EBP 2

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Understanding quantitative research: part 1 NS673 Hoe J, Hoare Z (2012) Understanding quantitative research: part 1. Nursing Standard. 27, 15-17, 52-57. Date of acceptance: March 2 2012.

Abstract This article, which is the first in a two-part series, provides an introduction to understanding quantitative research, basic statistics and terminology used in research articles. Critical appraisal of research articles is essential to ensure that nurses remain up to date with evidence-based practice to provide consistent and high-quality nursing care. This article focuses on developing critical appraisal skills and understanding the use and implications of different quantitative approaches to research. Part two of this article will focus on explaining common statistical terms and the presentation of statistical data in quantitative research.

Authors Juanita Hoe Senior clinical research associate, Research Department of Mental Health Sciences, University College London, London. Zoë Hoare Clinical trials statistician, Bangor University, Bangor. Correspondence to: [email protected]

Keywords Evidence-based practice, quantitative research, statistics, study design

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.

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Aims and intended learning outcomes This article aims to provide information to nurses who are attempting to appraise and review quantitative research articles critically. The broad nature of research means it is not possible to cover all aspects of research methodology in detail, however the article can help nurses gain a better understanding of quantitative research and the principles that underpin it. After reading this article and completing the time out activities you should be able to: �4Acknowledge the importance of identifying, appraising and understanding quantitative research evidence. �4Identify key questions for appraising research evidence critically. �4Recognise and identify the common quantitative research methods used within different studies. �4Appraise and evaluate the limitations of quantitative research evidence from a range of sources. �4Develop evidence-based knowledge relevant to your area of practice.

Introduction At a time of considerable advances in medical and nursing practice, it is important that healthcare professionals stay abreast of the changes (Department of Health (DH) 1997, 2008). The Code (Nursing and Midwifery Council (NMC) 2008) states that nurses need to provide a high standard of care at all times. Nurses also need to ensure that their skills and knowledge reflect evidence-based practice (NMC 2008). The ability of nurses to use or undertake research is therefore essential, not

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only in promoting best practice, but also in establishing nurses as competent, autonomous, highly skilled and knowledgeable professionals (Salvage 1998, Godshall 2009). The impetus for nurses to use research skills to implement evidence-based practice is not new and the ability to ‘think, apply, analyse, synthesise and evaluate’ are fundamental skills that nurses should possess (Elliot 1995).

It has been argued that evidence-based nursing offers a prescriptive approach to nursing practice, whereas in reality it allows nurses to decide how relevant the evidence is to practice and to patients (DiCenso et al 1998, Godshall 2009). Clinical decision making should be underpinned by an understanding of the evidence; it should not, however, replace clinical judgement – what is right for the patient – and may need to be adapted to accommodate patient choices and preferences.

Rycroft-Malone et al (2004) recommended that evidence-based practice should be based on research, clinical experience, patient and carer knowledge, and the environment in which care is applied. Moreover, patients now have greater access to information and research evidence (DH 2008), particularly through the media and internet. Nurses are in a prime position to help explain and interpret what the evidence means, whether it is valid and relevant, and how it can be integrated into care. Evidence-based practice is viewed as the ‘integration of best research evidence with clinical expertise and patient values’ (Sackett et al 2000).

Improvements in clinical judgement can only be achieved by developing abilities in deliberate reasoning (logical and reflective thinking) and analytical skill (Paniagua 1995, Benner et al 2009). Advances in medical and nursing research and technology, as well as the need to stay abreast of current evidence and best practice, may be daunting for some, but are vital to ensure best practice. It is important that nurses do not feel discouraged from developing and using critical appraisal skills. Only by using and practising such skills will nurses become more familiar with quantitative research methodology and outcomes, and develop the skills necessary to assess the quality of published evidence and its relevance to nursing practice.

