Nursing And Codes Of Ethics Assessment

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esearchSue Z. Green and Jennifer L. Johnson

And whatever you do, in word or deed, do everything in the name of the Lord Jesus, giving thanks to God the father through Him —Colossians 3:17 (English Standard Version)

Essential Questions

· Why are ethical principles important when conducting research on human subjects?

· What is the focus of qualitative nursing research in professional nursing practice?

· What methodologies are used to conduct qualitative research?

· Why should the BSN-prepared nurse critically appraise published research studies?

· How does the BSN-prepared nurse critically appraise published research studies?

Introduction

One of the hallmarks of any profession is a scientific research base. The nursing profession bases its practice on a solid foundation of evidence developed through research by nurses and results gleaned from multiple disciplines, such as psychology, social work, and medicine. Nurses are called upon to develop a safe practice that is grounded in evidence to promote positive health outcomes in the populations served.Nurses are called upon to develop a safe practice that is grounded in evidence to promote positive health outcomes in the populations served. The continued advancement of nursing research is critical for further development of the nursing profession. The process of conducting nursing research must be grounded in ethics and provide fair treatment of human subjects . A proficient registered nurse must be knowledgeable about ethical principles that are required when conducting nursing research.

Through a variety of methodologies, nurse researchers study phenomena of interest to the profession. For example, a nurse wishing to determine the causative factors related to increased infection rates in patients with urinary catheters may study nursing care procedures for these patients. Likewise, a nurse may desire a deeper understanding of culture on health practices and design a study to learn about these influences.

Nursing is considered to be both an art and a science. The science component requires nurses to seek methodical, logical methods for choosing nursing process actions. In addition, nurses seek answers to practice questions through application of scientific inquiry or research. Researchers may design studies that are quantitative or qualitative in nature. Quantitative design is based on the traditional scientific research design and the science aspect of nursing. Through quantitative design, researchers are able to quantify findings easily. For example, a quantitative study designed to address infection rates will provide factual data about the number of infections occurring and other statistical data.

Through qualitative research methodologies, nurse researchers study aspects of the art of nursing. These may include lived experiences, feelings, and perceptions among other facets of the human experience. For example, the nurse researcher may design a study to learn more about the lived experiences of breast cancer survivors. This information can then be used to prepare the registered nurse to provide care to this population of patients. The baccalaureate-prepared nurse is a consumer of nursing research. In this role, the nurse accesses, appraises, and may participate in clinical research. This chapter will provide an overview of the ethical implications for qualitative nursing research as well as discussion about qualitative nursing research methodologies.

Nursing and Codes of Ethics

Nursing is a profession grounded in ethical practice. Historical foundations of the nursing profession are deeply intertwined with ethical actions by those called to provide care for the sick, needy, and poor. Historically, nursing education curricula have included focus on the foundations of ethics, nursing codes of ethics from the American Nurses Association (ANA) and the International Council of Nursing, as well as the development of professional values as part of the essential elements of baccalaureate nursing education (American Association of Colleges of Nursing, 2008). The codes of ethics are used to guide professional nursing practice and role performance, including qualitative research. Nurse researchers are also guided by the Nuremburg Code, the Declaration of Helsinki, and the Universal Declaration of Human Rights in pursuit of ethical and safe nursing research (Kawar, Pugh, & Scruth, 2016; Schuster, 1997; United Nations, n.d.; World Medical Association, 2017). In addition to these guiding principles, nurse scientists are also responsible for adhering to federal, state, and local laws pertaining to research on human subjects (Mallari & Tariman, 2017).

As part of the professional role responsibility, the BSN-prepared nurse should engage in the examination of emerging ethical issues in practice and take an active role in solving these dilemmas. The process of ethical problem solving is complex; the nurse must understand basic ethical principles in order to aid in principled decision making. The use of ethical frameworks and decision-making models can guide the nurse through ethical dilemmas. An approach to ethical dilemmas and nursing research that is evidence-based may contribute to patient safety and improved outcomes (Mallari & Tariman, 2017). To fulfill professional role responsibilities, the BSN-prepared nurse should be familiar with both the ANA Code of Ethics and the International Code of Ethics.

