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Research Methodologies Used In Nursing Research

Research Methodologies Used In Nursing Research

Mixed methods research methodologies are increasingly used in nursing research to increase the depth and breadth of understanding nursing phenomena. This article discusses the history and benefits of using mixed-methods research methodologies, as well as two examples of mixed-methods nursing research. Mixed methods research has several advantages. The examples provided show specific benefits in the development of a culturally congruent picture of chronic pain management for American Indians, as well as the establishment of a method to assess the cost of providing chronic pain care.

Visit: Introduction

One of the three major research paradigms is mixed methods research. The others are quantitative research, qualitative research, and mixed methods research. Mixed methods research combines qualitative and quantitative approaches to broaden and deepen understanding. According to the first issue of the Journal of Mixed Methods Research, mixed methods research is “research in which the investigator collects and analyzes data, integrates the findings, and draws conclusions using both qualitative and quantitative approaches or methods in a single study or program of inquiry” (Tashakkori & Creswell, 2007, p.4).

In the early 1960s, anthropologists and sociologists pioneered mixed-methods research. The term “triangulation” first appeared in methodology discussions in the late 1970s. Triangulation was defined as using multiple methodologies to study the same phenomenon to reduce the bias inherent in using a single method (Morse, 1991). There are two types of sequencing for mixed methods design: simultaneous and sequential. One of the most important decisions in mixed methods study design is the type of sequencing. Simultaneous sequencing is defined as using qualitative and quantitative methods simultaneously, with little interaction between the two sources of data during data collection, but the data obtained is used in the data interpretation stage to support the findings of each method and reach a final understanding. The use of one method before the other is postulated to be sequential sequencing when the results of one method are required for planning the next method.
Mixed methods have grown in popularity since the 1960s (O’Cathain, 2009). Although there are numerous mixed methods designs to consider, the four major types are triangulation design, embedded design, explanatory design, and experimental design (Creswell & Plano Clark, 2007). Triangulation design remains the most common and well-known approach to mixed methods research.

Using a combination of methods has numerous advantages. Quantitative data can help qualitative research by identifying representative patients or outlier cases. In contrast, qualitative data can help quantitative components develop the conceptual model or instrument. During data collection, quantitative data can provide baseline information to assist researchers in selecting patients to interview. In contrast, qualitative data can assist researchers in understanding the barriers and facilitators to patient recruitment and retention. Qualitative data can help interpret, clarify, describe, and validate quantitative results during data analysis.

Mixed methods research has been reported to benefit four broad research situations. The first scenario occurs when concepts are novel and poorly understood. As a result, qualitative research is required before quantitative methods can be used. The second situation occurs when the results of one approach can be better understood with the help of a second source of data. The third situation occurs when more than a qualitative or quantitative approach is required to comprehend the concept under consideration. Finally, the fourth situation is when quantitative results are difficult to interpret, and qualitative data can help with comprehension (Creswell & Plano Clark, 2007).

This article aims to demonstrate mixed methods methodology through research into the chronic pain management experience of American Indians. These examples show the methodology used to provide (a) a detailed multilevel understanding of the chronic pain care experience for American Indians using triangulation design (multilevel model) and (b) a cost comparison of two different chronic pain care delivery models using triangulation design (data transformation model).

Visit: Understanding the Pain Management Experience Among Native Americans
Chronic pain presents unique challenges to the American healthcare system, such as rising costs, unintentional poisonings and deaths from painkiller overdoses, and incalculable suffering for patients and their families. Chronic pain affects approximately 100 million adults in the United States, with treatment costs and productivity losses totalling $635 billion annually (Institute of Medicine, 2011). Pain symptoms are the most common reason patients seek medical attention (Hing, Cherry, & Woodwell, 2006).
Research Methodologies Used In Nursing Research
There is frequently insufficient capacity to manage complex chronic pain cases at the level of the community-based primary care provider, particularly in tribal areas of the United States, and this is often due to a lack of access to speciality pain care (Momper, Delva, Tauiliili, Mueller-Williams, & Goral, 2013). The American Indian population, in particular, is underserved by health care and the most vulnerable to the effects of chronic pain, with high rates of opioid analgesic drug poisoning (Warner, Chen, Makuc, Anderson, & Minino, 2011). In the United States, 2.9 million people claim exclusive American Indian ancestry, with another 1.6 million claiming partial ancestry. They are a diverse group of people who live in 35 states and are divided into 564 federally recognized tribes (U.S. Census Bureau, 2010). There is, however, a paucity of published literature on the experience, epidemiology, and management of pain among American Indians (Haozous, Knobf, & Brant, 2010; Haozous & Knobf, 2013; Jimenez, Garroutte, Kundu, Morales, & Buchwald, 2011).