Critical appraisal Nurses may not be in a position to be involved in research studies or undertake research themselves. They do, however, have the capacity to make sense of published

evidence through appraisal of the literature. Critical appraisal is the process of examining systematically a research article to assess its validity – whether the study measures what is says it measures – results and relevance before using the evidence to inform decision making (Burls 2009). It is the process of assessing the facts presented and the quality of the study to determine best evidence (Fowkes and Fulton 1991, Burls 2009). Nurses should, however, be aware that not all published studies are of a good quality and that research may be poorly reported, weak in design or flawed (Greenhalgh 1997, Churchill 1998, Godshall 2009).

Critical appraisal is therefore a fundamental component of establishing evidence-based practice. Sackett et al (1996) suggested that critical appraisal of the best available and clinically relevant information is essential for designing and developing new research, and integrating it with clinical expertise to implement evidence-based practice. Nurses should be able to use their critical appraisal skills to decide whether the quality of the research evidence is sufficient to underpin their practice or whether the evidence is flawed.

Most published research articles go through a peer-review process, where the credibility of the article has been assessed by experts from within the area in which the research was carried out. The purpose of critiquing is to analyse a research article, identifying flaws, evidence of bias or other factors that might have affected the results and how this, in turn, might affect the findings or outcome (Godshall 2009). Complete time out activity 1

Assessing quality Greenhalgh (1997) identified three key questions for assessing the methodological quality of a research article: �4Why was the study done and what clinical question were the authors addressing? �4What type of study was undertaken? �4Was the study design appropriate for the research?

Nurses need to determine the relevance of the evidence to their patient population by considering whether the results of the study are valid – whether the authors of the study measured what they were supposed to measure – and how the results can be applied to their clinical area (Jaeschke et al 1994). To help assess the validity of the research, nurses may find it useful to use a checklist that asks key questions, such as:

1 Think about an area of practice that you know is evidence-based. Can you identify where that evidence came from? Was the evidence established from a single piece of research or from several studies? Has any additional or recent evidence been published in that area?

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�4Is the study of interest? �4Who are the subjects and how were they recruited? �4How accurate is the data collected? �4Are the measures used valid and reliable? �4Are the statistical methods used appropriate and performed properly? �4What did the study find? �4What are the implications of the study?

There are several online resources available to help develop skills in critical appraisal and literature searching, and several journal articles offer frameworks of questions for assessing the quality of research studies (Jaeschke et al 1994, Greenhalgh 1997, Greenhalgh and Taylor 1997, Churchill 1998, Morton and Morton 2003, Solutions for Public Health 2012). Nurses are also encouraged to attend workshops on how to conduct database searches to ensure access to the most recently published literature. Complete time out activity 2

Structure of a research article Published research articles generally consist of a standardised layout. This includes (Greenhalgh 1997): �4Abstract – the abstract summarises the main points of the study design, its aim, how the research was undertaken and key findings from the research. �4Introduction – the introduction provides a comprehensive overview of research previously undertaken in the area of interest and specifies why this particular piece of research is needed. It should be noted that the background information may be brief at times, particularly where authors are limited by word count. �4Method – the method section should begin with a description of the aims and objectives of the study and the hypothesis (research question) that the study intends to answer. This is followed by a description of the study design and the sample population, such as how many participants were needed and how they were recruited to the study, and if applicable the randomisation procedures followed. Where relevant, a description of the planned intervention should be given, and any procedures that were followed for the recruitment of participants, applying measures, providing interventions and collecting data should be outlined. This is necessary to ensure that the study can be replicated elsewhere. The primary

and secondary outcomes that are being measured should be identified as well as the tools (assessments or scales) used to determine this, with brief reference to their acceptability, validity and reliability. Scales are known to measure what they should measure and this can be done consistently and without any adverse effects, such as causing increased burden or distress to participants. Any ethical issues and details of who gave permission for the research to be undertaken should be detailed. �4Analysis – the analysis should describe the steps taken to analyse the data collected and justification for the statistical tests applied. �4Results – the results should include details of the number of people completing the study, with an explanation for those that did not complete the study. Demographic information, such as age, gender, ethnicity, living area, education and income should be provided for the sample population. This helps to determine whether the results are generalisable to the wider population or limited in their application. Descriptive and comparative data may be presented alongside figures or tables that help to illustrate any significant results. �4Discussion – the discussion covers key findings of the research, interpreting their usefulness for clinical practice and implications for future research. There should also be a comparison of the findings to other similar research studies, as this demonstrates how the findings fit with existing research and builds on the evidence. The authors should also reflect critically on the limitations of the study and any conclusions drawn should be justifiable and relevant to the results given. �4Conclusion – the conclusion restates the aims of the research study and provides a summary of the main points. This should include a statement about the significance of the research and how it can be applied or is useful to practice.

