Directional and Null Hypotheses

Week 3 Reading Textbook

Reference:

Grove, S. K. & Gray, S. G. (2019). Understanding nursing research: Building an evidence-based practice (7th ed.). Elsevier.

CHAPTER 5

Examining Research Problems, Purposes, and Hypotheses

We are constantly asking questions to gain a better understanding of ourselves and the world around us. This human ability to wonder and ask creative questions is the first step in the research process. By asking questions, clinical nurses, researchers, and educators are able to identify significant research topics and problems to direct the generation of research evidence for practice. A research topic is a concept or broad issue that is important to nursing, such as acute pain, chronic pain management, coping with illness, and health promotion. Each topic contains numerous research problems that might be investigated through quantitative and qualitative studies. For example, chronic pain management is a research topic that includes research problems such as “What is it like to live with chronic pain?” and “What strategies are useful in coping with chronic pain?” Different types of qualitative studies have been conducted to investigate these problems or areas of concern in nursing (Creswell & Poth, 2018). Quantitative studies have been conducted to address problems such as “What is an accurate and concise way to assess chronic pain?” and “What interventions are effective in managing chronic pain?”

The problem provides the basis for developing the research purpose. The purpose is the goal or focus of a study that guides the development of the objectives, questions, or hypotheses that further focus the intent of the study (Fig. 5.1). Objectives, questions, or hypotheses can be developed to bridge the gap between the more abstractly stated problem and purpose and the detailed design for conducting the study. However, many studies do not include objectives, questions, or hypotheses and are guided by the study problem and purpose. The study purpose, objectives, questions, and hypotheses include the variables, relationships among the variables, and often the population to be studied. In qualitative research, the purpose and sometimes broadly stated research questions or objectives guide the study of selected research concepts.

FIG 5.1 Linking research problem, purpose, and objectives, questions, or hypotheses.

This chapter includes content that will assist you in identifying problems and purposes in a variety of quantitative and qualitative studies. Objectives, questions, and hypotheses are discussed, and the different types of study variables are introduced. Also presented are guidelines that will assist you in critically appraising the problems, purposes, objectives, questions, hypotheses, and variables or concepts in published quantitative and qualitative studies.

What are research problems and purposes?

A research problem is an area of concern in which there is a gap in the knowledge needed for nursing practice. Research is required to generate essential knowledge to address the practice concern, with the ultimate goal of providing evidence-based nursing care (Brown, 2018; Melnyk & Fineout-Overholt, 2015). The research problem in a study (1) indicates the significance of the problem; (2) provides a background for the problem; and (3) includes a problem statement (Box 5.1). The significance of a research problem indicates the importance of the problem to nursing and health care and to the health of individuals, families, and communities. The background for a problem briefly identifies what we know about the problem area, and the problem statement identifies the specific gap in the knowledge needed for practice. Not all published studies include a clearly expressed problem, but the problem usually can be identified in the first page of the report.

Box 5.1

Elements of the research problem

•  Significance: Importance of the problem to nursing and health care

•  Background: Key knowledge that is known from previous research

•  Problem statement: Identified gap in the knowledge needed for practice

The research purpose is a clear concise statement of the specific goal or focus of a study. In quantitative studies, the goal of a study might be to identify and describe variables, examine relationships in a situation, determine the effectiveness of an intervention, or determine outcomes of health care (Shadish, Cook, & Campbell, 2002). In qualitative studies, the purpose might be to describe perceptions of a phenomenon and give it meaning, develop a theory of a health situation or issue, explore relevant concepts and concerns in nursing, or describe aspects of a culture (Creswell & Poth, 2018). The purpose includes the variables or concepts, the population, and sometimes the setting for the study. A clearly stated research purpose can capture the essence of a study in a single sentence and is essential for directing the remaining steps of the research process. In a research report, the purpose is usually identified and often follows the problem statement (see Fig. 5.1). The guidelines for critically appraising the problems and purposes in studies are presented as follows.

Critical appraisal guidelines

Problems and Purposes in Studies

1. Is the problem clearly and concisely expressed early in the study?

2. Does the problem include the significance, background, and problem statement (see Box 5.1)?

3. Does the purpose clearly express the goal or focus of the study?

4. Is the purpose focused on the study problem statement?

5. Are the study variables and population identified in the purpose?

The research problem and purpose from the study by Ruiz-González and colleagues (2016, p. 13) about the “long-term effects of an intensive-practical diabetes educational program on HbA1c and self-care” are presented as Research Example 5.1. This example is critically appraised using the identified guidelines.

Research example 5.1

Problem and Purpose of a Quantitative Study

Research Study Excerpt

Problem Significance

Diabetes mellitus is a disease that affects 246 million people world-wide (Steinsbekk, Rygg, Lisulo, Rise, & Fretheim, 2012) and has a high prevalence in the Spanish population… According to the World Health Organization, adequate control of the disease unequivocally requires educating patients and developing their skills to manage their treatment and prevent complications.

(Ruiz-González et al., 2016, p. 13)

Problem Background

Education is achieved through diabetes education programs (DEPs)… DEPs are available in various formats and types… and have been widely proven to be useful in improving biological, psychosocial, and behavioral parameters (Steinsbekk et al., 2012). Recent meta-analyses of controlled studies (Hopkins et al., 2012…) have shown improvements ranging from .52% to .81% in levels of hemoglobin (HbA1c)… and also shown considerable improvement in other areas such as self-efficacy and knowledge.

(Ruiz-González et al., 2016, p. 13)

Problem Statement

Despite there are many important variables in education and it is important to consider patient’s profile…, few studies have included them in the same DEP or have assessed their long-term effects. In addition, the effectiveness of DEPs should be determined by their influence on both biomedical and psychosocial variables.

(Ruiz-González et al., 2016, p. 14)

Research Purpose

The purpose of this study was to implement an intensive and practical DEP and evaluate its long-term effects and its impact on psychosocial variables.

(Ruiz-González et al., 2016, p.13)

Critical Appraisal

Research Problem

Ruiz-González et al. (2016) presented a clear concise research problem with the relevant areas of (1) significance, (2) background, and (3) problem statement. Diabetes is a significant, complex, chronic illness that requires extensive knowledge to manage effectively. A clear background of the problem was provided by citing findings from two meta-analyses (Hopkins et al., 2012; Steinsbekk et al., 2012) that summarized studies focused on the effectiveness of DEPs on the management of type 1 and type 2 diabetes. The discussion of the problem concluded with a concise problem statement that indicated the gap in the knowledge needed for practice and provided a basis for the study purpose.

Research Purpose

The research purpose frequently is reflected in the title of the study, stated in the abstract, and restated after the literature review. Ruiz-González and associates (2016) included the purpose of their study in all three places. However, the statements of the purpose in the article were varied, which can be confusing to readers. The researchers clearly identified the DEP intervention (independent variable) that was implemented to determine its long-term effects on psychosocial variables (dependent variables). The purpose would have been more complete if it had included the biomedical dependent variables and the population studied, which was adults with type 1 diabetes.

Ruiz-González and colleagues (2016) found that the DEP intervention was effective in improving biomedical and psychological variables, but more psychological strategies are needed in this intervention to motivate adults to make real lifestyle changes. This type of study supports the Quality and Safety Education for Nurses (QSEN, 2017; Sherwood & Barnsteiner, 2017) pre-licensure competency to ensure safe, quality, and cost-effective research-based health care that actively involves patients and families in their care process.

Identifying the problem and purpose in quantitative and qualitative studies

Quantitative and qualitative research approaches enable nurses to investigate a variety of research problems and purposes. Examples of research problems and purposes for different types of quantitative and qualitative studies are presented in this section.

Problems and Purposes in Types of Quantitative Studies

Example research problems and purposes for the different types of quantitative research—descriptive, correlational, quasi-experimental, and experimental—are presented in Table 5.1. If little is known about a topic, researchers usually start with descriptive and correlational studies and progress to quasi-experimental and experimental studies as knowledge expands in an area. An examination of the problems and purposes in Table 5.1 will reveal the differences and similarities among the types of quantitative research. The research purpose usually reflects the type of study that was conducted (Gray, Grove, & Sutherland, 2017). The purpose of descriptive research is to identify and describe concepts or variables, identify possible relationships among variables, and delineate differences between or among existing groups, such as males and females or different ethnic groups.

Table 5.1

Quantitative research topics, problems, and purposes

Type of research Research problem and purpose

Descriptive research Title of study: “Hand hygiene opportunities in pediatric extended care facilities [ECF].” (Buet et al., 2013, p. 72)

Problem: “The population in pediatric ECFs is increasingly complex, and such children are at high risk of healthcare-associated infections (HAIs), which are associated with increased morbidity, mortality, resources use, and cost (Burns et al., 2010) [problem significance]… The Centers for Disease Control and Prevention (CDC)… and the World Health Organization (WHO, 2009) have published evidence-based guidelines confirming the causal relationship between poor infection control practices, particularly hand hygiene (HH), and increased risk of HAIs [problem background]. However, most of the HH research has been focused in adult long term care facilities and acute care settings and findings from such studies are unlikely to be applicable to HH in pediatric ECFs given the different care patterns, including the relative distribution of different devices” [problem statement] (Buet et al., 2013, pp. 72 − 73).

