How do the authors justify having an alternative hierarchy of evidence for nursing, as contrasted with medicine
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2-How do the authors justify having an alternative hierarchy of evidence for nursing, as contrasted with medicine (pp. 24–26, Types of Evidence and Evidence Hierarchies, Ch. 2, Nursing Research)?
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PARADIGMS AND METHODS FOR NURSING RESEARCH
A paradigm is a worldview, a general perspective on the complexities of the world. Paradigms for human inquiry are often characterized in terms of the ways in which they respond to basic philosophical questions, such as, What is the nature of reality? (ontologic) and What is the relationship between the inquirer and those being studied? (epistemologic).
Disciplined inquiry in nursing has been conducted mainly within two broad paradigms, positivism and constructivism. This section describes these two paradigms and outlines the research methods associated with them. In later chapters, we describe the transformative paradigm that involves critical theory research ( Chapter 21 ), and a pragmatism paradigm that involves mixed methods research ( Chapter 26 ).
The Positivist Paradigm
The paradigm that dominated nursing research for decades is known as positivism (also called logical positivism ). Positivism is rooted in 19th century thought, guided by such philosophers as Mill, Newton, and Locke. Positivism reflects a broader cultural phenomenon that, in the humanities, is referred to as modernism, which emphasizes the rational and the scientific.
As shown in Table 1.2 , a fundamental assumption of positivists is that there is a reality out there that can be studied and known (an assumption is a basic principle that is believed to be true without proof or verification). Adherents of positivism assume that nature is basically ordered and regular and that reality exists independent of human observation. In other words, the world is assumed not to be merely a creation of the human mind. The related assumption of determinism refers to the positivists’ belief that phenomena are not haphazard but rather have antecedent causes. If a person has a cerebrovascular accident, the researcher in a positivist tradition assumes that there must be one or more reasons that can be potentially identified. Within the positivist paradigm, much research activity is directed at understanding the underlying causes of phenomena.
TABLE 1.2: Major Assumptions of the Positivist and Constructivist Paradigms
TYPE OF QUESTION
POSITIVIST PARADIGM ASSUMPTION
CONSTRUCTIVIST PARADIGM ASSUMPTION
Ontologic: What is the nature of reality?
Reality exists; there is a real world driven by real natural causes and subsequent effects
Reality is multiple and subjective, mentally constructed by individuals; simultaneous shaping, not cause and effect
Epistemologic: How is the inquirer related to those being researched?
The inquirer is independent from those being researched; findings are not influenced by the researcher
The inquirer interacts with those being researched; findings are the creation of the interactive process
Axiologic: What is the role of values in the inquiry?
Values and biases are to be held in check; objectivity is sought
Subjectivity and values are inevitable and desirable
Methodologic: How is evidence best obtained?
Deductive processes → hypothesis testing
Inductive processes → hypothesis generation
Emphasis on discrete, specific concepts
Emphasis on entirety of some phenomenon, holistic
Focus on the objective and quantifiable
Focus on the subjective and nonquantifiable
Corroboration of researchers’ predictions
Emerging insight grounded in participants’ experiences
Outsider knowledge—researcher is external, separate
Insider knowledge—researcher is internal, part of process
Fixed, prespecified design
Flexible, emergent design
Controls over context
Large, representative samples
Small, information-rich samples
Measured (quantitative) information
Narrative (unstructured) information
Seeks in-depth understanding
Positivists value objectivity and attempt to hold personal beliefs and biases in check to avoid contaminating the phenomena under study. The positivists’ scientific approach involves using orderly, disciplined procedures with tight controls of the research situation to test hunches about the phenomena being studied.
Strict positivist thinking has been challenged, and few researchers adhere to the tenets of pure positivism. In the postpositivist paradigm , there is still a belief in reality and a desire to understand it, but postpositivists recognize the impossibility of total objectivity. They do, however, see objectivity as a goal and strive to be as neutral as possible. Postpositivists also appreciate the impediments to knowing reality with certainty and therefore seek probabilistic evidence—that is, learning what the true state of a phenomenon probably is, with a high degree of likelihood. This modified positivist position remains a dominant force in nursing research. For the sake of simplicity, we refer to it as positivism.
