Lecture 4


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  • Research questions can come from a variety of sources and often arise during the course of everyday work and discussions. It may be a broad area that you have an interest in or a specific question you would like to answer. There are occasions when a funding body will put out research work to tender and invite applications to conduct the research, but most research in nursing is still researcher driven at the moment. There are arguments for and against both types of research and no doubt a place for both too.
  • The clinical environment may be a good source of inspiration. Questions such as these might arise Why do some patients seem reluctant to take their medication? What is the best way to break bad news to carers? . Discussion with colleagues is a good way to narrow down an interest in an area to what are the key issues to look at and which aspect might be of most interest and of most help in providing care. There has been a lot of early research in nursing around professional issues. As an emerging profession, nursing has had a lot of questions around the practice of the profession and the educational needs of the profession.
  • Theoretical questions relate to developing ideas and tools. They may also be concerned with whether particular theories can be helpful in explaining or understanding situations in healthcare. Policy questions relate to the development and impact of policy. They can however be very much grounded in practice too where the policy can have a direct impact on healthcare practice and patient outcome. Other types of research tend to arise around unusual or unanticipated events such as flu epidemics or natural disasters which require research with immediate effect.
  • Most types of research begin with questions but may be framed using hypotheses, questions, or aims and objectives. Only experimental research tends to use hypotheses which are then tested out in the experiment. All studies will have a general aim and some types of research may also set more precise objective or questions to guide the design and methods of the study. What is most important is that the design of the study is the right one to answer the research aim or the research questions. If the research question is asking ‘What is the difference between using one type of dressing or another’ it is clearly best answered by a quantitative approach. However a question that asks ‘what are service users perceptions of nursing care’ this could be answered by a qualitative design to gain explanation and understanding. However if there was enough already known in the area, it might be possible to design a questionnaire to collect data on the types of views that we expect service users to hold. In quantitative research, a research aim should lead to the research questions or objectives. The questions or objectives often break down the aim in to smaller more manageable parts. The questions must all relate to the aim and should not add anything over and above them. Most importantly, the research aims should not set out to ‘prove’ a point of view. A study can be set up to prove or disprove a hypothesis
  • Most importantly, the research aims should not be to ‘prove’ a point of view. A study can be set up to prove or disprove a hypothesis. Sometimes we have an idea about practice – for example that if we send a text reminder to people coming to outpatients appointments the day before then the number of non attenders will be lower. When we guess at an answer like this we can draw up a hypothesis – that a text reminder will lead to lower non attendance at out patients appointments. There also needs to be a null hypothesis which states there is no difference from what we are doing – that a text reminder does not change non attendance rates at outpatients appointments. We could also have another alternative hypothesis, that sending a text message might increase non attendance. Simply disproving the null hypothesis will not tell us which alternative hypothesis is supported and we would need to look closely at the data to determine that. In quantitative research we use statistics to support or refute hypotheses. What the statistics can tell us is whether it is likely that our hypothesis is true or unlikely. Statistics can never prove a hypothesis is true as they only work with probabilities and strength of relationships. Even when there is a very high probability that a text reminder works, there is still a very small chance that the findings are just due to chance and it may actually not work in the whole population.
  • When we start to design a study we need to define exactly what the terms of it are. This is called operationalising terms or creating an operational definition. So in our example, we used outpatients appointments. These might be at a hospital or a clinic but does that include visits to nurses and doctors, is it new visits or repeat patients ? What about outpatient appointments where minor procedures are carried out ? We need to define exactly what we mean by outpatients and what constitutes a text reminder message. We also need to define what the population is we want to study. Is it patients with a certain condition – maybe orthopaedic outpatients or is it a certain age group that we want to target ? Do we include patients who have previously not attended ? Such criteria are normally called inclusion and exclusion criteria. If we make these too tight then we may have a very restricted population and the results will not be applicable to that many people. On the other hand if we may these too broad the population may be so diverse that we are not able to see any trends as there are sub groups within the population who respond differently to the text message.
  • Sometimes we have an interest in a broad area and what to seek understanding or explanation about what is happening. It may be that we want to understand the patients experience of attending outpatient appointments or that there are a group of patients who still do not attend after a text reminder and we want to try and understand why that is. In this type of research we use inductive logic so that ideas and hypotheses will emerge from the data during the study. As stated in the example, there needs to be some broad aims to guide the study such as ‘To gain an understanding of the patient's experience of coming for an outpatient appointment’ or ‘to gain an understanding of the effect of text reminders on attendance at outpatient appointments’. In qualitative research we do not need to operationalise as such. The respondents will define the concepts as they go along so in our example they may talk about what they define as non attendance.