Visit: Using Mixed Methods to Overcome Research Barriers
The relatively small number of American Indian patients in any circumscribed area or tribe, the limitations of individual databases, and widespread racial misclassification are all barriers to effective research into chronic pain management among American Indians. To understand the complex experience, epidemiology, and management of chronic pain among American Indians, a mixed methods research approach is required, as well as to address the strengths and weaknesses of quantitative methodologies (large sample size, trends, generalizability) with those of qualitative methodologies (small sample size, details, in-depth).

This first example comes from an ongoing study that employs a triangulation design to understand better the phenomenon of chronic pain management among American Indians. The study employs a multilevel model in which quantitative data collected at the national and state levels will be analyzed concurrently with qualitative data collected and analyzed at the patient level (see Figure 1). This allows the shortcomings of one approach to be compensated for by the advantages of the other. The results of the individual-level analyses will be compared, contrasted, and blended to produce an overall interpretation of the results.

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Figure 1: Multilevel Triangulation Design
The Importance of Quantitative Data
Previous research using national databases in the United States found that American Indians had a higher prevalence of lower back pain than the general population (35% vs 26%; Deyo, Mirza, & Martin, 2002). Thus, at level 1, quantitative administrative data sets representing health care received by American Indians will be used to evaluate macro-level trends in healthcare utilization and primary outcomes, such as opioid-related deaths, across the United States and in broad regions.

Level 2 will use more detailed quantitative Washington state tribal clinic data to identify American Indian populations, evaluate breakdowns in care delivery, and identify processes that lead to unsuccessful outcomes. In one study with community health practitioners in Alaska, participants reported a lack of knowledge and comfort when discussing cancer pain (Cueva, Lanier, Dignan, Kuhnley, & Jenkins, 2005).

Qualitative data’s role
Level 3 qualitative research will provide more refined information about perceptions of recommended and received care through focus groups and key informant interviews. These interviews will provide information about specific immediate and proximal factors. Patients’ choice and use of services are among these factors: attitudes, motivations, and perceptions influencing their decisions. Interpersonal factors such as social support and perceived discrimination. This qualitative data will shed light on potential barriers to care that are not easily identified in administrative or clinical records, providing more detail about patients’ perspectives on chronic pain care.

The Function of (Quality) Indigenous Methodologies
Because this study focuses on the chronic pain experience of American Indian patients, the level 3 qualitative work must be guided by indigenous methodologies in data collection and analysis. The term “indigenous methodologies” refers to an evolving framework for conducting research that prioritizes the epistemologies of indigenous participants and communities while creating an equitable and respectful environment for bidirectional learning (Evans, Hole, Berg, Hutchinson, & Sookraj, 2009; Louis, 2007.; Smith, 2004). Although the tenets of indigenous methodologies differ depending on the source, there is agreement among sources that research with indigenous populations should be wellness-oriented, holistic, community-oriented, and focused on indigenous knowledge, with bidirectional learning incorporated (Louis, 2007; Smith, 2004).

The ongoing project adheres to these guidelines by increasing understanding of chronic pain from the perspective of American Indian patients. The data is being interpreted to create a usable and relevant model that will resonate with the American Indian community. To best achieve the goals of learning and building knowledge that reflects the participants’ experiences, the researchers conducted focus groups with the needs and priorities of the participants at the forefront. The focus groups were specifically scheduled within three tribes, ensuring high familiarity and social support among group members. These focus groups met in the evenings at a tribal community centre or a nearby tribally-owned casino. Each focus group began with a dinner followed by a discussion.

The facilitator of the focus groups was well-known in the community and, despite not being American Indian, had been an active participant in community events and had provided expert knowledge and consultation to the tribes. Each focus group was also co-facilitated by a tribal elder. The participants and research team’s high familiarity was an important component of the bidirectional learning: it helped reduce much of the mistrust that has historically prevented medical researchers from obtaining high-quality data in similarly vulnerable populations (Guadagnolo, Cina & Helbig, 2009).

Visit: Triangulation Design Advantages: Multilevel Model
In conclusion, only a mixed methods study using quantitative and qualitative methods could provide the data for a comprehensive multilevel assessment of chronic pain among American Indians. Although this study is still ongoing, the plan is to conduct a nationwide examination of variations in chronic pain outcomes among American Indians to examine the structure of service delivery and organization. The state-tribal clinic data will be analyzed to address intermediate factors and to investigate community-level variation in pain management and local access to pain specialists. Preliminary analysis of focus group data has already revealed that there is insufficient pain management among American Indians, owing in part to providers’ lack of knowledge about pain management and access to pain specialists.