The Constructivist Paradigm
The constructivist paradigm (often called the naturalistic paradigm ) began as a countermovement to positivism with writers such as Weber and Kant. Just as positivism reflects the cultural phenomenon of modernism that burgeoned after the industrial revolution, naturalism is an outgrowth of the cultural transformation called postmodernism. Postmodern thinking emphasizes the value of deconstruction—taking apart old ideas and structures—and reconstruction—putting ideas and structures together in new ways. The constructivist paradigm represents a major alternative system for conducting disciplined research in nursing. Table 1.2 compares the major assumptions of the positivist and constructivist paradigms.
For the naturalistic inquirer, reality is not a fixed entity but rather is a construction of the individuals participating in the research; reality exists within a context, and many constructions are possible. Naturalists thus take the position of relativism: If there are multiple interpretations of reality that exist in people’s minds, then there is no process by which the ultimate truth or falsity of the constructions can be determined.
The constructivist paradigm assumes that knowledge is maximized when the distance between the inquirer and those under study is minimized. The voices and interpretations of study participants are crucial to understanding the phenomenon of interest, and subjective interactions are the primary way to access them. Findings from a constructivist inquiry are the product of the interaction between the inquirer and the participants.
Paradigms and Methods: Quantitative and Qualitative Research
Research methods are the techniques researchers use to structure a study and to gather and analyze information relevant to the research question. The two alternative paradigms correspond to different methods for developing evidence. A key methodologic distinction is between quantitative research , which is most closely allied with positivism, and qualitative research , which is associated with constructivist inquiry—although positivists sometimes undertake qualitative studies, and constructivist researchers sometimes collect quantitative information. This section provides an overview of the methods associated with the two paradigms.
The Scientific Method and Quantitative Research
The traditional, positivist scientific method refers to a set of orderly, disciplined procedures used to acquire information. Quantitative researchers use deductive reasoning to generate predictions that are tested in the real world. They typically move in a systematic fashion from the definition of a problem and the selection of concepts on which to focus to the solution of the problem. By systematic, we mean that the investigator progresses logically through a series of steps, according to a specified plan of action.
Quantitative researchers use various control strategies. Control involves imposing conditions on the research situation so that biases are minimized and precision and validity are maximized. Control mechanisms are discussed at length in this book.
Quantitative researchers gather empirical evidence —evidence that is rooted in objective reality and gathered through the senses. Empirical evidence, then, consists of observations gathered through sight, hearing, taste, touch, or smell. Observations of the presence or absence of skin inflammation, patients’ anxiety level, or infant birth weight are all examples of empirical observations. The requirement to use empirical evidence means that findings are grounded in reality rather than in researchers’ personal beliefs.
Evidence for a study in the positivist paradigm is gathered according to an established plan, using structured methods to collect needed information. Usually (but not always) the information gathered is quantitative —that is, numeric information that is obtained from a formal measurement and is analyzed statistically.
A traditional scientific study strives to go beyond the specifics of a research situation. For example, quantitative researchers are typically not as interested in understanding why a particular person has a stroke as in understanding what factors influence its occurrence in people generally. The degree to which research findings can be generalized to individuals other than those who participated in the study is called the study’s generalizability .
The scientific method has enjoyed considerable stature as a method of inquiry and has been used productively by nurse researchers studying a range of nursing problems. This is not to say, however, that this approach can solve all nursing problems. One important limitation—common to both quantitative and qualitative research—is that research cannot be used to answer moral or ethical questions. Many persistent, intriguing questions about human beings fall into this area—questions such as whether euthanasia should be practiced or abortion should be legal.
The traditional research approach also must contend with problems of measurement. To study a phenomenon, quantitative researchers attempt to measure it by attaching numeric values that express quantity. For example, if the phenomenon of interest is patient stress, researchers would want to assess if patients’ stress is high or low, or higher under certain conditions or for some people. Physiologic phenomena such as blood pressure and temperature can be measured with great accuracy and precision, but the same cannot be said of most psychological phenomena, such as stress or resilience.
