Research for health professionals

CHAPTER 6 Research for health professionals



Patricia Barkway, Dianna Kenny



Key points


♦ Research is fundamental to the clinical practice of psychologists and health professionals as it provides the evidence on which healthcare practice is based.

♦ Research consumer skills are essential in healthcare practice.

♦ Research findings can identify healthcare practices that are effective and efficient, thereby identifying ‘best practice’.

♦ Research findings can identify healthcare practices that are not effective or efficient and thereby provides evidence to facilitate change.

♦ Health professionals play a key role in the ethical conduct of research.


Learning objectives


The material in this chapter will help you to:


♦ distinguish and describe various research paradigms used in psychological and health research

♦ describe how research shapes healthcare practice

♦ describe the role of health professionals as a research consumer

♦ critically appraise research reports and draw conclusions appropriate for practice

♦ describe the ethics of research participation and in particular the advocacy role played by health professionals.


Key terms


♦ Qualitative research


♦ Quantitative research


♦ Evidence-based practice


♦ Research consumer


♦ Research ethics



Introduction


This chapter examines how psychological and health research findings influence healthcare practice and provides an overview of research paradigms, methodologies and methods. It is not within the scope of this chapter to provide a detailed account of how to conduct research as this is covered in more detail and depth elsewhere in your course and in specific research textbooks. Rather, this chapter focuses on how research findings influence healthcare practice and how health professionals can use research in their day-to-day clinical practice and, thereby, be a competent consumer of research (Schneider et al 2007). Being a competent consumer of research involves knowing how to access, critique and utilise research findings in everyday clinical practice. Finally, the role of the professional in the ethical conduct of research is addressed.



Healthcare research: an overview


Research is a process of enquiry that seeks to develop new knowledge or to expand existing knowledge. In the health arena research findings are used to: identify the health needs of populations; test and choose appropriate interventions and treatments for illness and health problems; plan and implement intervention strategies for illness prevention and health promotion; evaluate programs and interventions; and assist with resource allocation.


Research can be either basic or applied. Basic research aims to develop new theory and/or knowledge while applied research examines the application of knowledge in certain circumstances. A study of the factors that influence an individual’s decision to follow or disregard a recommended health treatment, for example, is basic research and a randomised control trial (RCT) testing a new drug to treat cancer is an example of applied research.


A further important distinction between research studies is whether they are experimental, observational, interpretive or critical. Experimental studies utilise quantitative methods and are a powerful research method because people (subjects/participants) can be allocated to receive an exposure of interest, such as a new treatment or healthcare practice, or an intervention, such as allergen avoidance or dietary advice. In such studies, independent variables that distort the association between another independent variable and the problem (confounding factors) can be controlled and, therefore, the level of evidence obtained is high.


Observational research, also called descriptive studies, utilises either quantitative (e.g. census) or qualitative (e.g. ethnography) methods. They are less powerful for measuring associations; nevertheless, they are a valuable method for measuring the effects of non-modifiable risk factors, such as age or gender; of measuring the effects of exposures to which people cannot be ethically randomised, such as breast-feeding or environmental tobacco smoke; or for understanding social issues.


Interpretive and critical approaches are located within the qualitative research paradigm and aim to describe, explore and seek understanding of human and social phenomena. Interpretative research is focused on understanding or creating meaning while critical research has the additional goal of bringing about social and political change.



Research paradigms


Various methods can be utilised to conduct research and the choice of method is driven by the methodology (or the philosophical and theoretical tradition that underpins the enquiry). Methodologies, also referred to as paradigms, are the theoretical and philosophical positions that underpin the research approach. They are a broad framework of perception, understanding and beliefs within which theory and practice operate.


There are two main research paradigms: quantitative and qualitative. The quantitative research paradigm is scientific and positivist and seeks objective answers to the research question. It assumes that an objective answer to the question exists. The qualitative research paradigm is interpretative and critical and seeks greater meaning and understanding of the issue under investigation. It acknowledges the subjective nature of human experience.



