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Mental Health Work In The Community Theory And Practice In Social Work And Community Psychiatric Nursing 1st edition By Michael Sheppard 9781850009795 1850009791
Caring for the Vulnerable Perspectives in Nursing Theory Practice and Research 5th Edition by Mary de Chesnay, Barbara Anderson ISBN 1284194442 9781284194449
Family Health Care Nursing Theory practice and research 3rd Edition by Shirley May Harmon Hanson, Joanna Rowe Kaakinen, Vivian Gedaly Duff ISBN 0803612028 9780803612020
Family Health Care Nursing Theory Practice and Research 4th edition by Joanna Rowe Kaakinen, Vivian Gedaly-Duff , Shirley May Harmon Hanson ISBN 0803621663 978-0803621664
Lecturer in the Department of Sociology and Social Policy at the University of Southampton, UK and
Anne Mulhall
Freelance writer and researcher and former Deputy Director of the Nursing Practice Research Unit at the University of Surrey, UK
First edition 1994
@ 1994 Springer Science+Business Media Dordrecht
Originally published by Chapman & Hall London in 1994
Typeset in 10/12 Palatino by Mews Photosetting, Beckenham, Kent
ISBN 978-0-412-49850-3 ISBN 978-1-4899-3087-3 (eBook)
DOI10.1007/978-1-4899-3087-3
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright Designs and Patents Act, 1988, this publication may not be reproduced, stored, or transmitted, in any form or by any means, without the prior permission in writing of the publishers, or in the case of reprographic reproduction only in accordance with the terms of the licences issued by the Copyright Ucensing Agency in the UK, or in accordance with the terms of licences issued by the appropriate Reproduction Rights Organization outside the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publishers at the London address printed on this page. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made.
A catalogue record for this book is available from the British Ubrary Ubrary of Congress Catalog Card Number: 94-70919
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For Michael's daughter, Mariann and Anne's mother, Gwen Greer Robinson
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8
Contributors
Ann Adams is a Research Fellow at the University of Surrey. She is involved in research into the organization of nursing and the delivery of care that is funded by the Department of Health. She has worked as a theatre sister and has written a text about theatre nursing.
Nicky Cullum is a Research Fellow in the Department of Nursing at the University of Liverpool. She previously led a research project that undertook a critical review of the literature about leg ulcers while working at the Nursing Practice Research Unit at the University of Surrey.
Helen Glenister is Deputy Director of Consumer Affairs and Nursing for the Anglia and Oxford Regional Health Authority where she is involved in funding and managing nursing research. She is also engaged in developing health service research strategies at regional level.
Michael Hardey is a lecturer in the Department of Sociology and Social Policy at the University of Southampton where he holds a joint appointment with the University College of Nursing and Midwifery. His previous publications include Lone Parenthood: Coping with Constraints and Making Opportunities.
Nicholas Mays is Director of Health Services Research at the King's Fund Institute. He was previously Director of the Health and Health Care Research Unit at the Queen's University of Belfast.
x Contributors
Anne Mulhall is a writer and researcher. She qualified as a microbiologist and worked in health sciences research for some years before becoming the Deputy Director of the Nursing Practice Research Unit at the University of Surrey. She has written extensively on clinical nursing issues, in particular the problems of infections.
Catherine Pope is a Research Fellow at the London School of Hygiene and Tropical Medicine. She has recently worked on a Medical Research Council project that has undertaken a survey of surgical outcomes.
Preface
ABOUT THIS BOOK
For the last 40 years nursing research has been struggling to establish its theoretical roots and legitimate place within the wider arena of research in the health sciences. Overshadowed by the medical endeavour, both resources and support have been meagre. Initially this medical hegemony also restricted the range of research designs by favouring the quantitative approaches that have formed the backbone of much clinical research. However, despite these restrictions, nursing research has developed a particular diversity which matches the eclecticism of the discipline itself. Nursing and nurses have rapidly recognized that health-related research problems often require a multi-faceted approach that can be realized most effectively through multi-disciplinary activities. Not unexpectedly, however, individual researchers have frequently remained entrenched in the particular methodologies with which they are familiar and have only reluctantly (and perhaps wisely) ventured beyond these.
In contrast, the aim of this book has been to gather together material that reflects the diversity and richness of research in nursing. To juxtapose different designs springing from different epistemologies, with the aim of stimulating a more holistic approach. It hopes to provide readers with an understanding of nursing research through a consideration of the issues involved. The text is not intended as a recipe book on how to do research but rather an attempt to raise an awareness to the opportunities and constraints of different approaches and to situate them within the current milieu of
The organization of this book
nursing and the National Health Service. A major consideration has been to illustrate the material with studies that the authors themselves have undertaken and to provide some impression of the realities of the research world and the way in which it functions in today's society. Many nurses regard research as somewhat magical, academic and irrelevant to everyday clinical activities. This can only impede the effective dissemination and utilization of research; indeed this is one of the neglected topics that the book addresses. In particular, we hope that the text will contribute to the imaginative development and use of research by, and for, those working in all branches of nursing within the health service.
THE ORGANIZAnON OF THIS BOOK
The reader can follow this book from cover to cover or I dip' into parts that they feel are of interest. Each chapter is complete in itself but also follows a sequence from the initiation of nursing research to the utilization of its results. The chapters reflect the diversity of nursing research so that some draw on specific examples of studies, while others range across a broad body of literature.
In Chapter 1 the development of nursing research in relation to recent changes in the education of nurses, the reorganization of the National Health Service and health services research are explored. The nature of nursing research and the problems of underaking it are examined by Helen Glenister in Chapter 2. She considers the role of managers in relation to nursing research and the place of nursing within health services research. Funding is a particular problem for all researchers and some of the practical problems facing applicants are mapped out. The management of research, which tends to be neglected, is discussed and the relationships within multidisciplinary groups are explored. The gap between theory and practice is a theme that runs throughout this book. It is taken up by Nicky Cullum (Chapter 3) who suggests that critical reviews of the literature may represent an important way to bridge the divide. She provides some guidance on how such reviews may be undertaken and draws on her own experience in undertaking a major review of the care of leg ulcers in the community. The diversity of approaches represented within
Preface
nursing research is highlighted in the tensions between quantitative and qualitative methodologies. Michael Hardey (Chapter 4) considers the opportunities and constraints of qualitative nursing research. In doing this, important qualitative techniques are examined and related to theoretical and nursing problems. In contrast Anne Mulhall (Chapter 5) advocates the use of surveys in nursing research. She stresses that, within the purchaser/provider relationship of the restructured health services, nurses have the opportunity to undertake important research that can underpin management decisions. In Chapter 6 she goes on to consider the place of the experimental approach within nursing research. It is argued that the nursing profession must not neglect the contribution of experimentation simply because it is often regarded as the hallmark of biomedicine. Examples from recent research are used to illustrate and introduce some of the concepts used in the chapter. The secondary analysis of existing data is an established part of health services research but, as Ann Adams et al. (Chapter 7) suggest, it has been neglected in nursing research. Catherine Pope and Nick Mays (Chapter 8) bring together many of the issues that have been explored in the book in an imaginative encounter between a natural scientist who is director of a health services research unit and a sociologically inclined colleague. They illustrate the fundamental epistemological gap that divides the two speakers, and demonstrate some of the difficulties in attempting to develop a more qualitative perspective in a health services research milieu that is dominated by the natural sciences. In Chapter 9, Michael Hardey examines the important but largely unresolved aspect of how research is disseminated and used by practitioners. Unless this part of research work is recognized and effectiveness improved, nursing research will be undervlaued and irrelevant to many practitioners.
