literature review

TYPES OF RESEARCH: QUALITATIVE AND QUANTITATIVE

Research is classified into two major categories: qualitative and quantitative. A researcher chooses between these categories based on the question being asked. That is, a researcher may wish to test a cause-and-effect relationship, assess if variables are related, or discover and understand the meaning of an experience or process. A researcher would choose to conduct a qualitative research study if the question is about understanding the meaning of a human experience such as grief, hope, or loss. The meaning of an experience is based on the view that meaning varies, is subjective, and occurs in a context. That is, the experience of loss as a result of a miscarriage would be different than the experience of losing a parent.

Qualitative research is generally conducted in natural settings and uses data that are words or text rather than numeric to describe the experiences being studied. Qualitative studies are guided by research questions, and data are collected from a small number of subjects, allowing an in-depth study of a phenomenon. Example: ➤ Hanna et al. (2020) explored the perceptions that underlie health-related adherence behaviors from the perspective of patients who experienced a heart attack (see Appendix E). Although qualitative research is systematic in its method, it uses a subjective approach. Data from qualitative studies help nurses understand experiences or phenomena that affect patients; these data also assist in generating theories that lead clinicians to develop improved patient care and stimulate further research. Highlights of the general steps of qualitative studies and the journal format for a qualitative article are outlined in Table 1.1. Chapters 5 to 7 provide an in-depth view of qualitative research underpinnings, designs, and methods.

Table 1.1

Steps of the Research Process and Journal Format: Qualitative Research

Research Process Steps and/or Format Issues Usual Location in Journal Heading or Subheading

Identifying the phenomenon Abstract and/or in introduction

Research question or study purpose Abstract and/or in beginning or end of introduction

Literature review Introduction, background and/or discussion

Design Abstract and/or in introductory section or under method section entitled “Design” or stated in method section

Sample Method section labeled “Sample” or “Subjects”

Legal-ethical issues Measurement Data collection or procedures section or in sample section Methods section includes instruments used and their reliability and validity

Data collection procedure Data collection or procedures section

Data analysis Methods section under subhead “Data Analysis” or “Data Analysis and Interpretation”

Results Stated in separate heading: “Results” or “Findings”

Discussion and recommendation Combined in separate section: “Discussion” or “Discussion and Implications”

References At end of article

Whereas qualitative research looks for meaning, quantitative research encompasses the study of research questions and/or hypotheses that describe phenomena, test relationships, assess differences, seek to explain cause-and-effect relationships between variables, and test for intervention effectiveness. The numeric data in quantitative studies are summarized and analyzed using statistics. Quantitative research designs are systematic, and the methodology is controlled. Appendices B to D illustrate examples of different quantitative approaches to answering research questions or testing hypotheses. Table 1.2 indicates where each step of the research process can usually be located in a quantitative research article and where it is discussed in this text. Chapters 2, 3, and 8 to 18 describe processes related to quantitative research.

Table 1.2

Steps of the Research Process and Journal Format: Quantitative Research

Research Process Steps and/or Format Issue Usual Location in Journal Heading or Subheading Text Chapter

Introduction or Background Introductory/background that may or may not be labeled provides information that describes the context and significance of the study. 3

Purpose Abstract and/or in introduction, or end of literature review or theoretical framework section, or labeled separately: “Purpose” 2

Literature review At end of heading “Introduction” but not labeled as such, or labeled as separate heading: “Literature Review,” “Review of the Literature,” “Related Literature,” or not labeled, or variables reviewed appear as headings or subheadings 3

Theoretical or conceptual framework Combined with “Literature Review” or found in separate section as TF or CF; or each concept used in TF or CF may appear as separate subheading 3, 4

Hypothesis/research questions Stated or implied near end of introduction or literature review; may be labeled or found in separate heading or subheading: “Hypothesis” or “Research Questions”; or reported for first time in “Results” 2

Research design Stated or implied in abstract or introduction or in “Methods” or “Methodology” section 8–10

Sample: type and size “Size” may be stated in abstract, in methods section, or as separate subheading under methods section as “Sample,” “Sample/Subjects,” or “Participants”; “Type” may be implied or stated in any of previous headings described under size 12

Legal-ethical issues Stated or implied in sections: “Methods,” “Procedures,” “Sample,” or “Subjects” 13

Instruments Found in sections: “Methods,” “Instruments,” or “Measures” 14

Validity and reliability Specifically stated or implied in sections: “Methods,” “Instruments,” “Measures,” or “Procedures” 15

Data collection procedure In methods section under subheading “Procedure” or “Data Collection,” or as separate heading: “Procedure” 14

Data analysis Under subheading: “Data Analysis” 16

Results Stated in separate heading: “Results” 16, 17

Discussion of findings and new findings Combined with results or as separate heading: “Discussion” 17

Implications, limitations, and recommendations Combined in discussion or as separate major headings 17

References At end of article 4

Communicating research results Research articles, poster, and paper presentations 1, 20

CF, Conceptual framework; TF, theoretical framework.

The primary difference is that qualitative research seeks to interpret meaning and phenomena, whereas quantitative research seeks to test a hypothesis or answer research questions using statistical methods. Remember as you read research articles that, depending on the research question, a researcher may vary the steps slightly; however, each step should be addressed systematically.

CRITICAL APPRAISAL SKILLS

To develop expertise in EBP, you will need to be able to critically evaluate all types of research articles. As you read a research article, you may be struck by the difference in style or format of a research article versus a clinical article. The terms of a research article are new, and the content is different. You may also be thinking that the research article is hard to read or that it is technical and boring. You may simultaneously wonder, “How will I possibly learn to appraise all of the steps of a research study, the terminology, and the process of EBP? I’m only on Chapter 1. This is not so easy; research is as hard as everyone says.”