ANA Code of Ethics

The first official nursing Code of Ethics was developed by the ANA in 1950 (Epstein & Turner, 2015). The purpose of the original ANA Code of Ethics was to provide a framework to guide professional nursing practice through competence and ethical behaviors. The current ANA Code of Ethics has been through multiple revisions since origination, with the most current version approved by the ANA in 2015. The modern ANA Code of Ethics describes the profession’s “values, obligations, duties, and professional ideals” (Epstein & Turner, 2015, para. 21). The ANA Code of Ethics is an important framework for the registered nurse to use when navigating complex situations and ethical dilemmas in the health care setting. The document is also used as a guiding framework when conducting qualitative nursing research. Provisions 1–3 address nurse and patient relationships, Provisions 4–6 address nurse boundaries of duty and loyalty, and Provisions 7–9 address professional commitments beyond patient encounters. The registered nurse must utilize this framework to develop a professional moral compass and deliver high quality, safe nursing care. In addition, the nurse researcher must apply principles from the ANA Code of Ethics when conducting any type of research. For example, Provision 1, human dignity, compels qualitative nursing researchers to adhere to the patient’s right to self-determination (see Table 2.1). Likewise, Provision 4, ethics encompassing duty and loyalty, fosters accountability expectations for the researcher.

Table 2.1

Overview of the ANA Code of Ethics Applied in Qualitative Nursing Research

ANA Code of Ethics Provision

Application to Qualitative Nursing Research

Provision 1: The nurse practices with compassion and respect for inherent dignity, worth, and unique attributes of every person.

· Researchers must respect human dignity, relationships with patients, the nature of health, the patient’s right to self-determination.

Provision 2: The nurses’ primary commitment is to the patient, whether an individual, family, group, or community.

· Areas addressed include primacy of the patient’s interests, conflict of interest for nurses, collaboration, and professional boundaries.

· The researcher’s commitment is to the subject.

· Example: The nurse researcher should ensure a subject is comfortable when discussing the death of a child in a study focused on parental grieving. A private room and tissues would be provided by the researcher.

Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

· Areas addressed include protection or privacy and confidentiality for human participants in research, performance standards and review mechanisms, promoting culture of safety, and questioning unsafe and impaired practice.

· The researcher is a patient advocate.

· Example: The nurse researcher advocates for long-term counseling services to be made available to subjects in a study focused on surviving physical abuse after the study’s conclusion.

Provision 4: The nurse has authority, responsibility, and accountability for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.

· Areas addressed include authority, accountability, responsibility, nursing judgments/decisions/actions, assessment, and delegation.

· The researcher is responsible and accountable.

· Example: The nurse researcher determines that music therapy helped research subjects without improved mental health during chemotherapy treatment. To promote health, the nurse disseminates research findings in an appropriate manner.

Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

· Areas addressed include duties to self and others, promotion of personal health/safety/well-being, preservation of wholeness of character, preservation of integrity, maintenance of competency, and continuation of professional and personal growth.

· The researcher must take care of self.

· Example: The nurse researcher takes time to self-reflect after interviews with subjects who have reported being perpetrators of crimes.

Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work settings and conditions of employment that are conducive to safe, quality health care.

· Areas addressed include environment and moral virtue, environment and ethical obligation, and responsibility for health care environment.

· Researcher promotes an ethical environment.

· Example: The nurse researcher ensures that he or she is truthful in all communications with research subjects.

Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

· Areas addressed include research and scholarly inquiry, developing/maintaining/implementing professional practice standards, and nursing and health policy development.

· The researcher meets professional standards.

· Example: The nurse researcher develops a study to learn about the lived experiences of refugees. The information is then used to influence nursing practice in the care of refugees.

Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

· Areas addressed include health as a universal right, collaboration for human rights and diplomacy, and reduction of health disparities.

· The researcher collaborates to protect subjects.

· Example: The nurse researcher collaborates with a physician in designing a qualitative study to determine the impact of yoga therapy on the lived experience of patients with multiple sclerosis.

Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

· Areas addressed include articulation and assertion of values, integrity of the profession, integrating social justice, and social justice in nursing and health policy.

· The researcher represents the profession through all interactions.

· Example: The nurse researcher ensures fair and equitable treatment of all subjects. Subjects who are incarcerated are treated fairly in same manner as the public.

International Code of Ethics

The International Council of Nurses (ICN) (2012) first approved the Internal Code of Nursing Ethics in 1953. The most current 2012 version serves as a framework to guide professional nursing practice and ethical decision making globally. Inherent in the ICN code is the focus on human rights, dignity, and respect. According to the ICN code, professional nurses, regardless of practice area, have four basic responsibilities including promoting health, preventing illness, restoring health, and alleviating suffering (International Council of Nurses [ICN], 2012). The four basic elements of the code’s framework include nurses and people, nurses and practice, nurses and the profession, and nurses and coworkers. Within each basic element, there are specific directives the professional nurse may use to guide decision making and action. For example, directives regarding nurses and people guide patient-centered care decisions and actions by nurses (see Table 2.2). Likewise, the nurses and coworkers element fosters an ethical, collegial environment.

