Advanced Quantitative Methods

1. Advanced Quantitative Methods William L. Holzemer, RN, Ph.D., FAAN Professor, School of Nursing University of California, San Francisco bill.holzemer@nursing.ucsf.edu

2. Objectives • Develop your definition of nursing science • Use the Outcomes Model to think about your area(s) of interest • Review quantitative methods • Think about how we build knowledge to improve health and nursing practice.

3. Assignments • PhD Students -individual assignments • MS Students – group assignment • Mini-literature review • Outcomes Model • Substruction • Synthesis Tables • Summary

4. Nursing = Nursing Science? Definition of Nursing American Nurses Association: “Nursing is the assessment , diagnoses, and treatment of human responses”

5. Definition of Nursing Japan Nurses Association “Nursing is defined as to assist the individual and the group, sick or well, to maintain, promote and restore health.”

6. Definition of NursingInternational Council of Nurses “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.”

7. Common Elements:Definitions of Nursing • Person (individual, family, community) • Health (Wellness & Illness) • Environment • Nursing (care, interventions, treatments)

8. Nursing Science The body of knowledge that supports evidence-based practice

9. Qualitative Understanding Interview/observation Discovering frameworks Textual (words) Theory generating Quality of informant more important than sample size Rigor Subjective Intuitive Embedded knowledge Quantitative Prediction Survey/questionnaires Existing frameworks Numerical Theory testing (RCTs) Sample size core issue in reliability of data Rigor Objective Public Nursing Science Uses Various Research Methodologies

10. Quantitative Non-Experimental or Descriptive Experimental or Randomized Controlled Trials Ethnography Content Analysis Models of analysis: Parametric vs. non-parametric Qualitative Grounded theory Ethnography Critical feminist theory Phenomenology Types of Research Methods:(all have rules of evidence!) Models of analysis: fidelity to text or words of interviewees

11. Outcomes Model for Health Care Research(Holzemer, 1994)

12. Outcomes Model • Heuristic • Systems model (inputs are outputs, outputs become inputs) • Relates to Donabedian’s work on quality of care (Structure, Process, and Outcome Standards)

13. Outcomes Model: Nursing Process

14. Outcomes Model for Health Care Research

15. Outcomes Model: Your assignment(Think about a project or program of research)

16. Where Should We Find Evidence-Based Practice Guidelines? • Clinical practice guidelines • Nursing Standards/ Procedural Manuals • Great demand, low level of delivery (Great demand, growing level of delivery) • Knowledge base from research literature

17. Types of Evidence: How do we know what we know? • Clinical expertise • Intuition • Stories • Preferences, values, beliefs, & rights • Descriptive/quasi-experimental studies • Randomized clinical (controlled) trials (RCTs) - the gold standard

18. Summary: Introduction to Research • Think about nursing research – nursing science • Outcomes Model designed to put boundaries around your area of study and expertise (very difficult challenge in nursing!) • Variable identification • Understanding rigor – correct methods for any type of research design • Enhance enjoyment in reading research articles • Understand the challenge of the words so easily used, “evidence-based practice.”

19. Some Challenges: • Think about developing your definition of nursing science. • Use the Outcomes Model to help you think about your program of research. • Enhance your understanding of rigor in all types of research designs. • Increase your enjoyment of reading research articles. • Understand the complexities of “evidence-based practice.”

20. When thinking about your research problem: • Is it significant? • Are you really interested in it? • Is it novel? • Is it an important area? • High cost, high risk? • Can it be studied? • Is it relevant to clinical practice?

21. Where do ideas come from? • Literature reviews • Newspaper stories • Being a research assistant • Mentors/teachers • Fellow students • Patients • Clinical experience • Experts in the field Build your area of expertise from multiple sources.

