish to explore the article in full. Some of the research articles are more datedthan others. Where this is the case, it is often because they still offer the best option to explain, inmore detail, issues identified in chapters when compared to the later literature. The points to ponderare included precisely for that reason — to ponder over clinical issues and to think about them inrelation to one’s own practice. The tutorial triggers and the learning activities are provided as a self-testof the contents at the end of each chapter — to further aid understanding and provide a checklist ofknowledge gained or to be further developed. We hope that you enjoy using the fourth edition of this text and that it stimulates and encouragesyou to read and think about research and its place in your professional practice. We also hope itassists in the development of your skills and confidence in critically searching for and appraising theresearch literature. Most importantly, we hope that you will share your information about researchwith your colleagues and use research findings to inform the care that you deliver to your patientsand clients. The delivery of quality nursing and midwifery evidence-based care is a challenge in ourdynamic healthcare environment. Used appropriately, this text will be a valuable tool to assist you inthat process. Zevia Schneider and Dean Whitehead October 2012x sample proofs © Elsevier Australia
    • EDITORSZevia Schneider, PhD, MPsychEd, MAppSc, MEd (TESOL), BEd, BA, FACN, RN, RMConsultant, Formerly Associate Professor ResearchFaculty of Nursing, RMIT UniversityMelbourne, VicDean Whitehead, PhD, MSc, BEd, RNSenior LecturerMassey UniversityPalmerston North, NZGeri LoBiondo-Wood, PhD, RN, FAANDirector of Nursing Research and Evidence-Based Practice, Planning and DevelopmentThe University of TexasMD Anderson Cancer CenterHouston, Texas;Adjunct Associate ProfessorUniversity of Texas Health Sciences CenterSchool of NursingNursing Systems and TechnologyHouston, TexasJudith Haber, PhD, APRN, BC, FAANThe Ursula Springer Leadership Professor in NursingAssociate Dean for Graduate ProgramsNew York UniversityCollege of NursingNew York, New YorkCONTRIBUTORSAustralian and New Zealand ContributorsWendy Chaboyer, PhD, RNDirectorNHMRC Centre of Research Excellence in NursingInterventions for Hospitalised PatientsGriffith University, QldRuth Endacott, PhD, MA, DipN (Lond), RNDirectorResearch Centre for Health and Social Care Innovation, Faculty of HealthPlymouth University, UKProfessor of Critical Care NursingMonash UniversityMelbourne, Vic xi sample proofs © Elsevier Australia
    • Murray Fisher, PhD, DipAppSc, BHSc, MHPEd, RNAssociate Professor and Director of Pre-registration ProgramsSydney Nursing SchoolUniversity of Sydney, NSWBrigid M Gillespie, PhD, BHSc (Hons), RNSenior Research FellowNHMRC Research Centre for Excellence in Nursing Interventions (NCREN)Griffith UniversityGold Coast Campus, QldThomas Harding, PhD, RNAssociate ProfessorAustralian Catholic University, NSWBridie Kent, PhD, BSc (Hons), RNChair of NursingEastern HealthDeakin University, VicVioleta Lopez, PhD, MNA, MPET, JBICF, FACNProfessorSchool of Medicine and Health SciencesAustralian National University, ACTDirectorACT Government Health Directorate Research Centre for Nursing and Midwifery PracticeDirectorAustralian Capital Regional Centre for Evidence-based Nursing and Midwifery, ACTBrendan McCormack, DPhil (Oxon), BSc (Hons), PGCEA, RMN, RGNProfessor, Director, Institute of Nursing Research andHead of the Person-centred Practice Research CentreUniversity of Ulster, Northern IrelandAdjunct Professor of NursingUniversity of Technology, SydneyAdjunct Professor of Nursing, Faculty of Medicine, Nursing and Health CareMonash University, MelbourneVisiting Professor, School of Medicine & DentistryUniversity of AberdeenProfessor II, Buskerud University CollegeDrammen, NorwaySonya Osborne, PhD, MACORN, MACN, RNSenior LecturerQueensland University of Technology, QldZevia Schneider, PhD, MPsychEd, MAppSc, MEd (TESOL), BEd, BA, FACN, RN, RMConsultant, Formerly Associate Professor ResearchFaculty of Nursing, RMIT UniversityMelbourne, Vicxii sample proofs © Elsevier Australia
    • Linda Shields, PhD, MD, FACNProfessor of Nursing — Tropical HealthTropical Health Research Unit for Nursing and MidwiferyJames Cook University and Townsville Health Service DistrictTownsville, QldHonorary ProfessorSchool of MedicineThe University of QueenslandBrisbane, QldRoger Watson, PhD, FRCN, FAAN, RNEditor-in-ChiefJournal of Advanced NursingProfessor of NursingUniversity of Hull, UKDean Whitehead, PhD, MSc, BEd, RNSenior LecturerMassey UniversityPalmerston North, NZMartin Woods, PhD, MA, RNSenior LecturerSchool of Health & Social ServicesMassey University, NZ xiii sample proofs © Elsevier Australia
    • Contributors to the U.S. editionSusan Adams, PhD, RNAssociate DirectorResearch Translation and Dissemination Core Gerontological Nursing Interventions Research CenterCollege of NursingUniversity of IowaDirector, National Nursing Practice NetworkIowa City, IowaJulie Barroso, PhD, ANP, APRN, BC, FAANAssociate Professor and Specialty Director, Adult Nurse Practitioner ProgramResearch Development Coordinator, Office of Research AffairsDuke University School of NursingDurham, North CarolinaNancy Bergstrom, RN, PhD, FAANTheodore J. and Mary E. Trumble Professor of Aging ResearchDirector, Center on AgingUniversity of Texas Health Science CenterHouston, TexasCarol Bova, PhD, RN, ANPAssociate Professor of Nursing and MedicineGraduate School of NursingUniversity of Massachusetts, WorcesterWorcester, MassachusettsStephanie Fulton, MSISAssistant Library DirectorResearch Medical LibraryThe University of TexasMD Anderson Cancer CenterHouston, TexasSusan Gennaro, RN, DSN, FAANDean and ProfessorBoston CollegeChestnut Hill, MassachusettsCarl A. Kirton, DNP, ANP-BC, ACRNVice President, Nursing and Nurse PractitionerNorth General HospitalAdjunct Clinical Associate ProfessorCollege of NursingNew York UniversityNew York, New Yorkxiv sample proofs © Elsevier Australia
    • Nancy E. Kline, PhD, RN, CPNP, FAANDirector, Center for Evidence-Based Practice and ResearchDepartment of NursingMemorial Sloan-Kettering Cancer CenterNew York, New YorkBarbara Krainovich-Miller, EdD, APRN, BC, ANEF, FAANClinical ProfessorCollege of NursingNew York UniversityNew York, New YorkMarianne T. Marcus, EdD, RN, FAANJohn P. McGovern Professor in Addiction NursingDirectorCenter for Substance Abuse EducationPrevention and ResearchHealth Science Center School of NursingUniversity of Texas–HoustonHouston, TexasHelen J. Streubert, EdD, RN, CNE, ANEFVice President of Academic AffairsOur Lady of the Lake UniversitySan Antonio, TexasSusan Sullivan-Bolyai, DNSc, CNS, RNAssociate ProfessorGraduate School of Nursing and Department of PediatricsUniversity of Massachusetts, WorcesterWorcester, MassachusettsKristen M. Swanson, RN, PhD, FAANDean and Alumni Distinguished ProfessorSchool of NursingUniversity of North Carolina at Chapel HillChapel Hill, North CarolinaMarita Titler, PhD, RN, FAANProfessor of NursingRhetaugh Dumas Endowed ChairAssociate Dean of Practice and Clinical Scholarship DevelopmentUniversity of Michigan School of NursingAnn Arbor, Michigan xv sample proofs © Elsevier Australia
    • REVIEWERSLesley Andrew, MSc, BSc (Hons) Public Health Nursing, BSc (Hons) Applied Biology, RHV, RNCoordinatorUndergraduate NursingEdith Cowan University, WABeverley Copnell, PhD, RNSenior LecturerSchool of Nursing and MidwiferyMonash University, VicGlenn W Doolan, MNA, BAppSc AdvNur (Admin), FACN, AFACHSE, RNDPH ScholarDept Epidemiology and Preventive MedicineFaculty of Medicine, Nursing and Health SciencesMonash UniversityBurnett Tower, Alfred HospitalMelbourne, VicJudith Finn, PhD, MEdStud, GradDipPH, BSc, DipAppSc, ICCert, FACN, RN, RMProfessorDiscipline of Emergency MedicineThe University of Western Australia, WARobyn Gallagher, PhD, BA (Psych), MN, RNAssociate Professor Chronic and Complex CareHigher Degrees by Research CoordinatorFaculty of Nursing, Midwifery and HealthUniversity of TechnologySydney, NSWPauline Glover, EdD, MNSt, BEd, DipT (Nurse Ed), FACM, RMAssociate ProfessorNursing and MidwiferyAssociate Dean Academic Programs School of Nursing and MidwiferyFlinders UniversityAdelaide, SACaroline McKinney, MPH, GradDipBus (Māori Development), RNPrevious Head of NursingTe Whare Wananga O AwanuiārangiCurrently Projects ManagerNational Council of Māori NursesTrudi Mannix, EdD, NICC, GradDipHlthCouns, BN (Ed), MN, EdD, RN, RMLecturerNursing and MidwiferyFlinders UniversityAdelaide, SAxvi sample proofs © Elsevier Australia
    • Wendy Penney, PhD, RNSenior LecturerDiscipline Head (Nursing) School of Health ScienceUniversity of Ballarat, VicDiscipline Leader (Nursing), Master of Nursing Program CoordinatorSchool of Health SciencesUniversity of BallaratMt Helen, VicTracey Thornley, PhD, BN (Hons), GradCertEdStudies (Higher Ed), MACNUniversity of Notre DameAustraliaDonna Waters, PhD, MPH, FACN, RNAssociate professor, Associate Dean (Research)Sydney Nursing SchoolThe University of Sydney, NSW xvii sample proofs © Elsevier Australia