  • Here are some examples of research questions used by Carnwell and Baker in a study of Breast Care Nursing. The first question was answered with qualitative research and the second with a quantitative survey.
  • On this slide the activities for this weeks discussion board are listed. The idea is to try and develop each others ideas.
  • Moving on then to think about the research design. The argument has already been made that the study should be designed so as best to answer the research aim or research questions. However there are other things to take in to account as well. Resource implications are important. It may seem like the best design to have a very large randomized controlled trial but without the resources to conduct the trial it is not going to be possible. Another key influence is the values held by the researcher. As researchers we usually have a preference for the type of design we prefer and this tends to reflect our personal values and the way we see the world. Some might prefer quantitative approaches whilst others will have a preference for qualitative methods. Our knowledge and expertise using a particular design should also be considered. The more knowledgeable and experienced a researcher is in using a design, the more likely the research will be well conducted and provide valid and reliable results.
  • First lets consider quantitative research. The data can provide a description in terms of frequencies of occurrence or percentages or proportions. For example we could say that in our study of non attenders in outpatients, 67% were men and 33% were women. Quantitative studies can also be designed to look for relationships between subsets of data in terms of correlations and how they vary together. In our example we could look at age and frequency of non attendance. We might find that the younger the patients, the more non attendances they have. In causal studies an experiment is designed to support or refute a hypothesis. So we could answer the original research question - Does a text reminder will lead to lower non attendance at out patients appointments, in this way.
  • An experiment can test out both causal relationships and correlational ones. They can enable us to predict what will happen in the future when a certain set of conditions are applied. So for example we can predict a 23% reduction in outpatient non attendance when a text reminder system is used. Surveys on the other hand do not change anything but gather data from a situation as it is. Correlations can be studied but we can’t predict on the basis of them. Just because two conditions co-exist and vary in a certain way does not mean to say one causes the other. Case studies often use quantitative methods to study a whole system or organisation in depth. But they also use a mix of other methods too and can combine types of qualitative methods too.
  • We can also describe quantitative research by the time period in which it runs over. A longitudinal study starts with a large group of people or subjects and then follows them onward in to the future. This is a very strong design in that we can see how things change for the people over time and have measured everything at the time that it has happened. However there tends to be a lot of drop outs from this type of research, it can take a very log time to complete and it requires quite extensive and sustained funding. When we want to find out about people at different stages we are most likely to use a cross-sectional design. In this design, we choose different sub-groups to represent the different time points. So for example, rather than following through a group of students from year 1 to year 3 of a programme we choose students currently in year 1 and students currently in year 3. Otherwise our study will take 3 years to complete. This way we have the data straight away but we may also want to check the groups to see that they are comparable on some key features. It may be that the current 3 rd years have a higher than usual proportion of male students or that the group has followed an older version of the curriculum. In a retrospective study we can ask respondents to think back and give answers about how things were three years ago. However memory is not the most reliable and our views on what happened in the past tend to change over time. A study could use records but again they may be incomplete or not collect data on the exact thing we want to look at.
  • In qualitative designs we are looking at the experiences, beliefs attitudes and intentions of people. Data is most often from interviews of some kind or interactions. We are interested in how people interpret and report things. Their own perspective on something is what is sought. We are aiming to describe, understand and explain phenomena so whilst qualitative data can be collected in surveys and case studies, it is not usually the central focus. Different types of qualitative designs lead to different approaches.
  • Ethnography has its roots in anthropology where the researcher should be new to a situation or context. The researcher questions all aspects of this ‘foreign’ culture in order to understand its meaning. We look to understand behaviour in context. The focus is on the culture and context. The researcher immerses themselves in the culture and questions and observes through field work. The aim is to understand lives from their point of view. Data can be both field notes and interviews. Analysis of this data creates categories codes and concepts, patterns and theories. There are limitations though such as observer bias. There are often large amounts of data which can be overwhelming. There is also the question of whether those being studied are truly giving informed consent to take part when the researcher aims to observe everyone and everything. In nursing, researchers often choose the topic to study and in this sense are usually not naïve to the topic under study. Phenomenology has its roots in particular types of philosophy. Phenomenology is not a method but an approach to seeing things as the person’s lived experience. The focus is on individual interviews where respondents tell it as it is for them. Grounded theory was first proposed by Glaser and Strauss in 1967. The key feature of this approach is that theory is generated during the course of the research. The aim is not simply to describe but to create concepts and categories which can lead to the development of theories. These are developed and tested out in this constant comparative method. Grounded theory uses theoretical sampling to access respondents that may give the most illuminating responses and affirm or refute theories as they are developed. Grounded theory has become popular in nursing research but it is often used to guide a research design or used selectively rather than true to all the principles. This may weaken the strength of the research itself. Discourse Analysis studies the spoken or written word and aims to learn about hidden meaning in communication. The focus is often on culture and context eg power relationships.