Purpose: “The purpose of this observational study was to assess the frequency and type of HH opportunities initiated by clinical (e.g., physicians and nurses) and non-clinical (e.g., parents and teachers) care givers, as well as evaluate HH adherence using the WHO’s ‘5 Moments for HH’ observation tool” (Buet et al., 2013, p. 73).

Correlational research Title of study: “Emergency department [ED] weekend presentation and mortality in patients with acute myocardial infraction [AMI]” (de Cordova et al., 2017, p. 20).

Problem: “Each year in EDs across the United States, 8 million people are evaluated for symptoms that are consistent with AMI, and approximately 400,000 people die [problem significance]… Patients who present to the ED with an AMI require immediate interventions and treatments to increase their chances of survival… The recommended guidelines, according to the American Heart Association and the American College of Cardiology for the management of a patient with AMI includes diagnostic 12-lead electrocardiogram and biochemical markers, administration of aspirin, thrombolytic therapy within 30 minutes of arrival, and/or percutaneous coronary interventions (PCIs) within 90 minutes of arrival [problem background]… Few research teams have specifically examined patient mortality for the patient with AMI in the ED” and for those presenting to the ED on weekends and holidays [problem statement] (de Cordova et al., 2017, pp. 20 − 21).

Purpose: “… the purpose of this study was to determine if a weekend and holiday presentation is associated with an increase in mortality among patients with AMI presenting to the ED in New Jersey” (de Cordova et al., 2017, p. 21).

Quasi-experimental research Title of study: “Methods and design of a 10-week multi-component family meals intervention: A two group quasi-experimental effectiveness trial” (Rogers et al., 2017, p. 1).

Problem: There is an “ongoing childhood obesity public health crisis [problem significance]… American Academy of Pediatrics recommends participation in family meals as a childhood obesity prevention strategy due to the literature demonstrating a protective effect on participation in healthy mealtime routines on child and weight [problem background].… In addition, the majority of current research fails to examine the child health impact of family meals beyond BMI [body mass index]… Future research, specifically intervention work, would also benefit from expansion of the target age range to include younger children (4-7 year olds), who are laying the foundation of their eating patterns and are capable of participating in family meal preparations” [problem statement] (Rogers et al., 2017, pp. 1 − 2).

Purpose: The purpose of this study was to determine the effectiveness “of a 10-week multi-component family meals intervention aimed at eliciting positive changes in child diet and weight status” (Rogers et al., 2017, p. 1).

Experimental research Title of study: “Effects of oral care with glutamine in preventing ventilator-associated pneumonia in neurosurgical intensive care unit patients” (Kaya et al., 2017, p. 10).

Problem: “Ventilator-associated pneumonia (VAP) is one of the most frequent nosocomial infections in intensive care unit patients [problem significance]…. One of the measures to prevent the development of VAP is applying good oral care… In recent studies, glutamine was reported to be an essential amino acid that is critical for the regulation of protein synthesis, respiratory fueling, and nitrogen shuttling [problem background]…. Different products and protocols in oral care has been the subject for research. However, the number of studies about glutamine is limited” [problem statement] (Kaya et al., 2017, pp 10 − 11).

Purpose: The purpose of this study was “to determine the effects of oral care with glutamine in preventing ventilator-associated pneumonia in patients admitted to neurosurgical intensive care unit” (Kaya et al., 2017, p. 10).

Buet and colleagues (2013) conducted a descriptive study to identify the HH opportunities and adherence among clinical and nonclinical caregivers in extended pediatric care facilities. These researchers followed the World Health Organization (WHO) “5 Moments for Hand Hygiene” (WHO, 2009): before touching a patient, before clean or aseptic procedures, after body fluid exposure or risk, after touching a patient, and after touching patient surroundings. Researchers found that HH opportunities were numerous for clinical and nonclinical caregivers, but adherence to HH was low, especially for nonclinical individuals. HH evidence-based guidelines must be followed to prevent healthcare-associated infections.

The purpose of correlational research is to examine the type (positive or negative) and strength of relationships or associations among variables. Positive relationships (designated by a plus [+] sign) indicate that variables change in the same direction; they either increase or decrease together. For example, the more cigarettes an adult smokes each day, the greater his or her risk of lung cancer. Negative relationships (designated by a minus [−] sign) indicate that variables change in the opposite direction; as one variable increases, the other variable decreases. For example, the more minutes that a middle-aged adult exercises each week, the lower the BMI. The strength of relationships varies from − 1 to 0 to + 1, with − 1 indicating a perfect negative relationship, 0 indicating no relationship, and + 1 indicating a perfect positive relationship between variables (Grove & Cipher, 2017). Types of relationships are discussed in more detail in the section on hypotheses.

de Cordova, Johansen, Martinez, and Cimiotti (2017, p. 20) conducted a correlational study to determine if “weekend and holiday presentation was associated with increased mortality in EDs [emergency departments] among patients with AMI [acute myocardial infarction].” The researchers clearly identified the problem and purpose for this study (see Table 5.1). de Cordova and colleagues found that weekend and holiday presentations to the ED for AMI were associated with increased mortality, and further research is needed regarding ED resources during the week, weekend, and holidays to promote quality care.

Quasi-experimental studies are conducted to determine the effect of a treatment or independent variable on designated dependent or outcome variables (Shadish et al., 2002). Rogers and colleagues (2017) developed a quasi-experimental study to examine the effectiveness of a multicomponent family meals intervention called Simple Suppers on elementary school children’s (age, 4 − 10 years) diet and weight status. The research problem and purpose for this study are presented in Table 5.1. The researchers might have provided more detail on the problem significance and background in the article. However, they presented the intervention Simple Suppers and the outcomes to be measured in detail. Rogers et al. (2017) recommended further research to determine the effectiveness of this Simple Supper intervention developed for underserved families with elementary school-age children.

Experimental studies are conducted in highly controlled settings using a structured design to determine the effect of one or more independent variables on one or more dependent variables (Gray et al., 2017). Kaya and colleagues (2017, p. 11) conducted a “randomized, controlled, experimental study to determine the effects of oral care with glutamine in preventing ventilator-associated pneumonia in patients admitted to neurosurgical intensive care unit [ICU] in New Jersey.” They found that providing oral care with glutamine had no significant effect on the incidence of VAP in the neurosurgical ICU patients. Kaya et al. (2017) recommended additional research with a larger sample size over a longer time period.

Problems and Purposes in Types of Qualitative Studies

The problems formulated for qualitative research identify areas of concern that require investigation to gain new insights, expand understanding, and improve comprehension of the whole. The purpose of a qualitative study indicates the focus of the study, which may be a concept such as pain, an event such as loss of a child, or a facet of a culture such as the healing practices of a specific Native American tribe. In addition, the purpose often indicates the qualitative approach used to conduct the study (Creswell, 2014; Creswell & Poth, 2018; Munhall, 2012). Table 5.2 includes examples of research problems and purposes for the types of qualitative research—phenomenological, grounded theory, exploratory-descriptive, and ethnographic—commonly found in the nursing literature and included in this text.

Table 5.2

Qualitative research topics, problems, and purposes

Type of research Research problem and purpose

Phenomenological research Title of study: “Severe childhood autism: The family lived experience” (Gorlin et al., 2016, p. 580).

Problem: “Autism is the most prevalent developmental disability in the United States, affecting approximately 1 in 68 children (Center for Disease Control [CDC], 2014). Approximately one-third of the children with autism are considered to have ‘severe autism’ with significant functional challenges [problem significance]… There has been an effort to clarify autism severity based on a more holistic approach that focuses on the child’s daily needs within the context of the family instead of solely on symptoms [problem background]… In many of these studies, however, the severity of the child with autism is not identified… Additionally many of the phenomenological studies rely on the response of one family member, usually the mother to portray the family experience… Extended family members or others considered as family have not been included in the studies reviewed” [problem statement] (Gorlin et al., 2016, pp. 580 − 582).

Purpose: “The aim or purpose of this research was to interpret the meaning of the lived experience of families who live with a child who has severe autism” (Gorlin et al., 2016, p. 582).

Grounded theory research Title of study: “A grounded theory study of how nurses integrate pregnancy and full-time employment: Becoming someone different” (Quinn, 2016, p. 170).

Problem: “According to the U.S. Department of Labor (2010), there are approximately 1.7 million nurses in the United State, 40% of whom are women within the childbearing ages of 20-45 years, and more than 65% are employed full-time [problem significance]… Research from 1990 to 2000 reported mostly unfavorable findings related to attitudes surrounding pregnant employees in the workplace… Some employers conversely, embrace their pregnant employees and view them as valuable members of their work teams [problem background]… Nursing, as an international industry, has not explored how its female workforce (i.e., nurses) integrates pregnancy and employment” [problem statement] (Quinn, 2016, pp. 170 − 171).

