Introduction to Nursing ResearchCHAPTER 1

Research is diligent, systematic inquiry or investigation to validate and refine existing knowledge and generate new knowledge with some specific goals. It is a systematic process which focused on uncovering new knowledge to help understand phenomena, answer questions, or address problems. The main goal of research is the gathering and interpreting of information to answer questions. A number of different definitions for research exist however common to all of them is an agreement that research is systematic, disciplined and focused on gathering information to understand a phenomena, answer questions or solve research problems. The systematic nature of the research process means that research is undertaken in a methodological fashion using a rigorous approach to collect information (data) about a phenomena or research problem and to analyze and interpret that information in order to begin to answer questions or solve problems since research is directed at ultimately helping us to answer a question or address a problem. In general research means, the research process which deals with the ways and strategies used by researchers to understand the world around us. In the broadest sense of the word, the definition of research includes any gathering of data, information and facts for the advancement of knowledge.

‘A careful enquiry or examination in seeking facts or principles, a diligent investigation to ascertain something.’

This aim is especially applicable for descriptive research where the researcher observe and describe the gather information that illuminates relationships, patterns and links between variables. An example would be an investigation of the link between students’ study skills and course drop-out rates.

Prediction in research fulfils one of the basic desires of humanity, to discern the future and know what fate holds. Such foresight used to involve studying the stars or looking at the 3entrails of animals. To a certain extent, most scientists regularly use prediction in research as a fundamental of the scientific method, when they generate a hypothesis and predict what will happen. For example, some environments were unhealthier than others, especially in a hot climate where gangrene was a problem. The purpose of this type of research is to develop a model that predicts the likely course of events given particular intervening variables or circumstances.

The main aim of research is to explain the phenomena. Exploratory type of research investigates an area or issue on which little previous work has been carried out. In an organisational setting it may be used to discover whether or not a problem exists. Explanatory type of research also aims to show why relationships, patterns and links occur. For example, how could study skills support improve student retention? And does this depend on other factors such as different types of support available.

Sometimes research is implemented strategically, where researchers take account of current situations and speculate as to their future implications. For example, the introduction of a specific government policy might raise implications for practitioners involved in its implementation. Research of this nature might speculate as to what these implications might be and develop a programme of inquiry that can inform future responses to these issues.

To evaluate the impact of something, e.g. a new policy, event, law, treatment regime or the introduction of a new system.

A human child has to meet and solve his problems. The problems which present themselves in his physical surroundings, his intellectual association and in his social contacts can grow in number and complexity as the child grows older an older. His success in life is in large measure determined by individual's capacity and competence to solve them. Problem exists for him at every step; his growth, development and living lie in their solution. In school, the child is to be trained in the art and craft of problem-solution.

According to Yoakum and Simpson: ‘A problem occurs in a situation in which a felt-difficulty to act is realized. It is a difficulty that is clearly present and recognized by the thinker. It may be purely mental difficulty or it may be physical and involve the manipulation of data. The distinguishing thinks about a problem however is that it impresses the individual who meets it as needing a solution. He recognizes it as a challenge.’4

The problem-solving process consists of a series of steps that are followed depending on the type of problem to be solved. These are:

The normal process for solving a problem initiating involves defining the problem which is to be solved. In this first stage, there is a need to write down what exactly the problem entails, 5which helps to identify the real problem that is under study and needs an immediate solution. This is considered as the most essential steps of the problem-solving, because by defining the problem it helps in proper perceiving which helps in analyzing the problems. Without this next steps cannot be executed. Eminent author of the subject are of this opinion that a problem well-defined is half solved. Sufficient time should be spent on defining the problem as it is not always easy to define the problem and to see the fundamental thing that is causing difficulty and that needs correction. Right answer to the right question can be possible by having only clear definition.

After perceiving the problem the next step is to analyze how the problem affects the researcher and his or her current situation and the other people involved in this situation. In addition, the gravity of the problem and all the factors which are contributing to the problem are determined. Furthermore, the analysis helps in understanding the source of the problem and how it affects the current development and researcher's environment.

When the real problem is discovered, its contributing factors should be investigated. At this stage, focus must be on identifying and generating all possible solutions for a problem. Each potential idea for solution of a problem must be considered without discarding it through value judgment, however, each idea should be treated as a new idea in its own right and worthy of consideration.

