Basics of Conducting Nursing Research

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Nurses have an exceptional and influential role in impacting the future of healthcare through nursing research. As frontline caregivers, nurses possess instrumental insights into patient needs, clinical practices, and healthcare systems. These direct experiences put them in an optimal position to recognize improvement areas and innovate practices that directly impact patient outcomes. With the rapid advancements in technology, healthcare delivery, and educational methods, nursing can lead to the development and implementation of evidence-based practices through research. This course is designed for all nurses interested in nursing research.

Introduction

When we think of research, we often picture beakers and microscopes in a lab setting. However, research is not confined to laboratory spaces or conducted solely by scientists. Many healthcare professionals, including nurses, play a fundamental role in the research process. Research is a thorough and methodical investigation that generates new knowledge, refines existing knowledge by incorporating new findings, and validates the current body of knowledge (7). This process is essential in guiding evidence-based practice and informing healthcare decisions.

Given their constant presence at the bedside, nurses are uniquely positioned to identify critical gaps in practice and knowledge (9). They can observe firsthand where improvements are needed and contribute to developing solutions to bridge these gaps. Nurses not only have the ability to create and evaluate these solutions, but they can also implement them in ways that enhance nursing workflows and lead to improved patient outcomes.

How can Nurses Participate in Research?

Consumer—Nurses can read the latest information from nursing journals within their specialty or from a general standpoint (4). Many nursing organizations, such as the Emergency Nurses Association, publish journals on key topics within their practice area. Reading an article can inspire change within an organization, and some organizations even offer journal clubs to promote conversation.

Participator – Many nurse-led research studies are taking place worldwide, and nurses can assist in this process by participating in studies (4). This contributes to the future of nursing and nursing research. Nurses can also be champions for a research project on their unit by helping initiate quality improvement projects (4).

Principal Investigator or Co-investigator – An investigator is in charge of the research project, while a co-investigator assists in the principal investigation throughout the research project. Each organization may have limitations on who can be a principal investigator; however, these nurses have a minimum of a Master of Science in Nursing degree or are doctorly prepared with a Doctor of Nursing Practice or Doctor of Philosophy in Nursing degree. (8).

Nursing Research Step 1: Identifying a Problem

The problem to be researched may be obvious or be dismissed until it cannot be ignored. One example is when patients frequent the emergency department for mental health services that could be managed in an outpatient setting. Initially, this may not be seen as a problem to be researched; however, these patients may overwhelm the emergency department’s resources during a crisis.

There could also be problems with self-confidence in new nurses, which could lead to adverse patient outcomes. Unsurprisingly, nurse residents often struggle with confidence due to the complexity of patient care, high stress, and ever-changing priorities (1). They feel they cannot do the work they are expected to do or have low intelligence. This lack of self-confidence can negatively impact patient outcomes, and one method to address this self-confidence is through simulation (1). A nurse who has been in the profession for a while may know the benefits of simulation and seek to incorporate it into a nurse residency program; however, this nurse may be asked how they know this will work at their organization. This is where research comes in.

Nursing Research Step 2: Literature Review 

Once a problem is identified, the next step is to review the literature to identify what others have to say on a problem and what steps were taken to address it (7).   

Let us look back at one of the examples in step 1: building self-confidence in nurse residents using simulation. A PICOT question or statement must be formed to complete a literature review. 

Below is a table displaying the components of PICOT, their meanings, and how they apply to the scenario above (7).  

Forming a question or statement consists of organizing the components of the PICOT table (7). 

Question: In nurse residents, how does simulation compare to traditional training regarding self-confidence and patient outcomes over nine months? 

Statement: This nurse-led project will implement and evaluate the use of simulation compared to traditional training with nurse residents for increased self-confidence and patient outcomes over nine months.  

How can nurses review the literature to find evidence that supports their PICOT question?  

Many organizations have access to online medical journals through their medical libraries. Other nurses may be returning to school and have access to their university’s library. Many databases exist, but the Cumulative Index to Nursing and Allied Health Literature (CINAHL) is the most common. PubMed is another prominent resource. Regardless of the method, many of the steps remain the same.  