Purpose: “The purpose of this research was to explore how primiparous U.S. nurses integrated pregnancy and full-time employment” (Quinn, 2016, p. 170).

Exploratory-descriptive qualitative research Title of study: “Women’s perceptions of biases and barriers in their myocardial infarction triage experience” (Arslanian-Engoren & Scott, 2016, p. 166).

Problem: “Every 10 minutes a woman dies from a myocardial infarction (MI). Yet, symptoms of impending MI in women are less likely to be recognized than in men [problem significance]…. Investigators have examined the cardiac triage decisions of ED nurses, who are often the first healthcare provider to evaluate and triage women for MI and initiate guideline recommendations. Results indicated that nurses do not always recognize women’s cardiac symptoms and their practice does not consistently adhere to MI evidence-based guidelines [problem background]… Less is known about the personal experiences of women within the ED healthcare system that may affect the accuracy or timeliness of nurses’ cardiac triage decisions” [problem statement] (Arslanian-Engoren & Scott, 2016, pp. 166 − 167).

Purpose: “Therefore, the purpose of this study was to examine the cardiac triage experiences of women who presented to the ED with an acute MI” (Arslanian-Engoren & Scott, 2016, p. 167).

Ethnographic research Title of study: “Perceptions and experiences of using a nipple shield among parents and staff: An ethnographic study in neonatal units” (Flacking & Dykes, 2017, p. 1).

Problem: “Breast milk mediates unequalled beneficial effects regarding nutritional, immunological, and cognitive outcomes in preterm infants (< 37 gestational weeks, gw), therefore international recommendations state that infants should be exclusively breastfed for the first 6 months of life [problem significance]… Although research shows that preterm infants display rooting, efficient areolar grasp, and repeated short sucking bursts from 29 weeks, and occasional long sucking bursts and repeated swallowing from 31 weeks, the transition from tube feeding to exclusive breastfeeding at the breast takes time [problem background]… However, the use of nipple shields is very controversial and study results are contradictory. Furthermore, no study has previously explored the parents’ and staffs’ perspective and experiences of using a nipple shield in neonatal units” [problem statement] (Flacking & Dykes, 2017, pp. 1 − 2).

Purpose: The purpose of this ethnographic study “ is to explore perceptions and experiences of using a nipple shield among parents and staff in neonatal units” (Flacking & Dykes, 2017, p. 2).

ED, Emergency department; gw, gestational weeks.

Phenomenological research is conducted to promote a deeper understanding of complex human experiences as they have been lived by the study participants (Creswell & Poth, 2018). Gorlin, McAlpine, Garwick, and Wieling (2016) conducted a phenomenological study to examine the experiences of families living with a child with severe autism. The research problem and purpose for this study were clearly developed in the article and are presented in Table 5.2. Gorlin and colleagues’ (2016, p. 596) study findings “illuminated the extensive hardships and challenges of families who have a child with severe autism; identified needed resources; and illuminated how families formed hybrid families for additional support.”

In grounded theory research, the problem identifies the area of concern, and the purpose indicates the focus of the theory to be developed to account for a pattern of behavior of those involved in the study (Charmaz, 2014). For example, Quinn (2016, p. 170) conducted “a grounded theory study of how nurses integrate pregnancy and full-time employment.” The problem and purpose were clearly stated in this study and are presented in Table 5.2. Quinn (2016, p. 173) found that “Becoming someone different emerged as the basic social process of how RNs (registered nurses) integrate full-time employment and pregnancy. Four categories—looking different, feeling different; expectations while expecting; connecting differently; and transitioning labor—were identified from the data analysis.”

Exploratory-descriptive qualitative research is being conducted by several researchers to describe unique concepts, issues, health problems, or situations that lack clear description or definition. Kim, Sefcik, and Bradway (2017) conducted a systematic review to describe the characteristics of exploratory-descriptive qualitative studies, which often provide the basis for future qualitative and quantitative research. Arslanian-Engoren and Scott (2016) conducted an exploratory-descriptive qualitative study of “women’s perceptions of biases and barriers in their myocardial infarction (MI) triage experience.” The research problem and purpose for this study were clearly presented in the research report (see Table 5.2). These researchers found that women with an MI perceived multiple barriers to their prompt diagnosis and treatment in an ED. Thus Arslanian-Engoren and Scott (2016, p. 171) recommended research to “evaluate interventions to improve the care delivery processes, reduce barriers, and facilitate the prompt and accurate treatment of women for acute MI.”

In ethnographic research, the problem and purpose identify the culture and specific attributes of the culture that are to be examined, described, analyzed, and interpreted to reveal the social actions, beliefs, values, and norms of the culture (Creswell & Poth, 2018). Flacking and Dykes (2017, p. 1) conducted an ethnographic study of the “perceptions and experiences of using a nipple shield among parents and staff… in neonatal units.” Table 5.2 includes the concisely developed research problem and purpose for this ethnographic study. The researchers concluded that using a nipple shield had both positive and negative aspects. The nipple shield facilitated the premature neonate’s attachment to the breast and the quality of nutritional intake but was a barrier to the relationship between mother and infant during breastfeeding. The nipple shield is often viewed as a short-term solution, and nurses must take into consideration the particular needs of the mother and baby.

Determining the significance of a study problem and purpose

A research problem and purpose is significant when it has the potential to generate or refine relevant knowledge that directly or indirectly affects nursing practice (Gray et al., 2017). When critically appraising the significance of the problem and purpose in a published study, you need to determine whether the researchers made a clear link of how the findings (1) might be applied in nursing practice, (2) expanded on previous research, (3) improved understanding of a problem by developing theory, and/or (4) added knowledge to current nursing research priorities.

Application to Nursing Practice

Practice-focused studies are significant because they address clinical concerns and generate findings for application to nursing practice. In addition, studies with significant research problems promote healthy patient and family outcomes, decrease morbidity and mortality, and reduce the costs of care. The ultimate goal is providing evidence-based practice (EBP), in which nursing care is based on the most current research (Melnyk, Gallagher-Ford, Fineout-Overholt, 2017).

Several studies have focused on the effects of nursing interventions or on ways to improve these interventions. For example, in the Ruiz-González et al. (2016) study that was introduced earlier, a DEP was implemented to improve biomedical (e.g., HbA1c) and psychosocial (e.g., self-care) variables in adults with type 1 diabetes. Rogers et al. (2017) developed a multicomponent family meal intervention to improve children’s diets and weight status, with the goal of reducing childhood obesity. Intervention-focused studies have the potential to generate significant, practical, and credible knowledge that can be applied to patient care to promote quality and safe patient- and family-centered care (Brown, 2018; Sherwood & Barnsteiner, 2017).

Expands Previous Research

For knowledge to advance, researchers design their studies based on the findings of previous research. In a research article, the introduction and literature review sections include relevant studies that provide a basis for the current study. Often, a summary of the current literature indicates what is known and not known in the problem area being studied (see Chapter 6). The gaps in the current knowledge base (problem statement) provide support for the study’s purpose (see Fig. 5.1). Ruiz-González et al. (2016) based their study on findings indicating that DEPs were effective in helping patients manage their type 1 diabetes. Then, they focused their study on what was not known regarding the long-term effects of DEPs on both biomedical and psychosocial outcomes of adults with type 1 diabetes.

Most study problems and purposes are based on previous research, as indicated by the research sources in the study’s reference list. Studies from research and clinical practice journals are cited, indicating the findings on which the current study was based. You can review the reference list from the Ruiz-González et al. (2016) study to identify the types of studies and journals cited in this article.

Promotes Theory Testing or Development

Another way that knowledge grows is when researchers design studies to refine or expand theoretical understanding of a clinical problem. Significant problems and purposes in quantitative studies are supported by theory, and often the focus of these studies is theory testing (Chinn & Kramer, 2015). The focus of a qualitative study may be to develop a theory (Creswell & Poth, 2018). For example, Quinn (2016) conducted a grounded theory study to develop a theory that described how US nurses integrated pregnancy and full-time employment. A detailed discussion of the different types of theories tested and/or developed through research is presented in Chapter 7.

Addresses Nursing Research Priorities

There are literally thousands of topics that a nurse researcher could study. To have the most benefit, researchers need to study problems that are the most important to nursing. Over the last 50 years, expert researchers, professional organizations, and funding agencies have identified research priorities to encourage studies in the areas important for nursing. Many professional nursing organizations use their websites to communicate current research priorities. For example, the current research priorities of the American Association of Critical Care Nurses (AACN, 2017) are identified on their website (https://www.aacn.org/nursing-excellence/grants/research-priority-areas) as: “(1) effective and appropriate use of technology to achieve optimal patient assessment, management, and/or outcomes; (2) creation of a healing, humane environment; (3) processes and systems that foster the optimal contribution of critical care nurses; (4) effective approaches to symptom management; and (5) prevention and management of complications” (AACN, 2017).

You can access the AACN (2017) research priorities without being a member of the organization, but some organizations, such as the Oncology Nursing Society and Society of Pediatric Nurses require you to sign into their website to access research priorities and activities.