    • ACKNOWLEDGMENTSThe fourth edition of Nursing and Midwifery Research has been considerably enhanced by the additionof 12 new contributors. Their contribution has been instrumental in re-shaping this text in a verypositive direction. We thank our colleagues for their expertise, professionalism and commitment inmaking this edition even better than previous editions. The production of this edition was facilitated by the Elsevier Australia publishing Team. We wouldlike to express our appreciation to Libby Houston, Publisher Nursing & Midwifery, Elizabeth Coady,Developmental Editor, and Natalie Hamad, Project Coordinator, for their patience, guidance andunfailing assistance throughout the development of this book. We gratefully acknowledge thecopyright holders for allowing us to reproduce their works in the text. We also acknowledge thevaluable contribution of former editor Doug Elliott and all chapter contributors in the third editionof this book. Much of the work in this current edition builds upon that solid foundation. We areindebted to our families who patiently and enthusiastically provided advice, encouragement andsupport and stayed the course with us. Zevia thanks Saul, Cheryl and Brenda for their continuinglove, encouragement and support far beyond the call of duty. Dean thanks Katie, Tom, James andJoshua for their unstinting contribution — through ‘keeping him on his toes’ throughout the wholeprocess, albeit with generous warmth and affection. Zevia Schneider and Dean Whiteheadxviii sample proofs © Elsevier Australia
    • Chapter 14Mixed-methods researchDean Whitehead and Zevia SchneiderKEY TERMS LEARNING OUTCOMESaction research After reading this chapter, you should becase study able to:Delphi technique • understand the principles and issues underpinning mixed-methods researchmethodological triangulation/pluralism • appreciate the value, benefits andmixed-methods research dilemmas when using both qualitativeQ methodology and quantitative designs and methods in a single study • explain the structures and processes that underpin action research • explain the structures and processes that underpin Delphi technique research • describe the purpose and processes of less common nursing-related mixed- method approaches, such as case studies and Q methodology. sample proofs © Elsevier Australia
    • NURSING AND MIDWIFERY RESEARCH 4E INTRODUCTION A review of past nursing and midwifery research literature has noted broad acceptance of one epistemological (theoretical) position to the exclusion of another and consequent polarisation (expressing two directly opposite views) of the quantitative and qualitative paradigms. This situation has led to the noted paradigm tension mentioned previously in this book (see Chapter 2), and a subsequent attempt by many researchers to address this position. Method or methodological triangulation (mixing research methods and paradigms) has been suggested as the main means of introducing some harmony into the concept of ‘paradigmatic separatism’ (Williamson 2005). When compared to other health professions, nursing and midwifery have made strides in embracing mixed-methods research in a constructive and purposeful manner (Annells 2007; O’Cathain 2009); hence the need for a detailed chapter such as this in a nursing and midwifery research text. immediate benefits to be gained from not separating quantitative and qualitative research Point to ponder into distinct categories but, instead, Depending on which side of the paradigm acknowledging and understanding their ‘fence’ one sits, some researchers place interrelated nature and processes. The important mixed-methods research under the umbrella thing is that researchers do not restrict themselves of qualitative research. Others consider it to have its own distinct paradigm and approach. to a limited range of conventional research We favour the latter. While ‘classical’ mixed- approaches or methods. Traditionally, nursing methods research combines both qualitative and midwifery researchers have favoured and quantitative methods in a single study qualitative research whereas medicine has almost (Kroll & Neri 2009), some mixed-methods exclusively used quantitative methodology. This studies can be exclusively qualitative or situation is rapidly changing as multidisciplinary quantitative. health professions’ research becomes more the norm and each discipline brings its own unique research ‘worldview’ to collaborative projects.WHAT IS MIXED-METHODS Health professional researchers, regardless of discipline, can and should choose from anRESEARCH? increasingly wide and diverse range of researchMixed-methods research is currently being activities — from both paradigms, and withinrecognised as the third major research approach single studies, to address increasingly complexand those in the field are working towards a clinical issues (Whitehead 2005). Mixed-methodsdefinition of this paradigm (Giddings & Grant research offers a way of making research more2007; Johnson et al. 2011). Whether the search meaningful, complete and purposeful than isfor a single definition is necessary, or even the case when using either a singular qualitativedesirable, remains unclear. For the sake of clarity or quantitative approach, and provides thetherefore, we use the term as defined by researcher with other valuable tools to add toTashakkori and Creswell (2007 p 4) as ‘research their research resources. A unified perspectivein which the investigator collects and analyses of research facilitates the research question todata, integrates the findings, and draws inferences determine the research methods and gives riseusing both qualitative and quantitative to the concept of a pragmatic researcherapproaches or methods in a single study or a (Onwuegbuzie & Leech 2005). Annells (2007)program of inquiry’. There are many and and McKellar et al. (2006) have highlighted the264 sample proofs © Elsevier Australia
    • 14 • Mixed-methods researchnotable increase in nursing and midwifery-related contemporary nursing and midwifery researchmixed-methods research. Because of its rising should be developed accordingly. Methodpopularity the Journal of Mixed Methods Research triangulation is viewed as a very valuable toolis devoted to these methods. Whole texts on this in accommodating this (Foss & Ellefsen 2002).subject for nursing and midwifery are now As noted in Chapter 2, there will always beavailable too (i.e. Andrew & Halcomb 2009). more than one way to investigate nursing and midwifery issues in research and so the point of ‘best fit’ becomes the most important Evidence-based practice tip consideration. Each approach and method At present the definition of mixed-methods should also complement each other and so are research can vary depending on the context viewed as equally valuable in constructing and discipline using it. Healthcare services, research projects. However, with mixed-methods social science, management and education all research and as with any research, it is never wise increasingly recognise the benefits of using to reconstruct and add/subtract approaches and this paradigm, but may apply it differently. methods as the research progresses. With many conventional mixed-method approaches, forMETHODOLOGICAL example Delphi (see later in this chapter), the structure and format is well established andTRIANGULATION/PLURALISM known prior to study commencement.Historically, methodological triangulation (orpluralism), from its social science origins in the1950s, was limited to just parts of a whole study.Denzin (1978) later on sought to expand thescope of mixed-methods research to the whole 1 Tutorial Trigger When considering the notion of ‘best fit’ for a mixed-methods research topic, what factors could beresearch design. His intention was to reducethe incidence of research error often associated considered?with studies that used single methods, singleresearchers or single theories. In today’s context, Different types, categoriesmethodological triangulation/pluralism are termsused to denote a single research study that uses a and combinations ofcombination of research approaches, paradigms triangulation researchand/or methods. Essentially both terms refer to As suggested earlier, there is always more thanthe same process although it is more common to one way to approach a research issue with thesee the term triangulation, rather than pluralism, research question, statement or hypothesisused. As the position of mixed-methods research guiding the approach (see Chapter 4). The samebecomes more established it is becoming more is true for mixed-methods/triangulation research.commonplace to see studies that are of a mixed- It is necessary to have a good understanding ofmethods design, but they do not use the different types, categories and combinationsterm or associated terms to describe this fact. before commencing or reviewing this type ofAssumptions are made that the consumer of such research. Depending on what the main aims ofstudies will understand when a study uses mixed any research study are, certain triangulationmethodology. Where this is the case, the things methods will work better than others. There areto look for and the main rationales proposed for a number of different ‘types’ of triangulation.conducting a ‘blended’ mixed-methods study are: Before commencing mixed-methods basedtriangulation; completeness; off-setting research then, the first step is considering whatweaknesses and providing stronger inferences; type of triangulation will best suit the task atanswering different research questions; wider hand. Table 14.1 highlights the main types ofexplanation of findings; broader illustration of triangulation to be considered. Each one isdata; potential hypotheses development and important in its own right and has the potentialtesting; and possible instrument development to produce different perspectives and outcomesand testing (Doyle et al. 2009). To reflect this from the next — hence the importance ofmultiplicity, it is increasingly felt that choosing wisely. Triangulation research may sample proofs © Elsevier Australia 265