It is recommended that the PICOT question or statement guides the literature review with a focus on keywords and Boolean operators. Keywords are words or phrases of the PICOT question that can be searched, while Boolean operators are additional words to assist with the search process.  

Returning to the PICOT question: Simulation with nurse residents to build self-confidence. Some keywords identified would be nurse resident, simulation, self-confidence, and patient outcomes. However, these words alone may not be enough to generate a robust collection of articles. This is where the Boolean operators come in (7).  

Nurse residents could also be described as new graduate nurses or new nurses since virtual reality is a type of simulation that is starting to be incorporated more into the learning space. It can appear in searches for simulation. Using the Boolean operator NOT to search simulation NOT virtual reality can eliminate those articles from the generated results. It is essential to capture as many articles as possible during the initial literature review search to have a robust collection of articles.  

Once studies are identified, it is time to appraise them. A critical appraisal is important in ensuring that the articles align with the goal of the literature review (7). These critical appraisal tools (CATs) also ensure that the information contained in the Study is reported accurately (7). Many CATs are available, so they must be used with the appropriate study type. For example, qualitative results will not benefit from a CAT designed to appraise quantitative research, and vice versa. 

Hierarchy of Evidence 

A literature review also consists of determining the level or hierarchy of evidence. 

1. Systematic Reviews and Meta-Analysis – a collection of relevant data from randomized control trials (RTCs), evidence-based practice guidelines based on a systematic review of RTCs, or at least three RTCs conducted with similar results (3).
2. Randomized Control Trials (RTCs) are the strongest type of research. They involve subjects randomly assigned to control and experimental groups to reduce bias and threats to validity (7).
3. Quasi-Experimental Study – a study that does not randomly assign participants to a control group. These are often used when withholding an intervention could cause ethical or patient care concerns (7).
4. Descriptive Correlational, Cohort, and Predictive Correlational Studies – descriptive studies describe a relationship between at least two variables with no attempt to determine if a cause-and-effect connection exists; cohort studies follow a group of individuals over some time; predictive correlation studies are when a researcher has and uses data already existing from one variable and predicts the value of other variables (7).
5. Mixed Methods Research Synthesis – Collection of findings from various research methods to assess the current knowledge (7).
6. Descriptive Studies – descriptive studies describe a phenomenon or population by analyzing data collected without environmental manipulation (7).
7. Opinions and Expert Committees – Commentary or opinions by an individual or panel on a specific topic (7).

Nursing Research Step 3: Frameworks

The theoretical framework is created to explain, predict, and understand a subject or phenomenon to challenge and extend existing knowledge (10). This framework introduces the theory and explains why the problem being researched exists (10). Any theory used must be relevant to the research topic (7). While Florence Nightingale’s environmental theory is a testament to her nursing career, it would not apply to the nurse residents and simulation study. A theory that would be useful in that Study would be the constructivist learning theory. This theory, created by Jean Piaget, states that external experience absorbs present knowledge (11). Lev Vygotsky added to this theory by noting that learning derives from social interactions and students engaging with each other (11).

While conducting a literature review, it is important to note if a study has a noted theoretical framework to guide its process (7). Sometimes, the author will state that they are using a particular theory; however, not all studies do this. Some will give general commentary on supporting evidence; this is prominent in clinical experience (7).

Nursing Research Step 4: Design

Study designs play a significant factor in the success of the Study. Two main types of studies exist: qualitative and quantitative. Qualitative studies are based on individuals’ feelings or statements; think of the phrase “quality of life.” One’s view of quality of life is based on feelings or beliefs. Quantitative studies, on the other hand, involve numbers. Quantity is the number of items a store has in stock, which can be a helpful reminder.

Populations

A population will need to be selected to create the study design. Some populations are considered vulnerable (6):

• Minors
• Pregnant patients, fetuses, and newborns
• Those deemed mentally disabled
• Prisoners
• Economically and/or educationally disadvantaged

While this list may cover many individuals, it does not put everyone at risk. Researchers should also consider additional vulnerabilities that may not be as obvious: deferential, institutional, medical, social, cognitive, or communicative, and economic vulnerabilities also exist (6). Several of these vulnerabilities can be applied to nursing or ancillary staff. Let us look at an example.

