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Polit, Denise F., author. Nursing research : generating and assessing evidence for nursing practice / Denise F. Polit, Cheryl Tatano Beck. — Tenth edition.

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Our Beloved Family: Our Husbands, Our Children (Spouses/Fiancés), and Our Grandchildren

Husbands: Alan Janosy and Chuck Beck

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Acknowledgments

This 10th edition, like the previous nine editions, depended on the contribution of dozens of people. Many faculty and students who used the text have made invaluable suggestions for its improvement, and to all of you we are very grateful. In addition to all those who assisted us during the past 35 years with the earlier editions, the following individuals deserve special mention.

We would like to acknowledge the comments of reviewers of the previous edition of this book, anonymous to us initially, whose feedback influenced our revisions. Faculty at Griffith University in Australia made useful suggestions and also inspired the inclusion of some new content. Valori Banfi, reference librarian at the University of Connecticut, provided ongoing assistance. Dr. Deborah Dillon McDonald was extraordinarily generous in giving us access to her NINR grant application and related material for the Resource Manual.

We also extend our thanks to those who helped to turn the manuscript into a finished product. The staff at Wolters Kluwer has been of great assistance to us over the years. We are indebted to Christina Burns, Kate Burland, Cynthia Rudy, and all the others behind the scenes for their fine contributions.

Finally, we thank our family and friends. Our husbands Alan and Chuck have become accustomed to our demanding schedules, but we recognize that their support involves a lot of patience and many sacrifices.

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Reviewers

Ellise D. Adams, PhD, CNM Associate Professor The University of Alabama in Huntsville Huntsville, Alabama

Jennifer Bellot, PhD, RN, MHSA Associate Professor and Director, DNP Program Thomas Jefferson University Philadelphia, Pennsylvania

Kathleen D. Black, PhD, RNC Assistant Professor, Jefferson College of Nursing Thomas Jefferson University Philadelphia, Pennsylvania

Dee Campbell, PhD, APRN, NE-BC, CNL Professor, Graduate Department Felician College, School of Nursing Lodi, New Jersey

Patricia Cannistraci, DNS, RN, CNE Assistant Dean Excelsior College Albany, New York

Julie L. Daniels, DNP, CNM Assistant Professor Frontier Nursing University

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Hyden, Kentucky

Rebecca Fountain, PhD, RN Associate Professor University of Texas at Tyler Tyler, Texas

Teresa S. Johnson, PhD, RN Associate Professor, College of Nursing University of Wisconsin—Milwaukee Milwaukee, Wisconsin

Jacqueline Jones, PhD, RN, FAAN Associate Professor, College of Nursing University of Colorado, Anschutz Medical Campus Aurora, Colorado

Mary Lopez, PhD, RN Associate Dean, Research Western University of Health Sciences Pomona, California

Audra Malone, DNP, FNP-BC Assistant Professor Frontier Nursing University Hyden, Kentucky

Sharon R. Rainer, PhD, CRNP Assistant Professor, Jefferson College of Nursing Thomas Jefferson University Philadelphia, Pennsylvania

Maria A. Revell, PhD, RN Professor of Nursing Middle Tennessee State University Murfreesboro, Tennessee

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Stephanie Vaughn, PhD, RN, CRRN Interim Director, School of Nursing California State University, Fullerton Fullerton, California

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Preface

Research methodology is not a static enterprise. Even after writing nine editions of this book, we continue to draw inspiration and new material from groundbreaking advances in research methods and in nurse researchers’ use of those methods. It is exciting and uplifting to share many of those advances in this new edition. We expect that many of the new methodologic and technologic advances will be translated into powerful evidence for nursing practice. Five years ago, we considered the ninth edition as a watershed edition of a classic textbook. We are persuaded, however, that this 10th edition is even better. We have retained many features that made this book a classic textbook and resource, including its focus on research as a support for evidence-based nursing, but have introduced important innovations that will help to shape the future of nursing research.

