Based on your course reading assignments (Chapters 6?and 7)?as well as?your pending research problem, what type of study do you believe you are conducting, Please explain why.?Cha

7 IDENTIFYING A FOCUS OF PRACTICE INQUIRY

LEA ANN MATURA AND VIVIAN NOWAZEK

■ INTRODUCTION

Th ere are numerous sources of ideas for identifying the focus of an inquiry. Th e literature review presents what is currently known about the topic of interest and the gaps in the literature. Once a thorough search and evaluation of the available evidence have been conducted, the focus of the study can be defi ned in the form of a purpose, objectives, and specifi c aims, along with well-de- veloped research questions. Th is chapter delineates the components needed to defi ne a research topic. Examples are included to illustrate the concepts and to facilitate practice in critically evalu- ating material from an evidence-based perspective.

■ SOURCES OF TOPICS AND PROBLEMS

When a researcher is identifying a topic of inquiry, several sources can provide guidance in deter- mining the question or problem to investigate. Some areas previously identifi ed as starting points include clinical practice, the research literature, professional organizations, and conferences (Polit & Beck, 2020). Likewise, there are multiple examples from varying clinical settings or domains of healthcare where ideas may be generated. Clinical problems or questions, the literature, reg- ulatory agencies, new diagnoses, social media, sentinel events, and legislative issues are only a few possibilities, but these examples may stimulate thoughtful refl ection on practice as we look forward to future studies. Once an idea is generated, a search of the literature is the next step in discovering what is already known and not known about the topic.

Clinical Problems or Questions Th e clinical setting is an excellent place to generate research questions. For example, when a patient has an acute injury such as an ankle sprain, a commonly prescribed regimen is applying rest, ice, compression, and elevation (RICE) therapy within 72 hours of the injury (Ueblacker et al., 2016). However, is there suffi cient evidence to support this therapy? We need data to support our interventions; perhaps RICE is an ineff ective therapy, but more research is needed.

Another pervasive problem in healthcare is the prevention of pressure injuries. Standard prac- tices recommend turning patients every 2 hours, but there continues to be little support for this practice or other measures to prevent pressure injuries. A recent literature review investigated turning frequency in adult bed-ridden patients to prevent hospital-acquired pressure injuries (Jocelyn Chew et al., 2018). Th e majority of studies could not reach a conclusion for frequency

Copyright Springer Publishing Company. All Rights Reserved. From: Research for Advanced Practice Nurses: From Evidence to Practice DOI: 10.1891/9780826151339.0007

120 II: Building Blocks for Evidence

of turning. However, few studies have focused solely on frequency of turning and pressure ulcer prevention or development. One study using a descriptive correlational design analyzed the out- comes of a quality improvement project evaluating a turning intervention to prevent facility-ac- quired pressure injuries (Harmon et al., 2016). Th e study assessed a “turn team assignment” on pressure injury incidence in a surgical intensive care unit. Data were collected on cueing to turn, concurrent turning, independent turning in lieu of the cue, staff support, and possible barriers to turning and repositioning. Pressure injuries declined from 24.9% to 16.8% over 12 months. Th ere was an association between verbal cueing and turning (r = 0.82; p < .05). A turn team using verbal cueing appears to be an eff ective intervention that decreases pressure injury occurrence. In another study the investigators implemented a multi-component intervention that included pres- sure-reducing beds; nutritional support; mandatory 2-hour change of posture; turning clocks; early surgical intervention; spot checks by the wound care nurse; and education to patients and caregivers (Lam et al., 2018). Over a 3-year period the incidence of hospital-acquired pressure injuries at the institution was initially 1.36%, which decreased to 0.98% in year 2 and to 0.39% in year 3 (p = .002).

