Introduction to Nursing Research

Rajesh  Kumar

Introduction to Nursing Research1

INTRODUCTION TO RESEARCH

Nursing is noble profession which needs a continuous growing and expanding body of knowledge. Knowledge can be developed through many ways and research is one of them. Nurses are increasingly expected to understand and conduct research to develop a scientific basis for improving knowledge. Research is a systematic way of exploring the hidden issues and helps to maintain professional growth and dignity. Research based knowledge provides scientific basis for developing and refining the professional knowledge and practice.

Because nursing is a practice profession, it is important that clinical practice should be based on scientific knowledge. Evidences generated through nursing research provide support for quality and cost effectiveness of nursing intervention. Thus, recipient of health care and particularly nursing care–reap benefits when nurses attend to research evidence and introduce change based on that evidence into nursing practice. The result of research provides foundation on which practice, decision and behavior are based.

PROBLEM-SOLVING METHOD

A problem is a situation that can be quantitative or qualitative, confront an individual or groups of individual, and require solution. Problem-solving is a powerful human activity; it is a process, an activity, whereby the best solution is selected from available solutions. The ability to solve a problem comes from doing it. Many things must put together to solve a problem. Researchers have proposed many different models of problem-solving. The basic model of Problem-solving is discussed here;

Problem-Solving Model

Problem-solving process is series of logical steps, which when followed produce an optimal solution. The six step process is an easy approach to deal with issues and problems that students face in their day to day routine.

It is simple and systematic way to approach a problem with clearly defined steps to answer, ‘WHAT DO WE DO NEXT?’. The problem-solving model follows a series of six steps. The steps are explained here:

Identify and select the problem: The first step, identifying the problem is a broad view. In this first stage, researcher needs to write down about the problem in details. Writing about the problem in detail will help to comprehend the problem.
Analyze the problem: Once you have tentatively defined the problem, you can begin to collect the information about the problem with the help of ‘STAR’ (Fig. 1.1) or ‘PDSA’ (Fig. 1.2) approaches. In addition, gravity of the problem and all the factors which are contributing to the problem are determined.

In this way you should take a look at ‘what is really causing the difficulty?’. It is a thoughtful thought to examine the problem from different point of views.

Fig. 1.1: The star method

Fig. 1.2: The PDSA method
3
Develop alternative solutions: Once you explore the root cause of the problem, you may move to find the possible solutions. This is a creative and practical step where every possible solution is identified. However, a creative Problem-solving requires use of brain storming and other cognitive processes (i.e. intuition) to explore a full range of possible solutions. Assemble all possible alternative solutions and move to next step.
Evaluate possible solutions: At this step, now you may have a variety of solution to fix the problem given the circumstances, resources, and other considerations. Here, the individual trying to chose the best possible solution in given situation. There are always a number of things that can affect a solution; money, time, people, procedure, policies and so on. All of these factors must be taken in consideration. An effective solution should be technically feasible and sound. The solution should be acceptable to those who will have to implement it.
Implement the best solution: This is the DO stage of PDSA. This seems to be an easy step but it really requires a scientific approach to observing specifically what is going on with the implemented solution. Choosing the solution does not immediately solve the problem. Putting a solution into action may help to solve the problem.
Evaluate the solution for change: This is the final stage of problem-solving process. In this step, evaluation is made to judge the effectiveness of the solution to resolve the problem. This will helps to evaluate change in practice. It is the STUDY stage of the PDSA approach. This step enables an individual to ask, ‘Did the solution work? If not-why not? What went right, and what went wrong?’. Answer of all these questions enable the individual to ACT on finding best solution again. In case of failure, redefine and revise the problem and start the process again.

Both, problem-solving and research process use abstract critical thinking and complex reasoning to solve a problem. However, research process should be distinguished from problem-solving on following criteria as given in Table 1.1.

Table 1.1 Comparison of research process and problem-solving

Research process	Problem-solving
Research focus on multiple problems of an individual or organization	Target on single problem of individual or organization
Research contribute to professional growth by replication or generalization of findings	Solution derived from problem-solving cannot be replicated on others, as others may have different cause for same problem
Research process need to stick with certain ethical issues	No ethical issues come across in problem-solving process
Research subject to undergone external and peer review process to determine validity and reliability	A problem of an particular individual or organization is an isolated problem and only need solution

SCIENTIFIC METHOD AND RESEARCH

Scientific method is a systematic and objective method of investigation. Scientific method is the basis of scientific investigation. In scientific method, the investigator poses a research4 question and formulates hypotheses to answer research question. The hypotheses states a potential explanation or answer to question. Research is also systematic and based on empirical evidences to explore the issue under investigation.

Characteristics of Scientific Method

A scientific method should reflect following characteristics;

Systematic process: Scientific method is an orderly process. Investigator proceeds logically through a series of steps according to specified plan of action.
Control: Researcher imposes certain conditions on the research situation to minimize biases and maximize precision and validity of result.
Empirical (Objective) evidences: Researcher collect empirical evidence through the objective method like observation, sense, touch, smell, hear or taste.
Quantitative information: Usually, collected information in scientific method is numerical in nature. Numeric information is collected through use of valid and reliable measurement tools like questionnaire, rating scale or bio-physiological report, etc.
Generalizability: Findings of the scientific method can be generalized over other population.

Limitations of Scientific Method

The scientific method has enjoyed considerable stature as a method of inquiry and has been used productively by nurse researchers studying a range of nursing problems. However, scientific method imposed certain limitations.

Moral-ethical problem: The scientific method cannot be used to answer certain moral or ethical issues. For example, legalization of female feticides, legalization of Euthanasia, etc.
Measurement related problem: The traditional research approach study a phenomena by measuring a construct. Sometimes, researcher do not have sound measurement device to measure a specific construct like assessment of moral status, hope, motivation, etc.
Human behavior complexity: Human are inherently complex and diverse in nature. Scientific method can only study a handful of human characteristics, i.e. height, weight, anxiety, depression, etc. Scientific method fails to study the variation of one parameter among different human being. For example, why some people show quick reaction to something not others?, why some people get easily annoyed not others?, etc.
Control problem: The rigorous control is the core of scientific method. Hence, a specific problem is studied in a systematic and objective ways by keeping rigorous control and holding condition constant which permits only variation to phenomena comes under study. Sometime, researcher fails to control over external and internal environmental condition that can influence the phenomena under study.