Complete time out activity 3

Research study design There are two main approaches to research: qualitative and quantitative. Qualitative techniques are used to explore new topics and understanding of the human experience by making sense of or interpreting phenomena in terms of the meanings people bring to them (Greenhalgh and Taylor 1997, Bowling 2002). It is a rich source of data and examples of

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such research include focus groups, in-depth interviews and narrative inquiry (Polit and Hungler 1995, Greenhalgh and Taylor 1997, Bowling 2002). Qualitative data can be used to generate ideas (theory) or hypotheses, which may then be addressed using quantitative methods (Polit and Hungler 1995).

Quantitative techniques are used to test hypotheses, determine causation (relationships) between variables (characteristics or values that can be changed) and measure the frequency (number) of observations (Fowkes and Fulton 1991, Greenhalgh 1997, Bowling 2002). Quantitative data can be counted or measured and examples of such methods include clinical trials, surveys and cohort studies.

Quantitative methods have traditionally been considered more rigorous than qualitative methods, with randomised controlled trials (RCTs) and systematic reviews being the ‘gold standard’ for determining evidence (Sackett et al 2000). There is an established ranking or hierarchy of evidence for assessing the quality and robustness of methodological approaches (Evans 2003), but quantitative and qualitative methods are both considered valid and complementary when applied correctly, and may also be integrated (Bowling 2002).

Research in nursing has focused largely on qualitative approaches, although there is now a move towards using mixed methods, which combine qualitative and quantitative approaches. As it is beyond the scope of this article to describe the range of qualitative and quantitative research methods, the article focuses on common quantitative research methods. Qualitative approaches to research are dealt with elsewhere within the nursing literature (Ploeg 1999, Holloway and Wheeler 2010, Streubert and Carpenter 2010).

Quantitative approaches The hierarchy of evidence (weighting of the strength of the evidence) for quantitative approaches is generally recognised as set out below. As previously indicated, systematic reviews and RCTs are considered the gold standard for determining evidence.

Systematic reviews Systematic reviews provide an overview of the evidence relating to a specific research question by combining data from existing or primary research, usually published RCTs. Where RCTs are unavailable, observational studies such as controlled before and after or interrupted time

series (where outcomes are measured at specific points in the study) may be included, and the evidence may also be informed by the findings of qualitative studies.

The quality of the studies included in the review is assessed systematically. Where possible a meta-analysis is carried out in which numerical data from two or more clinical studies is pooled and a weighted average calculated. Systematic reviews and meta-analysis are used to determine the effectiveness of healthcare interventions. An example of a systematic review is Moore and Cowman’s (2008) review of risk assessment tools for the prevention of pressure ulcers.

Randomised controlled trials RCTs are experimental studies that are used to test the effectiveness of interventions between two or more groups, usually an intervention and a control (non-intervention or placebo) group. Participants are randomly allocated to a group and the intervention is delivered under tightly controlled conditions to avoid systematic errors (bias) and random errors (chance). The study participants and/or those undertaking the research assessments may be blinded (single-blind where either the participant or the researcher is unaware to which group the participant has been randomly allocated, or double-blind where the participant and researcher are unaware of the allocation), where information about who is and who is not receiving the intervention is concealed until the trial is complete. Data are usually collected before and after the intervention and differences in outcome examined between the groups. An example of an RCT is Kataoka et al’s (2010) study comparing the use of self-administered questionnaires versus interview as a screening method for intimate partner violence in the prenatal setting in Japan.

Cohort studies Longitudinal or cohort studies are observational studies of people with common characteristics or experiences and are used to determine the prognosis and progress of disease over time, from its early to late stages. Data are collected at two or more points over a particular period, usually of several years duration. An example of a cohort study is Mueller et al’s (2010) study of patient functioning as a predictor of nursing workload in acute hospital units providing rehabilitation care.