  • There are a number of other types of research design whose principles mean that they can draw on qualitative or quantitative approaches to fit the purpose. They may also use a mix of different methods in order to get at a variety of data around the one issue. For example, Evaluation Research, Action Research, Delphi studies, Case studies. Gerrish and Lacey (2010) have a number of chapters which covers these types of research.
  • Lecture 4

    1. 1. MSc/Dip/Cert Advancing Nursing Practice MSc by Research (Nursing) RESEARCH METHODS IN NURSING ANDNURSING STUDIESNURSING STUDIES HEALTHCARE (A) RESEARCH QUESTIONS AND RESEARCH DESIGN Dr. Sheila Rodgers Nursing Studies University of Edinburgh
    2. 2. Research Methods in Nursing and Healthcare (A) RESEARCH QUESTIONSNURSING STUDIESNURSING STUDIES Begin with ideas, issues and broad questions. Sources of questions:  Clinical experience  Professional issues  Theoretical frameworks  Policy imperatives  Other sources
    3. 3. Research Methods in Nursing and Healthcare (A) Clinical:NURSING STUDIESNURSING STUDIES Why do some patients seem reluctant to take their medication? What is the best way to break bad news to carers? Professional: What are the educational needs of consultant nurses? Are there any benefits in shared learning?
    4. 4. Research Methods in Nursing and Healthcare (A) Theoretical:NURSING STUDIESNURSING STUDIES Can the BARRIERS scale be used in community nursing in the UK? Policy: What is the effect of policy changes on the health care needs of asylum seekers? Other: Unusual or unanticipated events eg: Flu, BSE, natural disaster.
    5. 5. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES QUANTITATIVE RESEARCH Research Aim – leads to research questions or research objectives. Questions must relate to and achieve the aim with the answers, should not diverge, must be focused and set tasks.
    6. 6. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES QUANTITATIVE RESEARCH May guess at an answer to give a hypothesis Null hypothesis Support hypotheses but never prove
    7. 7. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES OPERATIONAL DEFINITION Define concepts precisely in explicit terms so they can be measured Define population and give inclusion / exclusion criteria
    8. 8. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES QUALITATIVE RESEARCH Inductive Hypotheses and theories emerge from the data May not have research questions but broad aims are needed to focus the study. No operationalising – respondents define own concepts
    9. 9. Research Methods in Nursing and Healthcare (A) RESEARCH QUESTIONSNURSING STUDIESNURSING STUDIES Carnwell and Baker (2003) Aim: To evaluate the Breast Care Nursing service from the patient’s perspective Q1. How do patients with breast cancer experience the Breast Care Nursing Service? Q2. What are the strengths and weaknesses of the Breast Care Nursing Service from the patients perspective?
    10. 10. Research Methods in Nursing and Healthcare (A) DISCUSSION BOARD WORKNURSING STUDIESNURSING STUDIES • Choose a research topic and write an aim • Post this on the discussion board •Choose a topic that someone else has posted • Write a set of objectives or research questions on it •Pick a topic that someone has posted research questions or objectives on, suggest how the research might be conducted.
    11. 11. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES RESEARCH DESIGN Choice influenced by; •Resource implications •Values •Knowledge •Expertise
    12. 12. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES QUANTITATIVE RESEARCH Descriptive Correlational Causal
    13. 13. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES QUANTITATIVE RESEARCH Experiments – Causal & Correlational Surveys – Descriptive & Correlational Case Studies – Descriptive (mixed methods)
    14. 14. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES QUANTITATIVE RESEARCH By time: Longitudinal (cohort) Cross-sectional Retrospective
    15. 15. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES QUALITATIVE RESEARCH Looks at experiences, beliefs, attitudes, intentions etc. Aim to describe, understand and explain Tend not to use survey or case study to describe
    16. 16. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES QUALITATIVE RESEARCH Ethnography – rooted in anthropology Phenomenology – Husserl, Heidegger Grounded Theory Discourse Analysis
    17. 17. NURSING STUDIES Research Methods in Nursing and Healthcare (A)NURSING STUDIES OTHER APPROACHES Evaluation Action Research Delphi technique