Table 2.2

Overview of the International Code of Nursing Ethics and Application in Qualitative Nursing Research

International Code of Nursing Ethics Element

Discussion of Elements

Nurses and People

· Patient-centered care, supportive environment, culturally appropriate care, meets needs of patients, advocates for social justice, and demonstrates professional values

· Example: The nurse researcher will respect the individual differences between cultural groups in qualitative research. Differences are valued and explored.

Nurses and Practice

· Responsibility, accountability, standard of care, good judgment, appropriate conduct, technology use, and ethical behavior

· Example: The nurse researcher adheres to all standards of care and ethical foundations when designing and performing qualitative nursing research.

Nurses and the Profession

· Implements professional standards, evidence-based practice, professional memberships, supports good work environment, supports protection of natural environment, and challenges unethical practices

· Example: The nurse researcher uses evidence and professional standards when designing qualitative study to promote ethical practice and fair treatment of subjects.

Nurses and Coworkers

· Collaborative, respectful work environments, safeguards individuals in the work environment if in harm, supports advancement of ethical conduct

· Example: The nurse researcher adheres to ethical conduct in research study that is qualitative in nature and avoids misconduct.

Professional Values

Ethics is defined as a set of moral principles (Ethic, 2018). Ethical behavior is fundamental to nursing practice to ensure optimal outcomes and patient safety, including nurse science and research. Nursing research ethics is important for protection of human subjects and safety of the public, which are critical points of professional nursing values. Consistent with the Christian worldview at Grand Canyon University, the nurse should seek, in all aspects of care, to pursue open dialogue, respectful interaction, and truth. When engaging in qualitative study, the nurse can learn about the lived experiences, thoughts, and feelings of others. There are times when this means nurses will engage with people who have differing viewpoints than those of their own. It is necessary to recall that although people may have different viewpoints and experiences, the nurse must treat all humans with dignity and respect. These approaches enable the nurse to provide care that is ethically sound and consistent with the values of the profession. Without attention to fundamental ethical principles, there is a possibility for research to cause undue harm. To conduct safe, ethical research, there must be an understanding of research ethics and basic ethical principles (Doody, 2016). The nurse must develop a working knowledge of the following ethical principles: autonomy , beneficence , nonmaleficence , justice , veracity , fidelity , and confidentiality (see Table 2.3).

Table 2.3

Foundational Ethical Principles

Ethical Principle

Meaning

Example

Autonomy

A person has the right to self-determination; the right to make decisions in an autonomous manner

A patient may decide to withdraw from a study about breast cancer survival after feeling depression. The nurse respects this decision.

Beneficence

The duty to do good; actions that are in the best interest of the patient

The nurse researcher allows ample time after an emotional interview with a research subject for reflection and discussion to enhance outcomes for subject.

Nonmaleficence

The duty to do no harm; actions to prevent harm to the patient

The researcher purposefully keeps subjects separated in a study designed to look at relationships between survivors of domestic abuse and abusers.

Justice

Moral obligation to act fairly

The researcher ensures that all study participants have equal access to resources during a study, such as counseling and other services.

Veracity

Truthfulness

The researcher provides clear and truthful information to study participants. Subjects in a study focused on perinatal loss will understand this will be a topic of discussion in interviews.

Fidelity

Keeping a commitment as stated to the patient; remaining faithful to commitments made

The researcher remains faithful to commitments. If there are supposed to be a total of four field visits, the researcher ensures there are four total visits made.

Confidentiality

Holding information in confidence appropriately

The researcher holds all information in confidence as designed in the study. The privacy of HIV positive patients is protected in a study focused on the lived experience of HIV diagnosis.

Note. Adapted from Nursing Research: Generating and Assessing Evidence for Nursing Practice (3rd ed.), by D. F. Polit and C. T. Beck, 2017. Copyright 2017 by Wolters Kluwer Health/Lippincott, Williams & Wilkins.

Check for Understanding

1. What vulnerable populations do you engage with as a nurse? Why are they considered vulnerable?

2. What is an example from your practice to demonstrate a patient’s right to self-determination?

3. What is the process for study approval in your agency?

4. What are the professional documents used by the nurse to guide ethical decision making?

5. What are examples of the ethical principles discussed in Table 2.3 that must be used in nursing research?

6. How should the nurse approach patients with diverse backgrounds and beliefs based on the Christian worldview at Grand Canyon University and professional nursing values?