2 Make a list of the main differences between quantitative and qualitative research. 3 Read the article

by Kataoka et al (2010) and answer the checklist questions in the ‘Assessing quality’ section to assess the validity of the research.

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Non-randomised trials Uncontrolled or non-randomised trials are used when randomisation is not possible or is unethical. The results of non-randomised or uncontrolled trials may be considered less reliable as there is an increased risk for errors affecting the outcome of the trial. An example of a non-randomised trial is Lam et al’s (2010) study of mental health first aid training for the Chinese community in Australia, which examined the effects of such training on knowledge about and attitudes towards people with mental illness

Case-control studies Case-control studies focus on people with a specific diagnosis or disease, who are matched with people who do not have the disease (the controls). Data are collected on the two groups and compared to explore what differences exist between the groups and identify any characteristics that may be contributing to the disease. An example of a case-control study is Lazovich et al’s (2010) study of indoor tanning and risk of melanoma.

Cross-sectional surveys Cross-sectional surveys are used to determine the frequency of disease or diagnosis (screening), risk factors or other phenomenon, such as events, behaviour and attitudes, at one point in time. Although methodologically weak, cross-sectional surveys can be used to explore causal relationships (cause and effect) between variables. An example of a cross-sectional survey is Aung et al’s (2010) study of access to and use of GP services among Burmese migrants in London.

Case studies Case series and case studies are descriptive in nature and are used to determine factors contributing to the development of an illness. Case studies are considered the weakest level of evidence, but are useful in the early stages of research about a particular disease. An example of a case study is Chaboyer et al’s (2010) study of bedside nursing handover. Complete time out activity 4

Ethics Consideration must be given to the ethical implications of the research being undertaken. Any health-related research project involving humans, their tissue and/or data must be reviewed and approved by a research ethics

committee before it can start. The research ethics committee will review the research protocol and other project documents to ensure that the dignity, rights, safety and wellbeing of research participants is protected. Of particular concern are issues related to participants’ capacity to consent to take part in the research study, maintaining confidentiality, and data management and storage.

Stringent guidance is provided by the Research Governance Framework for Health and Social Care (DH 2005), which supports undertaking good quality studies and promotes good clinical practice within research. The Mental Capacity Act 2007 also provides guidance on the inclusion of vulnerable adults in research, such as people with a learning disability or patients with dementia, who may not have the capacity to consent to their participation.

Results The results are an important part of a quantitative study as they provide information on the amount of data collected and the outcome of the statistical analyses performed. The results reported can be particularly difficult to follow and may be open to misinterpretation if the data are not reported accurately and clearly. The credibility of the research undertaken is based on the thoroughness of the data reported, appropriateness of the statistical tests performed and accurate interpretation of the findings. Researchers conducting good quality clinical studies will have sought advice and assistance from a qualified statistician in planning and undertaking the analysis, and there should be justification given for the analysis used. The statistical analysis used should be relevant to the design of the research proposed and the research question stated.

Conclusion Staying abreast of developments in health care, and using this knowledge to inform and improve patient care, can be both challenging and rewarding for nursing staff. Key to this is having good critical appraisal skills and an understanding of quantitative and qualitative research design and methodological approaches. While research terminology is not always easy to comprehend, it does become easier to understand with familiarity. The

4 Identify a relevant area in your clinical practice that would be of interest to research. What would be your research question? What quantitative research methods do you think you could use to investigate this area of practice? What outcomes would you measure? What support is available in your clinical area to help you undertake a research study?

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broad scope of this subject means it is not possible to incorporate all aspects of research design, but this article provides an overview of the key factors relevant for assessing the methodological quality of quantitative research articles and interpreting their findings.

The evidence base for nursing care and interventions is expanding and this is an exciting and challenging time for advancing

nursing practice. Nurses have a leading role in establishing this evidence base, as well as being central to the implementation of improvements in practice across care settings.