NEW TO THIS EDITION

New Chapters We have added two new chapters on “cutting-edge” topics that are not well covered in any major research methods textbook, regardless of discipline. The first is a chapter on an issue of critical importance to health professionals and yet inadequately addressed in the nursing literature: the clinical significance of research findings. In Chapter 20, we discuss various conceptualizations of clinical significance and present methods of operationalizing those conceptualizations so that clinical significance can be assessed at both the individual and group level. We believe that this is a “must-read” chapter for nurses whose research is designed to inform clinical practice. The second new chapter in this edition concerns the

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design and conduct of pilot studies. In recent years, experts have written at length about the poor quality of many pilot studies. Chapter 28 provides guidance on how to develop pilot study objectives and draw conclusions about the appropriate next step—that is, whether to proceed to a full-scale study, make major revisions, or abandon the project. This chapter is included in Part 5 of this book, which is devoted to mixed methods research, because pilots can benefit from both qualitative and quantitative evidence.

New Content Throughout the book, we have included material on methodologic innovations that have arisen in nursing, medicine, and the social sciences during the past 4 to 5 years. The many additions and changes are too numerous to describe here, but a few deserve special mention. In particular, we have totally revised the chapters on measurement (Chapter 14) and scale development (Chapter 15) to reflect emerging ideas about key measurement properties and the assessment of newly developed instruments.

The inclusion of two new chapters made it challenging to keep the textbook to a manageable length. Our solution was to move some content in the ninth edition to supplements that are available online. In fact, every chapter has an online supplement, which gave us the opportunity to add a considerable amount of new content. For example, one supplement is devoted to evidence-based methods to recruit and retain study participants. Other supplements include a description of various randomization methods, an overview of item response theory, guidance on wording proposals to conduct pilot studies, and a discussion of quality improvement studies. Following is a complete list of the supplements for the 31 chapters of this textbook:

1. The History of Nursing Research 2. Evaluating Clinical Practice Guidelines—AGREE II 3. Deductive and Inductive Reasoning 4. Complex Relationships and Hypotheses 5. Literature Review Matrices 6. Prominent Conceptual Models of Nursing Used by Nurse Researchers,

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and a Guide to Middle-Range Theories 7. Historical Background on Unethical Research Conduct 8. Research Control 9. Randomization Strategies 10. The RE-AIM Framework 11. Other Specific Types of Research 12. Sample Recruitment and Retention 13. Other Types of Structured Self-Reports 14. Cross-Cultural Validity and the Adaptation/Translation of Measures 15. Overview of Item Response Theory 16. SPSS Analysis of Descriptive Statistics 17. SPSS Analysis of Inferential Statistics 18. SPSS Analysis and Multivariate Statistics 19. Some Preliminary Steps in Quantitative Analysis Using SPSS 20. Clinical Significance Assessment with the Jacobson-Truax Approach 21. Historical Nursing Research 22. Generalizability and Qualitative Research 23. Additional Types of Unstructured Self-Reports 24. Transcribing Qualitative Data 25. Whittemore and Colleagues’ Framework of Quality Criteria in

Qualitative Research 26. Converting Quantitative and Qualitative Data 27. Complex Intervention Development: Exploratory Questions 28. Examples of Various Pilot Study Objectives 29. Publication Bias in Meta-Analyses 30. Tips for Publishing Reports on Pilot Intervention Studies 31. Proposals for Pilot Intervention Studies

Another new feature of this edition concerns our interest in readers’ access to references we cited. To the extent possible, the studies we have chosen as examples of particular research methods are published as open- access articles. These studies are identified with an asterisk in the reference list at the end of each chapter, and a link to the article is included in the Toolkit section of the Resource Manual. We hope that these revisions will help users of this book to maximize their learning experience.

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ORGANIZATION OF THE TEXT The content of this edition is organized into six main parts.

• Part I—Foundations of Nursing Research and Evidence-Based Practice introduces fundamental concepts in nursing research. Chapter 1 briefly summarizes the history and future of nursing research, discusses the philosophical underpinnings of qualitative research versus quantitative research, and describes major purposes of nursing research. Chapter 2 offers guidance on utilizing research to build an evidence- based practice. Chapter 3 introduces readers to key research terms and presents an overview of steps in the research process for both qualitative and quantitative studies.