Quality and Safety in Qualitative Nursing Research

The nursing profession’s ultimate responsibility is to the public, those served through nursing care, to protect and practice safely. The professional nurse should understand the key principles involved in safe and ethical nursing research. These include human rights protections such as self-determination, privacy, anonymity and confidentiality, fair selection and treatment, and protection from discomfort and harm. Each principle will be discussed further to enhance understanding.

Human Rights and Protections

Nurse researchers must recognize that human subjects are autonomous beings. Research subjects have the right to self-determination . This right allows for the research subject to decide freely, without coercion, whether to participate in research study. The subjects can ask questions or decide to stop participation in a study at any time considering this important principle (Polit & Beck, 2017).

When considering research with human subjects, the researcher must understand the concept of vulnerable populations . Ethical and human treatment is required for all research subjects; however, certain groups are at increased risk for harm during research. Groups that are vulnerable include children and pregnant women as well as people who are mentally or emotionally disabled, severely ill, physically disabled, terminally ill, and institutionalized (Polit & Beck, 2017). Because of increased vulnerability, special precautions and safeguards must be taken to ensure informed consent and safe nursing research practice with these groups. It is suggested that research be done with these population groups only when the benefit outweighs the risk (Polit & Beck, 2017).

Nursing research subjects must be guaranteed a right to privacy. Nurse researchers delve into personal health data when conducting research. Nursing research must be planned to collect needed data while being as unobtrusive as possible. Subjects must be assured that protected health information will be kept in confidence with privacy maintained (Polit & Beck, 2017). The concepts of anonymity and confidentiality are important considerations.

Anonymity means the nurse researcher has no means of connecting data collected with the subject providing the data (Polit & Beck, 2017). An example of this would be distribution of a survey on fast food choices at a local restaurant. If the surveys were collected with no identifying data, they would be considered anonymous. The researcher would have no means of connecting the survey data with the subject. It is important to note that during qualitative study, anonymity is not usually achieved as the researcher and subject often have close and continued contact (Polit & Beck, 2017).

Confidentiality implies there is a promise the researcher will not publish any data in a manner that may demonstrate a connection between the data and the research subject (Polit & Beck, 2017). When conducting research, there may be data collected that connects the subject and findings; however, confidentiality implies this connection will not be shared through dissemination of research findings. For example, in a qualitative study focused on the behavior of cigarette smokers, a researcher will have field notes on interviews with the subjects. The notes should be properly coded with an identifier other than the subject’s name to protect privacy.

Research subjects must always be protected from harm and discomfort considering the basic ethical principle of nonmaleficence. Researchers must protect human subjects from unnecessary harm while conducting studies. Harm may occur in the form of physical, emotional, social, or financial means (Polit & Beck, 2017). There are different methods to ensure no harm, which include qualified researchers, ensuring informed consent, and oversight from institutional review board for study approvals and monitoring.

Informed consent is mandatory for safe, ethical nursing research. Informed consent means a research subject has been provided a high level of detail about the proposed study, and the risks and benefits, as well as an explanation that they may withdraw from the study at any point (Polit & Beck, 2017). In certain cases, there may be a waiver for informed consent including a finding from the institutional review board that a study is exempt from this requirement or in limited emergency settings (U.S. Department of Health and Human Services [HHS], n.d.).

Institutional Review Boards

To ensure the highest protections are met in nursing research, studies should be approved and monitored by an institutional review board (IRB) . The role of the IRB is to ensure protection of human subjects through ethical research methods. The IRB meets on a regular basis to review all applications for new studies and to discuss ongoing monitoring of studies. An initial review by the IRB will include review of all study protocols as written by the researcher, all consent forms and communications that will be provided to subjects, and discussion with the researcher for a question and answer period. In some cases, the IRB will require revision of study protocol and documents from the researcher.

An IRB should have at least five members, and (Polit & Beck, 2017), one of whom is not a researcher and one who is not affiliated with the agency. Also, the IRB should include a mixture of male and female members. The requirements of IRB review according to the federal government are as follows (Polit & Beck, 2017):

· Risks to participants are minimized

· Risks to participants are reasonable in relation to anticipated benefits, if any, and the importance of the knowledge that may reasonably be expected to result.

· Selection of participants is equitable

· Informed consent will be sought, as required, and appropriately documented

· Adequate provision is made for monitoring the research to ensure participants’ safety

· Appropriate provisions are made to protect participants’ privacy and confidentiality of the data

· When vulnerable groups are involved, appropriate safeguards are included to protect their rights and welfare (p. 151)

In some cases, a researcher may request an expedited review from an IRB. This type of review can be requested only when the study has been found to present very minimal risk of harm to the research subject. Expedited reviews are usually carried out by one person, usually the chairperson of the IRB (Polit & Beck, 2017). A researcher may also request that a study be exempt from IRB review, meaning there is no risk of physical or mental harm to the subject.

