7-5 Nursing Research – Flashcards
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When evaluating evidence, the components evaluated are
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quality of evidence, level of evidence, strength of evidence (and when multiple studies are evaluated: consistency of evidence)
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Consistency of evidence exists when
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consistency of size, direction or effects across multiple studies
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Quality of evidence is determined by
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appraisal of study methods and execution
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Level of evidence is determined by
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the type of research design
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Strength of evidence is determined by
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synthesis of high level and quality that leads to practice recommendations
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systematic reviews aka research integrations aka evidence reports are summaries of
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critically appraised quantitative or qualitative or both types of research evidence usually of experimental of quasi-experimental studies related to a specific question
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Bias is minimized when
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a group of experts, rather than individuals, applies standardized methods to the evidence review process
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integrative reviews are
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like systematic reviews, but also contain non-experimental studies and theoretical literature (in addition to experimental and quasi-experimental research) to arrive at full comprehension of the topic of interest
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Systematic reviews summarize data through either
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meta-analysis or meta-synthesis
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A meta-analysis is
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a 'NUMBERS BASED' systematic review that AGGREGATES statistical/NUMERICAL DATA to summarize independent QUANTITATIVE studies to address a particular research question
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A meta-synthesis is
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a 'TEXT BASED' systematic review that INTERPRETS data and summarizes independent QUALITATIVE studies that address a particular research question
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The strongest meta-analysis contain only research that
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is done by RCT, randomized controlled trials
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Effect size, ES is
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a measure of the strength of the relationship between two variables. It can be a positive or a negative effect.
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(Re: relationship between two variables) Positive effect is
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when one variable increases, so does the other
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(Re: relationship between two variables) Negative effect is
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when one variable increases, the other decreases
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An overall summary statistic
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combines and averages effect sizes across studies
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A meta-ethnography is
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a type of meta-synthesis that compares concepts, themes and phrases of individual qualitative studies
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The four main categories of research types are
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experimental quasi-experimental non-experimental qualitative
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"Manipulation" means
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the researcher is doing something to at least some of the subjects in an effort to influence some aspect of health and well-being
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"Randomization" means
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subjects are assigned to an intervention or control on a random basis
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Experimental research is
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RCT, randomized controlled trials Features: an intervention a control group random assignment to the intervention or control group manipulation of independent variable
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Quasi-experimental research is
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non-equivalent control/comparison group research, post-test only or pretest/post-test research; (also factorial, randomized block and cross-over/repeated measures research) lacks random assignment to the intervention or control group (may or may not have a control group) some manipulation of independent variable
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Non-experimental research is
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descriptive research, predictive, explanatory, time-dimensional, case study research (may or may not have an intervention) no random assignment to a group a control group no manipulation of independent variables
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Qualitative research is
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subjective historical research, grounded theory, enthnographic, phenomenological-hermeneutic, narrative analysis no randomization no manipulation of independent variables little control over the natural environment
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Research type: RCT, randomized controlled trials
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experimental research
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Research type: non-equivalent control/comparison group research
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quasi-experimental research
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Research type: post-test only or pretest/post-test research
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quasi-experimental research
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Research type: descriptive research
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Non-experimental research
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Research type: predictive research
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Non-experimental research
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Research type: explanatory research
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Non-experimental research
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Research type: time-dimensional research
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Non-experimental research
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Research type: case study research
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Non-experimental research
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Research type: historical research
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qualitative research
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Research type: grounded theory research
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qualitative research
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Research type: enthnographic research
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qualitative research
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Research type: phenomenological-hermeneutic research
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qualitative research
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Research type: narrative analysis research
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qualitative research
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Experimental studies aka randomized control trials produce evidence which is
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reproducible
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The most commonly used, original design of experimental study is the
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pre-test/post-test study
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The independent variable is
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the intervention
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The dependent variable is
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the effect the researcher is trying to achieve; i.e. the 'dependent' effect of the independent variable
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The control is
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a group of subjects who do not get the intervention
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The placebo effect is
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when a subject reacts to a placebo
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Quasi-experimental designs are used when
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it is not practical, ethical or possible to randomly assign subjects to experimental and control groups For example: You have to use whatever patients are grouped in the cardiac ward, they can't be randomly grouped. If you're measuring the effect of bed alarms on patient falls, you can't deactivate some bed alarms.
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Most published studies have designs which are
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non-experimental or observational; i.e reporting observations of natural phenomena They are classified by research purpose or by time frame.