Acknowledgements
We would like to thank everyone who has been a member of the Nursing Practice Research Unit at the University of Surrey (1985-1993) for stimulating our interest in nursing and health care research. We hope that all the staff and associated students of the Unit found their time at Surrey an opportunity to exchange ideas with people from many different backgrounds and that this has helped shape their continuing contribution to research and management within the health care system. We would also like to thank the Department of Health who provided the funding and other support for both the Unit and many of the projects reported in this volume.
Our thanks also go to the British Medical Journal for permission to include a version of the paper by Catherine Pope and Nicholas Mays 'Opening the black box: An encounter in the corridors of health services research', that was published in the British Medical Journal, 1993, 30, 315-18.
1
The theory and practice of research
Michael Hardey and Anne Mulhall
INTRODUCTION
Nursing research is crucial to the effective delivery of care and to the role and status of the nursing profession. All branches of the nursing profession are undergoing a period of rapid change that is redefining their role and relationship with the health care and educational systems. Nursing research reflects this dynamic situation in which established practices and values are questioned. Although 'nursing research' and 'nurse researcher' are commonly used terms, their meaning is unclear. The authors believe that the title nurse researcher applies equally to nurses who undertake research and researchers who may not be qualified nurses but are investigating nursing issues. This highlights the need for researchers to become familiar with the culture and practice of nursing and for nurses to understand research and the theories behind particular techniques. These definitions are congruent with the multidisciplinary nature of much nursing research and accept that nurse researchers, whatever their background, must produce high-quality, rigorous studies if they are to have an impact on the delivery of care. It also implies that the boundaries around what constitutes nursing research are blurred. Like the discipline of nursing itself, nursing research embraces a range of methods, sciences and epistemologies. This eclecticism is reflected in both the contents and contributors to this book. Research about nursing can be traced back to the 19th century and Florence Nightingale who emphasized the need for
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The theory and practice of research
observation and statistics (Davies, 1980). It was not until 1953 that the first research conducted by a nurse other than Florence Nightingale was published (Lelean and Clarke, 1990). Nursing developed under the double disadvantage of medical hegemony and gender-based inequalities (Webb, 1985), and it was not until the 1940s that research into nursing developed to any extent. Reflecting the domination of the biomedical model and the lack of power of nursing within the health care system, the majority of this research was initiated and undertaken by people other than nurses (Baly, 1980). With the inception of the National Health Service, concerns about the role of nurses as the major part of the health work force promoted several projects that were funded by charitable trusts (Goddard, 1953; Menzies, 1959). Nursing research developed more rapidly and extensively in the USA where the journal Nursing Research was established in 1952. Until the 1950s nurse education was divided between the practical and the theoretical, significantly the latter was taught and examined by doctors (Maggs, 1983). During the 1950s and 1960s quantitative methods dominated research in nursing, reflecting the influence of the biomedical model of health. In 1963, the first post within the then Ministry of Health was created to foster the development of nursing research and the active role of nurses in research (Simpson, 1981). It was not until the 1960s that the Department of Health and Social Security began to commission nursing research. The Briggs Report (1972) recommended that nursing should develop a distinct research base and highlighted the way in which practitioners often undertook non-nursing work. This was timely and gave impetus to the struggle to establish the profeSSional credentials of nursing. As nursing research developed in its own right, qualitative research paradigms became increasingly influential.
KNOWLEDGE AND THE PROFESSION
Nursing research is not the inevitable consequence of scientific progress. It forms part of the political and cultural project to establish nursing as a profession that has necessitated distancing the discipline from the biomedical model of health (Chambers and Coates, 1992). The 1960s saw the emergence of a literature that highlighted that medical
Knowledge and the profession 3
knowledge and those delivering hospital care viewed patients as objects rather than persons (Illich, 1972; Foucault, 1973). Clinical evidence also suggested that the relationship between patients and practitioners affected recovery rates (Kelly and May, 1982). During the last 20 years nursing has embraced the concept of caring and a growing literature about this concept has evolved (Leininger, 1978; Watson, 1979). This coincided with a strong professionalizing movement that required a distinctive theoretical role for nurses. Nursing theory began to develop an individualized model of care and the concept of the 'whole' patient whose organic and social character must be understood. This orientation has underpinned several significant nursing theories and notions of what constitutes nursing. Roger's (1970) theory, for example, suggests that nursing is about the fullest development of human potential. Less diffuse, Orem (1985) suggests that the aim of nursing is to foster individual self-care, while Roy (1984) focuses on the need to promote a patient's adaptation to change. Such theories provide an holistic framework for practice that has been widely influential and significant in establishing a professional status.
The concept of the 'clinical gaze' (Foucault, 1973) demonstrated how medicine devalued subjective experience and individuality. In contrast, nursing has developed a psychosocial orientation that redefines caring in terms of a 'therapeutic' gaze (Bloor and McIntosh, 1990). The extension of nursing work into patients' subjective 'being' places a premium on communication within the nurse-patient relationship (Armstrong, 1983). This is central to therapy (Peplau, 1988; Barber, 1991) and contributes to the claim that nurses should embrace the role of patient advocate. This new area of nursing work is congruent with professional status and embraces the 'emotional labour' of caring (James, 1989) within a scientific and organizational discourse. However, if caring is to form the central core of nursing it is essential that it is critically examined and evaluated. Care is a social, cultural and political concept whose organization and content reflect social divisions and cultures. The practice and organization of care revolves around women, the home and children, traditional female domains that are ostensibly prized and valued but, in reality, devalued by current political and health care cultures. The
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The theory and practice of research
consequent public image of nursing is consistent across cultures and is associated with 'weakness' and lack of power (Austin et al., 1985). As care has moved from the private to the public domain it has been reconstructed into an individualistic and particularistic ethic, which is now being espoused enthusiastically by the profession as its raison d'etre. This has given rise to various attempts to define the nature of care that range from the abstract (Griffen, 1983) to the pragmatic (Benner, 1984). The focus on care should be seen as part of a process in which nursing as a discipline has distanced itself from the 'cure' orientation of the medical profession (Ellis, 1992). Two further points are worthy of mention here. First, the 'buying of this particular package' is as Dunlop (1986) notes strongly indicative of women's continuing socialization into the caring and domestic roles. Second, although nursing has justified its claims to caring through its historical roots in caring for the body, much recent nursing research has ignored this aspect. Rejection of the importance of physical care may be perceived as parallel to its relegation to less-qualified nursing staff. This has implications for research into the biology of the body, which faces a double disadvantage. Seen as falling within the sphere of medical and natural sciences from which the nursing profession has been seeking to distance itself, it is also accorded low status within nursing knowledge. Biological knowledge is associated with a mechanistic view of the body and goes against the trend to use methodologies that explore psychosocial dimensions. This status reflects the association of bodily care with the task-oriented nursing that professional status has transcended. Nevertheless, the physical care of the body remains one of the primary functions of nursing work so that research about direct bodily aspects of care and research techniques that are used to elicit information about bodily functions remain important to nursing (Chapters 5 and 6). Ironically medicine itself, particularly primary medicine, is moving towards holistic approaches that are concomitant with the 'mindful body' concept (Like and Steiner, 1986; Scheper-Hughes and Lock, 1987). This suggests that there is a developing common ground between some branches of medicine and nursing in their approach to patients and clients.