Learning the research process develops your critical appraisal skills. You will gradually be able to read a research article and determine whether the conclusions are based on the study’s findings. Once you have obtained this critical appraisal competency, you will be ready to synthesize the findings of multiple studies to use in developing an EBP.

HIGHLIGHT

Start an interprofessional education journal club with students from other health professions programs on your campus. Select a research study to read, understand, and critically appraise together. It is always helpful to collaborate on deciding whether the findings are applicable to clinical practice.

STRATEGIES FOR APPRAISING RESEARCH STUDIES

Critical appraisal of a study objectively and critically evaluates a study’s content for its strengths and weaknesses and overall applicability to practice. It requires some knowledge of the subject matter and knowledge of how to use critical appraisal criteria. In this text, you will find:

• Summarized examples of critical appraisal criteria for qualitative studies and an example of a qualitative critique in Chapter 7

• Summarized critical appraisal criteria and examples of a quantitative critique in Chapter 18

• An in-depth exploration of the criteria for evaluation required in quantitative research in Chapters 8 to 18

• Criteria for qualitative research in Chapters 5 to 7

• Principles for qualitative and quantitative research in Chapters 1 to 4

Critical appraisal criteria are the standards, appraisal guides, or questions used to evaluate an article. When analyzing a research article, you must evaluate each step of the research process and ask questions about whether each step meets the criteria. For instance, the critical appraisal criteria in Chapter 3 ask if “the literature review identifies gaps and inconsistencies in the literature about a subject, concept, or problem,” and if “all of the concepts and variables are included in the review.” These two questions relate to appraising the research question and the literature review components of the research process. Sometimes beginners confuse critical appraisal with criticism and think they are only being asked to identify the weaknesses of a study. Remember that when critiquing a study, you are pointing out strengths and weaknesses. Hopefully, a research study or group of research studies will have more strengths than weaknesses. Standardized critical appraisal tools such as those from the Centre for Evidence-Based Medicine (CEBM) Critical Appraisal Tools (http://www.cebm.net/critical-appraisal) can be used to systematically appraise the strength and quality of evidence provided in research articles (see Chapters 3 and 20).

Appraising can be thought of as looking at a completed jigsaw puzzle. Does it form a comprehensive picture, or is a piece out of place? What is the level of evidence provided by the study and the findings? What is the balance between the risks and benefits of the findings that contribute to clinical decisions? How can I apply the evidence to my patient, to my patient population, or in my setting? When reading several studies for synthesis, you must assess the overall strength and quality of evidence provided by the group of studies and determine the applicability of their findings to practice. Developing a table of evidence (see Chapter 20) will help you organize appraising one or more studies.

OVERCOMING BARRIERS: USEFUL APPRAISAL STRATEGIES

Throughout the text, you will find features that will help refine the skills essential to understanding and using research in your practice. In each chapter, you will find:

• A Critical-Thinking Decision Path related to each step of the research process that will sharpen your decision-making skills

• IT Resources to enhance your literature search skills

• Helpful Hints designed to reinforce your understanding of key information

• QSEN Evidence-Based Practice Tips to help you apply EBP strategies in your clinical practice

• Interprofessional Education Highlights

• Critical Appraisal Criteria

• Clinical Judgment Challenges at the end of each chapter designed to reinforce your critical reading skills

When you complete your first critique, congratulate yourself; mastering these skills is not easy. As you continue to use and perfect critical appraisal skills by critiquing studies, remember that these skills are an expected competency for delivering evidence-based and quality nursing care.

EVIDENCE-BASED PRACTICE AND RESEARCH

Along with gaining comfort while reading and appraising studies, there is one final step: deciding how, when, and if to apply the studies to your practice so your practice and the clinical care you provide is evidence based. EBP allows you to systematically make clinical decisions using the best available evidence with the integration of clinical expertise and the patient’s values and preferences (Sackett et al., 2000). For example, research evidence supports significant disparities in untreated tooth decay for children and adults in the United States. Race/ethnicity, age, family income, education level, and financial and nonfinancial barriers (e.g. insurance, transportation, geographic location) are associated with untreated cavities (Gupta et al., 2018). Determining potential interventions to decrease untreated tooth decay in children for whom dental care is an essential benefit of the Affordable Care Act (ACA) involves considering interventions that are affordable, accessible, available, and culturally congruent with the targeted community. EBP involves processes and steps, as does the research process. These steps are presented throughout the text. Chapter 19 provides an overview of EBP steps and strategies.

When using EBP strategies, the first step is to be able to read a study with an understanding of how each section is linked to the steps of the research process. The following section introduces you to the research process as presented in published articles. Once you read a study, you must decide which level of evidence the study provides and how well the study was designed and executed. Fig. 1.1 illustrates a model for determining the levels of evidence associated with a study’s design, ranging from systematic reviews of randomized controlled trials (RCTs) (see Chapters 9 and 10) to expert opinions. The rating system, or evidence hierarchy model, presented here is just one of many. Many hierarchies for assessing the relative worth of both qualitative and quantitative designs are available. Early in the development of EBP, evidence hierarchies were thought to be very inflexible, with systematic reviews or meta-analyses at the top and qualitative research at the bottom. This is no longer the case. There is no guarantee that a Level II RCT with design flaws will provide stronger evidence than a well-designed Level III cohort study.

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