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Non-experimental, 'research purpose' studies include
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descriptive, predictive and explanatory research studies
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Non-experimental, 'time frame' studies include
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prospective, longitudinal and retrospective research studies
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Definition: Descriptive study
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describes characteristics of phenomena; statistical analysis limited to frequencies and averages
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Descriptive research study designs include
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univariate descriptive (often uses exploratory or survey designs), descriptive comparative, descriptive correlational, epidemiologic descriptive (prevalence and incidence)
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Definition: Univariate descriptive study
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uses exploratory or survey designs to describe the frequency of a behavior or occurrence; but does NOT relate them to each other
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A common study design in nursing is the
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exploratory research design; the researcher uses this to identify previously unknown variables
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Once variables related to a particular phenomena are discovered through a research study, the researcher
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can design a descriptive study design to more thoroughly examine variables of interest
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Definition: Descriptive comparative study design
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describes differences between variables statistically WITHOUT attempting to determine causality, using frequency distributions and central tendencies such as: mean, mode, median
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Definition: Descriptive correlational study design
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Like a comparative study except that a numerical 'correlation coefficient' is sought to show the 'direction' of the association between two variables
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Definition: correlation coefficient studies
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0 to 1 is positive; one increases and so does the other 0 to -1 is negative; one increases, the other decreases Also: the closer to 1, the more positive the closer to -1, the more negative
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Definition: Prevalence (or point prevalence) and incidence studies
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determines the proportion of a population that has a particular condition at a specific point in in time useful to understand: risk for disease development frequency of new cases burden of a specific disease on a particular community
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Definition: Predictive design studies
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predict relationships; if x occurs, will y occur?
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Definition: Exploratory design studies
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seek to understand the foundation for and relationships among natural phenomena. (For example: what causes the depression and anxiety among Irish immigrant men? Conclusion: unemployment contributes most highly.)
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Time-dimensional design studies include
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retrospective, prospective and longitudinal studies
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Definition: retrospective studies
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investigator examines possible causes and effects for past events
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Definition: prospective studies
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examine causes that occurred in the past and looks to the future for possible effects
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Definition: longitudinal studies
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examines a variable or variables over time, going from present to future; seeks to correlate past causes and future effects
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Observational studies that have a time component include
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case-control, cohort and cross-sectional studies
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Definition: case-control studies
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examine relationships between exposure and disease occurrence; compares people with the disease (cases) to those without (controls) answers the question: is there a relationship between exposure to a particular phenomena and contracting a disease For example: Does obesity predispose a person to diabetes development?
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Definition: cohort studies
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look at a particular subset of a population from which different samples are taken at various points in time (can be retrospective or prospective) to determine the occurrence and outcome of interest For example: What is the incidence of teen smokers who develop lung cancer? What is the incidence of new mothers who develop post partum depression?
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Definition: cross-sectional studies
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collect data at one particular point in time; from a representative sample, gives both outcome and risk factor at the same time
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Prevalence studies use the design of a
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cross-sectional study design to determine variables in a population at a single time
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Definition: Qualitative Study
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allows researchers to summarize and interpret data in multiple ways to develop unique, potential insights
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Qualitative study types include
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historical research, grounded theory, ethnography, phenomenological-hermeneutic and narrative analysis
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Definition: Historical research study
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describe/analyze events that occurred in the remote or recent past to discover facts and relationships
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A narrative review or narrative analysis is
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a piece of literature that refers to research studies but does not critically appraise, evaluate or summarize them
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Definition: grounded theory study
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examines basic social/psychological problems/concerns to identify processes that resolve them
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Definition: ethnography study
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examines a culture by 'researcher-immersion' into the culture to discover definable cultural characteristics
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Definition: phenomenological-hermeneutic study
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reflects on themes that characterize an experience based on how the people involved interpret it Hermeneutic- concerning interpretation, esp. of the Bible or literary texts; a method or theory of interpretation Phenomenology- the study of subjective experience; an approach to psychological subject matter that has its roots in the philosophical work of Edmund Husserl.
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Qualitative studies are
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subjective
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Quantitative studies are
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objective
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When evaluating the statistical information presented in a study, the researcher determines the data's:
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validity, reliability and precision
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Definition: validity
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applicability; does the research measure what it was intended to measure? truth; do the findings approximate the truthfulness of the subject of interest or do they bend the truth?
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Definition: reliability
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repeatability; can another experiment produce the same results?
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Definition precision
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Are statistical measures of central tendency and statistical significance interpreted correctly?