• Part II—Conceptualizing and Planning a Study to Generate Evidence further sets the stage for learning about the research process by discussing issues relating to a study’s conceptualization: the formulation of research questions and hypotheses (Chapter 4), the review of relevant research (Chapter 5), the development of theoretical and conceptual contexts (Chapter 6), and the fostering of ethically sound approaches in doing research (Chapter 7). Chapter 8 provides an overview of important issues that researchers must attend to during the planning of any type of study.

• Part III—Designing and Conducting Quantitative Studies to Generate Evidence presents material on undertaking quantitative nursing studies. Chapter 9 describes fundamental principles and applications of quantitative research design, and Chapter 10 focuses on methods to enhance the rigor of a quantitative study, including mechanisms of research control. Chapter 11 examines research with different and distinct purposes, including surveys, outcomes research, and evaluations. Chapter 12 presents strategies for sampling study participants in quantitative research. Chapter 13 describes using structured data collection methods that yield quantitative information. Chapter 14 discusses the concept of measurement and then focuses on methods of assessing the quality of formal measuring instruments. In this edition, we describe methods to assess the properties of point-in- time measurements (reliability and validity) and longitudinal measurements—change scores (reliability of change scores and

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responsiveness). Chapter 15 presents material on how to develop high- quality self-report instruments. Chapters 16, 17, and 18 present an overview of univariate, bivariate, and multivariate statistical analyses, respectively. Chapter 19 describes the development of an overall analytic strategy for quantitative studies, including material on handling missing data. Chapter 20, a new chapter, discusses the issue of interpreting results and making inferences about clinical significance.

• Part IV—Designing and Conducting Qualitative Studies to Generate Evidence presents material on undertaking qualitative nursing studies. Chapter 21 is devoted to research designs and approaches for qualitative studies, including material on critical theory, feminist, and participatory action research. Chapter 22 discusses strategies for sampling study participants in qualitative inquiries. Chapter 23 describes methods of gathering unstructured self-report and observational data for qualitative studies. Chapter 24 discusses methods of analyzing qualitative data, with specific information on grounded theory, phenomenologic, and ethnographic analyses. Chapter 25 elaborates on methods qualitative researchers can use to enhance (and assess) integrity and quality throughout their inquiries.

• Part V—Designing and Conducting Mixed Methods Studies to Generate Evidence presents material on mixed methods nursing studies. Chapter 26 discusses a broad range of issues, including asking mixed methods questions, designing a study to address the questions, sampling participants in mixed methods research, and analyzing and integrating qualitative and quantitative data. Chapter 27 presents innovative information about using mixed methods approaches in the development of nursing interventions. In Chapter 28, a new chapter, we provide guidance for designing and conducting a pilot study and using data from the pilot to draw conclusions about how best to proceed.

• Part VI—Building an Evidence Base for Nursing Practice provides additional guidance on linking research and clinical practice. Chapter 29 offers an overview of methods of conducting systematic reviews that support EBP, with an emphasis on meta-analyses, metasyntheses, and mixed studies reviews. Chapter 30 discusses dissemination of evidence —how to prepare a research report (including theses and dissertations)

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and how to publish research findings. The concluding chapter (Chapter 31) offers suggestions and guidelines on developing research proposals and getting financial support and includes information about applying for NIH grants and interpreting scores from NIH’s new scoring system.

KEY FEATURES This textbook was designed to be helpful to those who are learning how to do research as well as to those who are learning to appraise research reports critically and to use research findings in practice. Many of the features successfully used in previous editions have been retained in this 10th edition. Among the basic principles that helped to shape this and earlier editions of this book are (1) an unswerving conviction that the development of research skills is critical to the nursing profession, (2) a fundamental belief that research is intellectually and professionally rewarding, and (3) a steadfast opinion that learning about research methods need be neither intimidating nor dull. Consistent with these principles, we have tried to present the fundamentals of research methods in a way that both facilitates understanding and arouses curiosity and interest. Key features of our approach include the following:

• Research Examples. Each chapter concludes with one or two actual research examples designed to highlight critical points made in the chapter and to sharpen the reader’s critical thinking skills. In addition, many research examples are used to illustrate key points in the text and to stimulate ideas for a study. Many of the examples used in this edition are open-access articles that can be used for further learning and classroom discussions.