Research Misconduct

It is important to address unethical practice in nursing research; thus, the nurse researcher must safeguard against research misconduct . This is clearly defined by the U.S. Department of Health and Human Service’s Office of Research Integrity (n.d.) as “ fabrication , falsification , or plagiarism in proposing, performing, or reviewing research, or in reporting research results” (para. 1). The Office of Research Integrity (ORI) is tasked with oversight of all Public Health Service research. To address its mission, the ORI develops polices to ensure ethical research, monitors research, provides technical assistance to agencies conducting research, provides education about research conduct, and administers programs to support ethical behavior in research (Office of Research Integrity [ORI], n.d.). Qualitative nursing researchers must be aware of the elements of research misconduct and take measures to avoid actions that could be construed as misconduct (see Table 2.4).

Table 2.4

Elements of Research Misconduct Applied in Qualitative Nursing Research

Element

Meaninga

Example of Misconduct

Fabrication

Making up data or results and reporting or recording them

· Creating records of subject interviews that were never performed

· Making progress notes of meetings that never occurred

· Preparing records for people who died during the study

Falsification

Manipulating research materials, equipment, or processes, or changing or omitting data or results such that the research is not accurately represented in the research record.

· Falsifying the times for an interview in the study

· Substituting one subject’s record for that of another

· Altering dates and results from a subject’s visit

Plagiarism

Appropriation of another person’s ideas, processes, results, or words without giving appropriate credit.

· Submitting another’s work as your own or not properly citing the original author

Note. aMaterial republished from “Definition of Research Misconduct,” by the U.S. Department of Health & Human Services, Office of Research Integrity, n.d.

Duty of Care

As a practice discipline and as part of the duty of care, professional nursing must develop evidence-based standards for care. One characteristic of a profession is a scientific research base that is continually expanding. Through safe, high-quality nursing research study, findings are beginning to be translated into care practices to improve the health outcomes of the patients nurses serve. The baccalaureate-prepared nurse is expected to be a consumer of nursing research. This means the nurse must understand how to access and analyze nursing research for applicability to practice. The baccalaureate-prepared nurse may participate in research studies as a team member to help create best practice guidelines. For example, many hospitals have nursing research teams to address areas of concern related to patient care outcomes on which the nurse may participate.

Evidence-Based Practice and Professional Role Responsibilities

Critical Appraisal of Nursing Research

The baccalaureate-prepared nurse should be able to complete a critical appraisal of a published research study. Critical appraisal is defined as the “process of carefully and systematically examining research to judge its trustworthiness and its value and relevance in a particular context” (Truluck & Leggett, 2016, p. 355). Through appraisal, the nurse can analyze the construction of the study, the methodologies, and the feasibility of application to nursing practice. This means the nurse can evaluate how the study is designed, the methods used in the study, and determine if the findings can be used to improve nursing practice. “Critically appraising the literature is necessary to inform evidence-based practice” (Truluck & Leggett, 2016, p. 356). There are many tools available to guide the nurse through the process of critical appraisal of nursing research; however, there are three main questions to ask:

· Are the results of the study valid?

· What are the results?

· Will the results help improve care for my patients? (Truluck & Leggett, 2016; Wilkins, 2016)

The first question, which addresses validity, aims to determine whether the researcher used appropriate methods when completing the research. In other words, it should be clear upon review that the study was designed properly, approved by an IRB, used appropriate measures, and was ethical in nature. The more well-designed and sound a study is, the more valid its results will be. A study designed with a high level of rigor, or standards, should produce results that are trustworthy and valid (Wilkins, 2016).

The second question addresses the actual study findings. For example, the baccalaureate prepared nurse should analyze study findings and determine whether the results were statistically significant and if similar results would be found if the study were replicated (Wilkins, 2016). The last question addresses applicability to professional practice. The BSN-prepared nurse should consider whether the findings would be relative to populations served and if the risks outweigh the harm (Wilkins, 2016). This is often identified through general questions the baccalaureate-prepared nurse should include in a critical appraisal.

Critically Appraisal of Published Research

According to Truluck and Leggett (2016), questions to include in the general critical appraisal when reading the article are:

1. Is the study question relevant?

2. Does the study add anything new?

3. What type of research question is being asked?

4. Was the study design appropriate for the research question?

5. Did the study methods address the most important potential sources of bias?

6. Was the study performed according to the original protocol?

7. Does the study test a stated hypothesis?

8. Were the statistical analyses performed correctly?

9. Does the data justify the conclusions?

10. Are there any conflicts of interest?

It is important to note that the usefulness of critical appraisal in qualitative research has been questioned (Truluck & Leggett, 2016). Most critical appraisal tools are formulated to analyze quantitative studies and may not be best suited for qualitative research, which focuses on feelings and perceptions (Truluck & Leggett, 2016).