Steps of Scientific Method

Scientific method is specific and often use following steps:

Select a research question: A well framed researchable question help to precede the research in right direction. A research question must be specific enough to explore.5
State hypothesis: It is tentative prediction of relationship between variables.
Design experiment: Design an experimental procedure to test the hypothesis and construct equipments and tools necessary for testing.
Conduct experiment: Implement the plan and conduct the experiment as according to plan.
Analysis: The collected data should be analyzed by using appropriate analysis technique.
Interpretation of result: Refine or correct hypothesis and continue the experiment if necessary.
Communication of findings: The evidenced-based findings can be communicated by choosing appropriate channel of communication like poster, journal, etc.

METHODS OF ACQUIRING KNOWLEDGE IN NURSING

Knowledge is essential information acquired in a variety of ways, expected to be an accurate reflection of reality and incorporated and used to direct a person's life. The quality of nursing practice has direct relation with the quality of knowledge that a nurse acquired. Nurses have relied on several sources of knowledge to guide nursing practice. This section describes various ways of acquiring knowledge in nursing.

Authority: An authority is a person with much knowledge and experience and who is capable to influence the others. Nurses who are frequently involved in research work and publication are considered authority. Knowledge acquired from higher authority does not have any scientific basis for truth. But, it is a great source of acquiring knowledge to novice researchers either from higher authority or from their published work.
Brainstorming: It is another cost effective and efficient means of acquiring knowledge. In brain storming, a group of experts will sit together and discuss the problem from different point of views to reach on a common consensus. Brainstorming helps to taking ideas from different background and specialized experts for an issue.
Intuition: Intuition is a part of thinking, including intuition in critical thinking helps to expand the person's ability to know about something. Intuition described as gut feeling or ‘hunch’ for something. It is an insight or understanding for a particular phenomenon. Some people do not believe in intuition. Nurses may have feeling of intuition while they provide care, for example, ‘I just have this feeling that Mr. Ram is heading for problem’. It is hard to explain what it is but it happens.
Literature review: Reading literature is a good source to acquire knowledge about certain topics in nursing. Novice researchers can profit from regularly reading published and unpublished work on nursing and its related issues. Reviewing literature need experience and multidimensional skills like critical appraisal, reasoning, and analytic skills.
Subjective experience and clinical field work: Gaining knowledge by being personally involved in an event, situation or circumstance is called subjective experience. Nurse's everyday experience is a rich source of acquiring knowledge. Personal experience in clinical setting is a provocative source of knowledge. A nurse can acquire knowledge from day to day routine in clinical area. Learning from experience enabled the nurses to gather ideas in a meaningful ways. For example, you may read about mouth care6 procedure in book but in reality you do not know how to give mouth care until you either assist or do the procedure on a patient in clinical area.
Trial and error: Since the existence of human being on earth, trial and error method are used to acquire and expand the knowledge. Likewise, nurses may use trial and error method while providing care. However, trial and error method does not have any scientific steps to follow, but it will help to improve the knowledge.
Tradition: Many question and problem are solved in the preview of traditional views or belief that is based on customs and traditional trends. Nursing tradition from past to present generation is transferred through oral or written communication. However, in the scenario of EBP, nursing knowledge must be based on scientific facts rather than traditional views to have a powerful impact on patient outcomes.
Borrowing: Borrowing in nursing involves the appropriation and use of knowledge from other field or disciplines to guide nursing practice. Knowledge can be borrowed from other health and other disciplines like medicine, sociology, psychology and physical sciences to improve nursing knowledge.
Scientific research: Scientific research is a most objective and reliable source of nursing knowledge. The knowledge needed for practice should be specific and outcomes focused. Thus, a variety of research methods are needed to generate nursing knowledge. Quantitative, qualitative and many other types of research are used to generate nursing knowledge.

RESEARCH AND NURSING RESEARCH

Research

The word Research is derived from ‘French’ word and it literal meaning is ‘to investigate thoroughly’. Research is to search again or examine carefully. The term Research in ‘Latin’ means ‘to know’. So, research is a careful, systematic patient study and investigation in some field of knowledge, undertaken to establish facts or principles. Given the complex nature of research, finding one definition that achieves consensus is difficult. Most research textbooks will contain a variation on this theme as a definition of research. Some important definitions are given below:

‘Systematic inquiry that use disciplined method to answer questions or solve problem’.

(Polit and Beck, 2008)

‘Research is an attempt to increase the sum of what is known, usually referred to as a ‘body of knowledge’ by the discovery of new facts or relationship through a process of systematic enquiry, the research process’.

(Hockey, 1984)

‘The attempt to derive generalization new knowledge by addressing clearly defined questions with systematic and rigorous method’.

(DOH, 2005)

‘A methodological examination that uses regimented techniques to resolve questions or decipher dilemmas’.

(Boswal and Cannon, 2007)

‘A careful investigation or inquiry especially through search for new facts in any branch of knowledge’.

(The Advanced Learner's Dictionary)

‘Research is a systematized effort to gain new knowledge’.

(Redman and Mory, 1933)7

‘The manipulation of things, concepts or symbols for the purpose of generalizing to extend, correct or verify knowledge, whether that knowledge aids in construction of theory or in the practice of an art’.

(Encyclopedia of Social Sciences)

‘It is search for knowledge through objective and systematic method of findings solution to a problem’.

‘Research is a structural inquiry that utilizes acceptable scientific methodology to solve problem and create new knowledge that is generally applicable’.

‘A systematic approach concerning generalization and the formulation of theory’.

‘Research comprises defining and redefining problem, formulating hypothesis or suggested solution; collecting, organizing and evaluating data; making deductions and reaching conclusions; and it last carefully testing the conclusions to determine whether they fit the following hypothesis’.