• Critiquing Guidelines. Most chapters include guidelines for conducting a critique of each aspect of a research report. These guidelines provide a list of questions that draw attention to specific aspects of a report that are amenable to appraisal.

• Clear, “user-friendly” style. Our writing style is designed to be easily digestible and nonintimidating. Concepts are introduced carefully and systematically, difficult ideas are presented clearly, and readers are assumed to have no prior exposure to technical terms.

• Specific practical tips on doing research. This textbook is filled with

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practical guidance on how to translate the abstract notions of research methods into realistic strategies for conducting research. Every chapter includes several tips for applying the chapter’s lessons to real-life situations. These suggestions are in recognition of the fact that there is often a large gap between what gets taught in research methods textbooks and what a researcher needs to know to conduct a study.

• Aids to student learning. Several features are used to enhance and reinforce learning and to help focus the student’s attention on specific areas of text content, including the following: succinct, bulleted summaries at the end of each chapter; tables and figures that provide examples and graphic materials in support of the text discussion; study suggestions at the end of each chapter; a detailed glossary; and a comprehensive index for accessing information quickly.

TEACHING–LEARNING PACKAGE Nursing Research: Generating and Assessing Evidence for Nursing Practice, 10th edition, has an ancillary package designed with both students and instructors in mind.

• The Resource Manual augments the textbook in important ways. The manual itself provides students with exercises that correspond to each text chapter, with a focus on opportunities to critique actual studies. The appendix includes 12 research journal articles in their entirety, plus a successful grant application for a study funded by the National Institute of Nursing Research. The 12 reports cover a range of nursing research ventures, including qualitative, quantitative, and mixed methods studies, an instrument development study, an evidence-based practice translation project, and two systematic reviews. Full critiques of two of the reports are also included and can serve as models for a comprehensive research critique.

• The Toolkit to the Resource Manual is a “must-have” innovation that will save considerable time for both students and seasoned researchers. Included on thePoint, the Toolkit offers dozens of research resources in Word documents that can be downloaded and used directly or adapted. The resources reflect best-practice research material, most of which have been pretested and refined in our own research. The Toolkit

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originated with our realization that in our technologically advanced environment, it is possible to not only illustrate methodologic tools as graphics in the textbook but also to make them directly available for use and adaptation. Thus, we have included dozens of documents in Word files that can readily be used in research projects, without requiring researchers to “reinvent the wheel” or tediously retype material from this textbook. Examples include informed consent forms, a demographic questionnaire, content validity forms, and a coding sheet for a meta-analysis—to name only a few. The Toolkit also has lists of relevant and useful websites for each chapter, which can be “clicked” on directly without having to retype the URL and risk a typographical error. Links to open-access articles cited in the textbook, as well as other open-access articles relevant to each chapter, are included in the Toolkit.

• The Instructor’s Resources on the Point include PowerPoint slides summarizing key points in each chapter, test questions that have been placed into a program that allows instructors to automatically generate a test, and an image bank.

It is our hope that the content, style, and organization of this book continue to meet the needs of a broad spectrum of nursing students and nurse researchers. We also hope that this book will help to foster enthusiasm for the kinds of discoveries that research can produce and for the knowledge that will help support an evidence-based nursing practice.