Critical Appraisal of Qualitative Research Articles

According to Patterson and Dawson (2017), questions to include in the appraisal of a qualitative study during initial reading include:

1. Is there is clear statement of the aims of the research?

2. Are the methods and design appropriate to the research question?

3. Is the recruitment strategy and sampling appropriate?

4. Is the method of data collection fully described and justified?

5. Have ethical considerations been described?

6. Does the study have sufficient validity, reliability, and rigor?

7. Is the data analysis sufficiently robust? (pp. 123-125)

The Critical Appraisal Skills Programme (CASP) provides a rapid critical appraisal tool that is useful for the nurse. This online resource provides free training for health care professionals to learn the skill of rapid critical appraisal for nursing research. The site provides free printable, downloadable checklists for a variety of study types, including qualitative nursing research. The online resources and tools are available at the CASP website (Critical Appraisal Skills Programme, n.d.).

In addition to the questions suggested, there are other general factors to consider when appraising nursing research. These include, but are not limited to, general relevance to nursing practice, currency of references, disciplines of authors, level of evidence used, databases used, and strength of the synthesis of data. For example, the nurse must not only access and review current nursing literature, but also consider its applicability to nursing practice. A nurse may review an excellent qualitative study on health care access for patients in urban areas, but if the nurse is practicing in an isolated rural area, some of the concepts of this research may not be applicable to his or her practice. The nurse should evaluate all reference citations within an article. Upon this review, references should generally be no older than five years unless they are considered to be classic articles of significance. Articles should cite credible sources as references including peer-reviewed journals, textbooks, or credible Internet references. Other factors included in the analysis of a research article include the expertise of the researcher, support of funding for the study and ensuring all ethical principles previously discussed have been applied. Databases that are appropriate for supporting nursing research include, but are not limited to, CINAHL, Cochrane, PubMed, National Institute of Health (NIH) or other government-based sources, ProQuest, and Ebsco. College libraries have software that sort through certain databases for published, peer-reviewed research articles related to search terms.

The profession of nursing must continually evolve. The BSN-prepared nurse can contribute to the continued development and improvement of the profession through positive attitudes toward implementation of evidence-based practice (Brower & Nemec, 2017). Through questioning current practices, accessing and appraising nursing literature, and proposing solutions to current practice problems, the professional nurse can impact health care outcomes in a positive manner (Brower & Nemec, 2017).

Components of Publishing Research

Dissemination of nursing research is needed for continued expansion of the scientific research base. Research that is conducted should be shared. Dissemination of nursing research is needed for continued expansion of the scientific research base. As a generalist, the baccalaureate-prepared nurse is prepared to participate in conducting research studies as a team member. While the baccalaureate-prepared nurse is not expected to design and lead a study, he or she may serve as research team member to assist in carrying out study protocol. Being a contributor to published nursing research is one outcome for nurses who participate on research teams, which means that the baccalaureate-prepared nurse should be familiar with structure and required elements for publishing nursing research articles in peer-reviewed journals. While nursing journals may have some variations in the requirements for manuscript formatting, the general structure of nursing research articles will be reviewed in this chapter. Many journals require what is referred to as an IMRAD (Introduction, Methods, Results, and Discussion) format along with an abstract and reference list (Polit & Beck, 2017). The nurse should also be aware of important areas of focus for nursing research. The National Institute of Nursing Research (2016) has identified the following areas of focus for continued nursing research in its strategic plan:

· Personalized health strategies

· Promoting health and preventing disease

· Improving quality of life for people with chronic disease

· End-of-life and palliative care

· Technology use in improving health care

· Innovative strategies for nurse research career development

An abstract provides a brief overview of the study, usually in 250 or fewer words. The abstract should provide the reader with an overview of the background, objectives, methodology, results, and conclusions in a succinct paragraph. An introduction should follow the abstract and provide background information and establish relevance. Elements that may be addressed in this section include the issue of focus, population of interest, current evidence, theoretical framework, purpose of the study, the research question, and reason why the study is needed. The methods section addresses the specific approaches or methodologies used by the researcher when conducting the study. Items included in this section include the design of the study, how sampling was decided upon, how data was collected, instruments used, how data was analyzed, and general study procedures, including how subjects were safeguarded. The results section of an article should address study findings in a detailed manner. If statistical tests were used in the study, detailed findings should be shared including names of tests used, value of statistical data and the significance of the findings. It is important to note that statistical tests are not often used in qualitative nursing research. Frequently, instead of sharing statistical data in this section, qualitative researchers will include excerpts from participant interviews for an article. Lastly, in the discussion section of the article, nurse researchers discuss interpretation of findings. This involves drawing conclusions about the findings, discussing study limitations and applicability to practice, and calling for further study on the topic.