In this section of the problem-solving process, various factors about each of the potential solutions are investigated where in the entire positive and negative aspects of each solution against the problem are analyzed. The feasibility of each solution are also analyzed.

At this stage, an attempt is made to compare the available solutions. The available solutions can not only compared in terms solving the problem but also in terms of feasibility, resources needed and time taken. The eventually the best solution is selected based on careful judgment, which is supposed to solve the problem swiftly and smoothly. The alternatives also evaluated on three matters those are:

Implementing the solution is the step of the problem-solving process which is putting plan into action. Here we practically solve the problem by implementing the selected solution.

This is the final stage of the problem-solving process where after implementation of the most potential solution and evaluation is made to judge the effectiveness of the solution in resolving 6the problem. This stage also helps to redefine the problem and revise the problem-solving process in case the initial solution fails to manage the problem effectively.

The scientific method is a logical and rational order of steps by which scientists come to conclusions about the world around them. The scientific method helps to organize thoughts and procedures so that scientists can be confident in the answers they find. Scientists use observations, hypotheses, and deductions to make these conclusions, various possibilities using the scientific method is to eventually come to an answer to the original question.

Retrospective means observe the past, retrospective studies examines the data already collected in the past. Here the outcomes have all occurred before the starting of the investigation. This type of study is known by a variety of names. Retrospective studies are generally more economical and produce results more quickly than prospective study. In these studies a phenomena existing in present is linked to the phenomena that occurred in past before the study was initiated. For example, review of medical records to assess the previous history of cholesterol levels in myocardial patients, in this type of study sometimes we move from effects which had already occurred to identify its cause. To identify predisposing factors of any diseases are the examples of retrospective studies.

The study starts with a presumed cause and then goes forward in time to the presumed effect. Independent variables is in present and its effect on dependent variables is studied in forward, i.e. in future to test the association. These studies are more costly than retrospective study but these studies are stronger than the other. For example, study describing social support and coping mechanisms of women with ovarian CA. Cohort studies are also the examples of prospective studies.

Research on nursing practice began slowly, but since 1950 has been accelerating rapidly. The ultimate purpose of nursing is to provide high quality patient care. Nursing research must address questions relevant to the profession of nursing. It grow the body of literature which means body of knowledge related to nursing profession. Clinical nursing practice without research is based on tradition without empirical evidences. Research is needed to evaluate the effectiveness of nursing treatment modalities, to determine the impact of nursing care on the health of the patients or to test theories.

According to International Council of Nurses (1986)—‘Nursing research is a way to identify new knowledge, improve professional education and practices and use of resources effectively.’

The scope of nursing practice describes the ‘who,’ ‘what,’ ‘where,’ ‘when,’ ‘why,’ and ‘how’ of nursing practice. Each of these questions must be answered to provide a complete picture of the dynamic and complex practice of nursing and its evolving boundaries and membership. The profession of nursing has one scope of practice that encompasses the full range of nursing practice, pertinent to general and specialty practice. The depth and breadth in which individual registered nurses engage in the total scope of nursing practice is dependent on their education, experience, role, and the population served.

Nursing education is another important area of nursing research where nurse researchers try to generate or refine the knowledge, which is useful to improve the teaching learning methods and environment in nursing discipline. The main aim of nursing education is to continuously provide skilled nursing manpower to country, which is the need of hour for a country like India. There are several issues and sub-areas of nursing education on which nursing research may focus they are:

Administration is one of the most difficult disciplines to manage. Similarly, nursing administration also encounters several problems and issues that require solution and a solution may be obtained through research. Therefore, there are several main subareas of nursing administration which requires investigation such as:

Research in health system and outcome of care is one of the important areas of nursing research, where nurse scholars may identify the success of presently existing health care delivery systems and models in country and to identify the ways and means to develop affordable quality of health care to individual, families and communities of the country.

If analyzed properly, historical knowledge can provide insight into the past, leading to resolution of present and future issues in nursing. The history of nursing comprises many changes and developments. The historical evolution of research in nursing can be traced back to Florence Nightingale, who made detailed records of observations about the effects of nursing actions. During 1970s and 1980s, numerous studies were conducted that focused on clinical practice.