‘Systematic method consisting of enunciating the problem, formulating a hypothesis, collecting the facts or data, analyzing the facts and reaching certain conclusion either in the form of solution(s) towards the concerned problem or in certain generalization for some theoretical formulation’.

Nursing Research

The purpose of nursing research is to build knowledge in a disciplined through the generation and/or testing theory. Research is conducted to describe, explain, and predict the outcomes. Nursing research concerned with the study of individual, its interaction with environment and discovering intervention that promotes optimal functioning and wellness across the life span. Nursing research is systematic, objective process of analyzing phenomena of importance to nursing. It includes studies concerning nursing practice, nursing education, nursing administration and nurses themselves. Clinical nursing research is research that has potential for affecting the care of clients.

‘Scientific process that validates and refines existing knowledge and generate new knowledge that directly or indirectly influence nursing practice’.

‘Systematic inquiry designed to develop knowledge about issues of importance to the nursing profession including nursing practice, education, administration and informatics’.

(Polit and Beck, 2004)

‘A systematic approach to gathering information for the purpose of answering questions and solving problems in the pursuit of creating new knowledge about nursing practice, education and policy’.

(Moule and Hek, 2011)

‘Nursing research refers to use of systematic, controlled, empirical and critical investigation in attempting to discover or conform facts that relate to specific problem or question about the practice of nursing’.

(Waltz and Bausell, 1981)

‘Nursing research is a way to identify new knowledge, improve professional education and practices and use of resources effectively’.

(ICN, 1986)

‘Nursing research is a systematic enquiry that seeks to add new nursing knowledge to benefits patients, families and communities. It encompasses all aspects of health that are interest to nursing, including promotion of health, prevention of illness, care of people of all ages during illness and recovery towards a peaceful and dignified death’.

(ICN, 2009)8

Research is directed towards understanding the nursing care of individuals and groups and the biological, physiological, social, behavioral and environmental mechanism influencing health and disease that are relevant to nursing care.

Characteristics of High-Quality Research

Research is a systematic process of collecting, analyzing and interpreting information to answer research question. A systematic designed research process must have certain characteristics. This section deal with the important characteristics of a high quality research;

Systematic: Research is a systematic process follows certain logical predefined steps. These steps are pre-planed and cannot be taken in haphazard way. For example, selection of research question, developing hypothesis, choosing design, collecting information, etc.
Controlled: A good quality research have control over factors that may have influence on research variables or process. A researcher should imply the control on research study to minimize the effects of other factors on the research variables. For example, randomization, taking control group, maintaining homogeneity of different group, etc.
Empirical: The research findings based on hard evidence gathered through objective methods, i.e. observation, biophysiological methods or through taste, hear, smell, touch and seeing, etc.
Rigorous: The research process plan must be rigorous in nature to find answer to a research question. Rigorous extend from appropriate selection of research question to collection, analysis and interpretation of data with much accuracy and control. Rigorously plan of a study reduce the bias and strengthen the credulity of findings.
Critical: The research procedure are critically examined for its strengths and weaknesses. The process of investigation must be foolproof and free from drawbacks and flaws.

Objectives/Purposes of Research

The main purpose of the research is to answer the research question through the application of scientific procedure. Through, each research study has its own specific purpose. The specific purpose of nursing research includes identification, description, exploration, prediction and control of phenomena. However, nursing research serve following purposes;

Describe a particular individual or group of individual or organization
Test the hypothesis of a casual relationship between two variables
Determine the frequency with which something occurs or with which it is associated with something else
Enhance the body of professional knowledge to improve patient care and outcomes
Improve personal and professional growth
Enhance the professional identity
Improve consumer (patient and their relative) satisfaction
Formulate and test nursing theories for possible refinement and change
Gain familiarity with a phenomenon or to achieve new insight in to it9
Help in prediction and control of certain phenomena in nursing practice
Explore areas where little is known or to investigate the problem in depth
Discover or establish the existence of relationship between two or more than two phenomena
Explain why and how the relation between two or more than two phenomena exists.

HISTORY OF NURSING RESEARCH

Nursing research was slow to develop in India as well as in the rest of the world. Slow growth of nursing research was related to lack of higher cadre nursing education. Nursing research was able to develop and expand only as nurses received advanced educational preparation. The growth of nursing research seems to be directly related to the educational level of nurses. In the early era of nursing, nursing leaders were more concerned about increasing the number of nurses and establishing hospital affiliated nursing school than with establishing university programs. Because nurses were not prepared to conduct research, many of the early nursing studies were conducted by member of other disciplines.

As nurses received advanced educational preparation and became qualified to conduct research, many of the studies they carried out were in nursing education because most of nurses before 1950 received their advanced degree in education. However, even during the early half century, the need for clinical nursing research was evident. Although, Florence Nightingale recommended clinical nursing research in the mid-1800s, her advice was ignored by nurses until over 100 years later. She emphasized some of the studies like environmental health hazards, are being conducted today.

There are many noteworthy events reported in the historical development of nursing research. Some of important milestones in history of nursing research at national and international level are given here;

Major Landmarks in History of Research at International Level

In the 19th century, Florence Nightingale, founder of modern nursing, was first nurse to do research in connection with nursing, when she used statistics in the analysis of her data. She was the first biostatician in nursing. Nightingale did her work alone and not until after world war II there an organized, continuing effort to conduct further nursing research. The following are some the major hallmarks in the history of nursing research.

1920: Josephine Goldmark, under the direction of Haven Emerson, conducted a comprehensive survey that identified the inadequacies of housing and instructional facilities for nursing students.

1924: The first nursing doctoral programme was established at Teacher's College, Columbia University.

1935: ANA published some facts about nursing: A handbook for speakers and others, which contained yearly compilation of statistical data about registered nurses.

1943: The National Organization of Public Health Nursing surveyed needs and resources for home care in the 16 communities. The work was reported in public health nursing care of the sick.10

1949: ANA conducted its first national inventory of professional registered nurses in the United States and Puerto Rico.