Part two of this article will focus on explaining common statistical terms and the presentation of statistical data in quantitative research NS Complete time out activity 5

References Aung NC, Rechel B, Odermatt P (2010) Access to and utilisation of GP services among Burmese migrants in London: a cross-sectional descriptive study. BMC Health Services Research. 10, 285.

Benner P, Tanner C, Chesla C (2009) Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. Second edition. Springer, New York NY.

Bowling A (2002) Research Methods in Health: Investigating Health and Health Services. Second edition. Open University Press, Maidenhead.

Burls A (2009) What is Critical Appraisal? www.whatisseries.co.uk/ whatis/pdfs/What_is_crit_appr.pdf (Last accessed: November 21 2012.)

Chaboyer W, McMurray A, Wallis M (2010) Bedside nursing handover: a case study. International Journal of Nursing Practice. 16, 1, 27-34.

Churchill R (1998) Critical appraisal and evidence-based psychiatry. International Review of Psychiatry. 10, 4, 344-352.

Department of Health (1997) The New NHS: Modern, Dependable. The Stationery Office, London.

Department of Health (2005) Research Governance Framework for Health and Social Care. Second edition. The Stationery Office, London.

Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report. The Stationery Office, London.

DiCenso A, Callum N, Ciliska D (1998) Implementing evidence-based nursing: some

misconceptions. Evidence-Based Nursing. 1, 2, 38-39.

Elliot PA (1995) The development of advanced nursing practice: 1. British Journal of Nursing. 4, 11, 633-636.

Evans D (2003) Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing. 12, 1, 77-84.

Fowkes FG, Fulton PM (1991) Critical appraisal of published research: introductory guidelines. British Medical Journal. 302, 6785, 1136-1140.

Godshall M (2009) Fast Facts for Evidence-Based Practice: Implementing EBP in A Nutshell. Springer Publishing Company, New York NY.

Greenhalgh T (1997) How to read a paper. Getting your bearings (deciding what the paper is about). British Medical Journal. 315, 7102, 243-246.

Greenhalgh T, Taylor R (1997) How to read a paper. Papers that go beyond numbers (qualitative research). British Medical Journal. 315, 7110, 740-743.

Holloway I, Wheeler S (2010) Qualitative Research in Nursing and Healthcare. Third edition. John Wiley & Sons, Chichester.

Jaeschke R, Guyatt G, Sackett DL (1994) Users’ guides to the medical literature: III. How to use an article about a diagnostic test: A. Are the results of the study valid? Journal of the American Medical Association. 271, 5, 389-391.

Kataoka Y, Yaju Y, Eto H, Horiuchi S (2010) Self-administered

questionnaire versus interview as a screening method for intimate partner violence in the prenatal setting in Japan: a randomised controlled trial. BMC Pregnancy and Childbirth. 10, 84.

Lam AY, Jorm AF, Wong DF (2010) Mental health first aid training for the Chinese community in Melbourne, Australia: effects on knowledge about and attitudes toward people with mental illness. International Journal of Mental Health Systems. 4, 18.

Lazovich D, Isaksson Vogel R, Berwick M, Weinstock MA, Anderson KE, Warshaw EM (2010) Indoor tanning and risk of melanoma: a case-control study in a highly exposed population. Cancer, Epidemiology, Biomarkers and Prevention. 19, 6, 1557-1568.

Moore ZE, Cowman S (2008) Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews. Issue 3, CD006471.

Morton and Morton (2003) Evidence Based Nursing Practice. www.ebnp.co.uk (Last accessed: November 21 2012.)

Mueller M, Lohmann S, Strobl R, Boldt C, Grill E (2010) Patients’ functioning as predictor of nursing workload in acute hospital units providing rehabilitation care: a multi-centre cohort study. BMC Health Service Research. 10, 295.

Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London.

Paniagua H (1995) The scope of advanced practice: action

potential for practice nurses. British Journal of Nursing. 4, 5, 270-274.

Ploeg J (1999) Identifying the best research design to fit the question. Part 2: qualitative designs. Evidence Based Nursing. 2, 36-37.