    • NURSING AND MIDWIFERY RESEARCH 4ETABLE 14.1 attempt to use just one of the listed types or itTypes of triangulation can use a combination of some or all. TYPE EXPLANATION As well as different types of triangulation, there are also options for different paradigmData The use of a variety of datatriangulation sources in a study. combinations to consider. For instance, simultaneous triangulation is the combination ofInvestigator The use of several different qualitative and quantitative methods in one studytriangulation researchers or evaluators. at the same time. Sequential (parallel, concurrent)Theory The use of multiple triangulation separates out the two paradigms buttriangulation perspectives to interpret a combines them in the overall findings (see Table single set of data. 14.2). Confusion can arise when designing andMethodological The use of multiple methods interpreting mixed-methods research, so attemptstriangulation to study a single problem. have been made to clarify situations. For instance,Multi-disciplinary The use of multiple in the International Journal of Nursing Studies,triangulation disciplines to inform the Östlund et al. (2011) explored the analytical research process. approaches of 168 sequentially triangulated(Modified from Denzin N K 1978 The Research Act: a studies as a means of clarifying related concepts.Theoretical Introduction to Sociological Methods, 2nd ed.McGraw-Hill, New York and Janesick V J 1994 The dance of Sometimes, it appears that two separatequalitative research design: metaphor, methodolatory, and studies are conducted in triangulated research.meaning. In Denzin N K & Lincoln Y S (eds) Handbook of That is, a quantitative study followed by aQualitative Research. Sage Publications, Thousand Oaks, qualitative study or vice versa. Where this occursCalifornia.)TABLE 14.2Simultaneous and sequential combinations of quantitative and qualitative mixed methods approaches COMBINATION RATIONALE EXAMPLE SimultaneousQualitative + quantitative There is a qualitative The research is focused on the experiences foundation and quantitative of feeling depressed after miscarriage. methods are used to provide Phenomenological methods could be used complementary information. to address the question, and use of a depression scale would provide complementary information.Quantitative + qualitative There is a quantitative The research is testing hypotheses about foundation and qualitative depression after miscarriage. The methods are used to provide phenomenological method is used to complementary information. uncover the experience for a select group who acknowledge feelings of depression. SequentialQualitative — quantitative Findings from qualitative The research has described the experience investigation lead to use of of feeling depressed after miscarriage. The the quantitative approach. themes emerging from the data are then used to create a depression scale, which is tested for reliability and validity.Quantitative — qualitative Findings from quantitative The research has tested hypotheses linking investigation lead to use of miscarriage with depression and found no the qualitative approach. significant relationships. A qualitative study is undertaken to uncover the experience of living through miscarriage, in an effort to let the data lead to common thoughts and feelings.(Modified from Morse J M 1991 Approaches to qualitative-quantitative methodological triangulation. Nurse Researcher 40:120–3.)266 sample proofs © Elsevier Australia
    • 14 • Mixed-methods researchone must remember that a research problem or exploratory mixed-methods study of midwives’question is determined by the aim of the study understandings and perceptions of clinical ‘nearwith consequent design to follow. As in all misses’ in maternity care settings. The first phaseresearch approaches, the researcher must be clear of this study was a survey-based questionnaireabout the information required from the study. design, analysing quantitative data throughWith mixed-methods research one is faced with simple descriptive statistic techniques. Thea potential conundrum — which research second phase of the study followed up theapproach does the research question address and questionnaire responses with follow-up groupbest answer? Where this is the case, the two interviews which were qualitatively transcribedstudies are triangulated if they both relate to the and analysed. Similarly, the aim of another studysame topic area, they are both planned prior to (Barnes et al. 2008) was to evaluate thethe research program commencing, one informs effectiveness of a new model of care on thethe other and, as a final outcome, they both provision of information and support for first-equally expand the related field of inquiry. For time mothers. Participants were interviewed byinstance, Van Hecke et al. (2011; see later telephone using a survey instrument which‘Research in brief ’) examined the changes included open responses/comments to determineassociated with the nursing intervention their knowledge and support needs. In addition,‘Adherence to leg ulcer lifestyle advice’ in order two focus-group interviews were conducted toto identify outcomes sensitive to leg ulcer provide qualitative data to enrich the evaluation.patients’ experience, and to explore quantitatively Tables 14.1 and 14.2 both offer useful(pre-post-test design) the effects of the examples of the most common types andintervention. Following on, data gathered combinations of mixed-method triangulation,through interviews and participant observation while Table 14.3 offers an example of a mixed-complemented the test design. In another method approach in a single study. Knowing thisexample, Symon et al. (2006) conducted an information allows the researcher to plan andTABLE 14.3Use of a triangulated approach in one study RESEARCH QUALITATIVE QUANTITATIVE PROCESS APPROACH FIRST QUANTITATIVE APPROACH APPROACH THIRDCOMPONENTS PHASE SECOND PHASE PHASEDesign Descriptive, Correlational, Health Needs Descriptive, correlational. exploratory. Instrument (HNI) tool Implementation of HNI development and testing. tool.Participants Purposive sample of Purposive sample of 32 elder Purposive sample of 54 34 elder patients. patients. older patients.Data collection Semi-structured Structured demographic data Structured interviews. interviews. from HNI (35 nominal questions).Analysis Content/thematic Internal consistency, content and Descriptive measures of analysis. concurrent validity. variance and distribution.Findings Health needs included; A significant negative correlation A significant correlation help in managing with patients’ tangible needs for between psychological tangible things, help with activities of daily life needs with the need for psychological support, (ADL) during hospitalisation medical support, health information, transition. Strong correlation informational needs and medical support and between educational level and maintaining ADLs during participation in the need for health-related period of hospitalisation. decision-making. information.(Source: Shih S-N, Gau M-L, Kao C-H, Shih F-J 2005 Health needs instrument for hospitalized single-living Taiwanese elders withheart disease: triangulation research design. Journal of Clinical Nursing 14:1210–22.) sample proofs © Elsevier Australia 267