Check for Understanding

1. Review a journal article and ask yourself at least three of the questions presented in this chapter for critical appraisal.

2. What is the purpose of critical appraisal?

Overview of Qualitative Nursing Research

Qualitative Research Study Design

Qualitative nursing research tells a story; it is a developing narrative that reflects realities and viewpoints of study subjects. Key characteristics of a qualitative study as identified by Polit and Beck (2017) include:

· Flexible, capable of adjusting to new information during the course of data collection

· Holistic, aimed at an understanding of the whole

· Involves merging various data collection strategies

· Requires researchers to become intensely involved

· Relies on ongoing analysis of the data to formulate subsequent strategies and to determine when data collection is done. (p. 463)

Qualitative researchers identify a study design early in the research process. There are various methods that may guide qualitative nursing research (see Figure 2.1). Ethnography is a method aimed at examination of cultural behaviors. Researchers using ethnography seek to understand cultural behaviors and the reasons behind them on a deeper level. The researcher may deeply immerse themselves in the culture being observed. Data is often collected through participant observations and key informant interviews (Polit & Beck, 2017). Phenomenology provides an approach that allows researchers to better understand a person’s lived experiences. Through this method, researchers attempt to gain a deeper understanding of significant phenomena in life. Data is usually collected through extensive interviews and conversations with study subjects. Sample sizes are generally small when this methodology is used (Polit & Beck, 2017). Grounded theory is an approach that allows for researchers to consider phenomena of significance to nursing. The aim is to understand actions taken in an area by those who are involved in performing the actions. This methodology has led to the development of many middle-range, or narrower, practice-related nursing theories (Polit & Beck, 2017).

Figure represents the types of qualitative research study designs.

In some cases, researchers may not identify a study design as one of the designs mentioned. This type of study is often referred to as a descriptive qualitative study design (Polit & Beck, 2017). Often, these studies are a meshwork of other types of study designs. Case study design allows for review of relationships between phenomena or trends over time. There is deep investigation centered on a single entity or focus (Polit & Beck, 2017). Narrative analyses focus on storytelling through the lens of culture. This methodology is designed on the premise that people interpret experiences and tell them through stories. The researcher using this methodology seeks to make meaning out of the stories told (Polit & Beck, 2017). Sometimes researchers design a study to include both qualitative and quantitative methodologies. This type of study design is referred to as mixed methods research.

Outcomes research is common in health care with an emphasis on assessing outcomes of patient care and using that data to improve health care provision (Agency for Healthcare Research and Quality [AHRQ], n.d.). This approach may involve the measurement of both quantitative and qualitative data. For example, data obtained through outcomes research may include quantitative data, such as mortality rates and qualitative data measured through patient satisfaction surveys. This area of research is growing in popularity and is described as the way to know what is happening in health care and how to determine measures to improve health care (AHRQ, n.d.).

Research Synthesis

Nurse researchers often have need to conduct extensive review of existing literature; this is broadly identified as research synthesis. Through a process referred to as systematic review , the nurse researcher conducts a structured review of existing nursing research on a selected topic. This process is identified as critical to the continued development of the nursing profession and evidence-based practice (Polit & Beck, 2017). A systematic review is more extensive and detailed than a simple literature review. This approach is used in qualitative research and may be referred to as metasynthesis (Polit & Beck, 2017). The process of metasynthesis is especially important for qualitative research, as one of the criticisms of this methodology is the concern about lack of generalizability of the findings (Polit & Beck, 2017). Because qualitative design often has a more flexible design approach, critics may argue that the research findings are less valid and thus not as readily applicable to larger populations. The process of metasynthesis allows for a larger grouping of qualitative data to review for commonalities. Identifying these commonalities in research findings supports the idea of generalizability to the larger population.