Florence nightingale was one of the founder of professional nursing and is considered as the first nurse researcher. During the Crimean war, she kept a meticulous record and statistics of mortality rates among the sick and the wounded.

Research related to nursing in India has its roots in the philosophy of Florence nightingale which stated that the profession is committed to the task enlarging professional body of knowledge through systematic approach to solve problems in nursing.

The use of research in nursing practice is a topic of pressing concern to the profession. Some would argue that the development of practice relevant research and the use of research findings into delivery of health care is unimportant. The amount of current literature devoted to topics related to use of research, the strong endorsement of the professional organization and the nature of federally funded projects all attest that the use of research findings in practice is a significant professional objective.

Barriers to the use of research findings by practicing nurses can be organized into three categories:

The nursing profession is acutely aware of the problems discussed above and a number of ways to facilitate the translation of nursing research into practice have been advanced.19

Lewin's three phases of planned changes:

It involves breaking down to old traditions and customs to make way for new alternatives. This might entail motivating nurses to abandon their usual approach to practice based on intuition and to substitute a desire to provide patient care based on tested theories and knowledge about human responses to health and illness.

It requires new patterns of behaviors acquired through the mechanism of identification and internalization.

It is the process by which the newly acquired behaviors become integrated into the nurse's personality and work role.

Nursing research focuses on the role of nursing care in the prevention of illness, care of sick and the promotion and restoration of health. Although it relies upon and utilizes the substantive scientific information and methodology provided by the other biological and behavioral sciences, it differs from those other scientific areas in that it focuses on their relevance to nursing rather than other aspects of health care. The product of research is knowledge or science (National Academy of Sciences,1977).

The purpose of conducting research is to generate new knowledge or to validate existing knowledge based on a theory. Research studies involve systematic, scientific inquiry to answer specific research questions or test hypotheses using disciplined, rigorous methods. While research is about investigation, exploration, and discovery, it also requires an understanding of the philosophy of science. For research results to be considered reliable and valid, researchers must use the scientific method in orderly, sequential steps.

Evidence-based practice (EBP) is a problem-solving approach to patient care that integrates the best evidence from well-designed studies with clinician's expertise, patient assessments, and patient's own preferences leads to better and safer care, better outcomes and lower health care costs. Unlike research, EBP is not about developing new knowledge or validating existing knowledge. It is about translating the evidence and applying it to clinical decision-making. The purpose of EBP is to use the best evidence available to make patient-care decisions. Most of the best evidence stems from research. But EBP goes beyond research use and includes clinical expertise as well as patient preferences and values. The use of EBP takes into consideration that sometimes the best evidence is that of opinion leaders and experts, even though no definitive knowledge from research results exists. Whereas research is about developing new knowledge, EBP involves innovation in terms of finding and translating the best evidence into clinical practice.

Research utilization (RU) is the process of synthesizing, disseminating and using research generated knowledge to make an impact or change in the existing practice in society. The time lag between generating and using new knowledge by society has been a concern for many years. For example, the time lag between the discovery of citrus as a preventive measure for scurvy and its use on British ships was 264 years (Glaser, Abelson and Garrisons 1983).

The EBP process has seven critical steps:

Cultivating a spirit of inquiry means that individually or collectively, nurses should always be Cultivating a spirit of inquiry how to improve health care delivery. For this the nurse should develop her own attitude to learn new things or attitude to enquiry what are the lacunas. By this the nurse can get different issues and problems inn health care delivery.

The burning clinical question commonly is triggered through either a problem focus or a knowledge focus. Problem-focused triggers may arise from identifying a clinical problem or from such areas as risk management, finance, or quality improvement. Knowledge-focused 23triggers may come from new research results or other literature findings, new philosophies of care, or new regulations. Sometime during giving care the nurse can face different challenges which can act as a base to go to next step.