The National Institute of Nursing Research (NINR) is the key agency for promoting nursing research in the United States. The NINR (2017) funds clinical and basic research and supports research training to promote the development of a scientific basis for clinical practice. A major initiative of the NINR is the development of a national nursing research agenda that involves identifying nursing research priorities, outlining a plan for implementing priority studies, and providing funds to support these priority projects.

The focus of the NINR’s (2016) Strategic Plan was “advancing science and improving lives.” The research agenda “focuses on areas of science in which the health needs are greatest, and in which NINR-supported research can have the largest impact.” The research priorities for the NINR include four areas of scientific focus:

• Symptom science: promoting personalized health strategies

• Wellness: promoting health and preventing illness

• Self-management: improving quality of life for individuals with chronic conditions

• End-of-life and palliative care: the science of compassion

“Two other areas, promoting innovation and developing the nurse scientists of the 21st century, are emphasized in all areas of NINR’s research programs. The plan is intended to be a living document, one which can be adapted as new opportunities and challenges arise” (NINR, 2016; https://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/NINR_StratPlan2016_reduced.pdf.)

Another federal agency with emphasis on facilitating healthcare research is the Agency for Healthcare Research and Quality (AHRQ). “The AHRQ mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used” (AHRQ, 2016; https://www.ahrq.gov/cpi/about/mission/index.html). The research priorities and funded projects are presented on the AHRQ (2017) website (http://www.ahrq.gov/legacy/fund/ragendix.htm).

Some of the research priorities identified by the AHRQ include the following:

• Optimizing care to people with multiple chronic conditions

• Quality care for low-income and racial and ethnic minority patients

• Research focused on translation, implementation, and diffusion of research into practice and policy

• Research to promote career development

The Healthy People 2020 website identifies and prioritizes the health topics and objectives of all age groups over the next decade (US Department of Health and Human Services [DHHS], 2017). These health topics and objectives direct future research in the areas of health promotion, illness prevention, illness management, and rehabilitation and can be accessed online at https://www.healthypeople.gov/2020/topics-objectives. Work is currently in progress for developing the topics and objectives for Healthy People 2030.

The WHO (2017) stresses the importance of research in building a healthier future for people all over the world. The WHO (2017) has offices in more than 190 countries and encourages the identification of priorities for a common nursing research agenda among these countries. A quality healthcare delivery system and improved patient and family health have become global goals. By 2020, the world’s population is expected to increase by 94%, with the older adult population increasing by almost 240%. Seven of every 10 deaths are expected to be caused by noncommunicable diseases, such as chronic conditions (e.g., heart disease, cancer, depression) and injuries (unintentional and intentional). The priority areas for research identified by WHO are to:

(1) improve the health of the world's most marginalized populations; (2) study new diseases that threaten public health around the world; (3) conduct comparative analyses of supply and demand of the health workforce of different countries; (4) analyze the feasibility, effectiveness, and quality of education and practice of nurses; (5) conduct research on healthcare delivery modes; and (6) examine the outcomes for healthcare agencies, providers, and patients around the world.

WHO, 2017; http://www.who.int/entity/en

In summary, expert nurse researchers, professional nursing organizations, and national and international agencies and organizations have identified research priorities to direct the future conduct of healthcare research to improve the outcomes for patients and families, nurses, and healthcare systems. When conducting a critical appraisal of a study, you need to examine the study’s contribution to nursing practice and determine whether the study’s problem and purpose are based on previous research, theory, and current research priorities.

Examining the feasibility of a study problem and purpose

A critical appraisal of research begins by determining the feasibility of the problem and purpose of the study. The feasibility of a study is determined by examining the researchers’ expertise; money commitment; availability of subjects, facilities, and equipment; and the study’s ethical considerations (Gray et al., 2017; Rogers, 1987). The feasibility of Ruiz-González and colleagues’ (2016) study of the long-term effects of a DEP on biological and psychosocial variables in adults with type 1 diabetes was critically appraised and presented as an example. You can review this study’s problem and purpose at the beginning of this chapter and locate this study through your library. The critical appraisal involves addressing the following questions about a study’s feasibility.

Critical appraisal guidelines

Examining the Feasibility of a Study’s Problem and Purpose

1. Did the researchers have the research, clinical, and educational expertise to conduct the study?

2. Was the study funded by local or national organizations or agencies? Did clinical agencies provide support for the study?

3. Did the researchers have adequate subjects, settings, and equipment to conduct their study?

4. Was the purpose of the study ethical?

Researcher Expertise

The research problem and purpose studied need to be within the area of expertise of the researchers. Research reports usually identify the education of the researchers and their current positions, which indicate their expertise to conduct a study. Doctor of philosophy (PhD) and postdoctorate degrees indicate very strong educational preparation for conducting research. Also, examine the reference list to determine whether the researchers have conducted additional studies in this area. If you need more information, you can search the Internet for the researchers’ accomplishments and involvement in research.

Ruiz-González (principal author), Guardia-Archilla, Rodríguez-Morales, Molina, and Casares were all master’s-prepared and working in the areas of endocrinology and nutrition at two different university hospitals. University hospitals usually have a strong focus on research and conduct a variety of studies. Fernández-Alcántara was also master’s-prepared and working in the university-based Mind, Brain, and Behavior Research Center. Santos-Roig was PhD-prepared and working in a university school of psychology. The reference list included no previous publications by these authors. Ruiz-González and colleagues (2016) demonstrated extremely strong clinical expertise in the areas of diabetes, endocrinology, nutrition, and psychology. Two authors were university-based and affiliated with research centers. The research and educational expertise of these authors was somewhat limited, with most being master’s-prepared and none having previous publications in this area.

Money Commitment

The problem and purpose studied are influenced by the amount of money available to the researchers. The cost of a research project can range from a few dollars for a student’s small study to hundreds of thousands and even millions of dollars for complex projects. Critically appraising the feasibility of a study involves examining the financial resources available to the researchers in conducting their study. Sources of funding for a study usually are identified in the article.

Studies might be funded by grants from national institutions (e.g., NINR, 2017; AHRQ, 2017), professional organizations, or private foundations. The researchers may have received financial assistance from companies that provided necessary equipment or support from the agencies where they conducted the study. Receiving funding for a study indicates that it was reviewed by peers who chose to support the research financially. The study by Ruiz-González et al. (2016, p. 13) was “funded by the Regional Ministry of Health of Andalusia, Spain.” These researchers were also supported in implementing the DEP intervention and collecting essential study data at the day clinic where the study was conducted. Ruiz-González et al. (2016) clearly identified the regional funding for their study and clinical agency support.

Availability of Subjects, Facilities, and Equipment

Researchers need to have adequate sample size, facilities, and equipment to implement their study. Most published studies indicate the sample size and setting(s) in the methods section of the research report. Often, nursing studies are conducted in natural or partially controlled settings, such as a home, school, hospital unit, or clinic. Many of these facilities are fairly easy to access, and the hospitals and clinics often provide access to adequate numbers of patients. Ruiz-González and colleagues’ (2016) study included an initial sample of 115 patients with type 1 diabetes who attended a diabetic outpatient clinic. However, the final sample included only 40 participants after this year-long study. Adequate subjects were available through the diabetic clinic, but the 34.7% retention rate ([40 ÷ 115] × 100% = 0.347 × 100% = 34.7%) could have affected the study results.

A review of the methods section of the research article will determine if adequate and accurate equipment was available. Nursing studies frequently require a limited amount of equipment, such as a tape or video recorder for interviews; physiological measures, such as laboratory values, vital signs, or BMI; and Internet-based or hard copy scales. Ruiz-González et al. (2016) assessed all participants’ biomedical variables (HbA1c, lipid levels, BMI) and psychosocial variables (knowledge of diabetes, self-reported self-care behaviors, perceived barriers, self-efficacy) before and after implementing the DEP in the clinic. Thus the subjects, equipment, and facility were adequate to conduct this study.

Ethical Considerations

The purpose selected for investigation must be ethical, which means that the subjects’ rights and the rights of others in the setting are protected (Gray et al., 2017). An ethical study confers more benefits than risks in its conduct and will generate useful knowledge for practice. Chapter 4 provides a detailed discussion of ethics in quantitative and qualitative research. Ruiz-González and colleagues (2016, p. 15) provided a clear discussion of the ethical aspects of their study in the following: “Patients were informed of the objectives of the study and gave written informed consent prior to test administration. The study was approved by the Ethics Committee of San Cecilio University Hospital.”

Examining research objectives, questions, and hypotheses in research reports

Research objectives, questions, and hypotheses evolve from the problem, purpose, literature review, and sometimes the study framework to direct the remaining steps of the research process (see Fig. 5.1). Many researchers only identify a problem and purpose to guide their quantitative or qualitative studies. However, some studies include specific objectives, questions, or hypotheses to guide the methodology, organize the results, and clarify the findings. In a published study, the objectives, questions, or hypotheses usually are presented after the literature review section, right before the methods section. The content in this section will assist you in identifying and critically appraising the objectives, questions, and hypotheses in studies.