1950: The National Nursing Accrediting Services established a system for accrediting Nursing Schools.

1952: The Journal of Nursing Research was published in June 1952. It was the ANA's first official journal for reporting nursing and health research.

1954: ANA established a committee on research and studies to plan, to promote, and to guide relating to the functions of the ANA (1968 published) ANA Guidelines in Ethical Values.

1955: ANA established the American Nurse's Foundation, a center for research to receive and administer funds and grants for nursing research.

1956: The study on patient care and patient satisfaction in 60 hospitals was published.

1957: The department of Nursing established at Walter Reed Army Institute of Research, provided opportunities for growth of Military Nursing Services.

1959: The National League for Nursing (NLN) Research studies was established to conduct research.

1960: Faye Abdellah developed the first federally tested coronary care unit and published patient centered approach to nursing, which altered nursing theory and practice.

1965: ANA Nursing Research Conferences (1965–1980s) provided a forum for critiquing nursing research.

1966: The International Nursing Index was published. One of the first textbook of nursing research was published by Abdellah and Levine: Better Patient Care through Nursing Research.

1970: ANA Commission on Nursing Research was established.

1970: The Western Council for Higher Education for Nursing (WCHEN) and Conduct and Utilization Research in Nursing (CURN) project implemented for utilization of research in nursing.

1971: ANA Council of Nurses Research was established.

1974: ANA Commission published Guidelines on Human rights for nurses in clinical and others research.

1976: The Stetller Model of Research Utilization (RU) was implemented

1977: Nursing Research became first Nursing Journal to be included in Med-line.

1980: ANA published a social policy statement which defined the nature and scope of nursing practice and characteristics of specialization in nursing.

1983: The Volume of Annual Review of Nursing Research Survives was published by Springer Publishing Company.

1983: The Institute of Medicine recommended that nursing research be included in the mainstream of bio-medical behavioral sciences.

1984: NIH task force study found that nursing research activities are relevant to NIH mission.

1985: The National Center for Nursing Research (NINR) was established in USPHS.

1993: The NINR launched Cochrane collaboration for funding of nursing research.11

1994: The Journal of Qualitative Research started being published.

1998: Sigma Theta Tau sponsored the first International Research Utilization Conference in Toronto.

2003: The NINR supported clinical and basic research to establish a scientific basis for the care of individual across the life span.

2004: The Journal Worldviews on Evidence-based Nursing started.

Major Landmarks in History of Nursing Research at National Level (India)

Nursing research in India has its roots in the Philosophy of Florence Nightingale, which stated that profession is committed to the task of enlarging professional body of knowledge through systematic approach to solve problems. The statistics on the unsanitary conditions in the Indian army prepared by Florence Nightingale may be starting point of nursing research in India. Afterwards, many developments have taken place in India. Some of the major landmarks in history of Nursing Research in India are as follows;

1946: Bhore Committee (1943) submitted a report in which recommendation were made for the improvement of various aspects of nursing profession, nursing education, nursing research, working condition, nursing services in both hospital and community, sending nurses for higher education to abroad, etc.

1953: Ms. Edith Buchanan, Vice Principal, Rajkumari Amrit Kaur College of Nursing New Delhi, was the first nurse from India who was sent to Columbia University to earn Doctorate in Education (DEd) under World Health Organization (WHO) fellowship programme.

1955: Ms. Margaretta Craig, Principal, College of Nursing, New Delhi, attended International Council of Nurses (ICN) meet at France to present a paper on the need for nursing research.

1960: First two years’ master degree programme in nursing was started at RAK College of Nursing, New Delhi, which included nursing research as a full subject with a thesis work on nursing topics. Nursing research recommended on all India basis along with a master's degree programme in nursing in an intensive manner, although nurse leaders had been already participating in research at various levels. Clinical studies were even being carried on short-term basis by the beginning-level postgraduate nursing students.

1963: A study of health services was carried out in connection with the revision of syllabus of General Nursing and Midwifery (GNM) by the Indian nursing council in 1963. The study provided valuable insights into trends in the health services and implications for nursing.

1964: Dr. Marie Ferguson, a public health nurse who joined RAK College of Nursing, New Delhi, was able to create greater appreciation and understanding and value of the research in nursing for nursing practice, administration and education. With senior nursing leaders of the country, she conducted a research study titled ‘Activity Study to define Nursing and Non-Nursing Functions of Nurses in Selected Health Institutions of India.

1966: Trained Nurses Association of India (TNAI) established a research section under the guidance of chairwomen Ms. Margareta Craig. TNAI conducted Nurses ‘time utilization study’ with assistance from Ms. Anna Gupta, Principal RAK College of Nursing, New Delhi under supervision of Dr. Sulochana Krishnan.12

1971: TNAI conducted a study on socioeconomic status of Nurses in India.

1976: Dr. Marie Farrell and Dr. Aparna Bhaduri of RAK College of Nursing, New Delhi conducted seminars on nursing research for educationists at Delhi, Mussoorie (Uttarakhand) and Yercaud (Tamil Nadu) to strengthen the nursing research in India.

1981: Dr. Farrell and Dr. Bhaduri's book Health Research: A Community-Based Approach was published by the World Health Organization (WHO).

1984: A nursing research workshop was launched titled Teaching Nursing Research to Nursing College Teachers at Bangalore, which was sponsored by University Grant Commission (UGC). This workshop was open all the teachers of all the nursing colleges in India. A workshop was conducted on ‘Nursing Process’ By Dr. Marie Farrell at Leelabai Thackersey College of Nursing, SNDT Women University Mumbai, which was sponsored by the WHO.

1986: The Nursing Research Society of India (NRSI) was established to promote research within and related to nursing. Dr. (Mrs) Inderjit Walia was founder president, and Mrs. Uma Handa was its first secretary. The association continues to organize conference every year.

1986: M Phil Program started at RAK College of Nursing, University of Delhi, New Delhi.

1986: Introduction of nursing research process was introduced in B.Sc. Nursing syllabus by Indian Nursing Council (INC).