    • NURSING AND MIDWIFERY RESEARCH 4Eorder their mixed-methods studies so as toimplement the best strategy for what it is that RESEARCH IN BRIEFthey want to know. For instance, Milton-Wildey Van Hecke et al. (2011) examined the changesand O’Brien (2010) had a clear intention to associated with the nursing interventioninvestigate the nursing care of older hospitalised ‘Adherence to leg ulcer lifestyle advice’ inpatients and how the nurses understood the order to identify outcomes sensitive to legclinical decision-making around this care. ulcer patients’ experience, and to explore quantitatively (pre-post-test design) the effectsThe subsequent qualitative study used data of the intervention. Data were gatheredtriangulation that included observations, through interviews and participant observation.interviews and, where needed, review of the The qualitative study started with listening tohospital records of older patients. As clinical the patient’s narrative of living with a leg ulcerissues and environments become increasingly to understand their point of view, needs andcomplex, researchers often attempt to push perceptions. The intervention consisted ofbeyond conventional boundaries and extend the educational, cognitive and behaviouralrange and diversity of mixed-methods research components. At the end of the nursingoptions for future researchers. Bolster and intervention, semi-structured interviews wereManias (2010) used a two-pronged qualitative conducted with 25 patients in their home. Inapproach in a single study, naturalistic addition, patients themselves recorded their hours wearing compression bandaging andobservation and semi-structured interviews to duration of leg exercises and leg elevation.examine the nature of the interactions between Quantitative data were analysed using thenurses and patients during medication activities. Wilcoxon signed-rank test to determineSometimes researchers conduct distinctly whether baseline differed from outcomesdifferent methodologies within a single study. three months later (see Chapter 13 forFor instance, Annells (2006) incorporated both description of tests.)hermeneutical phenomenology and groundedtheory in her Australian-based study on howflatus affects people receiving nursing care.Caution is advised here though. Experience THE VALUE OF MIXED-is required before attempting to combine METHODS RESEARCHpotentially ‘competing’ philosophical/theoretical Perhaps the greatest value of mixed-methodsframeworks within single studies. research is the potential to offer wider scope for constructive, contained and appropriate research, RESEARCH IN BRIEF with the potential to present as a more complete and comprehensive research opportunity. Hutchinson et al. (2010) conducted a three- According to Borkan (2004 p 4): stage sequential mixed-methods study. The aim was to explore bullying in the Australian mixed methods not only expand the toolbox, nursing workplace. In the first stage, in-depth, they also provide the opportunity for synthesis semi-structured interviews were conducted of research traditions and give the investigator with 26 nurses recruited from two large area additional perspectives and insights that are health services who had experience of beyond the scope of any single technique. bullying. Experiences, perceptions and beliefs of the participants were explored in the Mixed-methods also assist in resolving the issue semi-structured interviews. Content analysis of of methodological dominance and order and the verbatim interview transcripts was enable a rich and comprehensive picture of the performed using the NVIVO 7 software issue under investigation (Foss & Ellefsen 2002). program. In the second stage of the study, Another argument for triangulation of methods exploratory factor analysis was used to refine assumes that weaknesses in one method can be the concepts identified in the interviews. In the counter-balanced by strengths in another. This final stage, a multidimensional model of situation has challenged researchers to develop bullying was developed through structural equation modelling on data collected from a ‘conceptual triangulation’ as part of their previous survey of Australian nurses. planning (Morgan 2007). Here, each research approach that is incorporated into the overall268 sample proofs © Elsevier Australia
    • 14 • Mixed-methods researchresearch design is evaluated separately according 2006). A perhaps cynical observation might beto its own methodological criteria. Each that ‘purist’ quantitative or qualitative researcherscomponent can stand alone while also being believe that mixing methods means that onelinked conceptually to other parts. This is of paradigm taints or interferes with the other. It isgreat value when researchers want to understand perhaps for this reason that mixed-methodshow parts of clinical issues they are investigating studies are often placed under the umbrella ofrelate to the whole picture — again adding to qualitative research. It is argued here that thisthe comprehensiveness of the studies. can be both incorrect and misleading. For instance Delphi studies (mentioned later in this chapter) tend to contain similar amounts of RESEARCH IN BRIEF both quantitative and qualitative processes and Homer et al. (2009) used a multi-method outcomes and in many instances there are approach to research the role of midwives in actually more quantitative than qualitative Australia from the perspectives of women and aspects. With action research studies, they do midwives. The study was part of a tend to cluster under an emancipatory qualitative commissioned national research project to approach. However, this is not exclusively so develop national competency standards to and, again, studies may contain equal or even assist midwives to deliver safe and competent more quantitative than qualitative components. midwifery care. Qualitative and quantitative To illustrate this point, Miller and Fredericks data were collected from surveys with women (2006 p 567) state the case for a particular and interviews with midwives. Participants mixed-methods design called ‘quantitative- were midwives and women consumers of midwifery care and involved in maternity dominant sequential analysis’ as a means to activism. Each Australian state and territory conduct evaluation research. The Auckland-based was represented. authors Giddings and Grant (2007 p 52) advise caution though. They argue, in this context, that mixed-method approaches run the risk of being a ‘Trojan Horse for positivist enquiry’.LIMITATIONS ASSOCIATED WITH Another dilemma for mixed-method research is that critical commentary can uphold theMIXED-METHODS RESEARCH notion that rigour can be compromised in suchAs with any area of research, accompanying the studies (Williamson 2005; Miller & Fredericksvalue and benefits of a research method, both the 2006). However, Jones and Bugge (2006) arguelimitations and the barriers presented need to be to the contrary. They state that triangulationconsidered. Undertaking mixed-methods research leads to ‘completeness’, improved transparencyis usually more complex than single design and a more holistic understanding that, in turn,research. The limitations associated with mixed- improves rigour through challenging findings asmethods research are immediately obvious. They they emerge. A further possible limitation forare generally more time-consuming, complex if nursing and midwifery is that, while mixed-qualitative and quantitative phases need to methods research is evolving at pace andbe conducted concurrently (simultaneous increasing in frequency in all health professions,triangulation), involved (especially where a team two particular designs currently dominateapproach may be required), resource-intensive — those of action research and the Delphi(i.e. generating more complex data for collection technique. The following sections in this chapterand analysis) and the principal researchers need reflect this and, accordingly, focus on these twoa working knowledge of both quantitative and approaches. Other less common approaches,qualitative paradigms and how to combine them such as case study and Q methodology, areto ensure good outcomes. introduced later in the chapter. Another limitation for mixed-method researchis not with the method, but the way that it isperceived by the wider research community and ACTION RESEARCHthe fact that it still has to confirm its place Action research is fast becoming an importantwithin this community (Miller & Fredericks and well-established research approach for sample proofs © Elsevier Australia 269
