1. Introduction
In any health care practice, the carefully planned and implemented research is of great value. The research must adhere to the highest standards of scientific practice. There is no such activity as a perfect research study. However, all well designed researches will contribute to existing evidence even though they may not provide most reliable results. In health care research, a combination of the sciences of epidemiology and clinical studies has contributed to better knowledge about the effectiveness of health practices. Many research methods were first established in epidemiology. However, today they are applied widely in health care in order to measure the effectiveness of new treatments, interventions and health care practices with carefulness. This paper provides analyses of the essential features of quantitative research methods (based on counting and measurement) that require careful consideration at all points and are of great value in health care practice.
2. Advantages and Disadvantages of Quantitative Research
Healthcare professions are characterized by a body of specialized knowledge. Commonly this knowledge is the results of quantitative research. As for professional fields such as healthcare, quantitative research is critical for development. There are two major advantages. First, quantitative research yields new knowledge related to the many issues, questions, and problems in healthcare. Second, quantitative research ensures a process for distributing such knowledge when and if it is considered to be of high quality. Quantitative research, thus, has both a product and a process aspect. It addresses substantive findings and the process of obtaining and reporting them. Quantitative research is the essential force of medicine, aiming to advance understanding of professionals and improve practice (Creswell 1994, p.69).
There are important disadvantages related to quantitative research in healthcare. First, quantitative research is built on the assumption that reality exists largely independent of the researcher. Quantitative research is prone to materialisation. It fixes in time processes that might be very situational, dependent on context, and fluid. Events that depend on the social interaction among organizational members are difficult to capture with quantitative research which assume stability. Since many aspects, such as motivation, satisfaction, and commitment, cannot be directly perceived and measured but must be deduced, there is a problem of misinterpretation and understanding what the observer wants or expects to understand rather than what is really there.
A second major disadvantage of quantitative research is connected with the application of knowledge obtained (Creswell 1994, p.72). The main goal of researchers of quantitative research is to interpret reality and, possibly, comprehend how events are related to each other. It is not the fundamental objective of researchers to solve problems or make decision what action to take. The goals and tasks of researchers and professionals, thus, differ. Researchers attempt to make sense of what has already happened, professionals try to influence what is about to happen. Much of research, therefore, does not transform directly into practice. Healthcare requires attention to many more situational events than a quantitative research study can usually account for.
3. Improving health care delivery
Quantitative research is necessary to understand the operations of medicine today. Actually, there is no other way to evaluate and understand the healthcare issues, namely (Anderson 1996):
• Placing patients’ needs ahead of self-interest; scholarship; reaction to societal needs; working in collaboration with other health professionals.
• Adherence to moral principles, respect, sympathy, responsibility, politeness, sensitivity to patient needs and to members of a staff.
• High standards of moral and ethical behavior.
• Identification and management of physician impairment in peers and self.
• Psychosocial aspects for care.
• Understanding of the importance of self-assessment, and desire to teach.
• Understanding of the requirements for participation of patients in research study.
• Knowledge about the differences in gender, age, cultural, and social background.
• Fairness and reliability.
Two necessary components in the process of delivering high quality health care are the presence of scientifically based research and the practice of good critical appraisal skills in order to select the most appropriate evidence. Critical appraisal skills are necessary for helping to decide whether quantitative research is of a sufficiently high quality to show that changes in health practice are necessary. In this process, the disciplines of critical appraisal and research methods both complement and cover one another. Critical appraisal is a process that helps to determine and foster quantitative research.
4. Scientific merit
Critical appraisal is the tool used to evaluate the scientific merit of a research (Brannen 1992, p. 145). Critical appraisal has become an important clinical tool. The fundamental function of clinical appraisal is to inquire about whether a reported connection between an intervention and a health results has causal relation or can be explained by other factors such as occasion, bias or confusion. This approach is necessary in healthcare because professionals can only have certainty in outcomes that could not have arisen by chance.
Critical appraisal skills are essential for professionals. They use it in order to make decisions about whether to change clinical practice on the basis of the published literature. Critical appraisal skills are also used for making decisions about the most important directions for future research. In judging the published literature as valuable evidence, the conclusions reported must be justified regarding the appropriateness of the study methods used and the validity of the outcomes presented. This can be achieved with a sound understanding of the limitations and the benefits of different research methods (Sellitz, Jahoda, Deutsch, and Cook 1976, p.215).