1986: PhD in Nursing started in College of Nursing, PGIMER Chandigarh and some private colleges such as Manipal College of Nursing, Manipal and Shri Ramchandran College of Nursing, Chennai.

1998: Nursing Research Interest Section was organized under the chairmanship of Mr R. Raj Arathnam (A senior nursing tutor, NIMHANS, Bangalore).

2002: INC revised syllabus of GNM and Post Basic B Sc Nursing (revised 2005) and included nursing research as individual subject

2004: Publication of Nightingale Nursing Times was started by Jain & Co. Noida Uttar Pradesh.

2005: Nursing and Midwifery Research Journal was started at National Institute of Nursing Education (NINE), PGIMER under the editorship of Dr. Inderjit Walia. Principal NINE, PGIMER, Chandigarh.

2005: National Consortium PhD nursing has been started by INC under the leadership of Shri T. Dileep Kumar, President, INC, New Delhi to promote research activities in various fields of nursing collaboration with Rajiv Gandhi University Bangalore (RGUHS) in support of WHO. Initially 6 centers established with web-conferencing facility and later on 2 more centers were added on. These centers are; NIMHANS, Bangalore, RAK College of Nursing New-Delhi, Christian Medical College (CMC), Vellore, Christian Medical College (CMC) Ludhiana, Seth Sukhlal Karnani Memorial Hospital (SKMM), Kolkata, Government College of Nursing, Thiruvananthapuram, Government College of Nursing, Hyderabad, and Institute of Nursing Education (INE), Mumbai.

2009: Central Institute of Nursing and Research (CIN) was brought in existence under control of TNAI, New Delhi.

2009: Indira Gandhi National Open University (IGNOU) started PhD in Nursing.13

2010: Faculty of Nursing Sciences, Baba Farid University of Health Sciences Faridkot, Punjab started PhD in Nursing.

TYPES OF RESEARCH

Research process provides a general strategy for gathering, analyzing and interpreting data to answer research question or test hypothesis. Broadly, research is classified on the basis of purpose of the study and approach of studying a phenomenon. The basic types of research are as follows:

Basic vs Applied
Descriptive vs Analytical
Quantitative vs Qualitative
Conceptual vs Empirical
Other types of research

Basic Research vs Applied Research (Table 1.2)

Basic Research is often referred a pure or fundamental research. The major purpose of basic research is to gain knowledge for knowledge sake. It helps to obtain empirical data that can be used to develop, refine, or test a theory for direct application to clinical practice. For example, work of laboratory technician or scientist in a laboratory. A researcher conducts a study on adolescent's attitude towards safe sex practices. Here, the researcher collects the data from adolescents about their sex practices. But after study it will conform that scope for negative attitude also exist in adolescents. Finding about this negative attitude is a new knowledge for a researcher.

Applied Research is conducted to gain knowledge that can be used in practical settings to improve the quality care. This type of research is actually performed in actual practical conditions. Most of clinical research falls in category of applied research. Although, the difference between basic and applied research appears to be distinct, a continuum exist between two extremities. Many studied provide clinical application as well as new knowledge that contribute to theoretical understanding of basic behavior. For example, a researcher might have seen that there is a wide variation in oxygen saturation of patients receiving different modes of oxygen delivery after giving the same amount of oxygen. So, the researcher may conduct a study either to identify the reason (for improvement of knowledge) and best method of oxygen delivery (practice improvement).

Table 1.2 Comparison of basic and applied research

Basic research	Applied research
It is pure or fundamental research	It is used in the field of practice to solve a problem
It is done to study a general phenomena or a process	It is targeted to solve a practical problem for utilization purpose
It is abstract or theoretical	A theory or part of theory is tested to find the utility
It is conducted for the sake of knowledge and is believed as a starting point in knowledge expansion	It is useful in creating evidences

Descriptive vs Analytical

Descriptive research includes surveys and fact finding enquiries of different kinds. The major purpose of descriptive research is description of phenomena as it exists at present. In analytic research, on the other hand, the researcher has to use facts or information already available, and analyze these to make a critical evaluation of the material.

Quantitative vs Qualitative Research (Table 1.3)

Quantitative research is a systematic collection of numerical information, often under conditions of considerable control to test a hypothesis or refine a theory. The collected information are analyzed with the help of statistical procedure. Major quantitative research designs used are experimental, quasi experimental and non-experimental (descriptive, correlational and exploratory research).

For example, A descriptive study to assess stress and coping strategies among nursing students at a selected private nursing college, Punjab.

Qualitative research deals with the systematic collection of more subjective and narrative information to develop in depth understanding about the topic. Qualitative research is important when quantitative research is not feasible to study some aspects of human behavior like studying hope, and motivation level in a dying patient is easy to explore through qualitative study. Here, data are analyzed with the help of coding, indexing and narrations for the purpose of discovering meaning and pattern of relationship in underlying construct. The major qualitative research designs are phenomenology, grounded theory, ethnography, case study and historical research.

For example, a phenomenology on life experience of HIV/AIDS patients admitted in a palliative care center, New–Delhi, India.

A phenomenology on life experiences of Victims of Bhopal gas tragedy at Bhopal, Madhya Pradesh

Conceptual vs Empirical

Conceptual research is related to some abstract idea(s) or theory. It is generally used by philosophers and thinkers to develop new concepts or to reinterpret existing one. Empirical research is data based research, coming up with conclusions which are capable of being verified by observation or experiment. We can also call it as experimental type of research. In such a research it is necessary to get at facts first hand, at their sources and actively to go about doing certain things to stimulate the production of desired information.