Research Objectives

A research objective is a clear, concise, declarative statement expressed in the present tense to identify the goals of the study. The objectives are sometimes referred to as aims and are generally presented in descriptive and correlational quantitative studies. For clarity, an objective usually focuses on one or two variables and indicates whether they are to be identified or described. Sometimes the focus of objectives is to identify relationships among variables or determine differences between two or more existing groups, such as females and males, for selected variables.

Qualitative research is most appropriate when the focus of the study is to obtain a personal perspective of a situation, experience, or event (Creswell & Poth, 2018; Henson & Jeffrey, 2016). The research objectives or aims formulated for quantitative and qualitative studies have some similarities because they focus on exploration, description, and determination of relationships. However, the objectives directing qualitative studies are commonly broader in focus and include concepts that are more complex and abstract than those of quantitative studies. The aims in qualitative studies focus on participants’ experiences of certain events and health conditions, theory development, understanding of cultures of groups and institutions, and description of challenges, reasons for behaviors, and perceptions of specific care or interventions in nursing practice (Creswell & Poth, 2018; Kim et al., 2017).

Guillaume, Crawford, and Quigley (2016, p. 65) included aims to direct their study of the “characteristics of the middle-age adult inpatient fall.” These researchers demonstrated the logical flow from research problem and purpose to research aims (see Fig. 5.1) in reporting their quantitative descriptive study, presented in Research Example 5.2. The questions in the following box were used to conduct a critical appraisal of this study.

Critical appraisal guidelines

Research Objectives and Questions

1. Are the objectives (aims) or questions clearly and concisely expressed in the study?

2. Are the study objectives or questions based on the study purpose?

3. Do the objectives or questions appear to direct the study methodology, organize the study results, and facilitate the interpretations of findings?

Research example 5.2

Problem, Purpose, and Aims or Objectives

Research Study Excerpt

Research Problem

Falls with injuries remains one of the most reportable, serious, and costly type of adverse events that occur in United States (U.S.) hospitals, resulting in detrimental morbidity and mortality outcomes… In acute care hospitals, an estimated 1,000 falls occur per hospital each year regardless of size, with over one million inpatient falls reported annually at the national level [problem significance]…. The recent fall study by Williams et al. (2014) also identified that middle-aged inpatients 51–60 years old (n = 5,561) had the highest reported fall rates, followed by patients age 61–70 years (n = 4,699) [problem background]…. While predictors of falls and injuries have been studied across all adult inpatients…, research has not specifically addressed the fall risk characteristics in the middle-age [problem statement].

(Guillaume et al., 2016, pp. 65 − 66)

Research Purpose

The purpose of this study was to describe the characteristics of middle-age adult inpatients’ [ages 45–64] that fall, along with their fall and fall injury risk factors.

(Guillaume et al., 2016, p. 66)

Research Aims

The aims were to (a) describe falls and fall injury risk factors; (b) describe unit-specific data, fall numbers with type of falls, injuries from falls, and prevention strategies; and (c) compare the incidence of fall and fall injury rates of the middle-age (45–64) patients with the hospital adult age groups (21–44 and 65–90).

(Guillaume et al., 2016, p. 66)

Critical Appraisal

Guillaume and colleagues (2016) identified a significant problem regarding inpatient falls for middle-aged adults that had not been adequately studied. The problem statement clearly indicated what was not known and provided a basis for the purpose and aims of this study. The purpose clearly indicated that the focus of the study was to describe the characteristics of middle-age adult inpatient falls. The study aims built on the problem and purpose and provided more clarity regarding the specific goals of the study. These aims were very useful in organizing the study results and interpreting the findings. The specific variables described and compared related to falls were identified in the study aims. The first two aims were focused on description and the last on comparing fall and fall injury rates of middle-age adults with two other hospital adult age groups.

Research Questions

A research question is a clear, concise, interrogative statement that is worded in the present tense, includes one or more variables, and is expressed to guide the implementation of studies. The foci of research questions in quantitative studies are description of variable(s), examination of relationships among variables, use of independent variables to predict a dependent variable, and determination of differences between two or more groups regarding selected variable(s). These research questions are usually narrowly focused and inclusive of the study variables and population. It is really a matter of choice whether researchers identify objectives or questions in their study but, more often, questions are stated to guide descriptive and correlational quantitative studies. Hypotheses should be developed to direct quasi-experimental and experimental quantitative studies (Shadish et al., 2002).

Hernandez, Morgan, and Parshall (2016, p. 481) conducted a descriptive correlational study to examine the “resilience, stress, stigma, and barriers to mental healthcare in U.S. Air Force [USAF] nursing personnel.” These researchers identified a purpose and research questions to direct the implementation of their study, presented in Research Example 5.3. The critical appraisal guidelines for examining research objectives or questions in a study, presented earlier, were applied to this example.

Research example 5.3

Purpose and Research Questions From a Quantitative Study

Research Study Excerpt

Research Purpose

This study assessed the extent to which stigma and barriers to accessing MH [mental health] services as perceived by USAF nursing personnel are associated with resilience, stress, previous deployment, or demographic characteristics.

(Hernandez et al., 2016, p. 481)

Research Questions

1. What are USAF nursing personnel’s levels of stigma and barriers to accessing MH services, stress, and resilience?

2. What are the magnitude and direction of associations among stigma and barriers to accessing MH services, stress, and resilience in USAF nursing personnel?

3. Are the demographic characteristics, military grade, past deployment, and access to MH services related to stigma and barriers to accessing MH services, stress, and resilience among USAF nursing personnel?

(Hernandez et al., 2016, p. 482)

Critical Appraisal

Hernandez and colleagues (2016) clearly stated their study purpose, and the research questions evolved from the purpose and clarified the goals of their study. Question 1 focused on a description of nursing personnel’s levels of stigma and barriers to accessing MH services. Questions 2 and 3 focused on examining relationships or associations among the study variables. These questions were addressed by the study methodology, results, and findings. Hernandez et al. (2016, p. 481) found that a large percentage of the USAF nursing personnel had “concerns that accessing MH services may adversely affect their careers and how they are viewed by unit leaders and peers. In addition, higher levels of concern about stigma were associated with higher levels of stress and lower levels of resilience.”

The research questions directing qualitative studies are often limited in number, broadly focused, and inclusive of variables or concepts that are more complex and abstract than those of quantitative studies. Marshall and Rossman (2016) indicated that the questions developed to direct qualitative research might be theoretical, which can be studied with different populations or in a variety of sites, or the questions could be focused on a particular population or setting. The study questions formulated are very important for the selection of the qualitative research method used to conduct the study (Creswell & Poth, 2018).

Roll and Bowers (2017) conducted a qualitative study to describe how healthy aging is promoted for individuals with developmental disabilities. These investigators developed research questions to guide their study. The purpose and questions from this study are presented in Research Example 5.4.

Research example 5.4

Purpose and Research Questions From a Qualitative Study

Research Study Excerpt

Research Purpose

This qualitative study “sought to describe and analyze one innovative community nursing outreach program that emerged in 2009 in response to the observed health disparities and unmet health needs of people with I/DD [intellectual and developmental disabilities]” (Roll & Bowers, 2017, p. 236).

Research Questions

(Roll & Bowers, 2017, p. 237)

1. Why did this community outreach nursing program (CONP) for people with I/DD emerge?

2. What is the daily work of the community outreach nurses in this program with the goal of promoting healthy aging of individuals with I/DD in the community?

Critical Appraisal

Roll and Bowers (2017) clearly identified their study purpose and the research questions clarified the goals of the study. Question 1 focused on identifying and describing why the CONP for people with I/DD emerged, and question 2 focused on a description of the daily work of nurses in the CONP. These questions were the focus of data collection and analysis and provided organization to the discussion of findings. Roll and Bowers (2017, p. 234) found that the CONP was implemented to improve communication between primary care providers and individuals with I/DD. The nurses’ daily work included “health education, advocacy for the safe return home,… and enabling social participation” of individuals with I/DD.

Hypotheses

A hypothesis is a formal statement of the expected relationship(s) between two or more variables in a specified population. The hypothesis translates the research problem and purpose into a clear explanation or prediction of the expected results or outcomes of selected quantitative studies. A clearly stated study hypothesis includes the independent variables to be manipulated or measured, indicates the proposed outcomes or dependent variables to be measured, and identifies the population to be studied. Different types of variables are discussed in more detail at the end of this chapter. Hypotheses also influence the study design, sampling method, data collection and analysis process, and interpretation of findings (Fawcett & Garity, 2009; Grove & Cipher, 2017). Quasi-experimental and experimental quantitative studies are conducted to test the effectiveness of a treatment or intervention; these types of studies should include hypotheses to predict the study outcomes. Predictive correlational studies that measure independent variables to predict a dependent variable often include hypotheses (Gray et al., 2017). In this section, types of hypotheses are described, and the elements of a testable hypothesis are discussed, so that you can critically appraise hypotheses in published studies.

Types of Hypotheses

Different types of relationships and numbers of variables are identified in hypotheses. A study might have one, four, or more hypotheses, depending on its complexity. The type of hypothesis developed is based on the purpose of the study. Hypotheses can be described using four categories that are identified in Box 5.2 and described in this section.