Literature Reading and critiquing the literature are other mechanisms for identifying gaps in what is known and not known in clinical practice. For example, in a randomized controlled trial, the investi- gators assessed the eff ectiveness of auricular acupressure on sleep in patients with breast cancer undergoing chemotherapy (Yoon & Park, 2019). Participants were randomized to auricular pres- sure on specifi c acupoints benefi cial for sleep or a control group that received placebo auricular pressure on points not traditionally associated with improving sleep for 6 weeks. Th e quality of sleep was signifi cant between the experimental and control groups (F = 4.152, p = .048). Th ere were no signifi cant diff erences in total sleep time, sleep effi ciency, sleep latency, or number of times awakened during sleep. Th is study shows a non-pharmacological treatment for symptoms. However, more research is needed to determine if diff erent doses produce diff erent eff ects, how long the eff ects last, and can these results be translated to other disorders?

Regulatory Agencies Regulatory agencies such as Th e Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS) are rich sources for research ideas (TJC, 2019). TJC collaborated with the American Heart Association and the American College of Cardiology to develop perfor- mance measures, or core measure sets, for acute myocardial infarction (AMI). Th ese measures specify evidence-based interventions necessary to provide patients with quality care. Th ese mea- sures include such interventions as smoking-cessation education. Nursing is in an excellent posi- tion to test interventions that assist patients in their smoking-cessation eff orts. Examples of other measures include pneumonia, stroke, and venous thromboembolism.

Technology Mobile technology continues to expand in healthcare. In a randomized controlled trial of patients with irritable bowel syndrome, participants were randomized to telephone or web-based ther- apy or treatment as usual (Cook et al., 2019). Th ose in the treatment group received informa- tion on healthy eating patterns, managing stress, and reducing symptom severity. Th e telephone

7 Identifying a Focus of Practice Inquiry 121

intervention received a self-help manual and 8 hours of telephone therapist support. Th e web- based participants received online access to an interactive website and 2.5 hours of telephone therapist support. All groups had a reduction of symptoms at 1 year. Th e telephone group had 84% greater adherence rates than the other groups. Conclusions and implications of this study show that traditional face-to-face cognitive behavioral therapy, web, and telephone delivered therapy still require trained therapist input. Th ese results show the need to design and test tech- nology that is easily deployed and used by providers and patients.

New Diagnoses Discoveries in healthcare are frequent, including new diagnoses, especially because of research in genetics. As new syndromes are defi ned and new diseases and diagnoses are discovered, there will be an increasing need for research in these areas. Infectious diseases are continuing to emerge and evolve. For example, the Zika virus is spreading in the United States and can cause microcephaly and severe fetal brain defects (Baud et al., 2017). Zika is also associated with pregnancy loss and can cause issues with the infant’s eyes and deformities of the joints. We do not know the long-term eff ects of the Zika virus, and currently there is no vaccine. Nursing can play a key role in assisting in the care of these infants and their families, which is a topic for investigation.

An example of a new genetic syndrome is a microdeletion of 15q13.3, which causes intellectual disabilities, epilepsy, and facial and digital dysmorphisms (Hassfurther et al., 2015). Although this disorder is thought to aff ect about three out of 1,000 individuals with intellectual disabilities, there is a need for further investigation to determine the impact of this syndrome on patients and their caregivers. Th is again gives nursing an excellent opportunity to investigate the impact of this syndrome and possible interventions to improve patient care.

Similarly, researchers discovered a new genetic syndrome, which revealed a microduplication of chromosome 22q11.2 in patients previously diagnosed with DiGeorge anomaly/velocardio- facial syndrome (DG/VCFS; Radio et al., 2016). Th e phenotypic features of this new syndrome are widely spaced eyes and superior placement of the eyebrows, with increased distance from the eyebrow to upper eyelid crease, downslanting palpebral fi ssures, and a long narrow face. Th ese features are diff erent from DG/VCFS, which led researchers to conclude that this is a new syn- drome. Nursing would be especially poised to conduct research to improve the care and lives of these patients and their families.

Social Media Social media represents another avenue for generating ideas for investigation. Examples of social media include Facebook, Twitter, and blogs. In a recent study, social media was used as a means to improve infl uenza vaccination rates at a private college (Monn, 2016). In addition to provider education and announcement of immunization clinics, a Facebook college web portal was used to increase immunization rates by announcing the time and place of the vaccination clinicals and distributing three wellness articles via the portal. Results of this strategy showed a 226% increase in the number of students vaccinated compared to previous years.