Other Types of Research

All other types of research are variations of one or more of the above stated approaches, based on either purpose of the research, or the time required to complete the research, on the environment in which research is done, or on the basis of other similar factors. From the time point of view, we can take example of time series, cross sectional or longitudinal research. Research can be field setting or laboratory research or simulation research, depending upon the environment in which it is to be carried out.15

Characteristics of Qualitative Research

Many attempts have been made to characterize qualities that distinguish qualitative work from others research approaches. The following are some salient features of qualitative study;

Natural setting: Qualitative study conducted in natural setting to explore the phenomena in depth. In qualitative work, the intent is to explore human behaviors within the contexts of their natural settings.
Subjectivity: Qualitative researcher is interested in inner states of human activity. Because these inner states are not directly observable. Qualitative researcher must rely on subjective judgment to bring them to light. Most qualitative researcher would deny the possibility of pure objectivity in any scientific endeavors.
Participant perspective: Qualitative research seeks to understand the world from the perspective of research participants. Qualitative studies try to capture the perspective that human use as basis for their action in special social setting.
Researcher a data gathering instrument: Traditional quantitative methods generate information through the use of instruments such as questionnaire, scale, checklist, test and other measurement device, while the principal data for qualitative research are gathered directly by the researcher themselves. The logic behind research as instrument approach is that the human capacities necessary to participate in social life are the same capacities that enables researcher to make sense of the actions, intentions and understanding of those being studied.
Wholeness and complexity: Qualitative work starts with the assumptions that social settings are unique, dynamic and complex. Qualitative method provide means whereby social contexts can be systematically examined as whole, without breaking down in to isolated, incomplete and disconnected variable. Qualitative report are usually complete, detailed and narrative that included the voice of participants being studied.
Emergent design: It is characteristic of qualitative study that study change as they are being placed into operation. The goal of qualitative study is to get into a social phenomenon in deep inside in a special social setting, therefore, it is impossible to construct and choose a design before actual conduction of the study. So, design will be emerged during study process and so called ‘emergent design’.
Inductive data analysis: Qualitative researchers do not start with null hypothesis to retain or reject. They collect as many details information necessary from the research setting as possible, then establish pattern of relationship among the phenomena.
Reflexivity: This is another important characteristic of a qualitative study. Reflexivity can be broadly described as qualitative researcher's engagement for continuous examination and explanation about how they have influenced research project. Reflexivity involves an awareness that the researcher and the object of the study affect each others mutually and continually in the research process. However, the extent to which researchers engage in reflexivity depends on the methodological approach they have adopted for the study.

Table 1.3 Quantitative and qualitative research

Characteristics	Quantitative research	Qualitative research
Philosophical origin	Logical positivism	Naturalistic, interpretive and humanistic
General Nature	Objective approach to seek precise measurement in numerical form and also known as ‘hard science’	Subjective approach to study a phenomena in depth and also known as ‘soft science’
Aims	To test hypothesis or to refine theory	To develop theory, and assumptions
Focus	Concise and narrow	Broad and complete
Knowledge of Variable	Study variable are operationally defined and well understood	Researcher may have only rough ideas of study variables
Research design selection	Study is planned properly and a rigorous methodology is selected before preceding the study. It is reductionist in nature	Research Methodology is flexible and design emerges in between the study and called ‘emergent design’. It is holistic in nature
Origin of research problem	Researcher have to use deductive approach to formulate problem	Inductive approach is helpful to reason out problem
Sample size	Quantitative studies based on large sample size in order to generalize the findings	Usually, a small sample size is obtained
Data types	Numerical data	Narrative or descriptive data
Duration of data collection	It takes long time to collect data in case of large sample size	Usually, it is short but time consuming to explore the minute details
Study Instruments	Usually questionnaire, rating scale and checklist are used to collect numerical information	Interview,(structured, unstructured, focus group) and observation are common method used to collect information
Duration of data analysis	Usually, it takes very short time to analysis data with the help of many statistical software like SPSS, Minitab and SYSTAT	It takes very long time in indexing, coding the data. Scope for statistical software application is negligent
Use of Statistics	Researcher use descriptive and inferential statistic to analyze data	Scope of descriptive and inferential statistics is narrow. Researcher analyze the data through words, pictures, indexing, and thematic analysis, etc.
Role of researcher	Researcher is passive in quantitative study	Researcher has to participate actively to explore the given construct

SCOPE AND AREAS OF NURSING RESEARCH

The research findings can be utilized to solve problems in government, business, society and health care. Nursing research has wide scope in nursing practice, education and management/administration. The research findings are utilized in different areas of nursing in order to expand and improve knowledge for improving quality education and practice.17 The scope of research may be classified under following headings:

Research in nursing education
Research in nursing practice
Research in nursing management and administration.

Research in Nursing Education

Nursing education is an important area to build up theoretical knowledge about nursing and its related issues. Nursing education research centers on developing and testing more efficient educational processes, identifying new ways to incorporate technology in order to enhance learning and discovering more efficient approaches to promoting lifelong learning. To achieve these goals, the use of rigorous research strategies in the assessment of teaching and learning process and outcomes at all level of nursing education is essential. The expectation and competencies of graduate at each level of nursing education in regards to research are described below.

(As per National League for Nursing NLN, 2008)

Curriculum design and evaluation, including community driven model for curriculum development
New pedagogies
Innovation in teaching and learning
Use of instructional technology, including new approaches to simulated learning
Student/teacher learning partnership
Client teaching model
Assessment of students learning in class room settings and practice
New model for teacher preparation and faculty development
Quality improvement processes
Educational system and infrastructures.

Research in Nursing Practice

High quality and cost effective care is the demand of consumers nowadays. In the scenario of evidence base practice (EBP), the scope of research is widely recognized in nursing practice. Nursing's expanded view of health emphasizes health promotion, restoration, and rehabilitation as well commitment to caring and comfort. The scope of research in practice ranges from acute to chronic care experiences across the entire lifespan; health promotion, and preventive care to end of life care; care for individuals, families, and communities in diverse settings.

Research areas as per International Council of Nurses (ICN, 2009 and NINR, 2007, 2010)

Health promotion, prevention of illness and control of symptoms
Quality and cost effectiveness of care
Impact of nursing intervention on client outcomes
Evidence-based nursing practice
Community and primary health care
Living with chronic condition and quality of life
Caring for clients experiencing change in their health and illness18
Assessing and monitoring client problems
Providing and testing nursing care intervention
Symptom management, self management and care giving
End of life research.