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Measures of validity include:
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conclusion validity, internal validity, external validity and construct validity
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Definition: conclusion validity
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relationship between data and conclusions are reasonable, believable and credible If data, measures or observations are wrong or sample size was too small; conclusions will have low reliability
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Two types of error in conclusion reliability are
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Type I aka false positive error - finding statistical significance where none exists Type II aka false negative error - not finding statistical significance where it exists
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Definition: Internal validity
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the degree to which observed changes were caused by an intervention and not other causes
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Threats to internal validity include
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* investigator bias - subjects alter behavior because they know they're participating in a study (the Hawthorne Effect) * attrition bias - loss of subjects during study affects the sample * selection bias - affects all non-random samples * confounding bias - the measure of an intervention's effect is distorted because other factors actually had an effect * performance bias - systematic variations affect outcome; for example same wound care applied to patient group to evaluate wound care measures, but they have different quality beds * detection bias - two different skills levels of evaluators; example: wound care nurse evaluating one group of patients, RN evaluating other group
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Definition: External validity aka generalizability
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the likelihood that findings apply/results hold true to other settings or samples Lack of external validity is the most frequent criticism of clinicians of RCT studies.
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Threats to external validity include
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an inappropriate attempt to link findings from a group of people to another, time to another or site to another, when they are incompatible
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Definition: construct validity
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the assumption that the investigators actually measured the construct of interest Example: When the researchers say that they are measuring what they call fatigue, is that what they are really measuring?
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Factors that contribute to variation between measures and tests include:
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intra-subject variation - variations between test subjects intra-observer variations - variations of observations made by the same observer inter-observer variations - variations of observations made across those reading the test results
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The statistical/precision language that describes populations and their characteristics are:
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central tendency: mean (average), median (mid-point value) and mode (most frequently occurring value) variation: standard deviation (the variation of values from the mean/indicates the spread/distribution of data)
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Definition: Statistical significance
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unlikely to have occurred by chance indicated by p-value; a range from 0 to 1; the smaller the value/closer to 0, the more statistical significance exists (In nursing literature p-value is generally <0.05)
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Statistical significance vs. clinical significance
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Don't confuse the concepts of statistical and clinical significance. Statistically significant results do not always translate to practical practice recommendations. Statistically insignificant results may make for valuable practice recommendations. Consider that statistical evidence is influenced by sample size; if you cure 3 patients of a rare cancer, it's very clinically significant but not statistically significant.
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Definition: Confidence interval, CI
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an estimate of a range of values in which actual values lie; i.e. an investigator can be 95% certain that actual values lie between a set upper and lower limit to a range of values The range in which clinicians repeating a study can expect to get results if they present the intervention as it was in the study.
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Definition: Effect size
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a measure of the strength of a phenomenon (for example, the change in an outcome after experimental intervention); a measure of the effect of a treatment
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Example of calculating the effect size
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A group of test takers received an intervention and scored 80 with a standard deviation of 10 Another group got no intervention and scored 75 with a standard deviation of 10 80-75= 5 5÷10= 0.5 = the effect size is 0.5
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Definition: Cohen's d (effect size)
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0.8 = large effect 0.5 = medium effect 0.2 = small effect
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It's not the number of studies or projects that determines the reliability of their findings, but the
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uniformity and quality of their methods
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Evidence level I
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Systematic review or meta-analysis: evidence from all relevant randomized controlled trials
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Evidence level II
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Randomized controlled trial: an experiment in which subjects are non-randomly assigned to a treatment group or control group
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Evidence level III
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Controlled trial without randomization: an experiment in which subjects are non-randomly assigned to a treatment group or control group
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Evidence level IV
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Case-control study: a comparison of subjects with a condition (case) with those who don't have the condition (control) to determine characteristics that might predict the condition or cohort study: an observation of a group(s) (cohort[s]) to determine the development of an outcome(s) such as a disease
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Evidence level V
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Systematic review of qualitative or descriptive study: a synthesis of evidence from qualitative or descriptive studies to answer a clinical question
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Evidence level VI
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Qualitative study: gathers data on human behavior to understand why and how decisions are made or descriptive study: provides background information on the what, where and when of a topic of interest
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Evidence level VII
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Expert opinion or consensus: authoritative opinion of expert committee
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Questions to ask when reviewing a research study?
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Why was the study done? Was there a clear explanation of the purpose of the study and, if so, what was it? What is the sample size? Were there enough people in the study to establish that the findings did not occur by chance? Are the instruments of the major variables valid and reliable? How were variables defined? Were the instruments designed to measure a concept valid (did they measure what the researchers said they measured)? Were they reliable (did they measure a concept the same way every time they were used)? How were the data analyzed? What statistics were used to determine if the purpose of the study was achieved? Were there any untoward events during the study? Did people leave the study and, if so, was there something special about them? How do the results fit with previous research in the area? Did the researchers base their work on a thorough literature review? What does this research mean for clinical practice? Is the study purpose an important clinical issue?