In a randomized controlled trial investigators aimed to determine the eff ectiveness of Facebook alone or with text messaging to encourage optimal calcium intake (Rouf et al., 2020). Results showed that at the end of the program there was no increase in milk consumption (odds ratio [OR] 1.51, 95% CI 0.61–3.75 Facebook; OR 1.77, 95% CI 0.74-4.24 Facebook plus text messages; p = .41) or calcium-rich foods (p = .57). Knowledge improvement did improve in the Facebook

122 II: Building Blocks for Evidence

plus text message group (p < .001). Using social media shows promise in providing health educa- tion and promoting health and may be used in future research.

Sentinel Events Unfortunately, untoward or sentinel events sometimes occur. TJC defi nes a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifi cally includes loss of limb or function” (TJC, 2019). Th ese events may be related to system problems, knowledge defi cits, equipment malfunction, or a variety of other related problems. Some examples of sentinel events captured by TJC’s sentinel database in 2019 included delays in treatment; falls; postoperative complications; suicide; and wrong patient, wrong site, and wrong procedure. Nurses are well poised to study how these important occur- rences happen and to develop eff ective interventions for prevention.

While the nursing bedside report has been suggested as a way to enhance patient safety, this is an example where little is known through research if this actually does keep patients safer. One study aimed to describe how bedside nurses can use bedside shift reports to keep patients safe (Groves et al., 2016). In this qualitative study it was found that the nursing bedside report is a storytelling mechanism at shift change that allows nurses to identify any patient risks that may potentially cause harm. Th e researchers speculated that shift report can actually prevent errors and improve patient safety, but more research is needed.

Legislative Issues Other opportunities for nursing research are related to legislative and health policy issues. Nursing is an integral part of health policy discussions and should conduct research on legislative issues in order to promote and protect the public’s health. Th ere have been several states that have legalized recreational marijuana; however, we know little about changes in marijuana use and cannabis use disorder aft er recreational marijuana legalization. Investigators aimed to examine the associations between recreational marijuana legalization enactment and changes in marijuana use, frequent use, and cannabis use disorder in the United States between 2008 and 2016 (Cerdá et al., 2019). Results showed that among participants between 12 to 17 years, past-year cannabis use disorder increased from 2.2% to 2.7% aft er recreational marijuana legalization enactment, a 25% higher increase than that for the same age group in states that did not enact recreational marijuana legal- ization (OR, 1.25; 95% CI, 1.01–1.55). Th erefore, more research is needed to assess how these increases occur and to identify subpopulations that may be especially vulnerable.

Th ere have been several states that have implemented opioid prescribing mandates to help with the opioid epidemic. In 2016 Rhode Island passed a law that limited Rhode Island prescrib- ers to a maximum of 30 mg equivalents per day, 20 total doses, or a total of 150 mg equivalents in the fi rst opioid prescription for opioid-naïve patients. Th e legislation went into eff ect in April 2017. One study aimed to evaluate the prescribing opioids aft er orthopedic trauma before and aft er implementing opioid-limiting mandates (Reid et al., 2019). Th e post-law patients received less opioids (363.4 vs. 173.6 MMEs, p < 0.001) in the fi rst postoperative prescription. Th ey also received less cumulative levels of opioids during the 30-day postoperative period (677.4 vs. 481.7 MMEs, p  <  0.001). Results of this show that opioid legislation reduces opioid prescriptions. More research is needed in this area especially as other states implement their own legislation. Additionally, research on the impact of patient care should be conducted to determine if there are any untoward consequences such as inadequate pain control for patients.

7 Identifying a Focus of Practice Inquiry 123

■ BACKGROUND

An exhaustive review of the literature is imperative to determine what is currently known about the subject or phenomenon. Well-written studies provide insight into the implications of the fi nd- ings and suggestions for future research or directions for inquiry. A review of studies related to the topic helps to summarize the fi ndings and thereby helps the reader to develop a sense of where the next inquiry should begin. Th e review also gives ideas on possible research designs, along with potential leads for experts or consultants for the study. Th e review should give a good suggestion of theories or conceptual models that have been applied or should allude to possible conceptual frameworks for future studies.