5. Systematic reviews
Narrative reviews and articles, which appear constantly in most journals, often use the information that supports the authors’ points of view. These articles are necessary in order to be aware of new concepts and ideas. However, it is important that health professionals conduct systematic reviews that consider and summarise all of the relevant studies that are available.
Systematic reviews must use highly developed methods for finding and critically assessing all of the relevant literature and for making a summary of the findings. The process of systematic review consists of the following steps (Atkinson and Coffey 1997):
1. State precisely outcome variables
2. Determine intervention or exposure of interest
3. Determine search strategy and literature databases
4. Determine inclusion and exclusion criteria for studies
5. Conduct search
6. Examination of studies by two independent observers
7. Reach agreement about inclusion of studies
8. Conduct review
9. Pool data and accomplish meta-analysis
10. Propose and produce final review
6. Cochrane collaboration
The Cochrane collaboration has become an international system of great value. It monitors and publishes systematic reviews. Cochrane stated that a systematic review of a series of randomised controlled trials was a ‘real milestone in the history of randomised controlled trials and in the evaluation of care’ (Biltereyst 2001, p. 52). Since then, this has become the essential method of evaluating evidence for health care. Cochrane also stated that to have continuing value, reviews must be all the time updated with any new evidence and must be easily available through various media (Biltereyst 2001, p. 53).
7. Undertaking a Cochrane review
The fundamental task of Cochrane collaboration is to encourage the interest and eagerness of clinicians and researchers to be aware of new information. The aim of the programme is to provide professionals with the motivation, skills and supervision that are needed to conduct research to the standard required. The Cochrane collaboration assists its reviewers by presenting documents, coordinating seminars and providing software for summarising the results. The main principles of the collaboration are the following (Punch 1998, p.69):
• • consider specific health problems
• • train professionals in the review process
• • provide a collaboration of people with common interests
• • prevent duplication of literature reviews
• • teach effective search strategies
• • conduct meta-analyses
Meta-analytic findings are of the great value in healthcare. What is epidemiologically important is necessarily clinically important. The findings usually change clinical decisions. Meta-analysis is practiced as a method of evaluating whether a particular treatment works and more than that. Meta-analysis is developed and used far beyond clinical trials. Observational descriptive and analytic studies and the evaluation of diagnostic methods are also of great value. Meta-analysis in these fields works well. The pooling of results is sometimes appropriate (Neuman 1994, p.25).
8. Evidence-based practice
Evidence-based practice is an approach of quantitative research. It uses the best scientific evidence available with purpose to deliver the best patient care. The approach of evidence-based practice is means that it is better to know for sure, rather than believe. Assessments of probable effectiveness are best achieved by using systematic methods to assess the available literature in order to provide true answers to particular questions about healthcare. This process is connected with the recognition that increasing numbers of research studies are being published that have invalid findings for clinical care practices. The basic steps of evidence-based practice are the following (Bailey 1994):
1. Determine the problem
2. Break the problem down into questions
3. Find relevant clinical articles. Conduct an effective literature search
4. Define the best studies
5. Evaluate the evidence considering validity, repeatability, relevance, study strengths and weaknesses, outcomes etc.
6. Make clinical decisions, examine policy and implement the findings
7. Assess the outcomes of changes in practice
9. Benefits of evidence-based practice
The evidence-based practice has many benefits:
· focuses new research on practical issues of great value
· can be practiced to evaluate existing performance or give approval to the implementation of new practices
· has the capacity to lead to more effective decision making and more effective health care delivery
· saves time when regular reviews are available or when evaluations of research are published
The practice of scientific reviews of the evidence in order to assess the effectiveness of clinical practices increases the possibility that the healthcare delivery will be more effective. This process is improved by easy access to systematic reviews, for instance through the Cochrane collaboration, and by the making information public through journals such as Evidence-Based Medicine (Reason and Bradbury 2001, p. 278).