Quantitative research


Quantitative research is steeped in the conventional scientific tradition. It involves collecting data that are quantifiable and measurable and, therefore, can be analysed and interpreted numerically. It takes a positivist philosophical position and is underpinned by the view that reality is objective, measurable and separate from the researcher. In this way quantitative research follows a scientific tradition of objective observation, prediction and testing of causal or correlational relationships (Krauss 2005, Maggs-Rapport 2001).


Quantitative research generally involves extensive data collection and, thereby, seeks a broad understanding to enable explanations and predictions to be made. Hypotheses can either be supported or rejected by applying statistical tests of significance to the data. The data collected in quantitative research can be: nominal, when the data distinguish categories (like male/female); ordinal, when the data distinguish degree like never, sometimes, always; or numerical, when the data measures numbers like how many cigarettes smoked per day. Examples of quantitative methods include experiments (e.g. RCTs, questionnaires and surveys), structured interviews and census collection.


Quantitative research designs include: experimental, which attempt to show that one thing causes another; quasi experimental, which is an experimental design but does not have random allocation to control and experimental groups; descriptive, which summarises and describes a set of measurements; and correlational, which explores the relationship between two variables.



FOCUS ON QUANTITATIVE RESEARCH: RANDOMISED CONTROL TRIALS


In RCTs with human subjects, participants agree to enrol following informed consent and are then randomly allocated to a new treatment or control group. Depending on the type of study, the control group may receive a placebo or sham intervention or may receive current best practice. Placebo interventions are usually only used when a new treatment method is being assessed and, for this reason, placebo-controlled trials usually have a small sample size because they are seen as an intermediary step in the process of showing efficacy of a new treatment.


RCTs provide the highest level of evidence because the random allocation of participants to study groups minimises the influences of selection bias, of known and unknown confounders and of prognostic factors such as participant characteristics on the study results. The effects of other biases can also be reduced by blinding the participants and the research team to group status and by ensuring that both groups have equal contact with the study team.


The inclusion criteria are an important issue in RCTs. In trials to measure the effectiveness of a treatment or intervention, participants who have an identified health problem are enrolled. However, in interventions designed to prevent an illness or condition from developing, participants who are ‘at risk’ are enrolled before the illness or condition has developed. Although RCTs provide the most scientifically rigorous research method available, they are often difficult to conduct and low response rates may reduce the generalisability of the results. Table 6.1 summarises the strengths and weaknesses of RCTs.


Table 6.1 Strengths and weaknesses of RCTs


















STRENGTHS WEAKNESSES
Provide a high level of evidence Selection bias may be an issue if potential participants have treatment preferences
Confounders, prognostic factors and exposures are balanced between groups Follow-up bias may be influential if control group participants selectively drop out because they are receiving a placebo or existing treatment
Allocation, reporting and observer bias can be controlled by blinding Low participation rates may reduce the generalisability of the results
Willingness to participate does not influence group allocation Long-term outcomes may not be measured


Research focus: RCT


Barlow J, Powell L, Gilchrist M et al 2008 The effectiveness of the Training and Support Program for parents of children with disabilities: A randomized controlled trial. Journal of Psychosomatic Research Vol 64, pp 55–62



Abstract



OBJECTIVE

The Training and Support Program (TSP) was designed to equip parents of children with disabilities with a simple massage skill for use with their children in the home environment. The effectiveness of the TSP was examined in an RCT with a wait-list control group.



METHODS

Parents were trained in massage by suitably qualified therapists in eight weekly sessions, each lasting one hour. The sample comprised 188 parents who were randomised to an intervention group (n = 95) who attended the TSP with their children immediately, or a control group (n = 93) who were offered the TSP after four months of follow-up. Data were collected by self-administered questionnaires at baseline and at four-month follow-up.



RESULTS

The majority of participants were mothers (88%) with a partner (88%) and white European (82%); 40% worked full time or part time and 34% had health problems (e.g. chronic fatigue, cancer and arthritis). The TSP demonstrated statistically significant positive effects on parental self-efficacy for managing children’s psychosocial wellbeing and depressed mood (0.004 and 0.007). There were trends towards improvement on parental satisfaction with life (p = 0.053), global health (p = 0.065) and parental ratings of children’s sleeping (p = 0.074) and mobility (p = 0.012). Effect sizes were small (0.11–0.23). Levels of anxiety, depression and perceived stress were all higher than published norms.