Th e background section of the proposal for the study should give a concise overview of the body of science under investigation and how the study contributes to knowledge development. Th e background should connect the literature and defi ne the domains of the concepts under investigation. An explanation of how the literature search was conducted should also be pro- vided. Common research databases include the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medical Literature Analysis and Retrieval System Online (MEDLINE). CINAHL is primarily used by nurse scientists, but it is important not to limit oneself to only one research database as a tool for searches. MEDLINE is a search engine for biomedical research. It is important to use multiple databases when exploring a topic. Limiting oneself to one database may mean that one does not fi nd all available research on the topic. Research fi elds for nursing overlap with those of other disciplines, such as medicine, pharmacy, physical therapy, nutrition, and psychology.

When searching for relevant studies, one should employ a variety of methods, including searches by subject, keywords, and author. A subject search is a broad search in which one is looking for general information on a topic. Th is may be a good starting point when determining the breadth of a particular topic or phenomenon. Depending on the topic, a subject search may reveal literally thousands of papers. At this point, it can be helpful to narrow the topic area by using limits. Th ese limits may include gender, race, human subjects, or other areas. Selecting a particular article may be helpful to determine Medical Subject Heading (MeSH) terms as created by the National Library of Medicine (NLM). Th ese terms are helpful in fi nding other studies on the topic once a good study has been found to provide an exhaustive search on a particular topic. Chapter 2, on general searching, includes ways of maximizing the eff ectiveness of the literature search.

When reviewing the literature, one should review primary, not secondary, sources; that is, publications written by those who conducted the study, not publications that report on and sum- marize studies conducted by others. Reviewing primary sources allows the reviewer to determine the validity of the study rather than relying on another person’s interpretation of the study. An exception to this recommendation is the systematic review, the purpose of which is to summarize all the research on a topic to determine the outcome across a number of studies, populations, and clinical settings.

■ SIGNIFICANCE

Determining the signifi cance of a study is vital to deciding whether the topic is worthy of investiga- tion. Is the topic timely? Will the topic add signifi cant information to a body of knowledge? Does it provide new information, or does it help confi rm previous results by replicating a previously

124 II: Building Blocks for Evidence

done study? Is the study innovative? Does it describe a new phenomenon or a new way of study- ing a problem? On the one hand, the section on signifi cance should point out the limited amount of information currently available or determine whether no information is currently published. On the other hand, the section on signifi cance may indicate that there is confl icting evidence on the topic and that further investigation is needed to clarify what is known or unknown. Th e signifi cance of a study may be related to testing a theory or furthering scientists’ understanding of how the research will help a particular patient population. Following are examples of how the signifi cance of a study may be articulated.

Catheter-associated urinary tract infection (CAUTI) and catheter blockage are serious and signifi cant challenges for patients living with long-term indwelling catheters. CAUTI and catheter blockages can be painful and interfere with normal daily activities. Researchers aimed to deter- mine whether self-management strategies that focused on fl uid intake could decrease CAUTI and/or catheter blockages (Wilde et al., 2016). Th is intervention, self-management of fl uid intake, was found to have a positive eff ect on fl uid intake, and fl uid intake self-management predicted less frequent catheter blockages. Th is intervention has signifi cant implications for decreasing costs related to CAUTI and/or catheter blockages and improving patients’ lives.

Elderly patients who receive home healthcare may be at increased risk of mental health disor- ders that can impact morbidity, mortality, and recovery from illness. Th erefore, this is a signifi cant health issue that needs to be studied. Researchers sought to describe the prevalence and charac- teristics of mental health disorders in elderly adults in the United States (Wang et al., 2016). Forty percent of the elderly receiving home health had a health disorder, of which 28% had depression and 19% had anxiety. Th ose factors associated with mental health disorders were younger age, female, smoker, frailty, living alone, cognitively impaired, poor health status, and recent hospital- ization. Th ese data show the signifi cance of screening for mental health disorders, especially anxi- ety and depression in older adults. Th is may have implications for healthcare costs and improving morbidity and mortality in this population.