Box 5.2

Types of hypotheses

•  Associative versus causal hypotheses

•  Simple versus complex hypotheses

•  Nondirectional versus directional hypotheses

•  Statistical versus research hypotheses

Associative versus causal hypotheses

The relationships identified in hypotheses are associative or causal. An associative hypothesis proposes relationships among variables that occur or exist together in the real world so that when one variable changes, the other changes (Gray et al., 2017). Associative hypotheses identify relationships among variables in a study but do not indicate that one variable causes an effect on another variable. McKee, Long, Southward, Walker, and McCown (2016) conducted a predictive correlation study to determine the factors that were predictive of childhood obesity. They “hypothesized that children of overweight or obese parents are more likely to be obese” (McKee et al., 2016, p. 197). This associative hypothesis predicts two positive relationships between overweight parents and obese children and between obese parents and obese children. The relationships in this hypothesis are diagrammed as follows:

The lines that connect the three variables are straight, without arrows, which indicate linear relationships or associations. McKee et al. (2016, p. 200) found “that the second greatest predictor of childhood obesity was having at least one obese parent, and the third greatest predictor was having at least one overweight parent.”

A causal hypothesis proposes a cause and effect interaction between two or more variables, referred to as independent and dependent variables. The independent variable (treatment or intervention) is manipulated by the researcher to cause an effect on the dependent or outcome variable. The researcher then measures the dependent variable to examine the effect created by the independent variable (Waltz, Strickland, & Lenz, 2017). A format for stating a causal hypothesis is the following.

Study participants in the experimental group, who are exposed to the independent variable (intervention), demonstrate greater change, as measured by the dependent variable, than those in the comparison group who received standard care.

The study by Ruiz-González et al. (2016), presented earlier, was conducted to examine the long-term effects of a DEP (independent variable) on biomedical and psychosocial measures (dependent variables). This study included the following causal hypothesis: “after the DEP, patients will have lower levels of A1c hemoglobin, greater theoretical and practical knowledge about diabetes, fewer barriers [to self-care], higher frequency of self-care, and greater self-efficacy.” This hypothesis included seven variables—one independent variable (DEP) that was implemented to create an effect on the six dependent variables (HbA1c, theoretical and practical knowledge about diabetes, barriers to self-care, self-care, and self-efficacy). This causal hypothesis might be diagrammed as follows, with an arrow (→) to indicate cause and effect versus associative relationships:

This causal hypothesis identifies two negative and four positive relationships. The DEP was expected to decrease HbA1c and barriers to self-care and to increase knowledge of diabetes, frequency of self-care, and self-efficacy. The study by Ruiz-González et al. (2016, p. 13) supported this hypothesis because “significant changes were maintained at one-year follow-up in hemoglobin A1c, barriers to self-care, frequency of self-care, knowledge about the disease, and perceived self-efficacy.”

Simple versus complex hypotheses

Hypotheses are either simple or complex (see Box 5.2). A simple hypothesis states the relationship (associative or causal) between two variables. McKee and colleagues (2016, p. 197) stated a simple associate hypothesis in their study of predictors of childhood obesity. They hypothesized that children whose weight status is “misperceived by their parents are more likely to be obese.” This hypothesis might be diagrammed as follows:

The study by McKee et al. (2016) supported this hypothesis because 86.2% of the parents misperceived their child’s weight as healthy when the child was actually overweight or obese. These researchers found that the parents’ misperception of their child’s weight status was the strongest predictor of childhood obesity.

A complex hypothesis states the relationships (associative or causal) among three or more variables. The study by Ruiz-González and colleagues (2016) included the following complex causal hypothesis: “the DEP patients will show improvements in biomedical measures, particularly in cardiovascular risk factors such as cholesterol (total and LDL [low density lipoprotein]) and body mass index [BMI]” (Ruiz-González et al., 2016, p. 14). This hypothesis might be diagrammed as follows:

The researchers examined the effect of DEP (an independent variable) on the dependent variables of total cholesterol, LDL, and BMI. This hypothesis was not supported because no changes were observed in the BMI or the total and LDL cholesterol values. Thus the Ruiz-González et al. (2016) study had mixed results, with one hypothesis supported and the other not supported.

Nondirectional versus directional hypotheses

A nondirectional hypothesis states that a relationship exists but does not predict the nature (positive or negative) of the relationship. If the direction of the relationship being studied is not clear in clinical practice or in the theoretical or empirical literature, the researcher has no clear indication of the nature of the relationship. Under these circumstances, nondirectional hypotheses are developed, such as “hours playing video games is related to body mass index in school-age children.” This is an example of a simple (two variables), associative, and nondirectional hypothesis.

A directional hypothesis states the nature (positive or negative) of the interaction between two or more variables. The use of terms such as positive, negative, less, more, increase, decrease, greater, higher, or lower in a hypothesis indicates the direction of the relationship. Directional hypotheses are developed from theoretical statements (propositions), findings of previous studies, and clinical experience. As the knowledge on which a study is based increases, researchers are able to make a prediction about the direction of a relationship between the variables being studied. For example, McKee and colleagues (2016, p. 197) stated a directional hypothesis: “parents will be more likely to misperceive the weight status of younger children.” The italicized word indicates the nature of the relationship in this simple, associative, directional hypothesis. This hypothesis includes a negative relationship that might be diagrammed as follows:

The study by McKee et al. (2016) supported this hypothesis because the parents significantly misperceived the weight status of their younger children as being healthy when they were actually overweight or obese.

A causal hypothesis predicts the effect of an independent variable on a dependent variable, specifying the direction of the relationship. The independent variable increases or decreases each dependent variable; thus all causal hypotheses are directional. Huang, Chang, and Lai (2016) conducted a quasi-experimental study to determine the effects of music and exercise on insomnia in older adults. One of the hypotheses examined in this study was that “Participants who perform brisk walking exercise combined with music in the evening for two nights exhibit higher sleep quality scores than no-exercise baseline scores” (Huang et al., 2016, p.105). The hypothesis might be diagrammed as follows:

This causal hypothesis (as indicated by the arrows) is complex (three variables), directional (higher sleep scores), and positive (exercise and music increase sleep scores). The results of this study were statistically significant, supporting this hypothesis that exercise and music interventions did improve the quality of aging adults’ sleep scores.

Statistical versus research hypotheses

Hypotheses are either research or statistical (see Box 5.2). The statistical hypothesis, also referred to as a null hypothesis (H0), is used for statistical testing and for interpreting statistical outcomes. Even if the null hypothesis is not stated, it is implied because it is the converse of the research hypothesis (Grove & Cipher, 2017). Some researchers state the null hypothesis because it is more easily interpreted on the basis of the results of statistical analyses. The null hypothesis is also used when the researchers believes that there is no relationship between two variables and when theoretical or empirical information is inadequate to state a research hypothesis. Null hypotheses can be simple or complex and associative or causal but are always nondirectional because the null hypothesis states there is no relationship between variables or differences between groups. Huang and colleagues (2016, p. 105) stated the following null hypothesis in their study: “Subjective sleep quality scores do not differ between listening to soothing music and performing brisk walking exercise combined with music.” The null hypothesis was supported because the “results revealed that both the soothing music and brisk walking exercise combined with music exhibited the same effects on subjective sleep quality” (Huang et al., 2016, p. 107).

A research hypothesis is the alternative hypothesis (H1 or HA) to the null or statistical hypothesis and states that a relationship exists between two or more variables. All the hypotheses stated earlier in this chapter have been research hypotheses. Research hypotheses can be simple or complex, nondirectional or directional, and associative or causal.

Critical appraisal guidelines

Hypotheses in Studies

1. Are the hypotheses formally stated in the study? If the study is quasi-experimental or experimental, hypotheses are needed to direct the study.

2. Do the hypotheses clearly identify the relationships among the variables of the study?

3. Are the hypotheses associative or causal, simple or complex, directional or nondirectional, and research or null (statistical; see Box 5.2)?

4. If hypotheses are included in a study, are they used to organize research results and interpret study findings?

The study by Ruiz-González and colleagues’ (2016), introduced earlier, focused on the effects of a DEP on biomedical and psychosocial variables in adults with type 1 diabetes. These researchers developed causal hypotheses to direct the conduct of their study, presented in Research Example 5.5.

Research example 5.5

Hypothesis

Research Study Excerpt

The following hypotheses were developed: (1) after the DEP patients will have lower levels of HbA1c, greater theoretical and practical knowledge about diabetes, fewer barriers, higher frequency of self-care, and greater self-efficacy; (2) these changes will remain stable at six-month and one-year follow-up; (3) after the DEP patients will show improvements in biomedical measures, particularly in cardiovascular risk factors, such as cholesterol (total and LDL) and body mass index.