Go to: Cost Comparison of Two Models for Providing Chronic Pain Care to American Indians
Telehealth is one innovative approach to providing American Indians with high-quality, interdisciplinary pain care. A telehealth model based on provider-to-provider videoconference consultations allows community-based providers to present complex chronic pain cases to a panel of pain specialists via a videoconferencing infrastructure that also includes longitudinal outcomes tracking to monitor patient progress. Telehealth is an innovative healthcare delivery model that has grown in popularity among American Indians in recent years (Doorenbos et al., 2010; Doorenbos et al., 2011a; 2011b). Although the use of telehealth for chronic pain consultation is still in its early stages, the long-term effectiveness of this approach, as well as its impact on increasing pain management capacity among community providers, is being studied (Haozous et al., 2012; Tauben, Towle, Gordon, Theodore, & Doorenbos, 2013). This transaction cost analysis used a mixed methods approach that combined a unique triangulation design with a data transformation model to create a body of evidence for telehealth pain management.

With ever-increasing mandates to reduce the cost and improve the quality of pain management, healthcare institutions are challenged to demonstrate that new technologies add value while maintaining or even improving care quality (Harries & Yellowlees, 2013). This evidence can be provided by transaction cost analysis, which employs mixed methods research methodologies to provide a comparative evaluation of the costs and consequences of using alternative technologies and the accompanying organizational arrangements for providing care (Williamson, 2000).

The transaction cost theory arose from the observation that our structures governing transactions—how we organize, manage, support, and carry out an exchange—have economic consequences (Williamson, 1991). Though prices are important, this theory acknowledges that they can and do deviate from the cost of production and do not include the cost of transacting (Coase, 1960). Without regard for neoclassical economic concepts such as price, output, demand, and supply, the transaction becomes the unit of analysis (Williamson, 1985).

Transactions typically involve two parties exchanging goods or services, and both expend effort to complete the transaction, incurring costs in the hope or expectation of reaping benefits. Some methods of structuring or supporting a given transaction, such as a healthcare provider’s consultation or treatment for a patient, may be more efficient than others. The analysis examines the actual costs incurred and the consequences experienced by the parties over time, hypothesising that efficiency results from the selective alignment of transactions with alternative, more efficient governance structures (Williamson, 2002).

The University of Washington (UW) Center for Pain Relief and the UW TelePain program were among the speciality health care services that took part in the study described here. The UW Center for Pain Relief is an outpatient multispecialty consultation and treatment clinic that uses the combined expertise and skills of physicians and other medical team providers to aid in the diagnosis and treatment of chronic pain, such as for people with painful disorders that have lasted longer than expected, or for people who have persistent uncontrolled pain despite receiving appropriate treatment for the underlying medical condition. In addition, the clinic provides pain consultation and treatment for a wide range of new-onset or acute problems that may benefit from selective anaesthetic procedures such as nerve blocks or spinal nerve root compression.

The Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region is served by the UW TelePain program. Primary care physicians, physician assistants, and nurse practitioners are among the tribal providers. Weekly videoconferences with other community providers and university-based pain and symptom management experts are available to tribal providers. Providers manage cases, engage in evidence-based practice activities, and receive peer support during videoconferences. These community providers are in charge of direct patient care throughout the process and follow the recommendations of consulting pain specialists.

The two care delivery models mentioned above — traditional in-clinic consultation at the Center for Pain Relief and telehealth case consultation through TelePain — provided this mixed methods study with two comparative arrangements for delivering the same transaction: pain care to patients (see Figure 2).

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Figure 2: Data Transformation Model for Triangulation Design
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Procedures for Collecting Qualitative and Quantitative Data
Two comparable completed transactions for patients with chronic pain were identified and described using participant observation and structured interviews. Members of the clinical care teams chose one transaction from each service to represent the routines and norms of their healthcare organization. The chosen transactions were performed on patients of the same gender, age, and health characteristics. Clinical care teams from each service conducted two qualitative on-site interviews for the study, documenting clinical workflow and processes (i.e., the steps in the transaction). A nurse care coordinator, pain specialist, medical assistant, patient outcomes assessment coordinator, nurse triage manager, patient support services supervisor, and financial authorization specialist were among the clinical care team members interviewed for the in-clinic transaction. Team members interviewed for the Tele-Pain transaction included the TelePain nurse care coordinator, two pain specialists, an information technology specialist, and the clinic provider.

The process of the mixed methods analysis is described in detail below. First, using qualitative interviews, individual steps or discrete tasks within each transaction (in-clinic versus TelePain) were identified and itemized in detail. The qualitative data included a description of each task, the person(s) involved, the duration of each person’s engagement in minutes, the information accrued to the patient’s medical record, the technologies used, and the locations where tasks were performed, and information was transmitted or stored.