■ PURPOSE, OBJECTIVES, AND AIMS

Once researchers have identifi ed a topic of interest and conducted a thorough review of the litera- ture, they can defi ne the study further by developing its purpose, objectives, and specifi c aims. Th e purpose statement of a study is a statement of the essence of what the investigators are attempting to explore. Th e statement generally begins with, “Th e purpose of this study. . . .” Th is statement will guide the development of the research project by denoting what the focus of the research is. Following is an example of a purpose statement. In a qualitative study investigators stated: “Th e purpose of this study was to explore the experiences and support needs of adult patients living with rheumatoid arthritis (RA) in Singapore” (Poh et al., 2017).

In another study, researchers stated: “Th e purpose of this study is to analyze mean diff erences in weekly time spent engaging in physical activity by level of perceived environmental resources, for adults with diagnosed coronary heart disease, at 3 and 6 months following graduation from cardiac rehabilitation” (Perez et al., 2016).

Another example of a purpose statement is: “Th e purpose of this study was to better under- stand whether and how readiness for hospital discharge varies by personal characteristics, includ- ing health literacy” (Wallace et al., 2016).

Th e objectives of a study are very closely related to the purpose. Although some researchers may use the terms purpose and objectives interchangeably, they are distinct components in the

7 Identifying a Focus of Practice Inquiry 125

research protocol. Objectives are components of the study that can be measured. Although the objectives should fl ow from the purpose statement and are closely related to it, they are distinctly diff erent. One study stated the objective of the study was “to compare equine-assisted therapy to exercise education on pain, range of motion, and quality of life in adults and older adults with arthritis” (White-Lewis et al., 2019). Th is objective helped identify the purpose of the study to compare the eff ects of an equine-assisted therapy intervention compared with an exercise educa- tion attention-control intervention on pain and mobility in the hips, knees, shoulders, and backs of adults with arthritis.

Similarly, the aim of a study and its purpose can be interchangeable. Although the purpose is the essence of what is being studied, the aim is more aligned with the goal of the study or what the researchers want to accomplish. Generally, the aim of the study is contained in a statement that begins like this: “Th e aim of this study. . . .” In one study, the investigators aimed to increase non-supervised walking in patients with fi bromyalgia (Peñacoba et al., 2017). Th ey specifi cally outlined the following aims: (a) to analyze the prevalence of four walking beliefs in a sample of women with fi bromyalgia; (b) to examine how much each one of those beliefs is associated with certain sociodemographic, clinical, comorbidity, and symptom variables; and (c) to evaluate whether the presence of these beliefs is associated with walking, according to clinical guidelines for this population.

Th e decision whether to use a purpose statement or to present an aim may be based on the personal preference of the researcher, the audience that the researcher is presenting to, or the funding agency. For example, thesis or dissertation committees may require specifi c wording related to aims in a research proposal or protocol. When writing for publication in journals, one may encounter similar requirements. When one is writing a grant proposal, one may be required to provide a list of objectives for the research project. Whatever the requirements, the researcher will need to state in some form the essence of the project and what the researcher wants to accomplish.

■ RESEARCH QUESTIONS

Once the topic of inquiry has been identifi ed and the literature review conducted, the researcher can write the research questions. Research questions are interrogatives that bring out what is being stud- ied specifi cally. Not all studies have specifi c research questions; some studies may have a hypothesis or hypotheses, which are discussed in the next section. Th e research questions contain the indepen- dent variable (IV) and dependent variable (DV), which are also discussed in the “Variables” section of this chapter. Another important factor related to research questions is the way the question is stated. Th e wording of the question in a quantitative study drives the statistical analysis.