In practice, many other subareas maybe possible. However, researcher may select the topic of interest and area of specialization for research.

Nursing Management and Administration

This is extremely important area of nursing practice as well nursing education. Research may also be used to explore problem related to nursing management and administration in order to improve staff satisfaction, decrease turn over and augment work satisfaction.

(Research areas as per ICN, 2009)

Nursing manpower including quality nurses, work life, retention, turn over, satisfaction with work
Nursing research in delivery of care services
Impact of health care reform on health policy, programme planning and evaluation (impact studies)
Financing health sector.
Impact of equity and access to nursing care and its effect on nursing.(outcome research)

Apart from above mention areas, many other sub areas maybe possible in nursing management and administration which need investigation.

Other research areas given by various professional bodies and organizations

Indian Nursing Council (INC)

The following areas are given by Indian Nursing Council:

Clinical intervention studies
Practice standards in various nursing specialties
Nursing education measurement, evaluation competencies, innovation in teaching strategies
Manpower planning
Cost benefit analysis
Quality assurance in education and practice
Development of tools
Testing nursing theories and model and theory development
Impact studies that have policy implications for nursing education and practice
Independent nursing practice related research.

Areas according to Survey by nurse executives from Magnet Hospital (2007)

Clinical outcomes
Practice environment issues satisfaction
Human resources issues.

Areas according to Sigma Theta Tau International Honor Society

Promotion of healthy community through health promotion and disease prevention
Implementation of evidence-based practice
Targeting the needs of vulnerable populations (chronically ill)
Capacity development for research by nurses.

Many international and national bodies and organization like World Health Organization (WHO), Ministry of Health and Family Welfare (MOHFW) and Trained Nurses Association of India (TNAI) also given certain sub areas where research may be conducted to explore the hidden and buried issues.

IMPORTANCE OF RESEARCH IN NURSING

Nursing research has an important place in nursing science and is becoming increasingly recognized. Research is a vital aspect of the health services and essential to the provision of effective and safe health and social care. It is believed that patients and the public have the right to expect their care to be based on the best available research evidence. As nurses play a pivotal role in delivering health and social care, research on nursing practice and key nursing issues is essential to ensure continuous improvement and safe, effective and evidence-based health and social care for people seeking health care services. Some facts that justify the importance of conducting research are as follows:

Research promotes evidenced based nursing care: The nursing profession exists to provide services to individual, community or society as whole. The provided services based on scientific knowledge. Research has been determined to be the most reliable method of obtaining knowledge. Nursing research is essential for the development of empirical knowledge that enable nurses to provide evidence-based nursing care. Evidence based nursing (EBP) practice means that nurses make clinical decision based on best available research evidences, their clinical practice and the health care preferences of their patient/clients.
Provide accountability of nursing practice: Independent role of nurse brought a greater need of accountability in practice. To be accountable for their practice, nurses should have sound scientific research based knowledge.
Develop model and framework for nursing practice: Nursing research helps to formulate models and framework for variety of nursing settings. It provides a scientific basis for development of nursing models and theory. Nursing models helps to provide nursing care systematically. Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice.
Ensure credibility of nursing profession: Nurses must demonstrate to the general public that nursing makes difference in the health status. In the past nursing was thought of a vocation than profession. Research builds a body of professional knowledge that made nursing distinct from other disciplines.
Improve cost effectiveness in nursing practice: The goal of nursing services is to help people to achieve or maintain health, regardless of cost. The reality of the health care picture has forced nurses to think in monetary terms. Consumers have become more aware of the cost of health care and asking for explanation of service they receive. Nursing20 services consumes a large percentage of a hospital's budget. Quality patient care and reduction in cost through careful management of resources are the function of well designed research. By encouraging ongoing improvement to practice and exploring new approaches, research can improve the productivity and efficiency of the health and social organization.
Others
- Research helps to understand the practice environment and therefore help to design treatment in different environment.
- Research helps to understand the nurses to deliver best possible care.
- It develop new insight about the process involved in receiving and giving care.
- A research intensive environment is essential in order to generate the science base for nursing and interpersonal practice and to educate future generations of nurse scientists.
- Nurses’ frontline role puts them in a unique position to reflect the needs and concern of patients and the public. Encouraging nurses to lead and contribute to research keeps research activity focused on patient care and the needs of our health services.
- Fully resourced nursing research in priority areas of practice improves the quality of care given to patients and thereby increases public confidence in health and social care services.
- Nursing research and evidence implementation are essential parts of the education and training of India's existing and future nursing workforce.

EVIDENCE-BASED PRACTICE (EBP)

Over the past several years, the concept of EBP has appeared with increasing frequency in the nursing literature. EBP is similar to research based practice and has been called an approach to problem-solving in clinical practice that conscientiously uses the current ‘best’ evidence in the patient care. It involves identifying a clinical problem, searching in literature, critically evaluating the research evidence, and determining appropriate interventions. EBP will help to fill the gap between research, theory and practice.

Origin of Evidence-Based Practice (EBP)

The concept of EBP originated in the late 1980s. EBP was built on the premises that health professionals should not center practice on tradition and belief but on sound research based information. EBP and research are not synonymous. They are both scholarly process but focus on different phases of knowledge development. EBP refers to the integration of individual clinical expertise with the best available external clinical evidence from systematic search.

Definitions

In medicine, EBP has been defined as conscientious, explicit and judicious use of the current best evidence in making decision about the care of individual patient. To distinguish nursing from medicine regarding EBP, a number of different definitions are given by many scholars. Some important definitions are given here;21

‘EBP is the conscientious, explicit, and judicious use of theory derived research base information in making decision about care delivery of individual or group of patients and in the consideration of individual needs and preferences’.

(Ingersoll, 2000)

‘EBP is the using of best available evidence available to guide clinical decision making’.

(Benefield, 2002)

‘EBP is the use of evidence to support decision-making in health care’.

(Greenberg and Pyle, 2004)

‘EBP is an integration of the best evidence available, nursing expertise, and the values and preferences of the individual, families and communities who are served’.