DENISE F. POLIT, PhD, FAAN

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CHERYL TATANO BECK, DNSc, CNM, FAAN

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Contents

PART 1: FOUNDATIONS OF NURSING RESEARCH Chapter 1: Introduction to Nursing Research in an Evidence-Based

Practice Environment Chapter 2: Evidence-Based Nursing: Translating Research Evidence into

Practice Chapter 3: Key Concepts and Steps in Qualitative and Quantitative

Research

PART 2: CONCEPTUALIZING AND PLANNING A STUDY TO GENERATE EVIDENCE FOR NURSING

Chapter 4: Research Problems, Research Questions, and Hypotheses Chapter 5: Literature Reviews: Finding and Critiquing Evidence Chapter 6: Theoretical Frameworks Chapter 7: Ethics in Nursing Research Chapter 8: Planning a Nursing Study

PART 3: DESIGNING AND CONDUCTING QUANTITATIVE STUDIES TO GENERATE EVIDENCE FOR NURSING

Chapter 9: Quantitative Research Design Chapter 10: Rigor and Validity in Quantitative Research Chapter 11: Specific Types of Quantitative Research Chapter 12: Sampling in Quantitative Research Chapter 13: Data Collection in Quantitative Research Chapter 14: Measurement and Data Quality

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Chapter 15: Developing and Testing Self-Report Scales Chapter 16: Descriptive Statistics Chapter 17: Inferential Statistics Chapter 18: Multivariate Statistics Chapter 19: Processes of Quantitative Data Analysis Chapter 20: Clinical Significance and Interpretation of Quantitative

Results

PART 4: DESIGNING AND CONDUCTING QUALITATIVE STUDIES TO GENERATE EVIDENCE FOR NURSING

Chapter 21: Qualitative Research Design and Approaches Chapter 22: Sampling in Qualitative Research Chapter 23: Data Collection in Qualitative Research Chapter 24: Qualitative Data Analysis Chapter 25: Trustworthiness and Integrity in Qualitative Research

PART 5: DESIGNING AND CONDUCTING MIXED METHODS STUDIES TO GENERATE EVIDENCE FOR NURSING

Chapter 26: Basics of Mixed Methods Research Chapter 27: Developing Complex Nursing Interventions Using Mixed

Methods Research Chapter 28: Feasibility Assessments and Pilot Tests of Interventions Using

Mixed Methods

PART 6: BUILDING AN EVIDENCE BASE FOR NURSING PRACTICE

Chapter 29: Systematic Reviews of Research Evidence: Meta-Analysis, Metasynthesis, and Mixed Studies Review

Chapter 30: Disseminating Evidence: Reporting Research Findings Chapter 31: Writing Proposals to Generate Evidence

Glossary

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Appendix: Statistical Tables Index

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Check Out the Latest Book Authored by Research Expert Dr. Polit If you want to make thoughtful but practical decisions about the measurement of health constructs, check out Dr. Polit and Dr. Yang’s latest book, a “gentle” introduction to and overview of complex measurement content, called Measurement and the Measurement of Change.

This book is for researchers and clinicians from all health disciplines because measurement is vital to high-quality science and to excellence in clinical practice. The text focuses on the measurement of health constructs, particularly those constructs that are not amenable to quantification by means of laboratory analysis or technical instrumentation. These health

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constructs include a wide range of human attributes, such as quality of life, functional ability, self-efficacy, depression, and pain. Measures of such constructs are proliferating at a rapid rate and often without adequate attention paid to ensuring that standards of scientific rigor are met.

In this book, the authors offer guidance to those who develop new instruments, adapt existing ones, select instruments for use in a clinical trial or in clinical practice, interpret information from measurements and changes in scores, or undertake a systematic review on instruments. This book offers guidance on how to develop new instruments using both “classical” and “modern” approaches from psychometrics as well as methods used in clinimetrics. Much of this book, however, concerns the evaluation of instruments in relation to three key measurement domains: reliability, validity, and responsiveness.

This text was designed to be useful in graduate-level courses on measurement or research methods and will also serve as an important reference and resource for researchers and clinicians.

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PART 1

FOUNDATIONS OF NURSING RESEARCH

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1 Introduction to Nursing Research in an Evidence-Based Practice Environment

NURSING RESEARCH IN PERSPECTIVE In all parts of the world, nursing has experienced a profound culture change. Nurses are increasingly expected to understand and conduct research and to base their professional practice on research evidence—that is, to adopt an evidence-based practice (EBP). EBP involves using the best evidence (as well as clinical judgment and patient preferences) in making patient care decisions, and “best evidence” typically comes from research conducted by nurses and other health care professionals.