The above discussion has certain implications for research in nursing - for example, whether a science of caring is possible. Dunlop (1986) suggests that while the use of scientific methodologies and conceptualizations (be they from the natural or social sciences) to answer nursing questions poses few problems, a science of caring raises different issues. For how is caring to be operationalized? As Dreyfus (1984) argues, how can human capacities be described in terms of contextfree features? Leininger (1982) and others' interpretation of Heidegger (1962), that suggests caring is in essence altruistic, has implications for not only the profession but for the research that it undertakes. Research in nursing thus carries its own ideological and political dimensions. These are particular to nursing's position as a practice-based discipline, peopled mainly by women, and which needs to maintain a professional status. Thus research has a role in the promotion of nursing as a discipline in its own right, with a unique body of knowledge, different from that of medicine. Specially trained personnel are required to interpret and use such knowledge. Nursingknowledge, like any other knowledge, is notepistemologically homogeneous but recurrent and recursive. Knowledge develops through a mixture of beliefs and practice. Since action and thoughts occur concurrently, no actor is going to produce a homogenous set of knowledge. Knowledge has an ephemeral character that is not perceived by the individual because it is embedded in more than consciousness and is produced from a shifting base. As Young (1981, p. 379) when examining medicine stated, 'knowledge needs to be viewed in terms of the processes by which it is produced rather than its structure'. Knowledge is produced and legitimized within a cultural and professional context. A heritage of written work is essential to the development and accumulation of the knowledge that may underpin a discipline (Goody, 1977). Nursing lacks such an historical legacy and, in consequence, has to struggle not to be overshadowed by medicine. In many ways nursing can be said to be suffering from a severe case of ontological insecurity.
NURSING RESEARCH AND HEALTH SERVICES RESEARCH
Within the academic tradition, research is seen as contributing to a body of knowledge and thus may not have any declared
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The theory and practice of research
usefulness. In contrast, a commercial research and development tradition that is gaining influence within the restructured health care system seeks pragmatic and measurable research outcomes (Department of Health 1991a, 1993a, 1993b). Academic and professional status has been attached to the former concept of research, while the latter has been devalued as 'problem solving' or dismissed as mechanistic. However, in practice it may be hard to discern whether a decision or procedure has been changed as a result of research-based knowledge (Weiss, 1972). There is reason to doubt if all existing nursing practices can be traced back to research roots, so that some may have their origins in nursing history or in the contingencies of everyday practice (Walsh and Ford, 1989). Nursing research and much other health services research usually contain elements of both the academic and the pragmatic approaches. This creates tensions for both researchers and funders. At one level, funders are unlikely to support a project without knowing precisely what the direction and potential outcome will be. For research designs, such as some qualitative methods where it is hard to define an exact sample, timetable or predictable outcome this is a very real problem, for example in a grounded-theory approach (Chapter 4). Equally researchers will not be attracted to a project that leaves them little creative influence and is designed to 'provide the answer the funder anticipates'. The balance between 'research for its own sake' and 'customer-directed' research is hard to establish. Researchers tend to be suspicious of encroachments on academic freedom and 'political agendas', while policy makers and managers are concerned with the delivery of research results that can support purchaser/provider decisions and underpin the delivery of services. The Department of Health expects the research units that make up an important part of health services research to produce academically respectable and scientific work. Indeed this forms a major part of the criteria for their continued funding. Although the utility of research to customers and its dissemination beyond academic circles has been accorded greater significance in funding decisions, considerable weight is still given to publication in academic peer-refereed journals. Such publications are vital in establishing the credentials of individual researchers, which, in their tum, are assessed in the competition for research
funding. The logical outcome of this is the multi-authored academic paper so evident in medical journals (Epstein, 1993). While giving credit to all those involved in a research project, the practice obscures individual efforts and tends to reinforce the position of senior academics and managers who may insist that they share authorship by virtue of status.
Under the influence of the NHS research and development programme, an approach to nursing research is gaining ground that places it in the context of health services research (Department of Health, 1993a). While the Department of Health is not the only source of funding for research in nursing, it is the principle one for larger-scale, more-substantive studies that have the highest profiles within the research community. This type of research by its very nature is seeking 'generalizable contributions to knowledge' (Department of Health 1993a). The secondary analysis of large databases is an established part of health services research that can identify general changes and provide generalizable material, which tends to be neglected by nurse researchers (Chapter 7). The concern with generalizability is that, while providing strategic and economically significant answers integral to the provision of health care and policy making, it tends to mitigate against the qualitative investigation of the hidden practices and assumptions that underlie nursing. In the publication Research for Health (Department of Health, 1993b) it is claimed that insignificant research has been addressed towards a 'wide range of issues germane to health sector demands'. However, as Hampton (1993, p. 78) notes 'investigator-led' research should not be equated with 'inappropriate' research and it is not appropriate for all research and development funding to be spent on projects that are fully defined at policy-making level. This should not be seen as a rejection of health services research, indeed much of this book is concerned with the ways in which different research designs, which have been neglected by nurses, could be put to good effect in the pursuit of the goals of effective and efficient practice. It is, however, a plea to recognize that both nursing and medicine need to take a more eclectic approach to research questions, the mechanisms through which they are approached and the subsequent interpretation and use of the knowledge gained. This aspect is highlighted in Pope and Mays (Chapter 8)
The theory and practice of research
imaginary dialogue that emphasizes the nature of the divide between the natural and social sciences.