10. Designing a research
In designing a study and assessing the outcomes of studies conducted by other research groups, it is essential to determine the strengths and the limitations of the different types of research design that can be used (Creswell 1994, p.36). The choice of a research design is an important decision in designing a research by healthcare professional. The research design makes clearer with which a hypothesis the research can be tested, or to which causation it can be implied.
Usually, the research design that is chosen must be fitting for answering the research question. It also must be proper for the surroundings in which it is used. The different study types for the research are the following (Barbour and Kitzinger 1999):
1. Systematic review
2. Cohort studies
3. Follow-up studies
4. Non-randomised clinical trials
5. Pragmatic trials
6. Case-control studies
7. Matched case-control studies
8. Cross-sectional studies
9. Population studies
10. Ecological studies
11. Case reports
11. Choice of outcome measurements
Professionals must pay mach attention when choosing the result and explanatory variables that will be used to test the main hypotheses in a research study. It is essential to use both outcome and explanatory measurements that are as accurate and as valid as possible. This will increase the likelihood of being able to correctly determine the impact of interventions. The main features of accurate outcome measurements are the following (Black 1999):
1. good face and content validity
2. good criterion or construct validity
3. repeatable
4. good between-observer agreement
5. responsive to change
Good face and content validity are both essential characteristics of outcome measurements. They ensure that the measurement determines the symptoms and illnesses that are important in clinical terms. Besides, measurements with good criterion are of considerable importance because they measure what they are expected to measure with as much precision as possible. It is also important that measurements have good between-observer agreement and are accurate, or repeatable (Bernard 1995, p. 69).
12. Calculating the Sample Size
Sample size is one of the most important issues to consider when designing a research study. The size of the sample has effect on all aspects of conducting the research and interpreting the outcomes. A research study must be large enough to guarantee the faithful measurement of the results. Simultaneously, it must be small enough so that the research question can be answered completely.
The following issues must be considered when calculating sample size (Babbie 1990):
· Clinical importance—effect size
· Variability—spread of the measurements
· Resource availability—efficiency
· Subject availability—feasibility of recruitment
· Statistical power—correctness
· Ethics—balancing sample size against burden to subjects
13. Study management
The data collection stages must be correctly planned and conducted. The scientific integrity of the study must be maintained throughout the process. It is unethical to conduct a research that is poor. It is also unethical to present poor quality data that clearly will lead to poor quality results.
14. Data Collection
Quantitative research may give rise to particular difficulties about the ethical responsibilities of researchers in relation to dealing with the data collected. Researchers often use questionnaires from large numbers of patients. One instance is a research that set out to document the frequency of gastrointestinal symptoms in the community (Hammersley 1996, p.159). Because of the large sample required to obtain the necessary accuracy in the study, a small proportion of subjects turned out to have a complex of symptoms suggesting the possibility of serious, but until this time unrecognized, gastrointestinal disease (Jones and Tait 1995, pp 67-70). These symptoms were reported: rectal bleeding, changes in bowel habit, persistent abdominal pain, weight loss and difficulty in swallowing. The symptoms were reported by patients responding to structured questionnaires designed to determine the frequency of such symptoms. The individuals had been selected at random from registers held by health authorities and the practitioners had carefully examined the lists of participating patients before contact by post.
The practitioners that were involved in this research study expressed an interesting range of views. Some expressed a convinced belief that information of this kind should be reported without delay “so that appropriate action, perhaps an invitation for the registered patient to consult their general practitioner, might be taken” (Crosland and Jones 1995, p. 486). This, clearly, could be considered as a breaking of obligation of the confidentiality and anonymity promised by the researchers, even when such reporting is possibly to have been in the medical interests of the patient concerned. Autonomy is in conflict with kindness. Some professionals, however, took a completely opposite ethical position, and claimed that patients have a right to decide themselves about whether or not to consult. Although this position can to some degree be countered by arguing that many patients absolutely do not have enough needed information on which to base an informed decision about seeking medical advice, its proposers claimed that patient autonomy and confidentiality of information should have taken priority over uninvited medical intervention (Hammersley 1995, p.245). It is important that these issues are considered and resolved to the satisfaction of the research team, the participating practitioners and the subjects of the research study before the research begins.