Scenario: Nurse residents are enrolled in the simulation training study by their nurse manager.

Vulnerability: Institutional vulnerability

Why? The nurse residents are under the authority of their nurse manager and might feel like their jobs could be in jeopardy if they refuse to participate in the Study. The power dynamic between the nurse manager and the resident could lead to an unknown form of coercion.

How can it be prevented? Removing the nurse manager from enrolling nurse residents in the Study can eliminate this. The nurse educator or researcher could be the individual in recruitment.

The Institutional Review Board

The Institutional Review Board (IRB) is a group of at least five individuals of various backgrounds—both in and outside of the healthcare organization and profession—that come together to determine that studies being conducted are done so in an ethical manner (7). These hospitals and/or academic-based review boards evaluate a research study’s risk—high, medium, or low (7). They also decide whether a study is exempt from IRB approval; this is usually research that does not include patients as the test subjects (7). The IRB should always be consulted to determine what is and is not considered exempt from review (7). In addition to determining risk, the IRB is mandated by federal regulations to ensure that participant rights are protected, including obtaining informed consent.

Informed Consent

Informed consent is often discussed when patients receive care in the healthcare setting. They are told the risks and benefits of specific treatments so they can decide whether they would like to be a recipient of that treatment. Informed consent during research is very similar (13). Before starting a study, participants are given information about the Study, such as the Study’s name, the purpose of the Study, what will be expected of the participant, and what they can expect as a result (13). This information is often given to the patient as a typed and printed piece of paper to obtain a physical signature (13). Sometimes, an electronic form is acceptable.

The consent process includes the following (2):

• The individual has the mental capacity to make decisions
• The study’s role and process are reviewed, and it is ensured that they can be understood by the population being studied.
• Disclosure of:
  • The Study will entail, including the medication, equipment, or procedure.
  • Conflicts of interest
  • Foreseeable risks
  • Benefits that can occur
  • Alternative courses to participating
  • Difference between roles and responsibilities as a researcher versus a provider
• Answering questions
• Refraining from persuasion to participate, including unrealistic expectations

Assent

While minors cannot consent to participating in a study, they still have the right to assent. This means that the child has agreed to participate in the Study (12). The average age to assent is 10 years and older (12). If a child is unwilling to partake in a study, regardless of parental or guardian consent, they should be excluded. This assented process can also be implemented with those with diminished cognitive capacity and cannot consent (12).

Nursing Research Step 5: Implementation

Implementation is where the Study begins. A pilot study with a small participant group might be conducted to ensure that nothing needs to be adjusted before starting the Study (7). However, if significant changes are made to the process, the IRB might need to be consulted again, and the consent form may need to be adjusted to reflect the Study accurately (7). During the Study, consistency and control must be maintained (7). If multiple researchers are collecting data, running parts of the Study, or performing procedures, they should all be provided with the same guidelines to follow (7). In the simulation case, those managing it should be trained and given a list of what they can and cannot say. This prevents data from being skewed due to one group’s advantages or disadvantages.

Data Collection and Analysis

Data collection depends on the Study’s goals. Often, data collection includes demographic attributes of the participants such as age, gender/gender identity, race and ethnicity, years as a nurse, and more (7). Researchers must evaluate the benefit of collecting demographic information and if they can impact the Study (7). Some studies have reflected that specific age ranges or genders scored higher or lower in parts of the Study.

With the nurse resident and simulation example, questions regarding self-confidence should be presented to the participants. Researchers can look for tested instruments to measure desired variables, but sometimes, these instruments do not exist or must be tweaked to meet the study goals (7). Careful consideration must be given to the utilization of any data collection instrument.

Data can be collected in various ways. There is the researcher-administered and participant-completed method, where the researcher gives the participant instructions to complete the survey (7). This allows for flexibility for special considerations, such as those with hearing impairment or minimal literacy ability (7). Surveys can be provided to participants via hardcopy or electronically (7).