RESEARCH AND NURSE EDUCATION
A significant change in nursing has been the absorption of nurse education into the university sector, which, in the 195Os, was seen as the key to equal status with other health care professions (Akester, 1955). The Project 2000 programme and the revisions to many degree level courses will help undermine the traditional barriers between the social and biomedical disciplines. However, health professionals need to appreciate and understand the distinctiveness of different disciplines and the differing contribution they make to the delivery of nursing care. It is at the boundaries of disciplines and through their cross fertilization that new understanding of nursing issues develop and give rise to new innovations in practice. The recognition of an integrated approach to health care is not new. Engel (1977) advocated a 'biopsychosocial' model, while others have suggested a clinical 'social science' (Kleinman et al., 1978). However, this degree of integration is difficult, if not impossible because of the lack of uniform approach in the contributing disciplines and their dynamic nature that tends to produce new paradigms and divisions. It is also important to recognize the dynamiC nature of health services research, which is subject to an increasing rate of change that is driven by policy fluctuations, scientific innovations and public expectations and demands. Thus, while it is an interesting intellectual exercise to attempt to define 'nursing' or the scope of 'nursing research', even if common agreement was established external and internal changes would soon subvert the definition. The diversity of disciplines that are of use to nursing are also reflected in the debate about whether nursing is an 'art' or a 'science'. These debates had a significant role during the professionalization of nursing, which had to promote its uniqueness and autonomy in the face of biomedicine. The contribution of the social sciences to medical practice and the recognition of holistic approaches in several clinical areas, suggest that some of the traditional barriers to the dialogue across the health professions may be crumbling.
The development of nurse autonomy has been supported by the growth of primary nursing, which provides both a philosophy and an organizational method for delivering care (Manthey, 1980; Giovanetti, 1986). Primary nurses are personally accountable for the care they deliver and thus need both expertise and autonomy (Anderson and Choi, 1980; Manthey, 1980; Hegyvary, 1982). At a policy level, primary nursing has been approved by the Chief Nursing Officer of England (Department of Health, 1989) and is implicit in the Patient's Charter (Department of Health, 1992b). The acceptance of primary nursing suggests that there will be an increasing number of highly educated and skilled nurses who will be instrumental in delivering patient care. Primary nursing may thus further define an established clinical elite (Carpenter, 1977). The boundaries around what constitutes a qualified and experienced member of the core nursing workforce and the periphery of less trained and less experienced staff are blurred. This is reflected in the ambiguity in the title 'nurse', which, unlike that of doctor, is extended to 'nursing assistants' and 'nursing auxiliaries' (Mackay, 1993). It is these nurses on the periphery of the profession who undertake much of the routine care of the body. The cost of employing professional nurses may increase pressure to employ more peripheral staff who are frequently engaged on a part-time basis (Walby, 1993; Walby et al., 1993). The development of a highly educated elite may provide an academically inclined audience for the dissemination of nursing research and provide the pool of active nurse researchers. However, this constructs a nursing hierarchy, based on education and divided from other health care staff. Those outside the core of the nursing profession can be seen as 'pragmatic practitioners' who will not have any recognized role in research. However, this should not exclude them from the dissemination of research information that could improve the delivery of their care.
An expanded and more defined nursing core will make further demands for postgraduate education (Chambers and Coates, 1992). Postgraduate level education is the key to an active involvement in research and there are several schemes designed to support nurses undertaking such courses (Chapter 2). The need for expanded and improved research training (Department of Health, 1993a) should lead to increased
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The theory and practice of research
opportunities for postgraduate education. The recommendation to diminish the gap between mid-career salaries and studentship grants may also encourage more nurses to return to education. However, even graduate nurses have experienced some suspicion from both doctors and established nurses who may regard them as threatening traditional occupational hierarchies and as possessing academic knowledge at the expense of pragmatic skills (Chapman, 1975; Mackay, 1993). Nurses with postgraduate qualifications and especially those who have gained doctorates often experience a degree of ambiguity about their role. Despite a practice qualification they have in a sense transcended practice and qualified for entry into academic or managerial cultures. It is questionable whether postgraduate qualifications create a practitioner who is better able to deliver care directly. However, studies undertaken by research students have often made a valuable contribution to nursing knowledge and practice. The Department of Health (1993a) has noted the need for more nurses at postdoctoral level but this is not just a matter of the provision of more funds. There are many problems involved in the supervision of postgraduate students in nursing (Sheehan, 1993) and these are accentuated by the small size of academic departments; this makes it hard to establish a sense of collegiality among research students. The isolation, or poor supervision (Britvati, 1991) experienced by research students is not unique to nursing but it is compounded by the lack of staff with experience in the supervision of postgraduate research (Clark, 1992). Nursing departments may also have difficulties in providing 'taught' elements of doctorate programmes and may need to place students in courses provided by other departments. Nurses, especially at doctoral level, often have to develop a detailed knowledge of a discipline that can provide the theory and methodology for a research project. This highlights the potential contribution of researchers who are not nurses to nursing research and the potential benefits to be derived from practitioner and researcher collaborations. It also suggests that some postgraduate nurses will leave the profession behind to establish careers in other disciplines. There is thus scope for a fruitful reciprocal flow of nurses into traditional academic disciplines and of academics into nursing research.
Research in the real world 11
RESEARCH IN THE REAL WORLD
Research has always been shrouded by the mystique of academia and cloaked with an aura of authority. Rigorous scientific research uncovers 'facts', or so the rhetoric suggests. However, science does not uncover facts it produces them (Young, 1981), and research creates, and is created, through a set of cultural values and meanings. Latour and Woolgar (1979) have described the production of biological 'facts' by a research group in terms of sOcially evolved ideation. We cannot escape from the fact that just as nursing and medicine are constructed and practised through a set of ideological and sociocultural constraints, so research, be it objective naturalistic science or more qualitative in approach, is also bound by the same constraints.
In the introduction to his book, Silverman (1987) provides a 'real life' account of what went on behind the scenes during the research, which provided the focus for his text. He notes that polished research reports conceal the cognitive, temporal and political processes through which the research was developed, undertaken and disseminated. Discussions of these aspects of research are rare in published accounts - particularly those of a more biomedical or scientific nature. To the uninitiated, research, which in reality often involves setbacks, the use of contingencies, tedium, luck, imagination and inspiration, appears from a reading of research reports to be logical, bureaucratic, consistent and conforming to plans and schedules. Research may also form part of 'hidden agendas' whereby institutions seek apparently neutral results to legitimate controversial or unpopular decisions. Some research will never be funded because it threatens cultural or political practices and policies, while other studies will not be disseminated (Cox et al., 1978; Bell and Roberts, 1984; Townsend and Davidson, 1988). Unlike medicine, much clinical nursing is conducted in environments where research is frequently not perceived as a priority, if it is evident at all. Thus research that is disseminated may never achieve its potential to improve practice because it is not used fully.
The role of nursing research and its relationship to the organizations in which nurses work is an issue that is taken up by many of the contributors to this book. A particular
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The theory and practice of research
challenge for nurse researchers is the dissemination of their work to a practitioner audience that does not read articles and papers that report research findings (Horsley et al. 1978; Hunt, 1981, 1987; Edwards-Beckett, 1990). An important step in overcoming this is the development of a nursing culture in which research and debates about nursing are valued by all nurses and those who manage them. Changes in nurse education should enable more practitioners to understand and assess critically research articles than at present (Hunt, 1981, 1987; Armitage, 1990; Millar, 1993) but this does not mean that researchers can afford to neglect the development of better ways to communicate with the customers and users of nursing research.