(Ruiz-González et al., 2016, p. 14)

Critical Appraisal

Ruiz-González and colleagues (2016) stated causal hypotheses, which are appropriate for quasi-experimental research that examines the effects of an intervention on selected dependent variables. The study included three complex, causal, and directional research hypotheses. Hypotheses 1 and 3 were clearly stated and identified the DEP intervention and the specific psychosocial variables (knowledge of diabetes, barriers, self-care, and self-efficacy) and biomedical variables (HbA1c, total cholesterol, LDL, and BMI) that were measured. These two hypotheses were diagrammed earlier in this section and clarify the relationships between the independent and dependent variables. Hypothesis 2 focused on the prediction of the relationships among the variables over time (6 months and a year). The results section of the article was focused on the study variables and did not clearly address whether the hypotheses were supported or not.

Testable Hypothesis

The value of a hypothesis ultimately is derived from whether it is testable in the real world. A testable hypothesis is one that clearly predicts the relationships among variables and contains variables that are measurable or able to be manipulated in a study. The independent variable must be clearly defined, often by a protocol, so that it can be implemented precisely and consistently as an intervention in a study. The dependent variable must be clearly defined to indicate how it will be precisely and accurately measured (see the next section on defining study variables).

A testable hypothesis also needs to predict a relationship that can be “supported” or “not supported,” as indicated by the data collected and analyzed. If the hypothesis states an associative relationship, correlational analyses are conducted on the data to determine the existence, type, and strength of the relationship between the variables studied. The hypothesis that states a causal link between the independent and dependent variables is evaluated using statistical analyses, such as the t-test or analysis of variance (ANOVA), that examine differences between the means of the dependent variables for the experimental and comparison or control groups (Grove & Cipher, 2017; see Chapter 11). It is the statistical or null hypothesis (stated or implied) that is tested to determine whether the independent variable produced a significant effect on the dependent variable.

Hypotheses are clearer without specifying the presence or absence of a significant difference because determination of the level of significance is only a statistical technique applied to sample data. In addition, hypotheses should not identify methodological points, such as techniques of sampling, measurement, and data analysis (Grove & Cipher, 2017). Therefore such phrases as measured by, in a random sample of, and using ANOVA are inappropriate because they limit the hypothesis to the measurement methods, sample, or analysis techniques identified for one study. In addition, hypotheses need to reflect the variables and population outlined in the research purpose.

In summary, the research objectives, questions, and hypotheses must be clearly focused and concisely expressed in studies. Both objectives and questions are used in qualitative studies and descriptive and correlational quantitative studies, but questions are more common. Some correlational studies focus on predicting relationships and may include hypotheses. Quasi-experimental and experimental studies should be directed by hypotheses.

Understanding study variables and research concepts

The research purpose and objectives, questions, and hypotheses include the variables or concepts to be examined in a study. Variables are qualities, properties, or characteristics of persons, things, or situations that change or vary. Variables should be concisely defined to promote their measurement or manipulation in quantitative or outcomes studies (Chinn & Kramer, 2015; Waltz et al., 2017). Research concepts are usually studied in qualitative research, are at higher levels of abstraction than variables, and are not manipulated in studies (Creswell & Poth, 2018). In this section, different types of variables are described, and conceptual and operational definitions of variables are discussed. The research concepts investigated in qualitative research are also discussed.

Types of Variables in Quantitative Research

Variables are classified into a variety of types to explain their use in research. Some variables are manipulated; others are controlled. Some variables are identified but not measured; others are measured with refined measurement devices. The types of variables presented in this section include research, independent, dependent, and extraneous variables (Gray et al., 2017; Waltz et al., 2017).

Research Variables

Descriptive and correlational quantitative studies involve the investigation of research variables. Research variables are the qualities, properties, or characteristics identified in the research purpose and objectives or questions that are measured in a study. Research variables are included in a study when the intent is to observe or measure variables as they exist in a natural setting, without the implementation of a treatment. Thus no independent variables are manipulated, and no cause and effect relationships are examined. Buet and associates (2013) described the research variables of HH opportunities and HH adherence for clinical caregivers (e.g., nurses, physicians) and nonclinical caregivers (e.g., parents, teachers) in pediatric extended-care facilities (see Table 5.1 for the study problem and purpose).

Independent and Dependent Variables

The relationship between independent and dependent variables is the basis for formulating hypotheses for correlational, quasi-experimental, and experimental studies. In predictive correlational studies, the variables measured to predict a single dependent variable are called independent variables (Grove & Cipher, 2017). For example, McKee and colleagues (2016) conducted a predictive correlational study to determine if the independent variables of parents’ misperceptions of their child’s weight status (healthy, overweight, obese), parents’ weight status as either overweight or obese, and the age of child were used to predict the likelihood of childhood obesity (dependent variable). The hypotheses from this study were presented earlier and were supported by the study results.

The term independent variable is more frequently used to identify an intervention that is manipulated or varied by the researcher to create an effect on the dependent variable. The independent variable is also called an intervention, treatment, or experimental variable. A dependent variable is the outcome that the researcher wants to predict or explain. Changes in the dependent variable are presumed to be caused by the independent variable. Strohfus and colleagues (2017) conducted a study to examine the effects of peer-to-peer immunization education and training on health personnel’s knowledge and the immunization rates in their medical offices. These researchers stated the following null hypothesis: “there would be no significant increase and retention of knowledge, and no increased immunization rates after the education was provided” (p. 132). The independent variable was the immunization education and training that was implemented to determine its effects on 113 health personnel’s knowledge and the immunization rates in 28 medical offices. Strohfus et al. (2017, p. 133) found that “overall knowledge increased by 7.8% (n = 113) 12-months post education,” and the immunization rates increased significantly in the medical offices.

Extraneous Variables

Extraneous variables exist in all studies and can affect the measurement of study variables and the relationships among these variables. Extraneous variables are of primary concern in quantitative studies examining the effects of interventions because they can interfere with obtaining a clear understanding of the relational or causal dynamics within these studies. These variables are classified as recognized or unrecognized and controlled or uncontrolled. Some extraneous variables are not recognized until the study is in progress or has been completed, but their presence influences the study outcome.

Researchers attempt to recognize and control as many extraneous variables as possible in quasi-experimental and experimental studies, and specific designs, intervention protocols, and sample criteria have been developed to control the influence of extraneous variables that might influence the outcomes of these studies. Ruiz-González et al. (2016, p. 14) selected a quasi-experimental design “where every single participant is subjected to every single treatment (including control)… The fact that subjects act as their own control provides a way of reducing the amount of error arising from natural variance between individuals.” The sample exclusion criteria ensured that individuals with physical and psychological impairments were not included in the study, reducing additional potential for error. The scales used to measure knowledge of diabetes, self-care behaviors, barriers, and self-efficacy were presented in detail. However, the intervention (DEP) lacked detail in the article; having a protocol that was evidence-based for the intervention would have reduced the potential for error. The processes for measuring the biomedical variables (total cholesterol, LDL, and BMI) lacked description.

The extraneous variables that are not recognized until the study is in process, or are recognized before the study is initiated but cannot be controlled, are referred to as confounding variables. Sometimes, extraneous variables can be measured during the study and controlled statistically during analysis. However, extraneous variables that cannot be controlled or measured are a design weakness and can hinder the interpretation of findings (see Chapter 8). As control in correlational, quasi-experimental, and experimental studies decreases, the potential influence of confounding variables increases.

Environmental variables are a type of extraneous variable that compose the setting in which the study is conducted. Examples of these variables include climate, family, healthcare system, and governmental organizations. If a researcher is studying people in an uncontrolled or natural setting, it is impossible and undesirable to control all the extraneous variables. In qualitative and some quantitative studies (descriptive and correlational), little or no attempt is made to control extraneous variables. The intent is to study participants in their natural environment, without controlling or altering that setting or situation (Creswell, 2014; Creswell & Poth, 2018). The environmental variables in quasi-experimental and experimental research can be controlled by using a laboratory setting or a specially constructed research unit in a hospital.

Environmental control is an extremely important part of conducting an experimental study. For example, Kaya and colleagues (2017) conducted an experimental study in a neurosurgical ICU, which is a highly controlled clinical setting (see Table 5.1). The controlled setting, structured intervention of oral care with glutamine, and detailed measurement of VAP decreased the potential impact of extraneous variables on the study outcomes.

Conceptual and Operational Definitions of Variables in Quantitative Research

A variable is described in a study by the development of conceptual and operational definitions. A conceptual definition provides the theoretical meaning of a variable (Chinn & Kramer, 2015) and is often derived from a theorist’s definition of a related concept. In a published study, the framework includes concepts and their definitions, and the variables are selected to represent these concepts (see Chapter 7 for more details). The variables are conceptually defined, indicating the link with the concepts in the framework. An operational definition is derived from a set of procedures or progressive acts that a researcher performs to receive sensory impressions (e.g., sound, visual, tactile impressions) that indicate the existence or degree of existence of a variable (Waltz et al., 2017). Operational definitions need to be independent of time and setting so that variables can be investigated at different times and in different settings using the same operational definitions. An operational definition is developed so that a variable can be measured or manipulated in a concrete situation; the knowledge gained from studying the variable will increase the understanding of the theoretical concepts that this variable represents.