The quantitative data gathered included the date and time and the duration in business days, which accumulated with each step in the transaction. Finally, the costs of each step identified in the qualitative data were converted into quantitatively estimated data for each transaction. The analysis concentrated on the most significant cost in health care: the value of people’s time. These values were limited to labour costs for in-clinic and telehealth personnel; time proxies were used with patient time estimates. Costs were estimated based on the amount of time spent on each task and patient and the actual wage, including benefits, of the personnel involved in the transaction.

Go to: Analysis of Qualitative and Quantitative Data
Personally identifiable information was removed from each patient’s medical record, and the records were examined for comparability and norms and routines of care for the in-clinic and telehealth organizations. The two patients had similar characteristics. Both were first-time patients at their respective organizations and were referred for specialized care by their primary care providers. The reasons for seeking care and reporting potential chronic pain conditions were similar. Both transactions resulted in a consultation that recommended further specialized care or treatment.

Two work flows, one in-clinic and one telehealth, were created by documenting actual tasks performed during the transactions. These workflows were presented to participants for review and comment in follow-up interviews. These interviews yielded a detailed itemized list of dates, personnel, and time spent on discrete steps or tasks per person. Tables and graphs were created and compared for each transaction, to each other, and concerning participants’ rationales for the tasks in each transaction.

The cost per transaction is expressed by the following equation, where the total cost of the transaction (CT) is the sum of the costs of each discrete task (ki) in the transaction, measured per participant (x, y, z…) on the task, as the product of time (t) and wage rate (w), or in the case of the patient (x, y, z…), a proxy for the value of time (w) and estimated time (t) (t).

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The typical in-clinic transaction at the UW Center for Pain Relief (one patient case reviewed by two pain specialists) took 46 discrete steps. In contrast, the typical TelePain transaction took 27 steps (three patient cases reviewed by six pain specialists). The more administrative steps taken to schedule, execute, and follow up on the in-clinic consultation, the longer the time between receiving the initial referral request and completing the consultation with the pain specialists. Between referral and completion of the entire in-clinic transaction, 153 business days (213 calendar days) elapsed, compared to 4 business days (4 calendar days) for the TelePain transaction. Importantly, the UW Center for Pain Relief transaction took 72 business days before the consultation concluded with a referral for the patient’s record, whereas the TelePain transaction took only four days. These methods for determining transaction costs are an excellent example of mixed methods research, as the transaction cost results require both qualitative and quantitative data and analysis.
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Research methodologies used in nursing research can be classified into several different categories. These include quantitative research, qualitative research, and mixed methods research.

Quantitative research is a type of research that involves the use of numerical data and statistical analysis to test hypotheses and answer research questions (Polit & Beck, 2017). This type of research is often used to study phenomena that can be measured and quantified, such as patient outcomes or the effectiveness of treatment. Quantitative research methods include experimental designs, surveys, and observational studies. For example, a quantitative study might use a randomized controlled trial to examine the effectiveness of a new medication in reducing symptoms of a specific condition.
Qualitative research focuses on understanding the experiences, perceptions, and meanings of individuals and groups (Creswell & Poth, 2018). This type of research is often used to explore complex and subjective phenomena, such as patient experiences or healthcare provider perspectives. Qualitative research methods include ethnography, case study, phenomenology, and grounded theory. For example, a qualitative study might use in-depth interviews to understand patients’ experiences with a chronic illness and how they cope with their condition.

Mixed methods research is a type of research that combines both quantitative and qualitative methods in order to gain a complete understanding of a research question (Greene & Caracelli, 2019). Research of this type is often used to triangulate data or examine different aspects of a phenomenon. Mixed methods research can include contemporary, sequential, or transformative designs. For example, a mixed methods study might use a survey to gather numerical data on a particular phenomenon and then use in-depth interviews to explore the experiences and perceptions of participants in more detail.

In nursing research, these methods are used in different ways depending on the questions and objectives of the study (Greene & Caracelli, 2019).. For example, quantitative research methods are often used to measure the effectiveness of interventions and to identify risk factors for specific conditions. Qualitative research methods, on the other hand, are often used to explore the perspectives of patients and healthcare providers and to understand the experiences of individuals and groups. Mixed methods research is used to combine the strengths of both quantitative and qualitative methods and to gain a complete understanding of a research question.
Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry and research design: Choosing among five approaches. Sage publications.

Greene, J. A., & Caracelli, V. J. (2019). Mixing methods: Combining qualitative and quantitative approaches. Sage publications.

Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice. Wolters Kluwer Health.

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