All too often nurses are involved in other people's research projects as data collectors, or providers of information for studies for which they feel little involvement and less respect. This creates an atmosphere where research is devalued, its relevance to patient care obscured and its processes surrounded in mystique. It may also inhibit the process whereby issues and problems that confront the practitioner can be developed into areas for research and thus reinforce the 'top down' image of research. The hierarchical nature of nursing and the divide between the core and periphery of nursing staff does not make it easy for problems that demand research to emerge from those directly delivering care. It is even harder for research questions to come from clients and patients, although pressure groups may have a significant influence, as is evident in midwifery. If the aims of A Strategy for Nursing (Department of Health, 1989) and the Report of the Taskforce on a Strategy for Nursing Research (Department of Health, 1993a) are to be tackled in any real sense then some of the barriers surrounding the different, managerial, clinical, educational and academic cultures will need to be broken down.
Nursing research represents a challenge to potential funding bodies and a danger for researchers who may find that their research proposals fail to fit within the core concerns of particular funders. Nurse researchers are disadvantaged in terms of access to funding (Dunn, 1991) and they have been over-reliant on the Department of Health as a direct or indirect funding body. Alternative sources of funding such as research councils, charities and industry have been relatively neglected
Research in the real world 13
(MacGuire, 1990; Chambers and Coates, 1992). The relative newness of nursing in research and academic settings and the uncertain boundaries around the discipline means that nursing is under-represented in the decision-making mechanisms of major funders. Despite nursing representation on bodies such as the Medical Research Council, there is a relative lack of nurse researchers with sufficient experience to compete with established medical researchers. There are also few nurse research groups with sufficient experience and influence to bid for major research programmes such as those tendered by government departments and research councils. At a time when research funding is under considerable constraint and subject to ever increasing competition from academic departments keen to increase their research profile, the role of nurse researchers who take part in decisions about funding is important. Despite calls at policy level for research councils and charitable trusts to become more open to nursing research (Department of Health, 1991a, 1993a) this will not, on its own, result in more funds for nursing research without pressure from nurse researchers, health care managers and practitioners. The recognition of a distinctive nursing agenda in the research and development division of the Department of Health has done much to foster the development of nursing research. However, the degree to which the restructuring of the NHS and the proposed changes to research support will further promote the role of nursing research is as yet unclear. The devolving of important research decisions to regional, district and institutional levels may be positive but the future structure of regional health authorities and other bodies is, at the time of writing, uncertain. The developing purchaser-provider model in the NHS means that research will have to compete for increasingly scarce resources. It is possible that many nurse researchers will find that 'research' is institutionally defined to include evaluation, audit and other organizational strategies. There is a role for research in developing and validating audit and other instruments but the routine administration of such devices should not form part of the research role. Another threat to nursing research is pressure for institutions to undertake 'quick and cheap' studies to legitimate policies or management decisions. Such exercises can only produce limited and inadequate research.
The theory and practice of research
THEORY AND PRAXIS
Traditionally the roles of researcher, educator and practitioner have been separate; however in both the USA and the UK there is a growing number of nurses who hold posts that combine two or more of these roles. There are advantages in having the participation of a researcher who is identified as an 'insider' by nursing and other staff and who is part of a common professional and organizational culture. At a time of increasing demands on nursing time, practitioners are more likely to respond positively to requests for collaboration if they are confident that some feedback from the research may improve their practice. Combined posts have the potential for overcoming the negative experience of research that many nurses have (Webb, 1990) and also the potential for acting as a channel for the communication of research studies. There is potential for a 'reciprocal relationship' (Wilson-Barnett et al., 1990) to be established in which practice and research reinforce each other to the benefit of both. However, it is important to recognize that the differing goals of research and practice mean that conflicts of interest are inevitable and require careful negotiation (Hinshaw et al. 1981; Tierney and Taylor, 1991). At an organizational level, the scope of nurse-researcher posts varies considerably (Knafl et al., 1989) and the existence of one or two combined posts within a large organization is unlikely to be sufficient for close relationships with many practitioners to be developed. Several combined posts are based partly in clinical and partly in academic departments. Such posts can provide an important link between the clinical and academic cultures and act as a conduit for the exchange of information. However, without adequate managerial and institutional support post-holders can become estranged from both organizations. In particular, posts that bridge the academic and practitioner cultures require experienced nurse researchers who can reconcile the competing priorities of two very different traditions. It is useful to distinguish between two models of combined posts. One model assumes that the nurse researcher has close links with practitioners and undertakes direct clinical work on an everyday basis. The second model places less emphasis on actual practice and positions the post-holder at a relatively senior organizational level.
Theory and praxis
Thus there may be one combined appointee within a large organization much of whose time will be taken up with the representation of nursing at various committees and ensuring that the organization is aware of new developments in the delivery of care. While important contributions to nursing can be made by appointees who hold posts under either of the models the nature and scope of their work varies considerably. However, both require an organizational culture that values innovations in the delivery of care and that is able to allocate resources to research and its dissemination.
It is essential that nursing does not replicate the medical model under which practitioners become isolated and build barriers around their clinical autonomy. A culture that values research and recognizes that it may not provide comfortable answers or clear solutions to problems is necessary. This culture cannot be created by practitioners alone because delivery of care is dependent on a range of expertise and resources. Policy makers and managers contribute to creating such a culture, as well as enabling nurses to have the resources to undertake research at any level. Modern nursing practice draws on an emergent knowledge base that represents a synthesis of material from many disciplines. Nursing research reflects this breadth and is often interdisciplinary in character, ranging from phenomenological studies to the analysis of secondary data sets. Mills (1970) refers to the 'sociological imagination' that is needed to recognize that what appears to be 'personal troubles' can only be understood and explained in the context of social, economic and political 'public issues'. In a similar way practitioners and researchers need to foster a 'nursing imagination' so that 'personal troubles' are understood and explained in the context of organic, social and organizational issues. In an overview of nursing research Hockey (1986) highlights the importance of individual academic curiosity to the development of research. This curiosity forms part of the nursing imagination that is essential to deal with uncomfortable or contradictory results and to generate new questions for future research. A nursing imagination will enable nursing to make an important contribution to health services research.
This book has evolved through our experiences of a research unit where staff (of whom only some were nurses) from several
16
The theory and practice of research
academic disciplines, worked together in the generation, and solving of research problems with relevance to nursing. The participation of researchers from many disciplines in creating and promoting new innovations in the delivery of nursing care does not imply that nursing research should lose its identity within health services research. It is important that nursing should have a distinctive voice that can contribute to health services research in its own right. Working in a multidisciplinary environment such as a research unit is not easy and requires the flexibility and imagination to ask awkward questions and sometimes provide challenging answers. It also demands a creative, facilitating and open approach to management at all levels. Where staff have been trained and encultured in a particular world view some problems are bound to arise. The division between practitioners and others represents the most obvious hurdle to successful collaboration and is exacerbated by the limited number of postdoctoral nurses with experience who follow a research career (Department of Health, 1993a). Those without a background in nursing had to be 'immersed' within a nursing culture and able to share, or at least appreciate, a practitioner's professional culture and the contexts in which nursing takes place. This highlights the problem of discipline' dilution' or 'overload'. Stainton-Rogers (1991) describes her discovery that many disciplines other than her own original one (psychology) had 'interests' in explaining health and sickness. The difficulties in becoming familiar with not only the literature but also the research 'scene' in several subjects should not be underestimated. It is also important to recognize that members of multidisciplinary groups must be able to maintain links with their own discipline and should not be the sole representative within the immediate working environment. It is at the interface of disciplines with their variety of perspectives and methods that some of the most exciting and innovative research work can develop.