15. Sequence for data analysis
Analysing the data and interpreting the outcomes is one of the most exciting stages in a quantitative research study (Bryman and Cramer 1997, p.93). The analysis provides the answers to the study questions. However, this stage is one of the critical stages in the search for truth. Therefore, it is important that the process is undertaken in a scrupulous and considered way. In general, the data analyses should go through the logical steps. First it should be conducting univariate analyses and then the bivariate and the multivariate analyses (Alvesson and Sköldberg 2000, pp 96-8).
16. Research Results
Researchers must protect the sources of research information. Protection is important part of the undertaking of confidentiality and anonymity. It may, however, be that going to excessive amount to keep secret the sources of data makes it impossible for readers of the research report completely to realise the setting in which the research was conducted and to decide whether the results can be applied to their own setting. It is also important for the subject of the research to be able to see the research results before they are published.
Providing results to subjects is very important in clinical settings. For example, in one study on general practitioner referrals of patients with rectal bleeding, 83 per cent of patients said that they would appreciate a copy of the study (Greenwood and Levin 1998, pp 36-42). In another study on patients’ consulting behaviour, almost two-thirds of participants asked for information about the results (Greenwood and Levin 1998, p. 56). This may indicate willingness for more involvement and wish for more information by subjects in some areas of research at least. However, there are logistic difficulties when professionals provide this information. It is difficult for professional to interpret the information when it forms part of a professional report. It is clear that an abbreviated or summary version of the research can be made separately.
The unpleasant results of dissemination of research information for the subjects also need to be considered. Research information sometimes might simply stigmatize certain social groups and create inappropriate stereotypes. Changing research information because of the interests of the lay media may produce a caricature of not only the research results but also the research subjects (Alasuutari 1999, p. 69). Research that has suggestions for increasing the provision of medical services, with resource allocation implications, may create inappropriate expectations in the minds of the subjects and generate subsequent disappointments (Denzin 1989, p.39). Researchers also need to have in mind that future research collaboration is likely to be of great value. Therefore, professionals should remember that the presentation and discussion of information in which judgments of the subjects of research are either explicit or implicit may jeopardize this.
Conclusively, it is important to think carefully about the possibility of over-researching particular groups or individuals. It will be useful for professionals to keep careful records of patients who have been involved to participate in studies, and for practices to do the same. This presents a further reason why general practitioners should always see lists of patients selected from catalogues before they are used for research studies.
17. Nurses are given resuscitation power. Case Study
According to new guidelines to health professionals, nurses are able to decide that a dying patient should not be resuscitated. Until now, only GPs and consultants had authority to decide whether there was any point in making efforts to save a life. In 2007 guidance by the British Medical Association has changed. Now suitably experienced nurses have power to make this important decision (The Daily Mail 2007, p. 1). These new guidelines generated many controversies.
The research questions were as follows: 1) some experts feel that sustained resuscitation efforts can be undignified and often worthless; 2) the survival rate after a patient has a cardiac arrest and receives cardiopulmonary resuscitation is relatively low; 3) nurses only are able to make such decisions – they know more about the personality of the patient; 4) often it is a long and traumatic procedure and is not always successful. The guidelines met oppositions, such as: 1) these senior nurses should be properly qualified and in a position to make these decisions; 2) a person can die because of unqualified decision.
The relationship between theory and practice should receive some attention within the nursing literature. The qualitative data from debriefing interviews with nurses should be gathered. The nursing power to decide whether patients should or should not be resuscitated is being subjected to increasing research.
18. Conclusion
The future certainly belongs to the quantitative research. Well-entrenched quantitative research is complementary to health problem solving. Quantitative research reflects the current state of medicine today. Ultimately, physicians should learn more and more about qualitative research. Good quantitative research and its results do not necessarily lead to good clinical decisions. They are, however, the necessary foundation of good decisions. These decisions put research results within a context where the patient, the care professional and the conditions and circumstances of health delivery are brought together for optimal success.
Quantitative research in health care generates a set of ethical questions, and some dilemmas. In particular, health care researchers have to be quite aware about their responsibilities to the patients. Little information is at present available about patients’ views of being involved in research of this kind. This would be an important base point for evaluating methods.
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