Qualitative Research Methodologies

Methodologies used in qualitative design may vary from quantitative study because of the different focus and aims of the two approaches. Selection of study participants, or sampling , is an important area for consideration. When selecting study participants, the qualitative researcher seeks to find subjects who can enrich understanding of the issue studied. Questions the researcher may ask when recruiting subjects include, “who can confirm my understandings, challenge or modify my understandings, enrich my understandings?” (Polit & Beck, 2017, p. 491). Key concepts that differentiate sampling in qualitative study rather than the probability sampling associated with quantitative study include smaller sample sizes, lack of random sampling, and emerging sample selection (Polit & Beck, 2017). Various types of nonprobability sampling methods may be used in qualitative study (see Figure 2.2). These include convenience sampling, snowball sampling, and purposive sampling. Convenience sampling is also referred to as volunteer sampling. Subjects present themselves, or volunteer, for participation in the study. While considered an easier method of sampling, it can present concern for the researcher. In some cases, the sample may not produce the desired results or information (Polit & Beck, 2017). Snowball sampling involves study participants referring other participants to the researcher for inclusion in the study. The effect is that the sample size snowballs or increases in size. This method may help the researcher develop a more desirable sample with less risk of bias. Purposive sampling involves selection of subjects who are of benefit to the research focus (Polit & Beck, 2017). In other words, the subjects are recruited because the researcher believes the subjects’ data will enhance the findings of the study. For example, if a researcher is designing a study to address the lived experience of breast cancer survivors, he or she may visit a breast cancer support group to recruit subjects. Regardless of sampling method used, it is important to understand the concept of data saturation in qualitative research. This refers to the idea that the researcher will continue with sampling and data collection until there is a point in which no new findings are discovered (Polit & Beck, 2017). Once data saturation has occurred, the research using qualitative study design will move to analysis of the data.

Figure 2.2

Comparison of Sampling Techniques

Figure compares terms associated for qualitative nonprobability sampling with terms for quantitative probability sampling.

Data is collected in a qualitative study in a variety of ways (see Table 2.5). For example, a qualitative study with subjects experiencing childbirth may be interviewed, asked to journal about their experiences, or both. It is important to note that in qualitative studies, the process of data collection generally requires a higher level of flexibility and fluidity than that of quantitative nursing research (Polit & Beck, 2017). The researcher often conducts field visits and may meet with a subject more than once. This means the process of qualitative research evolves as the process is carried out. Because of the nature of this type of study and the aim of the research, it is important for the researcher to build trust with subject participants during data collection processes. Another important consideration for the researcher is to safeguard against emotional attachment to the study subjects (Polit & Beck, 2017). Because of the in-depth nature of this research design, researchers and study participants spend an increased amount of time together discussing intensive personal thoughts and feelings. The researcher must be aware of this risk and take precautions to avoid this from occurring by maintaining professional boundaries and adhering to professional standards of practice and the nursing codes of ethics previously discussed.

Table 2.5

Qualitative Research Data Collection Methods

Data Collection Method

Description

Interviews

· Structured or unstructured

· Involve specific questions derived from the research questions established for the study

· Transcripts of conversations needed

Focus Groups

· Group of people, usually at least five, assembled for discussion

· Popular in health-related research

· Interviewer is moderator

· Interviewer has a set of questions to ask or topics to discuss

· Transcripts of conversations needed

Diaries and Journals

· Format may be unstructured or structured to address certain issues

· Good for historical review and learning about subject experiences/feelings

Observation

· Observing participants in the field during times of social interactions

· Daily notes recorded in field logs

Check for Understanding

1. What type of qualitative study design would be best to study cultural implications on health?

2. What is data saturation, and why is it important?

3. Why are transcripts important from subject interviews in qualitative design?

Future of Nursing and Trends

Outcomes research is a developing trend in health care, including nursing research. Nurses are on the forefront of health care. Through careful analysis of health care provision, risks, policy, and evidence; nurses can create and use data to help transform health care. The development of a sound scientific research base in a hallmark of any profession. Nurses of all educational preparations are expected to develop practice that is grounded in the best evidence available. To continue to advance nursing as a profession, each nurse must embrace the development of practice that is evidence based.

Reflective Summary

In terms of the future, the nursing profession brings a “steadfast commitment to patient care, improved safety and quality, and better outcomes” (Institute of Medicine, 2011, p. xi). With the passage of the Affordable Care Act in 2010, nurses have been called upon to be leaders on the forefront of health care improvement and change. Upon review of professional standards, such as the ANA Code of Ethics, nurses are expected to be consumers of research. Through continued focus on building profession practice upon a scientific base of evidence, the BSN-prepared nurse can positively impact health care outcomes on a broad scale. There is a need to consider unique approaches to addressing the complex problems seen in the population served by the health care system. Nurses are called upon to lead these efforts through recognizing clinical problems, asking questions, developing and participating in nursing research, appraising current evidence and translating evidence into professional practice. The BSN-prepared nurse must develop an appreciation and understanding of nursing research to develop a best-practice approach to providing safe, high-quality, professional nursing care.

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