Research questions are oft en restatements of the purpose. For example, in a qualitative study the researchers’ purpose was to explore the experiences and support needs of adult patients living with RA in Singapore (Poh et al., 2017). Th ey identifi ed two research questions. Th e fi rst research question was “What are the experiences of patients living with RA?” and the second question was “What type of support needs do RA patients require or desire?” (Poh et al., 2017). In another study, the purpose was to investigate the eff ect of acupressure on quality of life of female nurses with chronic back pain (Najafabadi et al., 2019). Th e research question pertaining to the study was: What is the eff ect of acupressure on quality of life in female nurses with chronic back pain? Some researchers may decide to use hypotheses instead of research questions; these are discussed in the following section.

126 II: Building Blocks for Evidence

■ HYPOTHESES

A hypothesis is a prediction of outcomes between one or more variable(s) (Polit & Beck, 2020). Generally, in order to state a hypothesis, a researcher relies on previous literature or a theoretical framework to support the relationship between variables. Hypotheses can be directional, nondi- rectional, or null.

A directional hypothesis not only predicts the relationship between one or more variables but also states the direction of the relationship. Researchers were interested to determine if self-care using motivational interviewing in multimorbid heart failure patients would decrease hospital readmission rates and mortality (Riegel et al., 2016). Th e directional hypothesis was that patients with heart failure who were assigned to the motivational interviewing intervention would expe- rience fewer readmissions than those assigned to the control group (Riegel et al., 2016). In this hypothesis, those who receive the motivational interviewing will have decreased hospital read- missions. Usually, theory or past fi ndings enable the prediction. In this particular study their prior research determined the direction of their hypothesis.

In another study the researchers aimed to test the effi cacy of a meridian cuffi ng exercise on functional fi tness and cardiopulmonary functioning in older adults (Tung et al., 2020). Meridians in Chinese medicine are the pathways in the body where energy fl ows. Merdian cuffi ng unblocks these pathways via the Healthy Beat Acupunch (HBA). Th e HBA involves a serious of movements of the hands and feet in a rhythmic fashion. Th e investigators tested this directional hypothe- ses: aft er 6 months of the HBA regimen, the functional fi tness and cardiopulmonary functioning would be signifi cantly improved compared to baseline.

In contrast, a nondirectional hypothesis does not predict the direction of the relationship. An example of a nondirectional hypothesis is from investigators who wanted to better understand how readiness for hospital discharge varies by personal characteristics, including health liter- acy. Th e hypothesis was “patient characteristics, including patient health literacy, are associated with patient- and nurse-perceived readiness for hospital discharge” (Wallace et al., 2016). Th e investigators stated that there would be a relationship between the variables, but did not state the direction.

A null hypothesis or statistical hypothesis is a statement that predicts that there is no relation- ship between variables (Polit & Beck, 2020). Th e null hypothesis is not always explicitly written but can be derived from the hypotheses that are stated. Th e null hypothesis is what is accepted or rejected in relation to statistical procedures. A study hypothesized that those patients with higher levels of depressive symptoms would have poorer levels of cardiovascular health factors (McCarthy et al., 2019). Th e null hypothesis would be that those patients with higher levels of depressive symptoms will not have poor levels of cardiovascular health factors. In another study investigators hypothesized that self-effi cacy for the human papillomavirus (HPV) vaccination would mediate the relationships between social-cognitive factors and intention to receive the HPV vaccine (Christy et al., 2019). Th e null hypothesis would be that self-effi cacy for the HPV vaccination would not mediate the relationships between social-cognitive factors and intention to receive the HPV vaccine.

■ VARIABLES

A research question is written in terms of the dependent variables (DVs), also known as the observed outcome, and the independent variables (IVs), or the variable(s) hypothesized or

7 Identifying a Focus of Practice Inquiry 127

thought to produce the DV. DV values depend on the IVs. Variables are operationally defi ned by what is measured, how the indicators are measured, and how the values are interpreted. In other words, an operational defi nition characterizes how the variable is measured.

Variables are classifi ed according to the level or scale of measurement; the four scales are nom- inal, ordinal, interval, and ratio (NOIR). Knowing the level or scale of measurement provides the necessary information for readers to interpret the data from that variable. Certain statistical analyses are used only for data measured at certain measur

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