The development of research units marked an important stage in the recognition of nursing research. However, their future is unclear (O'Grady, 1990) and several units including our own have been closed during the 1990s. The role of those that remain within the Department of Health's research and development strategy is unresolved. Centres and units that bring together researchers can provide the structure for
adequate research careers. They can also provide the resources for disseminating and promoting the use of research at all levels of the health care system. Current career structures within research are both precarious and professionally and financially unrewarding for both nurses and doctors (Lancet, 1993). This makes it difficult to establish a cadre of qualified and experienced researchers who are able to compete for research council awards. There are consequently limited numbers of established nurse researchers who can provide high-quality supervision and guidance. One of the particular strengths of research units is that their primary concern is research, not teaching. They consequently place most emphasis on developing research skills that extend beyond merely learning the procedures for undertaking research but also encompass the wider milieu of research activities such as planning future strategies, negotiating with funding bodies and maintaining a high profile within the research community. Continuity is another crucial issue. The recent taskforce report (Department of Health, 1993a) recommends that nursing departments should concentrate their research efforts in a limited number of fields. However, despite the universities' natural desire to perform well in national research rating exercises, staff are frequently employed to meet teaching needs, rather than research priorities. Alongside the professional bodies' requirements for a certain range of staff, it is therefore not surprising that nursing departments in particular often display an extremely diverse set of research interests. This problem is even more apparent in the nursing colleges. So long as research is funded in a piecemeal way through short-term contracts the problem of continuity will remain. Centres of excellence in research, and the depth of expertise that runs alongside them, can best be fostered where a commitment to longer-term funding is more evident. For nurses it is also essential that research is recognized throughout the profession as an important and worthwhile long-term career.
2
Undertaking research • • In nursIng
Helen Glenister
INTRODUCTION
This chapter examines the place of research in nursing in current nursing practice and considers the relationship of research about nursing with other health service research. Ways of setting the agenda and the initiation and funding of research projects are explored also. Finally the management of research will be discussed. Although, for brevity, the term nursing is used throughout this chapter, the principles also apply to the midwifery and health visiting professions.
THE SCOPE AND OBJECTIVES OF NURSING RESEARCH
Research in nursing is relatively 'new' in terms of the long history of the profession. In the UK its roots can be traced to the early National Health Service when concerns focused on the appropriate use of nursing staff resources in hospitals. Early research was funded by charitable organizations and attempted to undertake a fundamental analysis of the task of nursing (Goddard, 1953; Menzies, 1959). Since then, particularly in the last 10 years, there has been considerable growth in the amount of research in nursing that has been undertaken. This is due to several factors, including the wider educational opportunities for nurses and the increased acknowledgement of the need for research in nursing at all levels, from government departments to clinical areas. It has been recognized that the National Health Service (NHS) is dependent on nursing
20 Undertaking research in nursing
services and there is a need for all in the NHS to be accountable for practices and services. These developments are also linked to the professionalization of nursing which demands a scientific knowledge base that is separate from that of medicine.
Research in nursing is not fundamentally different from research in any other field and there is no shortage of definitions ranging from the oversimplified to the over-obtuse. For the purpose of this chapter the definition published by Macleod-Clark and Hockey (1989) is adopted. This suggests that research is a systematic process that adds to knowledge through the discovery of new facts or relationships. Research in nursing involves any activity that may have an impact on the delivery of nursing care. Ultimately the aim should be to influence nursing organization or practice so that health gain is maximized for the user of the service. Research in nursing is not limited to aspects of care, it may be undertaken to examine factors that affect indirectly the process of nursing for example, the management and education of nurses, the design of equipment and the economic dimensions of different nursing practices. It may also incorporate the individual or collective public's perspective to care. Such wide-ranging issues will often necessitate the involvement in research of personnel who are not nurses.
Nursing itself is eclectic and the scope of its research is wideranging. This is because of several factors. Nursing derives many of its concepts from other disciplines such as psychology, biochemistry, medical physics, medicine, epidemiology, sociology, social anthropology and microbiology. There are also various branches and specialties within nursing. The former include adult, paediatric and mental health nursing, while the latter include coronary care, renal, stoma and infection-control nursing. Research into aspects of nursing often requires a knowledge base from another discipline. For example, research considering nursing practice to prevent pressure sores may require detailed knowledge of pressure sore phYSiology and mechanical injury. Research considering the decision-making processes involved in identifying patient problems will require considerable knowledge of psychology and SOciology. As nursing borrows many concepts from other disciplines, research in nursing is not only undertaken by nurses. Other
The scope and objectives of nursing research 21
scientists have an important role in conducting research and contributing to the body of knowledge. Research in nursing also cannot be considered in isolation from other health services research. Nurses work with other members of the health care team such as physiotherapists, occupational therapists, dieticians, doctors, radiographers and chiropodists. Some aspects of care may be shared by different professionals; for example, tracheal suction of a patient in an intensive care unit may be undertaken both by nurses and physiotherapists. The findings of research therefore could have implications for other professions in addition to nursing.
As research in nursing is relatively new, habitual routine and convention, rather than the results of scientific enquiry have guided much practice. It is only in recent years that the efficacy of some practices has been questioned. An example is the use of salt baths to promote healing and prevent infection of wounds. Watson (1984) and Sherman (1979) questioned this practice and found large variations in both the amount and type of salt used and could find no evidence to support the activity. Ayliffe et al. (1975) demonstrated that adding as much as 250 g of salt to bath water had no bacterial effect and suggested that the practice be discontinued. This is an example of one practice whose efficacy has been examined, there are many others that have not been investigated by scientific enquiry.
In addition to practice, various organizational changes within nursing have been introduced and yet not been evaluated. Many could have influenced the outcomes for patients. Some examples are the introduction of team nursing in 1950s and 1960s, the nursing process in 1970s and, more recently, primary nursing. Team nursing involved nurses being responsible for the total care of a small number of patients. Before the middle of the century, nursing was performed as a series of tasks for the whole ward (Duncan, 1964; Maggs, 1983). The nursing process is a 'systematic approach to planning nursing care' and involves: (i) assessing patient needs; (ii) planning nursing care; (iii) implementing nursing care; and (iv) evaluating the care given (Kratz, 1979). Primary nursing involves designating 24 h responsibility for each patient's care to one individual nurse (Manthey, 1988). The changes are purported to have improved the quality of care
22 Undertaking research in nursing
however, few studies have been undertaken to provide empirical evidence to substantiate these claims. This problem is compounded further by the lack of theoretical work to establish criteria for the definition of change in terms of patient outcome. The lack of empirical knowledge in the written form impedes the formation of a profession.