(Sigma Theta Tau, 2005)

‘EBP is an integration of the best research evidence with clinical expertise and patient value to facilitate clinical decision making’.

(Di Censo et al, 2005)

So, all above definitions indicates that EBP is a problem-solving approach using current best evidence to answer a clinical question incorporating one's own clinical expertise, and patient values and preferences.

Terms related to Evidence-Based Practice (EBP)

Best research evidence: The research evidence are ranked and described here. Researcher has to select the best available evidence according to clinical research questions.

Level 1: Systematic review of randomized and nonrandomized clinical trails

Level 2: Single randomized and nonrandomized clinical trails

Level 3: Systematic review of correlational and observational studies

Level 4: Single correlational and observational studies

Level 5: Systematic review of descriptive, qualitative and physiologic studies

Level 6: Single descriptive, qualitative and physiologic studies

Level 7: Opinions from authorities, and expert committees

Fig. 1.3: Evidence hierarchy
22

Level 1 is the best resource to use when looking for evidence-based practice.
Clinical expertise: The knowledge and experience of the clinician (physician, nurse and other health professionals).
Patient value and preferences: These are individual's own concern, preferences, expectation and social and financial resources that impact the health and health care.
Clinical data (assessment) and history: A patient's assessment includes important evidences that should be considered in treatment decision.

Fig. 1.4: The EBP model

Fig. 1.5: The EBP model (Best patient outcomes)

Critical Features of Evidence-Based Practice (EBP)

EBP has several critical features. Some of the important features are given below:

It is problem based approach and considered the context of the practioner's current experience.23
EBP bring together the best available evidence and current practice by combining research with tacit knowledge and theory.
EBP is a systematic and objective process.
EBP facilitates the application of research findings by incorporating first and second hand knowledge.

Table 1.4 Comparison of nursing research and evidence-based practice

Nursing research	Evidence base practice
Problem identification	Clinical problem identification
Conducting research	Using research already conducted
Following steps of research process	Synthesizing all of the evidence and integrating with expert opinion and patient input
Findings usually not immediately applicable and need to be translated to practice through research or EBNP	Findings usually applied at bed side and tailored to individual patient

Steps of Evidence-Based Practice (EBP)

Melnyk and Fineout-Overhott (2011) suggest that EBP involve five critical steps:

Select a clinical research question: The first step of EBP is to select a research question from clinical area. The selection of clinical research problem can be result of following triggers;
Knowledge focused triggers: These triggers come from advancement of knowledge of health care professionals through reading literature or attending professional conferences. For example, implementation of revised guidelines or standard to improve the health care practices.
Problem focused triggers: These triggers are identified by the health care professionals in response to clinical problem, barriers or any others constrained face in day-to-day life in clinical areas. Problem focused triggers may arise in the course of clinical practice or in the context of quality assessment of quality improvement efforts. For example, problem of high sepsis or relapse rate in ICUs or high fall rate of patients, etc. The clinician should appropriately frame clinical research question by using following acronym called PICO. PICO should be part of every search for evidence to improve practice. PICO stand for following;
- P–Patient population
- I–Intervention of interest
- C–Comparison intervention or status
- O–Outcome of interest.

For example, ‘are self-management strategies are more effective than medical care alone for improving health status, quality of life and occupational functioning among adult with coronary heart disease?’24

Use of PICO approach

P–Adult with coronary heart disease
I–Self-management strategies
C–Medical care
O–Health status, quality of life and occupational functioning.

Search relevant literature review: Once the clinical question selected, the researcher should explore the relevant literature review through clinical studies, meta analysis findings, expert opinions or existing EBP guidelines. Before concluding the literature, it is also a good strategy to read and understands the literature in whole.
Critically appraise the evidences: The available evidences should be critically evaluated for strengthen and weaknesses. Critical appraisal should be focused for evaluation of their feasibility like in term of cost, duration, need of manpower, and other resources, etc.
Implement the best evidence in practice: After critical appraisal of the evidence, the researchers should decide to implement the best available evidence in clinical setting. Following review and systematic analysis of the systematic data, the nurse must determine what the research demonstrate and decide the level of evidence in order to make recommendations to promote EBP. The best evidence should be integrated with patient preferences, values, clinical experts, and patients’ assessment information before actual implementation in clinical practice.
Evaluate the change in practice: Finally the researcher must determine the expected change in practice and level of evidence in order to make recommendations to promote evidence-based practice.

5 As Step of EBP

Ask: formulate the question
Acquire: evidence search for answers
Appraise: the evidence for quality and relevance
Apply: the results
Assess: the outcome

Importance of EBP in Nursing

Nursing is a practice profession; it is important that clinical practice to be based on research based evidence rather than intuition and other traditional belief. EBP help to improve the nursing care by providing evidence-based nursing care. Importance of EBP in nursing are given below:

EBP improve patient care
Incorporating research findings in practice helps in decision making
It improves nurses and other health care professional's job satisfaction and reduce employees turnover in a organization
Providing evidence-based care develop confidence in health professionals
EBP improve the consumer (patient and their family members) satisfaction in health care services
EBP support for quality and cost effectiveness of nursing intervention.

Barriers to EBP in Nursing

The concept of EBP is relatively new in nursing, still somewhat sophisticated because many nursing practices are based on tradition, belief, experience, common sense and untested theories. Although, there is significant support for increasing emphasis on EBP in nursing still, there are many barriers to implement EBP in nursing. Some of the common barriers to EBP in nursing are given below:

Lack of knowledge regarding EBP strategies
Negative views about research and evidence-based practice
Lack of belief that EBP will result in more positive outcomes than traditional care
Voluminous amount of information in profession journals
Lack of time and resources to research
Overwhelming patient load
Organizational constraints (i.e. lack of administrative support)
Demands for certain types of treatment from patient side
Peer pressure to continue with practices that are steeped in tradition
Inadequate theoretical contents and skill regarding EBP in educational programme
Lack of support from colleagues
Lack of motivation to do new things in nursing
Fear of rejection or to change.

Chapter Notes

Introduction to Nursing Research1