Table 5.3 includes the concepts and variables from the study by Ruiz-González et al. (2016) of the effects of the DEP on the management of type 1 diabetes. Reading across the table, you see the link of each concept to the variable(s), and the type of variable is identified. The conceptual and operational definitions for the independent variable DEP and one of the dependent variables, HbA1c, are presented in Research Example 5.6. The guidelines identified in the following box were used to critically appraise the variables and their definitions in this study.

Table 5.3

Linking concepts to variables and identifying types of variables

Concept Variable Type of variable

Diabetes education Diabetes education program Independent

Psychosocial measures Theoretical knowledge diabetes

Practical knowledge diabetes

Barriers

Self-care

Self-efficacy Dependent

Dependent

Dependent

Dependent

Dependent

Biomedical measures Hemoglobin A1c

Total cholesterol

Low density lipoprotein

Body mass index Dependent

Dependent

Dependent

Dependent

Data from Ruiz-González, I., Fernández-Alcántara, M., Guardia-Archilla, T., Rodríquez-Morales, S., Molina, A., Casares, D. et al. (2016). Long-term effects of an intensive-practical diabetes education program on HbA1c and self-care. Applied Nursing Research, 31(1), 13-18.

Critical appraisal guidelines

Study Variables

1. Are the variables clearly identified in the study purpose and/or research objectives, questions, or hypotheses?

2. What types of variables are examined in the study? Are independent and dependent variables or research variables examined in the study?

3. If a quasi-experimental or experimental study is conducted, are the extraneous variables identified and controlled?

4. Are the variables conceptually defined?

5. Are the variables clearly operationally defined?

Research example 5.6

Conceptual and Operational Definitions of Variables

Independent Variable: Diabetes Education Program (DEP)

Conceptual Definition

The DEP was based on the study framework concept of therapeutic education implemented to “help patients develop skills to conduct behaviors leading to better health-related parameters and quality of life” (Ruiz-González et al., 2016, p. 13). The DEP included evidence-based coaching strategies designed to improve intermediate and long-term outcomes for individuals with type 1 diabetes (Steinsbekk et al., 2012).

Operational Definition

The DEP “sessions included a theoretical part, devoted to teaching the topics that are considered essential in the education of patients with diabetes (illness, diet, exercise, insulin and hypoglycemia, self-analysis, self-management, macro and microvascular complications). Also the sessions include a practical part, in which patients put their skills into practice (e.g., self-monitoring and self-care, insulin injections, carbohydrate counting)” (Ruiz-González et al., 2016, p. 15).

Dependent Variable: Hemoglobin (HbA1c)

Conceptual Definition

HbA1c is a biomedical measure of an individual’s success in managing their type 1 diabetes (Ruiz-González et al., 2016).

Operational Definition

HbA1c is a laboratory value that reflects the average blood sugar reading for a patient over 90 days.

Critical Appraisal

These independent and dependent variables were clearly identified in the research purpose and hypotheses stated earlier. The conceptual definitions for the DEP and HbA1c were based on the study concepts (see Table 5.3). The operational definitions for the variables were found in the methods section of the research report. The conceptual definitions for DEP and HbA1c were strong, but the operational definitions might have included more detail to direct the implementation of the DEP intervention and the measurement process for HgA1c in the study.

Research Concepts Investigated in Qualitative Research

The variables in quasi-experimental and experimental research are narrow and specific in focus and can be quantified (converted to numbers) or manipulated using specified steps that are often developed into a protocol. In addition, the variables are objectively defined to decrease researcher bias, as indicated in the previous section. Qualitative research is more abstract, subjective, and holistic than quantitative research and involves the investigation of research concepts versus research variables. Research concepts include the ideas, experiences, situations, events, or cultures that are investigated in qualitative research. For example, Gorlin and colleagues (2016) conducted a qualitative study to explore the phenomenon of living with severe childhood autism. The problem and purpose for this phenomenological study are presented in Table 5.2, and the following research question directed the study: “What is the lived experience of the family living with a child who has severe autism?” (Gorlin et al., 2016, p. 582). The research concept explored was “experiences of living with severe autism” as perceived by the family. In many qualitative studies, the focus of the study is to define or describe the concept(s) being studied (Creswell & Poth, 2018). In this study, the concept of living with severe autism illuminated the extensive hardships and challenges for families and identified their needed resources (Gorlin et al., 2016). More details on the research concepts studied in qualitative research can be found in Chapter 3.

Demographic Variables

Demographic variables are attributes of subjects that are collected to describe the sample. The demographic variables are identified by the researcher when a proposal is developed for conducting a study. Some common demographic variables are age, education, gender, ethnic origin (race), marital status, income, job classification, and medical diagnosis. Once data are collected from the study participants on these demographic variables and analyzed, the results are called demographic or sample characteristics used to describe the sample (see Chapter 9). A study’s demographic characteristics can be presented in table format and/or narrative. Gorlin and colleagues (2016) identified the types of family members included in the study in the narrative of their article and presented the demographic characteristics in a table, as seen in Research Example 5.7.

Research example 5.7

Demographic Characteristics

Research Study Excerpt

Almost half of the mothers (5 out of 11) identified members outside the immediate family and home—such as grandparents, an aunt, or a friend—as part of their family. Participants included: 11 mothers, 4 fathers, 4 grandmothers, 1 aunt, 1 sibling, and 1 friend… Demographics of the 22 individual family participants are described in [Table 4].

(Gorlin et al., 2016, p. 584)

Critical Appraisal

The demographic variables identified in Table 4 included relationship to the child, gender, age range, race, religion, and highest level of education. Data on many of these demographic variables are commonly collected and analyzed to describe study samples. The Gorlin et al. (2016) sample characteristics can be used to compare this sample with the samples from other studies. The researchers clearly identified the 22 study participants and provided a quality description of their demographic characteristics in Table 4.

Table 4

Demographic characteristics of individual family participants (N = 22)

Variable Frequency %

Relationship to Childa

• Mother

• Father

• Grandmother

• Aunt

• Friend

• Sibling

11

  4

  4

  1

  1

  1

50

18

18

  4

  4

  4

Gender

• Male

• Female

  4

18

18

82

Age Range

• 20–30

• 31–40

• 41–50

• 51–60

• 61–75

  2

  7

  7

  2

  4

  9

32

32

  9

18

Race

• White European American

• African American

• Southeast Asian

• Multiracial

15

  3

  1

  3

68

14

  4

14

Religion

• Practicing Christian

• Nonpracticing Christian

• No affiliation

• Agnostic

12

  5

  3

  2

54

23

14

  9

Highest Level of Education

• High school degree

• 1 − 2 years of college

• 4-year college

• Graduate degree

  3

  8

  7

  4

14

36

32

18

Adapted from Gorlin, J. B., McAlpine, C. P., Garwick, A., & Wieling, E. (2016). Severe childhood autism: The family lived experience. Journal of Pediatric Nursing, 31(6), 586.

a Percentage may not equal 100 due to rounding to nearest integer.

Key Points

•  The research problem is an area of concern in which there is a gap in the knowledge base needed for nursing practice. The problem includes significance, background, and problem statement.

•  The research purpose is a concise clear statement of the specific goal or focus of the study.

•  A significant problem and purpose identify findings for nursing practice, expand previous research, promote theory development, and/or address current research priorities in nursing.

•  Study feasibility is evaluated by examining the researchers’ expertise, costs and funding, availability of subjects, facilities, and equipment, and the study’s ethical considerations.

•  Research objectives, questions, or hypotheses are formulated to bridge the gap between the more abstractly stated research problem and purpose and the detailed quantitative design, results, and interpretation of findings.

•  A qualitative study often includes the problem, purpose, and research questions or aims to direct the study.

•  A hypothesis is the formal statement of the expected relationship(s) between two or more variables in a specified population in a quantitative study.

•  Quasi-experimental and experimental studies should include hypotheses that predicted the potential outcomes for the study.

•  Hypotheses can be described using four categories: (1) associative versus causal; (2) simple versus complex; (3) nondirectional versus directional; and (4) statistical versus research.

•  Variables are qualities, properties, or characteristics of persons, things, or situations that change or vary.

•  Research variables are the qualities, properties, or characteristics that are observed or measured in descriptive and correlational studies.

•  An independent variable is an intervention or treatment that is manipulated or varied by the researcher to create an effect on the dependent variable.

•  A dependent variable is the outcome that the researcher wants to predict or explain.

•  In predictive correlational studies, independent variables are measured to predict a dependent variable.

•  A variable is described in a study by developing conceptual and operational definitions.

•  A conceptual definition provides the theoretical meaning of a variable and is derived from a theorist’s definition of a related concept.

•  Operational definitions indicate how a treatment or independent variable will be implemented and how the dependent or outcome variable will be measured.

•  Research concepts include the ideas, experiences, situations, events, or behaviors that are investigated in qualitative research.

•  Research concepts are defined and described during the conduct of qualitative studies.

•  Demographic variables are collected and analyzed to determine demographic or sample characteristics for describing the study subjects or participants.

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