Another issue is that nursing research focuses on humans, who are inherently complex and diverse. Traditional quantitative methods typically concentrate on a relatively small portion of the human experience (e.g., weight gain, depression) in a single study. Complexities tend to be controlled and, if possible, eliminated, rather than studied directly, and this narrowness of focus can sometimes obscure insights. Finally, quantitative research within the positivist paradigm has been accused of an inflexibility of vision that does not capture the full breadth of human experience.
Constructivist Methods and Qualitative Research
Researchers in constructivist traditions emphasize the inherent complexity of humans, their ability to shape and create their own experiences, and the idea that truth is a composite of realities. Consequently, constructivist studies are heavily focused on understanding the human experience as it is lived, usually through the careful collection and analysis of qualitative materials that are narrative and subjective.
Researchers who reject the traditional scientific method believe that it is overly reductionist—that is, it reduces human experience to the few concepts under investigation, and those concepts are defined in advance by the researcher rather than emerging from the experiences of those under study. Constructivist researchers tend to emphasize the dynamic, holistic, and individual aspects of human life and attempt to capture those aspects in their entirety, within the context of those who are experiencing them.
Flexible, evolving procedures are used to capitalize on findings that emerge in the course of the study. Constructivist inquiry usually takes place in the field (i.e., in naturalistic settings), often over an extended time period. In constructivist research, the collection of information and its analysis typically progress concurrently; as researchers sift through information, insights are gained, new questions emerge, and further evidence is sought to amplify or confirm the insights. Through an inductive process, researchers integrate information to develop a theory or description that helps illuminate the phenomenon under observation.
Constructivist studies yield rich, in-depth information that can elucidate varied dimensions of a complicated phenomenon. Findings from in-depth qualitative research are typically grounded in the real-life experiences of people with first-hand knowledge of a phenomenon. Nevertheless, the approach has several limitations. Human beings are used directly as the instrument through which information is gathered, and humans are extremely intelligent and sensitive—but fallible—tools. The subjectivity that enriches the analytic insights of skillful researchers can yield trivial and obvious “findings” among less competent ones.
Another potential limitation involves the subjectivity of constructivist inquiry, which sometimes raises concerns about the idiosyncratic nature of the conclusions. Would two constructivist researchers studying the same phenomenon in similar settings arrive at similar conclusions? The situation is further complicated by the fact that most constructivist studies involve a small group of participants. Thus, the generalizability of findings from constructivist inquiries is an issue of potential concern.
Multiple Paradigms and Nursing Research
Paradigms should be viewed as lenses that help to sharpen our focus on a phenomenon, not as blinders that limit intellectual curiosity. The emergence of alternative paradigms for studying nursing problems is, in our view, a healthy and desirable path that can maximize the breadth of evidence for practice. Although researchers’ worldview may be paradigmatic, knowledge itself is not. Nursing knowledge would be thin if there were not a rich array of methods available within the two paradigms—methods that are often complementary in their strengths and limitations. We believe that intellectual pluralism is advantageous.
We have emphasized differences between the two paradigms and associated methods so that distinctions would be easy to understand—although for many of the issues included in Table 1.2 , differences are more on a continuum than they are a dichotomy. Subsequent chapters of this book elaborate further on differences in terminology, methods, and research products. It is equally important, however, to note that the two main paradigms have many features in common, only some of which are mentioned here:
· Ultimate goals. The ultimate aim of disciplined research, regardless of the underlying paradigm, is to gain understanding about phenomena. Both quantitative and qualitative researchers seek to capture the truth with regard to an aspect of the world in which they are interested, and both groups can make meaningful—and mutually beneficial—contributions to evidence for nursing practice.
· External evidence. Although the word empiricism has come to be allied with the classic scientific method, researchers in both traditions gather and analyze evidence empirically, that is, through their senses. Neither qualitative nor quantitative researchers are armchair analysts, depending on their own beliefs and worldviews to generate knowledge.
· Reliance on human cooperation. Because evidence for nursing research comes primarily from humans, human cooperation is essential. To understand people’s characteristics and experiences, researchers must persuade them to participate in the investigation and to speak and act candidly.