CONCLUSION

The TSP is an effective means of improving parental self-efficacy and depressed mood. Additional means of supporting parents need to be investigated.



CRITICAL THINKING



image Is this research basic or applied?

image What is the rationale for your decision?

image The authors recommend further research. What further research can be undertaken to identify the support needs of parents?


Qualitative research


Qualitative research proposes that there is no objective reality as assumed by the quantitative positivist paradigm. It is a constructivist approach in which the individual constructs the meaning and interpretation of reality from their own experience. Nevertheless, like quantitative studies, qualitative research utilises a range of methods and methodologies that facilitate the exploration of different phenomena, meaning and experience.


In qualitative research, data are collected from observation and interview within a population and describe the range of response, as well as variation between responses. Narrative data are collected as opposed to numerical in quantitative research and, thereby, a depth of understanding about the issue under investigation is provided in contrast to the breadth of understanding sought in quantitative research.


Examples of qualitative methodologies include:


• symbolic interactionism – that seeks to understand the social meaning that shapes human behaviour (see Beard & Fox 2008)

• phenomenology – that seeks the discovery of a phenomenon (European tradition) or the experience of a phenomenon (North American tradition) (Dowling 2007, Paley 2005) (see Ranse & Arbon 2008)

• ethnography – that seeks to discover cultural meaning from a native perspective (see Larun & Malterud 2007)

• grounded theory – that uses induction to develop theory (see Bahora et al 2007).

Methods for collecting data in a qualitative study include but are not limited to: focus groups; unstructured or semi-structured interviews; participant observation; ethnography; case study; and document analysis.



FOCUS ON QUALITATIVE RESEARCH: PHENOMENOLOGY


Phenomenology began as a philosophical mode of enquiry in continental Europe around the turn of the 20th century. Its acknowledged founder is the German philosopher Edmund Husserl (1859–1938). Throughout the latter part of the 20th century and early 21st century phenomenology was adapted as an approach in health research enquiry, particularly by nurse researchers (Dowling 2007, Paley 2005). The goal of phenomenological health research is to understand a human or social issue by examining the human experience of the phenomenon under investigation, whereas the goal of philosophical phenomenology is to examine the phenomenon itself (Barkway 2001, Crotty 1996).


Consequently, phenomenology is both a philosophy and a research method. As a philosophy it is interested in the subjective understanding of the meaning of the phenomenon, such as the phenomenon of sadness. And, as a research approach, phenomenology is interested in understanding the human (or lived) experience of a particular phenomenon such as what it is like to be sad? It is the latter form of phenomenology that is prevalent in the health research literature. This form of phenomenological research generally takes the form of interviewing participants, followed by analysis of the data and the development of themes from which conclusions and recommendations are drawn.


Controversy surrounds the use of phenomenology as a method in health research. Crotty (1996) refers to the study of the lived experience as ‘new’ phenomenology, which he argued differs from philosophical phenomenology because it attempts to draw objective conclusions from subjective data. Paley (2005), too, is critical of phenomenological health research stating that in attempting to make sense of subjective data nurse researchers draw objective conclusions and in doing so ‘mimic science’ in assuming that an objective reality exists. Nevertheless, despite the methodological debate surrounding phenomenological health research, phenomenological studies contribute to the body of knowledge about individuals’ experiences of health and illness issues and thereby can influence healthcare practices.



Research focus: phenomenology


Karlsson A, Arman M, Wikblad K 2008 Teenagers with type 1 diabetes – a phenomenological study of the transition towards autonomy in self-management. International Journal of Nursing Studies Vol 45, pp 562–570



Abstract



BACKGROUND

Becoming autonomous is an important aspect of teenagers’ psychosocial development and this is especially true of teenagers with type 1 diabetes. Previous studies exploring the everyday problems of teenagers with diabetes have focused on adherence to self-care management, how self-determination affects metabolic control and the perception of social support.



OBJECTIVE

The aim of the study was to elucidate lived experiences, focusing on the transition towards autonomy in diabetes self-management among teenagers with type 1 diabetes.