    • NURSING AND MIDWIFERY RESEARCH 4Enursing and midwifery practice. The term ‘action TABLE 14.4research’, informed by critical social theory (see Nursing and midwifery examples ofChapter 2), was coined in 1946 by the social action researchpsychologist Kurt Lewin to describe the research AUTHORS FOCUSprogram he developed in response to serious Organisationalpost-World War II social problems in America Whitehead et al. 2004 Osteoporosis(Lewin 1946). Lewin’s interest was in narrowing prevention inthe gap between research recommendation and hospital.implementation so that democratic (inclusive Deery 2005 Supportingand negotiated) inquiry could pave the way midwives’ needsto group decisions and a commitment to in clinical practice.organisational improvement (Lewin 1951). He Reed 2005 Discharge planningwanted to develop a concrete procedure for from hospital totranslating evidence into action. In this respect, home care.action research is a particularly useful method of Waterman et al. 2005 Advancingchoice for changing clinical practice. ophthalmic Action research may be viewed as an umbrella nursing practice.term that can be, and often is, referred to using McKellar et al. 2006 Improving parentdifferent terms to describe similar processes. This postnatalhas caused part of the confusion presented by education in aaction research. Research processes that are maternity hospital.grouped under the action research umbrella Spence & Anderson 2007 Improving Mastersinclude action science, action inquiry, action in Advancedlearning, participatory research, co-operative Practice delivery.inquiry, transparent research, community Socio-communitydevelopment research and organisational-change Holkup et al. 2004 A collaborativeresearch (Whitehead et al. 2003). From the last model for workingtwo stated terms, it should be noted that most with nativeaction research is categorised into either a social/ Americans.community development approach or an Mills & Fitzgerald 2008 The changing roleorganisational-change process approach. Some of of practice nursesthe different action research topics that nurses in Australia.and midwives have recently investigated,demonstrating the two approaches, are found inTable 14.4. More recently, the emergence of Creative techniques used were: scrap-booking,‘practice development’ and ‘practice change’, in poster-making, sharing of journal entries,clinical environments, has reinforced the use of postcard prompt to express feelings andaction research processes as effective tools for brainstorming. Analytical feedback occurredengaging all health professionals to through a secure internet blog. Three themescollaboratively solve practice-based issues (see were identified that related to the myth ofChapter 16). Mills and Fitzgerald (2008) report interdisciplinary collaboration in general practice.on the findings of an Australian action researchstudy involving three registered nurses workingin general practice credentialled to providecervical screening services. Initially the study was Point to ponderto report on the methods used to develop a new Is it better to use a process like actionmodel of service delivery in a nurse-led well- research that ‘forces’ the researcher to applywomen’s clinic. However, the participants change to the issue under investigation beforeidentified several key barriers; how the group final outcomes are known, or is it better, when using other research approaches, to beaddressed these barriers became the action mindful of how change is actioned once theresearch study. Six reflective group meetings outcomes are known?were held facilitated by the lead researcher.270 sample proofs © Elsevier Australia
    • 14 • Mixed-methods research Evidence-based practice tip RESEARCH IN BRIEF Action research is seen as one of the most Spence and Anderson (2007) report the effective research methods for clinical implementation of a collaborative New healthcare-related practice. Its processes Zealand-based project using a developmental demand that the researchers move away action research approach undertaken to from the position where researchers often monitor and improve the effectiveness of investigate issues but do not act upon the the prescribing practicum papers delivered presented findings — they merely report within two Master’s degree programs in them. Action research can move research advanced nursing practice. Data were more towards situations where findings have collected through interviews with practicum to be evidenced, acted upon and notable students, their medical supervisors and strategies for change are implemented and academic staff. Formative findings were evaluated. Action research requires action as progressively used to refine delivery of the part of the research process and is focused practicum papers and a qualitative thematic on the researcher’s professional values analysis of summative findings identified areas rather than methodological considerations. for further improvement. The researchers Subsequently, action research is viewed as recommend that further education is critical ‘inside’ research where researchers required to clearly differentiate medical and investigate and act upon their own advanced nursing roles. They recommend professional actions. that greater attention needs to be paid to the preparation of medical supervisors and, most significantly, revision of funding is required to more equitably support the ongoing development of nurses for advanced practiceThe process of action research roles.While most forms of research are constructed ina series of linear steps from question/hypothesisthrough to recommendations for action, actionresearch is presented as a variation of a spiral/ problems in their own social systems. Thecycle design. It uses a cyclical research process function of action research is to focus onthat enables steps or actions to be carefully ‘real-world’ events, as opposed to controlledmonitored, analysed and evaluated. This forms environments as in experimental researchthe basis for reflection on the success of the (Kelly & Simpson 2001). Preliminaryplan and the possibility of modifying it and investigation demonstrates the extent of thestarting another cycle of planning, action, data problems in the situation under considerationcollection, analysis, evaluation and reflection. and assists the research team to develop specificThe spiral or cycle consists of a number of research question/s. In action research, thestages, some of which are repeated until the change/action cycles emerge from the creationsituation under examination improves (see of new knowledge emerging from the processesFigure 14.1). Figure 14.1 clearly describes of ‘cycles of agreement’ (consensus-building).each continuing stage, starting with initial These processes observe and reflect ondiagnosis of the clinical problem/s, through to immediate experiences, form concepts anddata collection and analysis and resultant test and apply these experiences in newfeedback to participants. Following on from situations.this is the actioning of changes, leading to theprocesses of reflection and program evaluation,before planning further action and starting thecycle again. It is worth noting that attached tothe main spiral or cycle many projects developmini sub-projects with their own distinctspirals. 2 Tutorial Trigger Why do you think that some researchers might be reluctant to adopt a mixed-methods approach to Action research involves the use of change their studies?experiments with real people and their real sample proofs © Elsevier Australia 271
    • 272 • Identify problem/s to be addressed and proposed solutions /interventions. • Review the associated literature for evidence base. • Identify structural / organisational systems and processes. • Ascertain structural / organisational barriers / opportunities. • Forge constructive relationships with potential participants. Clarify and • Participants decide if further validate problem/s with potential participants. interventions are required, either as • Possible pilot study to investigate validity of action research activity and an extension of the existing program to highlight the most appropriate participants for main study. or as a separate add-on program. • Investigate ethical considerations / constraints. • Further action becomes part of a continuous cycle of reflexive practice. • Program may ‘complete’ here with the consent of participants. • Establish the nature and range of the most appropriate data collection methods. DIAGNOSIS • Determine documentation and recording methods. NURSING AND MIDWIFERY RESEARCH 4E PLANNING • The dissemination DATA FURTHER and publication of COLLECTION ACTION outcomes to • Initial interpretation of relevant local / collected data occurs. national • Collaborative analysis and audiences occurs. measurement of outcomes takes place. RESEARCH PARTICIPANTS • Validation of problem/s DISSEMINATION DATA • Effectiveness of program is AND against analysed data. ANALYSIS measured against agreed ORGANISATION • Data analysis informs draft outcomes, targets and success action-change program. criteria. • Methods and approaches are reviewed for validity and • Collaborative discussion and reliability. examination of data outcomes leads • Critical reflections of participants REFLECTION / to agreement on draft and final are collated. FEEDBACK EVALUATION change program. • Change targets and outcomes aresample proofs © Elsevier Australia agreed. ACTION • The program is communicated and • Individual commitment to change implemented according to agreed protocols. processes and roles are agreed, while parameters of ‘ownership’ are • Participants are supported and developed in established. their change-management role. • Intentions / interventions are • Progress is recorded at regular intervals. discussed with relevant • All changes are monitored and recorded. stakeholders. Any necessary systems / policy changes are formalised. Figure 14.1 An organisational-change action research cycle (Source: adapted from: Whitehead et al. 2003 with kind permission from Health Education Journal. Reprinted by Permission of SAGE.)