Research in nursing is likely to increase in importance. Nurses are directly accountable for their practice and, in the interests of professional accountability, 'must act in a manner so as to promote and safeguard the interests and well-being of patients and clients [and] ... maintain and improve their professional knowledge and competence' (UK Central Council Code of Conduct, 1992). Therefore, all members of the nursing professions need an understanding of the research process and the ability and time to retrieve and assess research critically. This is essential if professional knowledge is to be improved and nursing is to be practised competently. The findings of research in nursing therefore need to be disseminated widely if they are to be considered by the nursing community. Furthermore, at a time when there are limited resources for health care, nurses will be required to provide justification for practices and determine the most cost-effective ways of delivering them. These will be the main objectives for research in nursing over the coming years. The call for high standards will result in increasing attempts to develop scientifically credible indicators of quality. The education reforms such as Project 2000 (UK Central Council for Nursing, Midwifery and Health Visiting, 1986) will also encourage research based teaching. In general, the climate for the recognition of research in nursing is not only favourable but compelling. It is now incumbent on the UK nursing profession to build on and refine existing knowledge and techniques. Findings may not always be in line with presently held popular beliefs in the profession but they should be accepted if they have implications for improving the health gain for the user of the service.
SEmNG THE AGENDA FOR NURSING RESEARCH
It is often assumed that only health care workers at top levels set the agenda for research in nursing. This is not the case, nurses and other health care workers at all levels and in
Setting the agenda for nursing research 23
various organizations can help influence the future agenda by using the appropriate informal networks. Nurses have a particular responsibility for identifying research problems and ways of influencing the local and national agenda will be considered.
If a nurse has an idea for an area of research, it is useful to discuss the project with local managers at an early stage. If the project is considered to be worthwhile, and to meet the overall objectives of the organization, it may be given support. For example, a project that is investigating the activity undertaken by, and skill-mix of, district nurses might appeal to community managers if the outcome could improve the quality of care and produce a more cost-effective service. This does not mean that only research that meets an organization's objectives can be undertaken, although inevitably there will be priorities. For example, currently there is an emphasis on economic implications, and other aspects of nursing research may not be so well supported. It is essential, however, that fundamental research is also undertaken and therefore other avenues of funding, perhaps the charities or professional organizations need to be identified.
Where local managers are unable to fund projects, it is worth investigating more widely for external funding perhaps, from a regional health authority (Regional Office), the Department of Health, charities and research councils. It may be useful initially to contact the organization on an informal basis to discuss the project. However, some effort may be required to determine the appropriate person/organization and this may require several telephone calls to seek the advice of colleagues. Where there is something to see, for example if the project was to evaluate a system of care that had already been introduced, an invitation to visit the organization concerned may be appropriate. This helps to give the background context for the project and may be a useful supplement to written information. Where the project is considered to be useful, alternative avenues of support may be suggested by the person contacted. It should be acknowledged that personnel at regional and department levels have a wide area of responsibility and often welcome the opportunity of being informed of new developments or areas for research. When appropriate these can be fed into the national agenda via lobbying the relevant personnel and those who control and manage research budgets.
24
Undertaking research in nursing
Individuals need to be aware of the national agenda for research since it is sometimes possible to set the nursing agenda within this. For example, the Central Research and Development Committee of the NHS is responsible for setting priorities for research and development (Department of Health, 1991a). Projects focused on priority areas may be more successful in achieving funding than other subjects. Within the priority areas it may also be possible to influence the agenda for research. For example, one priority identified by the Central Research and Development Committee was the subject of mental health. Applications for research projects were invited from all disciplines; however, it should be acknowledged that nurses were competing with other disciplines and there was a shortage of nurse researchers who had the research training and skills to prepare a research proposal, nevertheless there was the opportunity to influence the agenda.
The question of whether research in nursing should be identified as a special case is a subject that has received considerable debate. The Task Force on a Strategy for Research in Nursing, Midwifery and Health Visiting Research received arguments for and against treating research in nursing as a special case. Overall the taskforce considered that there was merit in both arguments. They concluded that there was no reason to separate research in nursing from other health service research, but acknowledged that the nursing professions were at a disadvantage in terms of the small number of nurses having the necessary research skills. Recommendations to overcome such barriers and to enhance opportunities and performance were included in the final report (Department of Health, 1993a).
Other ways of influencing the research agenda include lobbying members of committees or councils who are part of the decision-making process. For example, it could be useful to liaise with members of the NHS Central Research and Development Committee for setting the priority areas. It is, however, important to ensure that the people lobbied are sufficiently empowered to contribute to group/committee discussions. Another strategy is to publish ideas for research in the nursing and health care press. These may then be read by those who can influence the agenda. A negative factor is that the ideas may be taken by another group of workers. The author has to strike a balance between identifying key areas
The place of nursing research in health services research 25
without giving too much detail of proposed projects. Organizations also invite views on research. For example, the Task Force on a Strategy for Research in Nursing, Midwifery and Health Visiting Research invited practitioners to submit written comments/evidence (Department of Health, 1992a). This was an ideal opportunity for individuals to influence the broad agenda of research in nursing.
THE PLACE OF NURSING RESEARCH IN HEALTH SERVICES RESEARCH
Health services research is concerned with the problems in the organization, staffing, financing, use and evaluation of health services (Flook and Sanazaro, 1973). This is in contrast to biomedical research, which is orientated to the aetiology, diagnosis and treatment of disease. Health services research subsumes medical care and patient care research. It grew out of the need for more knowledge about health services and began in the USA in the 1920s. By the 1960s, health services research had become a distinct field of inquiry and, in 1967, President Johnson ordered the creation of the National Centre for Health Service Research and Development within the Department of Health Education and Welfare (Institute of Medicine, 1979).
Health services research has been slower to develop in the UK, although it has become increasingly important during the last 10 years, when the emphasis has been on developing costeffective, efficient, appropriate, high-quality, equitable, responsive and accessible health services. During recent years, several health services research groups have been established. These have consisted of people from different disciplines working together. Some examples are the Health Services Research Group at the University of Cambridge and the Medical Care Research Unit at the University of Sheffield. Both have employed nurses to coordinate and work on specific projects. Nursing research has an important role in health services research. It can be undertaken to determine ways by which nurses and nursing care can contribute more effectively to the entire spectrum of health services delivery. Some examples (summaries) of health service research that involve nursing and/or nurses are:
Undertaking research in nursing
1. A study of the postoperative arrangements for gynaecological day surgery patients. The effect of routine postoperative visiting by a nurse following laparoscopic sterilization is being assessed. Women visited are to be compared with a group not visited. The outcome and the patients' satisfaction with care is to be examined.