· Ethical constraints. Research with human beings is guided by ethical principles that sometimes interfere with research goals. As we discuss in Chapter 7 , ethical dilemmas often confront researchers, regardless of paradigms or methods.
· Fallibility of disciplined research. Virtually all studies have some limitations. Every research question can be addressed in many ways, and inevitably, there are trade-offs. The fallibility of any single study makes it important to understand and critique researchers’ methodologic decisions when evaluating evidence quality.
Thus, despite philosophic and methodologic differences, researchers using traditional scientific methods or constructivist methods share overall goals and face many similar challenges. The selection of an appropriate method depends on researchers’ personal philosophy and also on the research question. If a researcher asks, “What are the effects of cryotherapy on nausea and oral mucositis in patients undergoing chemotherapy?” the researcher needs to examine the effects through the careful measurement of patient outcomes. On the other hand, if a researcher asks, “What is the process by which parents learn to cope with the death of a child?” the researcher would be hard pressed to quantify such a process. Personal worldviews of researchers help to shape their questions.
In reading about the alternative paradigms for nursing research, you likely were more attracted to one of the two paradigms. It is important, however, to learn about both approaches to disciplined inquiry and to recognize their respective strengths and limitations. In this textbook, we describe methods associated with both qualitative and quantitative research in an effort to assist you in becoming methodologically bilingual. This is especially important because large numbers of nurse researchers are now undertaking mixed methods research that involves gathering and analyzing both qualitative and quantitative data ( Chapters 26 – 28 ).
THE PURPOSES OF NURSING RESEARCH
The general purpose of nursing research is to answer questions or solve problems of relevance to nursing. Specific purposes can be classified in various ways. We describe three such classifications—not because it is important for you to categorize a study as having one purpose or the other but rather because this will help us to illustrate the broad range of questions that have intrigued nurses and to further show differences between qualitative and quantitative inquiry.
Applied and Basic Research
Sometimes a distinction is made between basic and applied research. As traditionally defined, basic research is undertaken to enhance the base of knowledge or to formulate or refine a theory. For example, a researcher may perform an in-depth study to better understand normal grieving processes, without having explicit nursing applications in mind. Some types of basic research are called bench research, which is usually performed in a laboratory and focuses on the molecular and cellular mechanisms that underlie disease.
Example of Basic Nursing Research: Kishi and a multidisciplinary team of researchers (2015) studied the effect of hypo-osmotic shock of epidermal cells on skin inflammation in a rat model, in an effort to understand the physiologic mechanism underlying aquagenic pruritus (disrupted skin barrier function) in the elderly.
Applied research seeks solutions to existing problems and tends to be of greater immediate utility for EBP. Basic research is appropriate for discovering general principles of human behavior and biophysiologic processes; applied research is designed to indicate how these principles can be used to solve problems in nursing practice. In nursing, the findings from applied research may pose questions for basic research, and the results of basic research often suggest clinical applications.
Example of Applied Nursing Research: S. Martin and colleagues (2014) studied whether positive therapeutic suggestions given via headphones to children emerging from anesthesia after a tonsillectomy would help to lower the children’s pain.
Research to Achieve Varying Levels of Explanation
Another way to classify research purposes concerns the extent to which studies provide explanatory information. Although specific study goals can range along an explanatory continuum, a fundamental distinction (relevant especially in quantitative research) is between studies whose primary intent is to describe phenomena, and those that are cause-probing —that is, designed to illuminate the underlying causes of phenomena.
Within a descriptive/explanatory framework, the specific purposes of nursing research include identification, description, exploration, prediction/control, and explanation. For each purpose, various types of question are addressed—some more amenable to qualitative than to quantitative inquiry and vice versa.
Identification and Description
Qualitative researchers sometimes study phenomena about which little is known. In some cases, so little is known that the phenomenon has yet to be clearly identified or named or has been inadequately defined. The in-depth, probing nature of qualitative research is well suited to the task of answering such questions as, “What is this phenomenon?” and “What is its name?” ( Table 1.3 ). In quantitative research, by contrast, researchers begin with a phenomenon that has been previously studied or defined—sometimes in a qualitative study. Thus, in quantitative research, identification typically precedes the inquiry.