    • 14 • Mixed-methods research RESEARCH IN BRIEF BOX 14.1 Action research project structure Deery (2005) uses an action research approach to explore the support needs of eight • Identify a health-related situation that needs participant (co-researcher) community improvement. midwives, through interview, focus group and workshop sessions. Findings showed that • Establish a collaborative research group recent organisational changes had placed concerned with addressing the situation. increased managerial demands on the • Establish a reference group composed of all midwives that were detrimental to their key stakeholders. working relationships and processes of clinical • Conduct training action research workshops supervision. Subsequently, a clinical for participating researchers. supervision support program was set up to • Conduct a preliminary investigation to address these issues. This article is a develop baseline data and understand the particularly useful example of how difficult it scope of the concern. can be to translate and initiate organisational change and the dilemmas that participants • Meet with the reference group to examine (co-researchers) can face when conducting the data and assess the proposed plans. action research, but equally so, highlights the • Implement the first action plan, collect and obvious rewards and benefits. analyse data. • Research group reflection and re-planning through the spiral or cycle. • Meet with the reference group to discuss project results. Action research stresses the importance of • Disseminate the findings in accessibleactively engaging participants in the process formats to all stakeholders.of a democratic and reformatory social inquiryfocusing on active partnerships and involvement.This is where the concepts of critical socialtheory and emancipatory research aredemonstrated (see Chapter 2). The process isdesigned to be participatory and empowering possible involvement of representativefor all its research participants, who are often stakeholders. Box 14.1 highlights how variousreferred to as ‘co-researchers’. Action research, stakeholder groups might interact with thetherefore, often enjoys a reputation of action research process.encouraging the shared learning of individualsand teams who are able to learn across theboundaries of any organisation, as and when newideas and assumptions are presented to them.The key to participatory action research lies notwith any given method but, rather, in the 3 Tutorial Trigger Identify all the stakeholders who might be affected in an action research study on improving theattitudes of researchers, which in turn affect how sexual and reproductive health information forand for whom the research is constructed and community-based teenagers — as part ofconducted (Green et al. 2001). This connection preconception care.between collecting evidence to understand asituation and collaborative action is the hallmarkof an action research approach. Action research is necessarily ‘insider’ research, With action research, as descriptive data arein the sense that practitioners research their own collected and analysed, the values, theories,professional actions. As action research aims attitudes and assumptions used in professionalto be inclusive of those the research outcomes practice are exposed through a process ofare expected to affect, there are a number of reflection and careful consideration. This capacitystrategies that are used to facilitate the widest to generate ‘theories-in-use’ and build them into sample proofs © Elsevier Australia 273
    • NURSING AND MIDWIFERY RESEARCH 4Etheories or conceptual models is a distinguishing the intention is to effect wholesale community-trademark of action research — separating it wide or organisational change, it can be appliedfrom continuous quality improvement processes. more manageably to a localised context, such asThe participant co-researchers usually share their a single ward/unit (i.e. Deery 2005; Glassonreflective accounts and understandings with et al. 2006).other group members. This group reflection hasan evaluative component as the co-researchersjudge progress in preparation for the next Limitations of action researchplanning stage. It also has a responsive Action researchers will usually apply an actioncomponent. During reflection, researchers not research-related study knowing the immenseonly examine the analysed data but also the benefits that it can bring, especially in relation toresearch processes and the roles of all involved. measurable change in practice and structures. At Reflecting on the main concerns at various the same time, action researchers are also acutelycycles in the project can help to keep the team aware of the limitations that contradict itsorientated. The interest is not only in what was nature. As one might already appreciate, actiondiscovered but how it was discovered, under research is not easy to set up or initiate. Greatwhat conditions and how this relates to the effort, enthusiasm and widespread equalwider concern. This ‘lessons learnt so far’ stage participation, over long periods, are necessary forprovides a rationale to lead on to the next action effective action research (Karim 2001). Theplan. At this stage the group decides if the literature, however, can be critical of actionprevious action plan needs to proceed with research’s ability to offer ‘true’ equality,modifications or whether a new, but related plan, empowerment and participation (Whiteheadcan be introduced to address the research et al. 2003). The nature and intention of actionquestion/s. research is often quite broad as it relates to the whole situation under investigation. This means that process and outcomes are often difficult toThe value of action research predict. Action researchers face situations wherePerhaps the greatest value of action research they may not know exactly what to investigate,is that it allows health professionals to learn when and where to start or even when theabout their local situation and facilitate the research is likely to complete. Therefore, inimplementation and evaluation of research into action research, participants are often unaware ofthis situation. Added to this is the obvious exactly where their research ‘journey’ will takebenefit that this type of research approach lends them (Williamson & Prosser 2002). This aspect,to ongoing evidence-based practice change (see therefore, has implications for gaining funding,Chapter 16). Action research also offers the organisational support and seeking ethicalflexibility for research projects to evolve naturally. approval.As the study evolves and changes, the Action research can be viewed as an insensitiveco-researchers have the opportunity to further ‘blunt tool’ by the fact that it carefully examinesdevelop and refine the process and provide a and challenges organisations or communities.much fuller and comprehensive picture of the The inference, prior to the outset of actionproblem at hand (Adami & Kiger 2005). Action research, is that something is wrong and requiresresearch studies, therefore, have the potential to fixing/change, even though any criticism isreach aims and outcomes that may not have intended to be constructive. In fact, actionbeen recognised or realised at project research is usually applied in situations wherecommencement. Many action research projects groups or communities are perceived to begain their own impetus and researchers often powerless, vulnerable or oppressed by awant to keep working through more cycles to dominant group, organisation or culture. Actionachieve better outcomes — usually until funding research, therefore, with its intention ofor support has ceased. As with some aspects of systematic inquiry made public, can appearaction research, though, this may be viewed as threatening to the research participants and themuch as a limitation by some as it is of value to viewed organisation/community. Imposedothers. While action research works best when political or managerial agendas may work to274 sample proofs © Elsevier Australia
    • 14 • Mixed-methods researchoppose this type of scrutiny and hinder rather expert so that responses are usually anonymousthan assist research efforts. The need for many (Biondo et al. 2008). Their identity is notstakeholders to be involved at different levels can usually revealed, even after the completion ofalso provide organisational difficulties and may the final report. This prevents the personality,affect the willingness of some people to become reputation or authority of any participant frominvolved. dominating others in the process. It is argued The notion of methodological rigour has been that it also frees participants from their personalchallenged with action research. The dynamic biases and encourages a more open criticaland fluid aspect of action research and the debate. The process is achieved by extracting theinvolvement of stakeholders, as potentially novice viewpoints of all parties, enabling individualand learning researchers, may mean that there responses to the viewpoints and ultimatelyare difficulties maintaining research rigour and achieving a degree of consensus. The Delphivalidity. To offset this, many action researchers technique is a useful strategy for examining anadopt several qualitative criteria including area with a scant empirical research base and/orcredibility, auditability and fittingness (see for where there are questions for which thereChapter 8). The emphasis on finding concrete may be no definitive answers. The technique,and practical solutions may, however, become therefore, is particularly useful for determiningthe focus of the research to the detriment of best academic and practice standards and as asystematic recording; that is, the researchers may basis for policy-driven mechanisms.be more focused on action than on research. The Expert opinion, on a clinical practice issue,findings of action research are context-specific may be the only available evidence when noand therefore not generalisable from one setting quality primary research findings are evidentto another. It is, however, certainly desirable to (National Health and Medical Research Councilcompare and contrast settings against each other [NHMRC] 2000). Schulz et al. (2009) usedwhile looking for commonalities as they may a Delphi approach on the development andapply to all organisations/communities face validity testing of a brief clinical version(Whitehead 2005). (MWAT-C) and detailed research version (MWAT-R) of the Malignant Wound Assessment Tool (MWAT). An international panel of experts was formed. For each round of Delphi review, Evidence-based practice tip panel members completed evaluation surveys A useful exercise is to identify an issue that electronically. Based on the agreement scores and concerns you from your clinical experience comments, revisions were made. The revised and create an action research proposal. This tools were then sent to panel members for a exercise could include justification of your second round of review, as for round 1. A third action research question, how you would round was not required. conduct a preliminary investigation on this In Australasian terms, the Delphi technique is topic, what might an initial plan look like and often used in nursing and midwifery studies for what kind of data you would collect and the very reason of expert consensus. Annells analyse. et al. (2005) conducted a Delphi study to investigate the research priorities of 320 district nurses throughout Australia, as a means of determining best research practice. Similarly,DELPHI TECHNIQUE Rodger et al. (2004) conducted a Delphi studyThe Delphi technique is named with reference with 115 emergency nurses throughout Westernto the Ancient Greek god Apollo, whose Delphi Australia, to identify the most clinically relevantoracle was viewed as his most expert, truthful research questions for this professional group.and trustworthy informant (Kennedy 2004). The Mannix (2011) used Delphi to determine theDelphi technique is a research approach and first draft of The Australian College of Neonataleffective method for collecting and synthesising Nurses (ACNN) national standards for neonatalinformed opinion on a specific topic/area. The intensive care education, using a panel of 13information is collected individually from each education experts. The participants’ responses sample proofs © Elsevier Australia 275