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Odds Ratio (OR)
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The odds of an outcome occurring in the intervention group compared with the odds of it occurring in the comparison or control group. If an OR is equal to 1, then the intervention didn't make a difference.
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Relative Risk (RR)
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The risk of an outcome occurring in the intervention group compared with the risk of it occurring in the comparison or control group. If an RR is equal to 1, then the intervention didn't make a difference.
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An example of non-evidence research is:
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Clinical practice guidelines
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According the NGC, clinical practice guidelines should include statements that recommend strategies that assist health care practitioners and patients, not just nurses, in making decisions. Guidelines should be officially sponsored by one or more medical specialty, professional, or government agency organizations, and should be reviewed or revised every
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5 years
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Attributes of summative documents should include
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management of study quality, clarity of method, applicability of phenomenon of interest, comprehensiveness of search strategy; unity and consistency of findings; transparency of limitations; believability of conclusions, and collective expertise BUT NOT application to practice
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Organizational experience most commonly comes from
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program or financial evaluations conducted as part of an organization's quality improvement program; an evaluation of an organization's economic measures is an example of non-research evidence, which may be used to determine best clinical practice
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According to Melnyk and Fineout-Overholt (2006), no "magic bullet: exists when determining how to
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utilize evidence from research and non-research activities. Both forms of evidence are dynamic, and clinical practice is continuously updated once new information is identified
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High quality evidence is produced by studies with
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results which are generalizable and consistent; a sufficient sample size, adequate controls, definitive conclusions, consistent recommendations based on comprehensive literature review that includes through reference to scientific evidence
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Good quality evidence is produced by studies with
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reasonably consistent results, sufficient sample size for the study design, some control, fairly definitive conclusions, comprehensive literature review that includes some reference to scientific evidence
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Low or major flaw quality evidence is produced by studies with
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little evidence with inconsistent results; insufficient sample size for the study design; conclusions cannot be drawn
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The John's Hopkins Nursing Evidence Based Practice, JHNEBP model uses
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a broadly defined quality rating scale which accommodates qualitative judgments
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Definition: Random error
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an error in measurement caused by factors that vary from one measurement to another
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Single-bind study means
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the patients don't know if they're in the intervention group or control group
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Double-bind study means
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the patients and caregivers don't know who is in the intervention group or control group
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The occurrence of external events during a study can
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completely undermine it's validity
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When an intervention is assessed in a patient over time external influences on the effect include:
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maturation in the patient; for example: in evaluating expressions of emotional instability over time, a more mature person will have a naturally better self-control measuring instruments improve with time, an improved measuring device may record different measures
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Definition: Transactional validity
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an interactive process between the subject and researcher that reflects trust and good communication
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Definition: Transformational validity
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has a goal of effecting progressive social change; involves self-reflection and empathy on the part of the researcher while working with subjects
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Definition: Holistic validity
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more than one voice is used in a non-judgmental, narrative, open way which adds validity to the text and action
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Explicit search strategies employ the use of
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inclusion and exclusion criteria
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The classic elements of a published research study includes
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title, abstract, introduction, method, results, discussion and conclusion
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A good abstract contains information about
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the study's purpose, method, results, conclusions and clinical relevance
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For the investigator looking for research articles of interest, the abstracts serves as
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a screening device only; to help decide if the article fits
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The introduction includes
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background, problem statement (why the investigators chose the study), identification of knowledge gap (what is known vs. what the study seeks to find), a clear statement of purpose ("The purpose of this study is to..."), a statement of expected results or hypothesis
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The conclusion includes:
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a brief restatement of the results and implications of the study
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The method includes:
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how the study is conducted (in sufficient detail so that a reader can replicate the study), the intended study population, a description of inclusion and exclusion criteria, how subjects were recruited, demographic characteristics, description of any instrumentation used and evidence quality for instrumentation, description of how data were collected and analyzed
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The results includes:
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a list of findings of data analysis WITHOUT commentary, figures and tables (the heart of most papers), whether results report statistical or clinical significance
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The discussion includes:
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research findings and their meaning/interpretation of value, main weaknesses or limitations of the study and actions taken to minimize them, broad implications of results/broad interpretation of findings CAUTION: report facts and supportable conclusions, avoid casual overstatements such as: it is generally believed, most people would agree...etc...
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Duplicate findings, is a concern regarding
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the use of multiple review articles which are evaluating the same studies