DESIGN AND METHOD

Data were collected using interviews and a qualitative phenomenological approach was chosen for the analysis.



PARTICIPANTS

Thirty-two teenagers (18 females and 14 males) were interviewed about their individual experiences of self-management of diabetes.



FINDINGS

The lived experiences of the transition towards autonomy in self-management were characterised by the overriding theme ‘hovering between individual actions and support of others’. The findings indicate that individual self-reliance and confirmation of others are helpful in the transition process. Growth through individual self-reliance was viewed as a developmental process of making one’s own decisions; psychological maturity enabled increased responsibility and freedom; motivation was related to wellbeing and how well the diabetes could be managed. The theme ‘confirmation of others’ showed that parental encouragement increased the certainty of teenagers’ standpoints; peers’ acceptance of diabetes facilitated incorporation of daily self-management activities; and support from the diabetes team strengthened teenagers’ self-esteem.



CONCLUSION

In striving for autonomy, teenagers needed distance from others but still to retain the support of others. A stable foundation for self-management includes having the knowledge required to practise diabetes management and handle different situations.



CRITICAL THINKING



image Is Karlsson et al’s research basic or applied?

What is the rationale for your decision?

image Based on the findings of this study what advice would you give to the parents of a teenager with type 1 diabetes? Why?


Quantitative or qualitative?


In the planning phase of an investigation a decision is made early in the research process concerning which methods or methodology to use, namely, quantitative, qualitative or whether to use multiple methods or methodologies – triangulation. Choosing a method is best addressed by considering the question to be investigated and the methodology that best informs the research question. For example, if a researcher wants to investigate the incidence of asthma in the community, then epidemiological (quantitative) data will provide that information. However, if the researcher wants to know what is the experience of a person living with asthma? then a semi-structured interview or focus group is an appropriate (qualitative) method for data collection. Table 6.2 summarises the similarities and differences between quantitative and qualitative research.


Table 6.2 Types of research
































TYPES OF RESEARCH
  Quantitative Qualitative
Methodology
Scientific

Positivist
Philosophical

Sociological

Post-modern
Purpose
Explanation

Prediction

Objective truth
Interpretive

Critical

Subjective understanding
Methods
Experimental

Measurement

Statistical analysis
Interview

Observation

Narrative analysis
Sample size Usually large Usually small
Research evaluation
Reliability

Validity

Correlation
Rigour

Credibility

Auditability
Ethics
Beneficence not harm

Informed consent

Confidentiality

Right to withdraw from research

Merit and integrity of the research


Triangulation


Triangulation, or the use of multiple methods and/or methodologies, is a process whereby various forms of data are collected from different sources. Triangulation may be applied to one or more of the following: methodology, method, data and/or investigator. It can utilise both quantitative and qualitative paradigms and methods for data collection, for example, by obtaining data from key informant interviews (qualitative) and questionnaires (quantitative). It can also include collecting data using different methods within the same research paradigm, for example, focus group and participant observation, which are both qualitative.


The purpose of triangulation is to validate the findings by collecting data on the same phenomenon from different sources (Roberts & Taylor 2002). Collecting data from various sources enables researchers to corroborate their findings. And if both quantitative and qualitative methods are used, a broad as well as a deep understanding of the issue is obtained. For example, in determining the needs of parents who have a child with a disability, a researcher could interview key informants (qualitative research) and use this data to design a questionnaire to canvass the opinions of a wider selection of the target population (quantitative research).


In summary, the question of whether to use quantitative or qualitative methods to conduct research relates not to what is a better method but to what is the most appropriate method of providing the information sought. If the identification of the magnitude – or the extent – of an issue is sought or a hypothesis is to be tested, then quantitative methods are required. On the other hand, if the researcher is concerned with understanding human experience from an informant’s perspective, then a qualitative method is called for. Furthermore, by utilising both quantitative and qualitative methods – as in triangulation – researchers can obtain a greater understanding of the research question under investigation.

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Jun 19, 2016 | Posted by in PSYCHOLOGY | Comments Off on Research for health professionals

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