    • NURSING AND MIDWIFERY RESEARCH 4Ewere all transcribed verbatim from the qualitative the expert panel, formulation of the question(s),first round questionnaire into the single round generation of statements, reduction andtwo document and participants were then asked categorisation of statements, rating of statementsto score their agreement to each response using a and analysis and iteration (Mead & MoseleyLikert Scale format. In the third and final round 2001). A Delphi study is a mixed-method designthe panel members whose scores were more than in that both qualitative and quantitativetwo quartiles variant from the mode of the rest techniques are used to collect and analyse theof the panel received their score from the questionnaire data. It normally takes on theprevious round in one column and, alongside it, structure of a methodological triangulation/datathe mode score of the rest of the panel. The triangulation with a sequential combinationpercentage of agreement was also included. This method (see Tables 14.1 and 14.2).provided each panel member with the Typically with Delphi studies, the first roundopportunity to compare their responses with questionnaire collects qualitative data throughthose of other members. They were invited to unstructured questions seeking open responses.change their score or respond with further This type of data is needed initially to providecomments if they wished to, in light of their the necessary richness of data in order toown personal further consideration, or the formulate subsequent focused questions oropinions of the panel. statements. Qualitative content and thematic analysis processes of the collected first-round data are used as a basis to synthesise responses for each survey round (see Chapter 8). This RESEARCH IN BRIEF analysis reveals a number of categories and The study by Wilkes et al. (2010) reports the themes which are, in turn, grouped and listed. first phase of a project using Delphi technique Generally, the data from the first round are to develop and test the construct and specific and structured, but then require predictive validity and reliability of a violence quantification through descriptive quantitative assessment tool to be used in the emergency survey design questionnaires. These are department. Purposive sampling technique conventionally formulated as a list of Likert was used to recruit 11 expert nurse academics Scale questions or sometimes visual analogue and clinicians. Round 1 produced a 37-item scale-related questions (see Chapter 11), and violence tool: the items were grouped under returned to the study participants for further five major components of observable feedback. behaviour. All cues that had a mean rating of 2.64 or more were retained. Round 2 In many cases the initial first-round analysis produced a 27-item-refined tool. The experts reveals a large number of categories and therefore were asked to rate the importance of each the second-round questionnaire may be very item on a Likert Scale. Round 3 produced a detailed. The aim of a Delphi study is to extract 17-item tool. The experts were then asked to a fairly ‘narrow’ consensus on the investigated refine the tool and rate the importance of topic. Where this is the case, it usually requires a each cue for a final time. All items that had a number of rounds of similarly structured Likert- mean rating above 2.33 were retained. style questionnaire rounds to help break the categories down into a manageable number. The lowest scoring questions are removed whereas the highest scores are kept for the following round/sThe Delphi process (see previous ‘Research in brief ’ related to meanA Delphi study involves a series (or rounds) of scoring). A predetermined consensus level orquestionnaires, interspersed with controlled percentage is often set prior to analysing thefeedback from usually anonymous participants. data. Mannix’s (2011) study, for instance,The exception to this is with ‘quasi-anonymous’ states a predetermined consensus level of 75%.participants — where names of the participants Whitehead’s (2008) international Delphi studyare known but their judgments remain set the consensus level at 80%. A mean ofanonymous (Löfmark & Thorell-Ekstrand 2004). 81.3% agreement is reported on the accepted 65Stages of the Delphi process include selection of statements of the second-round questionnaire.276 sample proofs © Elsevier Australia
    • 14 • Mixed-methods researchOnce the main points are manageable and/or Evidence-based practice tipcannot be broken down further, a degree of‘saturation’ or consensus is considered to have You might want to identify a clinically relatedbeen met. In most cases it is by the second or issue that you think is not well defined, developed or researched in the literature, andthird round that this situation occurs, but there that would benefit from the expert consensusis always the scope to continue for a number of that a Delphi study potentially offers.other rounds. The validity and rigour in Delphiis maintained during each round, as participantscheck and provide feedback that the interpreted CASE STUDY APPROACHdata are consistent with their responses andoverall position on the topic. The term case study has different meanings in research and clinical contexts. A case study research approach enables a detailed examinationThe value of the Delphi technique of a single ‘case’ or ‘unit’ within a real-life andThe benefits of the Delphi technique include contemporary context using multiple datathe ability to harness many opinions across sources (Hewitt-Taylor 2002). The casegeographical distance, the freedom of individuals (phenomenon of interest) can be an individual/sto express their opinion without being influenced (e.g. Hotham et al. 2005; Yoshioka-Maeda et al.by other group members, allowing individuals to 2006; Jones et al. 2011), a group or community,participate at a convenient time, and relatively an organisation (e.g. Fullerton et al. 2003;small expense. Delphi can also be performed Cooke 2006), a process (e.g. Koch et al. 2005;over relatively short periods of time, especially if Brazier et al. 2008) or an event. There is aconducted using electronic mail (Marsden et al. misconception amongst nurse and midwifery2003). These benefits overcome the potential researchers that the case study approach (oftenlimitations of other consensus methods such as confused with the case study teaching method) isfocus groups, nominal group technique or not as rigorous as other mixed-methodsconsensus conferences (Mead & Moseley 2001). techniques, yet it is used frequently inIt is a flexible technique and modifications can psychology, sociology and education (Andersonbe made to suit the study at hand. Potentially 2011). Anderson states that a limitation of manysmall study groups can be used and the range nursing and midwifery research texts is that theycan be anywhere from 4 to 3000 participants often do not address or mention this method.(Campbell & Cantrell 2001). Most commonly,though, Delphi study participant numbers areusually anywhere between 20 and 50. In Point to ponderMcKenna et al.’s (2002) Delphi survey ofmidwives and midwifery students’ identification Do not confuse case study research with a ‘case presentation’ of a particular clinical caseof non-midwifery duties, they used a total of or a ‘case-control’ study of an epidemiological275 participants. design (see Chapter 9).Limitations of the Delphi techniqueAs well as a number of benefits, there are a RESEARCH IN BRIEFnumber of methodological considerations to Hotham et al. (2005) supplement theiraddress with Delphi studies. These include randomised controlled trial of nicotineinadequate descriptions of panellist characteristics replacement therapy with in-depth case(especially in terms of identifying who or what studies of three pregnant smokers from theconstitutes an expert), subjective researcher trial. The case studies were designed tointerpretation of definitions and measures of demonstrate the unique difficulties andconsensus, and high wastage of respondents due barriers that this group of women face when attempting to stop smoking. In another study,to response fatigue. It is also important to Brazier et al. (2008) used a case studyremember that the findings of a Delphi study approach to assist the client evaluation of anrepresent expert opinion but not indisputable integrative approach to cancer care.fact (Powell 2003). sample proofs © Elsevier Australia 277