Regardless of the origin, the next step in the EBP process is to review and appraise the literature. Whereas a literature review for research involves identifying gaps in knowledge, a literature review in EBP is done to find the best current evidence. Here the nurse researcher has to collect the most relevant and best evidence. In searching for the best available evidence, nurses must understand that a hierarchy exists with regard to the level and strength of evidence. All of the various hierarchies of evidence are similar to some degree. The highest (strongest) level of evidence typically comes from a systematic review, a meta-analysis, or an established evidence-based clinical practice guideline based on a systematic review. Other levels of evidence come from randomized controlled trials (RCTs), other types of quantitative studies, qualitative studies, and expert opinion and analyses.

Once the evidence is gathered, the researcher must critically appraise each study to ensure its credibility and clinical significance. Critical appraisal often is thought to be tedious and time-consuming. But it's crucial to determine not only what was done and how, but how well it was done. An easy method for conducting critical appraisal is to answer these three key questions:

The final steps of the EBP process include integrating the evidence with one's clinical expertise, taking into account patient preferences, and evaluating the effectiveness of applying the evidence. Disseminating or reporting the results of EBP projects may help others learn about and apply the best evidence. Examples of potential EBP projects include implementing an evidence-based clinical practice guideline to reduce or prevent UTIs, evaluating an evidence-based intervention to improve wound healing, and applying an EBP to improve compliance with a specific treatment for a chronic disease.

The first step of EBP is to select a research question from clinical area. The selection of clinical research problem can be result following triggers:

Once the clinical question selected, the researcher should explore the relevant literature review through clinical studies, expert opinions or existing EBP guidelines.

Finally after the implementation of the useful findings for the clinical practice; the researcher must determine the expected change in practice and the benefits of the evidence used.

Most people believe that a good idea generated through research will spread rapidly and the idea will quickly be used. But this is seldom true. During most of the 20th century research findings where seldom used by nurses to improve practice.25

This is the first stage of awareness of the existence of an innovation or a new ideas for use in practice. Knowledge of research finding can be obtained by formal communication through conference presentation, publications in clinical and research journal. Internet sites, news releases on television and in newspaper. In addition, informal communication within an agency from one nurse to another or among different health professionals can be effective in increasing awareness of research knowledge.

In this stage an individual or a group is motivated to adopt the innovation. Innovations with highly relative advantages and beneficial result will be easily and rapidly adopted. In this stage, the proposed change is best communicated in small group or one-to-one interaction.

All this stage, the innovation is either adopted or rejected. Adoption involves full acceptance and implementation of the innovation or intervention in practice.

In this stage, the intervention is put to use by an individual, a clinic a hospital unit, many units or a group of hospitals. A detailed plan for implementation that addresses the risk and benefits of the intervention will facilitate change.

During this stage nurses evaluate the effectiveness of the change in practice and decided to either continue or discontinue it. After using the new interventions one-two month onwards, data must be collected about the effectiveness If any advantages evaluated then the innovation can be adopted easily. It there is no benefit occurred then intervention may be discontinued.

The Iowa model of evidence-based practice provides direction for the development of EBP in a clinical agency. This EBP model was initially developed by Titler and colleagues in 1994 and revise in 2001.

The Stetler model of research utilization helps practitioners assess how research findings and other relevant evidence can be applied in practice. This model examines how to use evidence to create formal change within organizations, as well how individual practitioners can use research on an informal basis as part of critical thinking and reflective practice. The model links research use, as a first step, with evidence-informed practice. The Stetler model provides a way to think about the relationship between research use and evidence-informed practice. These two concepts are not the same. Integrating both concepts enhances the overall application of research. The Stetler model first developed in 1976 and refined in 1994 and once again update in 2001.

This step include the identification of the purpose of consulting evidence (such as need to solve a problem and recognize the need to consider important contextual factors that could influence implementation. The researcher should note that the reasons for using evidence will also identify measurable outcomes.

This step include critiquing and synthesizing of the evidence. When using the evidence the nurse has to assess each source of the evidence for its level of overall credibility, applicability and operational details, with the assumption that a methodologically weak study may still provide useful information in light of additional evidence and determine whether a given source has no credibility or fit and thus whether to accept or reject it for synthesis with other evidence and lastly summarize relevant details regarding each source in an ‘applicable statement of findings’ to look at the implications for practice.

This step include:

When the nurse is using evidence-based practice she should be, write generalizations that logically take research findings and form action terms:

In this last stage of utilizing research evidence the nurse has to evaluate change strategies and pilot project.