22. Uses of Substruction • Critique a published study • Plan a new study

23. Substruction • A strategy to help you understand the theory and methods (operational system) in a research study • Applies to empirical, quantitative research studies • There is no word, Substruction, in the dictionary. It has an inductive meaning, constructing and a deductive meaning, deconstructing • Hueristic

24. Substruction

25. Substruction: Building Blocks or Statements of Relationships

26. Statements of Relationships

27. Co-variates Z Severity of illness for risk adjustment (analysis of covariance) Independent Variable X treatment how measured? Dependent Variable Y Substruction: Research Design Perspective Focus of Study (RCT?)

28. Substruction: Theoretical System, an example Pain Intervention Study Post Surgical Patient Severity of illness age gender Pain Management Intervention Patient communication Standing PRN orders Non pharmacological tx Pain Control Length of stay Patient Satisfaction

29. Pain Intensity Instrument: VAS 10 cm scale (low to high pain) Functional Status Instrument:1-5 Likert scale, 1=low & 5=high function Scale: continuous or discrete? Substruction: Operational System Scale: continuous or discrete?

30. Scaling Discrete: non-parametric (Chi square) • Nominal gender • Ordinal low, medium, high income Continuous: parametric (t or F tests) • Interval Likert scale, 1-5 functionality • Ratio money, age, blood pressure

31. Issues • What is the conceptual basis of the study? • What are the major concepts and their relationships? • Are the proposed relationships among the constructs and concepts logical and defensible? • How are the concepts measured? valid? reliable? • What is the level of scaling and does it relate to the appropriate statistical or data analytical plan? • Is there logical consistency between the theoretical system and the operational system?

32. Is there a relationship between touch and pain control, accounting for initial amount of post-operative pain? rx,y.z

33. Literature Review • We review the literature in order to understand the theoretical and operational systems relevant to our area of interest. • What is known about the constructs and concepts in our area of interest? • What theories are proposed that link our variables of interest?

34. Literature Review • What is known? • What is not known? • Resources • The Cochran Library • Library Data Bases • PubMed • CINYL

35. Literature Review:How to combine, synthesis, and demonstrate direction?

36. Literature Review

37. Table 1. Outline of study variables related to your topic

38. Table 2. Threats to validity of research studies related to topic

39. Table 3. Instruments

40. Table 4. Power analysis for literature review on topic.

41. Literature Synthesis • Synthesis - what we know and do not know • Strengths – rigor, types of design, instruments? • Weaknesses –lack of rigor, no RCTs, poorly developed instruments • Future needs – what is the next step?

42. Research Designs

43. Research Design: Qualitative • Ethnography • Phenomenology • Hermeneutics • Grounded Theory • Historical • Case Study • Narrative

44. Rigor in Qualitative Research • Dependability • Credibility • Transferability • Confirmability

45. Types of Quantitative Research Designs • We will focus on RIGOR: • Experimental • Non-experimental

46. X,Y, Z notation • Z = covariate • Severity of illness • X = independent variable (interventions) • Self-care symptom management • Y = dependent variable (outcome) • Quality of life

47. Types of Quantitative Research Designs • Descriptive X? Y? Z? • What is X, Y, and Z? • Correlational rxy.z • Is there a relationship between X and Y? • Causal ΔX ΔY? • Does a change in X cause a change in Y?

48. Rigor in Quantitative Research • Theoretical Grounding: Axioms & postulates – substruction-validity of hypothesized relationships • Design validity (internal & external) of research design; Instrument validity and reliability • Statistical assumptions met (scaling, normal curve, linear relationship, etc.) (Note: Polit & Beck: reliability, validity, generalizability, objectivity)

49. Literature Review Study Aims Study Aims Study Question Study Question Study Hypothesis

50. Aim, Question, and Hypothesis • Study Aim: To explore if it is possible to reduce patient falls for elderly in nursing homes. • Study Question: Does putting a “sitter” in a patient room reduce the incidence of falls? • Study Hypothesis: Null: H0: There is no difference between patients who have a “sitter” and those who do not in the incidence of falls.