    • NURSING AND MIDWIFERY RESEARCH 4E The case study approach is exploratory, interviews to form the Q sample. Statements inobservational and responsive to the context and the Q sample are representative, but nottherefore qualitative in terms of philosophical exhaustive, of the diversity of attitudes possibleposition (Fitzgerald 1999). Triangulation of about the topic. Once the set of statements hasmethods, however, enables use of the full range been verified and finalised, each statement orof data collection strategies — such as material is placed on an individual card to enableinterviews, field notes, participant observation the cards to be sorted into some order.and contemporary documents. Data analysis can Participants are instructed how to rank-order theuse a constant comparative approach (Hewitt- set of Q sample statements or materials. This isTaylor 2002; see Chapter 8) or be more referred to as the Q-sort technique. Rankingstructured (Yin 2003). Data can be examined in commonly follows a Likert scale format (seetheir own right with no requirement for Chapter 11); for example, from strongly agree togeneralisability (Keyzer 2000), or the study strongly disagree, using a quasi-normalprocedure may include steps to ensure reliability, distribution (Ryan & Zerwic 2004). That is, leastvalidity and generalisability (Yin 2003). The cards are able to be assigned scores at the ends ofstudy examples mentioned in this section the scale, while proportionally more can bedemonstrate the breadth of strategies available located in the middle of the distribution.with this approach. Cross-Sudworth et al. (2011) used a Q methodology technique to explore the views of first- and second-generation Pakistani women RESEARCH IN BRIEF accessing maternity services in Britain, while Jones et al. (2011) use a single case study Herron-Marx et al. (2007) used Q methodology evaluative approach with nurse prescribers, for the study of women’s experience of postnatal doctors and clients in acute care. Interviews, perineal and pelvic floor morbidity in Britain. non-participant observation and a patient questionnaire survey were used. No differences were found in prescribing performance between nurses and doctors, but Point to ponder there was statistically significant difference in Q methodology applies quantitative analysis favour of the nurses in relation to medication- to qualitatively derived data. related information satisfaction of patients who had seen a prescriber. Figure 14.2 illustrates a hypothetical example for a 36-item Q sample, with an 11-point LikertQ METHODOLOGY Scale, from strongly disagree (–5) to stronglyQ methodology uses a unique set of processes to agree (+5). One card is placed per cell on thereveal subjective attitudes and perspectives of Q-sort diagram. In this example, only one cardparticipants about a particular topic. The can be placed in the +5 location, while fourtechnique reveals the structure of views and is statements can be located at –2.useful for exploring values, beliefs, perceptionsetc. of life experiences (Akhtar-Danesh &Baumann 2008). It is an alternative method Strongly disagree Neutral Strongly agreeapproach for studying individual subjectivity –5 –4 –3 –2 –1 0 1 2 3 4 5 Number of statements per value(qualitative part) through the use of factor 1analysis (quantitative part) (Barker 2008). There 2is a misconception that Q methodology is 3mainly about psychometric testing but it is, in 4fact, more a systematic process of assessing 5qualitative data (Dziopa & Ahern 2011). A set 6of stimulus material (i.e. textual statements,pictures or recordings) amenable to appraisal areconstructed. They are usually from prior Figure 14.2 Q-sort diagram278 sample proofs © Elsevier Australia
    • 14 • Mixed-methods research The resulting order of material is then • the attitudes of emergency department nursesanalysed using quantitative techniques to to health promotion (Cross 2005)produce correlational matrices and factor analysis • exploring narrative approaches to therapysolutions (see Chapter 12). The use of factor (Wallis et al. 2009); interestingly, this studyanalysis enables the statements to be collated combines both Q methodology and a Delphiinto factors for clearer interpretation (see the technique pollfollowing ‘Research in brief ’ section). • family care giving by women and the issue of non-support (Neufeld et al. 2004). RESEARCH IN BRIEF Ryan and Zerwic (2004) explored a cluster of symptoms that high-risk individuals and their significant others associate with an acute myocardial infarction (AMI). The Q sample 4 Tutorial Trigger You or your study group have been asked to present the steps involved in a Q methodology study, using a statements were sourced from 141 transcripts of patients describing their actual AMI published paper to illustrate the concepts. symptoms. A series of validation steps with Access two published Q methodology papers patients and clinicians resulted in a set of 49 and identify the common steps undertaken. statements. Participants (n = 63) ranked the Provide a one-paragraph general description statements into 11 piles that ranged from with an accompanying example. ‘most like a heart attack’ to ‘least like a heart attack’. A correlation matrix of the Q-sorts was constructed and a factor analysis applied. A four-factor solution accounted for 36% of the SUMMARY variance — where the factors were ‘traditional symptoms’, ‘symptoms attributed to MI The value and contribution of mixed-methods causes’, ‘non-specific symptoms’ and ‘variation research to and for nursing and midwifery on traditional symptoms.’ A –5 to +5 Likert practice is beyond question. Many researchers, Scale (11 points), with a quasi-normal with any understanding of mixed-methods and distribution, directed the participants in their triangulation techniques, will be able to Q-sort. The study demonstrated varied appreciate the benefits of expanding research expectations regarding AMI symptoms, and intentions and outcomes, to accommodate a the authors linked this finding to implications range of paradigmatic approaches and methods. for practice, as the need for education to While researchers need to be aware that mixed- include differences in actual symptoms method research brings with it a unique series of experienced by different demographic groups. challenges, it is argued that the benefits far outweigh the dilemmas. This is particularly in relation to the higher likelihood of research This approach has been used to examine a comprehensiveness, completeness and notablevariety of clinical issues — although none could changes in practice. In bringing together thebe found which incorporated specific midwifery paradigms of both qualitative and quantitativeelements. For example: research (to create a third paradigm of mixed-• the attitudes of Korean adults towards human methods), this chapter completes the dignity (Kae Hwa et al. 2012) ‘paradigmatic circle’. sample proofs © Elsevier Australia 279
    • NURSING AND MIDWIFERY RESEARCH 4E KEY POINTS • Mixed-methods research is rapidly gaining recognition and approval in nursing and midwifery. Method triangulation/mixed-methods research combines methods, paradigms, and the approaches of qualitative and quantitative research — whereby triangulation of methods and data sources enable a broader and more comprehensive picture to emerge about the research topic. • Action research is a useful method to use when researchers want to understand and improve a situation, as it is action-focused and context-specific, and therefore can address problems of practical concern. Action research uses a cyclical process in which the research, implementation, evaluation and theorising are linked to reduce the theory–practice gap. • Delphi studies seek to gain expert consensus when there is little empirical evidence or understanding of a health-related issue, and typically combine qualitative and quantitative data from a series of questionnaire rounds. • A case study approach enables a detailed examination of a single ‘case’ or ‘unit’ within a real-life setting. The ‘case’ can be an individual, social group, community, organisation or event. Q methodology combines interview (qualitative) data to form statements about the topic of interest, which are then rank-ordered to produce quantitative data. Learning activities 1. The main value of using mixed-methods 3. A mixed-methods research study that research in nursing is it: sought to initially identify the lived health- a) allows the researcher to understand a related experiences of a group of patients wider range of research methods and follow this up by using a tool to measure the extent of those health-related b) helps researchers champion particular experiences, would be using which of the research paradigms following combinations: c) offers a higher probability that the a) simultaneous — qualitative and conducted research will be viewed as quantitative complete and comprehensive b) simultaneous — quantitative and d) assists in reducing research error. qualitative 2. Data triangulation involves: c) sequential — quantitative leading to a) prioritising data into discrete groups in a qualitative single study d) sequential — qualitative leading to b) using a variety of data sources in a single quantitative. study 4. Conventional Delphi studies have the c) differentiating between data sources in a following properties: single study a) use experts, quantitative first-round, d) using specific data sources in a single qualitative second-round, consensus study. b) use clients, qualitative first-round, quantitative second-round, consensus c) use experts, qualitative first-round, quantitative second-round, consensus d) use clients, qualitative first-round, quantitative second-round, non-consensus.280 sample proofs © Elsevier Australia
    • 14 • Mixed-methods research5. With the Delphi technique, how many 8. Action research studies mainly focus on one questionnaire rounds are most likely to of two broad areas. These being: occur: a) organisational development/operational a) 1 development b) 2 b) organisational development/community c) 3 development d) 4. c) procedural development/community development6. The main features of action research are: d) organisational development/procedural a) mixed-methods, participation, development. randomisation, change cycles 9. With a case study, the phenomenon of b) mixed methods, change cycles, interest can be: participation, empowerment a) an individual/s, a group or community, a c) participation, mixed methods, conference, a process, an event empowerment, organisational b) an individual/s, a nation, an d) change cycles, socio-community, mixed organisation, a process, an event methods, empowerment. c) an individual/s, a culture, an7. An action research cycle or spiral would organisation, a process, an event typically contain the stages: d) an individual/s, a group or community, a) diagnosis, data collection and analysis, an organisation, a process, an event. feedback, actioning, reflection and evaluation, and further change cycles 10. With Q methodology, participants are instructed how to rank-order the set of Q b) diagnosis, evaluation, feedback, sample statements or materials. This process actioning, and further change cycles is called the: c) diagnosis, data collection and analysis, a) Q-filter technique feedback, actioning, reflection and evaluation b) Q-sort technique d) diagnosis, data collection and analysis, c) Q-sieve technique feedback, reflection and evaluation, and d) Q-sift technique. further change cycles. Additional resources O’Cathain A (editorial) 2011 Mixed Methods Research in the Health Sciences A Quiet Revolution. JournalAndrew E S, Halcomb E J (eds) 2009 Mixed Methods of Mixed Methods Research 3(1):3–6 Research for Nursing and the Health Sciences. Williamson G R 2005 Illustrating triangulation in Wiley-Blackwell, Chichester, UK mixed-methods nursing research. Nurse ResearcherClibbens N, Walters S, Baird W 2012 Delphi research: 12:7–17 issues raised by a pilot study. Nurse Researcher 19(2):37–44 ReferencesCreswell J, Plano-Clark V 2010 Designing and Conducting Mixed-methods Research, 2nd edn. Sage Adami M F, Kiger A 2005 The use of triangulation for Publications, Thousand Oaks, California, USA completeness purposes. Nurse Researcher 12:19–29Keeney S, Hasson F, McKenna H 2006 Consulting the Akhtar-Danesh N, Baumann A 2008 Q-methodology oracle: ten lessons from using the Delphi technique in nursing research: a promising method for the in nursing research. Journal of Advanced Nursing study of subjectivity. Western Journal of Nursing 53:205–12 Research 30:759–73 sample proofs © Elsevier Australia 281
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