Additionally, performance can be evaluated using technology (7). In simulation, many high-fidelity manikins have sensors to collect chest compressions and ventilation data. This can determine if participants have improved their skills over the study period. Direct observation from researchers can also provide objective data. They can time how long it takes for someone to recognize that a patient’s condition is declining or how they may react to something in the environment.

Data collection should be completed at regular intervals decided upon by the research team. Depending on the Study, family, diagnostic tests, unit workload, and staffing can all impact data collection (7). Those tasked with collecting data should know these barriers and how to overcome them (7). If multiple people collect data, they should all be trained to collect that information similarly to ensure consistency (7).

Analysis of the data depends on the type of data collected. Data in its original form is considered raw and difficult to interpret. Data must be “cleaned” through transformation and extraction (5). Data can be loaded into a warehouse for storage (5). Data can be analyzed and summarized using a variety of statistical methods. Collaboration with a statistician can be beneficial for the research team.

Nursing Research Step 6: Dissemination

Dissemination is distributing information to the nursing and healthcare community at large (7). This process can be done through journal publications, which can be time-consuming and tedious (7). Nursing researchers can also partake in presentations at conferences, meetings, panels, lectures, and more (7). These presentations can be traditional in nature or poster presentations where the information is displayed in a poster format (7). This allows those interested to read the poster and ask the researcher questions. If a research project is done for academics, it can be written as a dissertation or thesis (7). These can be published online in a repository or on the institution’s website.

Putting it Altogether

Throughout this course, references have been made to nurse residents and how simulation can increase self-confidence and patient outcomes. Let’s see how a research study could be created using this scenario.

For reference, here is the PICOT question:

In nurse residents, how does simulation compare to traditional training regarding self-confidence and patient outcomes over nine months?

After an extensive literature review, articles are selected as evidence to support the incorporation of simulation into the organization’s nurse residency to increase self-confidence and patient outcomes. Since nurse residents are hired in cohorts due to employee clearance and orientation periods, any studies conducted would focus on cohorts while including a randomized component. Each nurse resident will be randomly assigned to the control or experimental groups.

Key stakeholders in this Study include nurse managers, nurse educators, the nurse residency program leads, orientation leads, and upper leadership to provide support. This group would plan how the simulation would be integrated into the nurse residency program without compromising the nurse residents’ knowledge to provide safe, competent care. This group would also identify key patient outcomes to be evaluated: fall rates, rapid responses, and medication errors. The research team would create the study protocol and framework.

The IRB will be consulted to ensure that approval is not needed due to the identified population. A consent form would be created for all participants to highlight the key purposes of the Study and what is expected of them. There would be a notice that the participant could back out of the Study at any time without consequence.

The Study would start at the beginning of the month during the first orientation, during which nurse residents were present. One simulation expert would be in charge of running the simulation to ensure consistency among all cohorts—demographic attributes and pre-surveys, whether traditional training or simulation, would be collected before participation. Post-participation evaluation surveys would be completed immediately after the training or simulation and every month after.

Someone within the research team would be responsible for entering data as appropriate. At the same time, another would be responsible for collecting and entering data on patient outcomes as identified by the key stakeholders. This data, especially patient outcomes, should be assessed regularly to ensure that no serious adverse outcomes from the Study must be addressed. This could even lead to the early termination of the Study.

At the end of the study period, data should then be analyzed to determine if a significant change occurred in reports of self-confidence in nurse residents and patient outcomes. If the change is positive and important, it should be continued, taking in participant feedback to improve or adjust the program. If there is no significant change, then discontinuing the program can be discussed.

Conclusion

Nurses have an exceptional and influential role in impacting the future of healthcare through nursing research. As frontline caregivers, nurses possess instrumental insights into patient needs, clinical practices, and healthcare systems. These direct experiences put them in an optimal position to recognize improvement areas and innovate practices that directly impact patient outcomes. With the rapid advancements in technology, healthcare delivery, and educational methods, nursing can lead to the development and implementation of evidence-based practices through research.

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