2. The Peterborough Hip Fracture Project. This project has compared traditional hospital care with hospital at home care for patients with fractured neck of femur. Early planned discharge to home from the orthopaedic wards was found to improve the long-term outcome for these patients.
3. A study to determine the reasons for children not completing their primary immunization schedule. The aims of this project are to establish whether computer records are correct and reflect children's immunization schedule. It also aims to determine the reasons why parents do not have their children immunized so that ways of improving uptake can be suggested for the future (currently being undertaken by the author).
4. An evaluation of triage in a British Accident and Emergency Department. This project compared a formal system of triage by nurses for patients presenting at an accident and emergency department with an informal system of prioritization carried out during patients' passage through the department. There were two outcome measures: the first was the time waited between arrival in the department and first contact with a doctor; the second was patient satisfaction (George et al., 1992).
Researchers with a background in nursing also have much to offer across a wide variety of health services research topics. This is partly due to the very nature of nursing. In particular, nurses can contribute knowledge and experience of the actual delivery of care in different settings. Unfortunately few nurses have the appropriate skills to participate in health services research. This has been recognized by the Task Force on a Strategy for Research in Nursing, Midwifery and Health Visiting Research and their report (Department of Health, 1993a) suggests various ways of addressing this.
INITIATION AND FUNDING OF RESEARCH IN NURSING
The challenge to acquire resources to fund research in nursing can be daunting. Although not always necessary, most research projects will require some additional funding. This can be obtained from a variety of different sources but the process of finding a suitable agency and the application can be extremely time-consuming. In this section some of the difficulties faced by nurses in initiating research in nursing, preparing a research proposal and applying for funds are discussed.
Initiating research in nursing
One of the problems in initiating research in nursing is defining the research problem. Identifying potential areas for research is easy but the careful development of a researchable question less so. A literature review must be undertaken to establish whether and how the chosen area has already been addressed. The availability and usefulness of libraries in different parts of the country varies. It can be useful to spend time working in national libraries such as that of the Royal College of Nursing, rather than waiting for inter-library loans. The latter can take a considerable time and be expensive. The literature review will indicate whether the proposed question is already satisfactorily answered and, if so, whether a replication study is merited. If it is still considered useful to undertake the study a research proposal must be produced. An example of how an idea for a research project was identified, successfully funded and published follows (Glenister, 1987).
In 1985 an infection control nurse (ICN) wanted to introduce the wearing of gloves for the emptying of urinary catheter bags. It was not policy to wear gloves for this procedure. Hands, however, are considered to be the most important vehicle for transmitting microorganisms associated with hospital-acquired infection. The ICN had a 'hunch' that no research had investigated whether nurses contaminate their hands with microorganisms during catheter bag emptying. A literature review indicated that, although guidelines had been produced advocating the use of gloves, there was no evidence of research that had examined the problem of microbial contamination of the hands. The leN prepared a research proposal and applied
28 Undertaking research in nursing
and received funding from the hospital research committee to undertake a study.
THE RESEARCH PROPOSAL
A research proposal has been defined as 'a written summary of what the reserarcher intends to do, how and why' (Seaman and Verhonick, 1982); to this can be added 'where, when and at what cost'. Preparing a proposal also facilitates the researcher in defining clearly the research problem and planning the project. Modified versions are also useful for submitting to ethical committees and managers to inform them about the project. They also may be required by funding agencies, if proformas are not used. A problem for the profession is that few nurses have experience of producing research proposals and may omit important material or fail to emphasize the relevance and salience of the project to potential £Unders. One way of overcoming this is to make a joint application with a researcher experienced in the relevant area. The following section considers the issues that need to be addressed in preparing a research proposal.
The research proposal commonly takes the following form:
• title and summary;
• introduction;
• objectives/aims of the study;
• methodology and analytical procedures;
• time scale;
• resources;
• dissemination and implementation; and
• curriculum vitae of researcher(s).
Title and summary
The title and summary are crucial as they are the first sections to be read and an application may be rejected on this alone. Particular thought is required to devise a title as a project can be labelled thus henceforth. The summary should give an overview of the proposed project and include many of the themes that are developed further within the proposal.
Introduction
This section explains why the research project is important, relevant and worthwhile. It is also where the proposer can 'sell' the research to the funding agency. Careful analysis of the sort of research undertaken by the agency, and sometimes the interests of the board that may consider it, can pay dividends. The introduction should include a description of the problem and how it relates to what is already known. A review of the research/literature undertaken in the particular field of study should be included. Here the researcher can describe how much is known about the subject area and discuss issues relevant to the project. Possible gaps in knowledge can be identified. A discussion of methodological approaches should also be incorporated and the section should end with speculation concerning the general and practical applications, or benefits of the results.
Objectives/aims of the study
Devising concisely defined objectives and aims for a project can be a particular challenge, they are essential, however, in providing the reader with a comprehensive and coherent statement of what the researcher hopes to achieve.
Methodology and analytical procedures
This section should include an overall description of the research design and details of the proposed methodology. A research proposal is often rejected if this section is not clearly outlined. Terms may need to be defined and the location of the project and choice of subjects should be described. The sample size with the rationale for choosing it should be given. Details of sampling techniques must also be included. The methods of data collection can be described first in general terms (e.g. questionnaire, interview, direct observation) and then in detail, identifying how the data is to be collected. Ways of checking the validity and reliability of the proposed methods should also be included, together with details of pilot studies. The researcher should indicate whether ethical approval or access to facilities has been requested and/or given. Some funding organizations require ethical approval before submission; the need for this should be established when organizations are
30 Undertaking research in nursing
first contacted. Finally, an indication of methods of data analysis should be given, such as the use of a computer and the types of statistical techniques that will be used. The entry of data about individuals onto computers may come under the Data Protection Act 1982, to which reference should be made. Researchers using a qualitative approach may find it difficult to give full details of analysis as these may not be decided until fieldwork is in progress. The researcher, however, needs to provide as much information as possible about how the analysis will proceed. It should be realized that some bodies, particularly those based within the biomedical model may not recognize the value of qualitative studies since emphasis has been placed on quantitative projects, however, this is beginning to change.
Time scale
The time scale should present a detailed and realistic description of the sequence and duration of the tasks involved. It is a form of forward planning that requires great care in its preparation. The time framework should not only include dates when the project is due to start and finish, but also how much time is allocated to the specific stages. It may include the time (e.g. months) allocated to detailed literature review, development of datacollection methods, pilot studies, collection of data, computerization of data-collection methods, pilot studies, collection of data, computerization of data, analysis and writing of the report. An underestimate of the time scale may be seriously detrimental to the whole project, not least in terms of finance, therefore it is advisable initially to seek advice from more experienced colleagues. Sometimes it is useful to use a diagram or flow chart to illustrate the time framework. An example is given in Figure 2.1.
Resources
This section should include an itemized, realistic set of estimates. This will vary with different studies but, in general, it as well to take account of the following possible categories of expenditure:
• salaries (all staff directly employed by the project based on gross costs and to include increments if applicable);