Polit DF, Hungler BP (1995) Nursing Research: Principles and Methods. Fifth edition. Lippincott Williams and Wilkins, Philadelphia PA.

Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B (2004) What counts as evidence in evidence-based practice? Journal of Advanced Nursing. 47, 1, 81-90.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Editorial. Evidence based medicine: what it is and what it isn’t. British Medical Journal. 312, 7023, 71-72.

Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB (2000) Evidence-Based Medicine: How to Practice and Teach EBM. Second edition. Churchill Livingstone, Edinburgh.

Salvage J (1998) Evidence-based practice: a mixture of motives? Journal of Research in Nursing. 3, 6, 406-418.

Solutions for Public Health (2012) Critical Appraisal Skills Programme. tiny.cc/SPH_CASP (Last accessed: November 21 2012.)

Streubert HJ, Carpenter DR (2010) Qualitative Research in Nursing: Advancing the Humanistic Imperative. Fifth edition. Lippincott Williams & Wilkins, Philadelphia PA.

5 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 60.

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Statistics: part 1 TEST YOUR KNOWLEDGE AND WIN A £50 BOOK TOKEN

This self-assessment questionnaire (SAQ) will help you to test your knowledge. Each week you will find ten multiple-choice questions that are broadly linked to the learning zone article. Note: There is only one correct answer for each question.

Ways to use this assessment ��You could test your subject knowledge by attempting the questions before reading the article, and then go back over them to see if you would answer any differently.

��You might like to read the article to update yourself before attempting the questions.

Prize draw Each week there is a draw for correct entries. Please send your answers on a postcard to Zena Latcham, Nursing Standard, The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex HA1 3AW, or send them by email to [email protected]. Subscribers can complete the assessment at www.nursing-standard.co.uk by clicking on the Learning zone CPD questionnaire tab.

Ensure you include your name and address and the SAQ number. This is SAQ 673. Entries must be received by 10am on Tuesday January 8 2013.

When you have completed your self-assessment, cut out this page and add it to your professional portfolio. You can record the amount of time it has taken. Space has been provided for comments.

You might like to consider writing a practice profile, see page 60.

How to use this assessment

1. Healthcare professionals should ensure that: a) They provide high quality care o b) Their knowledge and skills

reflect evidence-based practice o c) They stay abreast of changes in

healthcare practice o d) All of the above o

2. Clinical decision making: a) Should replace clinical

judgement o b) Does not need to be adapted

to accommodate patient choice o

c) Should be underpinned by an understanding of the evidence o

d) Does not consider what is right for the patient o

3. All research: a) Should be published o b) Is high quality o c) Is reliable o d) Should be interpreted carefully o

4. Which of the following is not one of the main sections of a research article? a) Abstract o b) Editorial o c) Method o d) Results o

5. The gold standard quantitative approach for determining evidence is: a) Systematic review o b) Case-control studies o c) Non-randomised trials o d) Cross-sectional surveys o

6. Qualitative research involves: a) Cohort studies o b) Measurements of frequency o c) Exploring the human experience o d) Randomised controlled trials o

7. When conducting research with people: a) Research ethics committee

approval is not required o b) Confidentiality is not important o c) Anonymity is not essential o d) Consider capacity to consent o

8. Cohort studies are also known as: a) Case studies o b) Longitudinal studies o c) Systematic reviews o d) Randomised controlled trials o

9. Evidence-based practice involves integration of: a) Best research evidence o b) Clinical expertise o c) Patient values o d) All of the above o

10. Peer-reviews involve feedback from: a) Experts in the relevant area o b) The author’s colleagues o c) The publisher of the article o d) Research participants o

This self-assessment questionnaire was compiled by Tanya Fernandes

The answers to this questionnaire will be published on January 9

The answers to SAQ 671 on ethical practice, which appeared in the November 28 issue, are: 1. c 2. d 3. c 4. c 5. a 6. a 7. c 8. b 9. d 10. a

Report back This activity has taken me _ ____ hours to complete. Other comments:

Now that I have read this article and completed this assessment, I think my knowledge is: Excellent o Good o Satisfactory o Unsatisfactory o Poor o As a result of this I intend to:

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