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The DISCUSSION Section of a Research Article:

What does the Results Section Mean?

After reading the last few blog posts you should now be able to recognize a published research report as having these key sections:
Title
Abstract
Introduction
Methods 
Discussion

Key Point: Now we turn to DISCUSSION section  where the researcher tells you what the Results section means.   Discussion gives "the investigator's explanations of some of their findings and their opinions of what they think their study means for practice & future research" (p. 22, Davies & Logan, 2008).

Let’s see how this works by looking at an example of Results & then Discussion in Apfelbaum et al’s 2013 study of “Postoperative pain experience” published in Anesthesia and analgesia.

In the RESULTS section Apfelbaum et al’s statistical analysis results were:

Approximately two thirds of patients reported that a health care professional talked with them before surgery about how their pain would be treated….Overall, nurses were more likely than other health care professionals to educate patients about pain and pain management. Among surgical outpatients, surgeons were as likely as nurses to provide patient pain education, but nurses were more likely to provide this service for surgical inpatients. After surgery, two thirds of patients reported being asked by a health care professional about their pain, most frequently by a nurse….75% of patients believed that it was necessary to experience some pain after surgery, and 8% of patients had postponed surgery because they were worried about the possibility of experiencing pain (pp. 537-8)

You can see that the Results above tells only results of statistical tests.  In the DISCUSSION section Apfelbaum and co-authors explained what the Results mean for RNs & providers.

We were surprised to find that more than half of the patients surveyed were concerned about experiencing pain after surgery and that this caused some of them even to postpone surgery. Although most patients claimed to receive preoperative education on postoperative pain management, our findings suggest that a patient’s real concern is not adequately addressed.  Despite the increased focus on pain management over the last several years and the development of formal standards and guidelines for the management of acute pain, a significant number of patients continue to experience unacceptable levels of pain after surgery and after discharge. This fact is alarming, considering the trend toward ambulatory surgery and shorter hospital stays. (p. 539)

Critical thinking:  

FIRST read the following Results of a study by Fayh et al (2013) that was an experiment to test “the effects of 5 % weight loss, through diet only or diet plus exercise, on lipid profile, inflammation and endothelial function in obese individuals.”  THEN write your own Discussion section explaining what these results mean. 

Results: Thirteen individuals dropped out before completing the weight loss intervention. The median time required for reduction of 5 % of initial body weight was 79.7 days for the Diet group and 65.9 days for the Diet + Exercise group ( P = 0.16). In both Diet( n = 18) and Diet + Exercise ( n = 17), total cholesterol (−15.8 ± 4.8 and −10.5 ± 4.9 mg/dL, respectively), triglycerides (−33.8 ± 10.0 and −39.4 ± 10.3 mg/dL, respectively) and hs-CRP (−1.35 ± 0.41 and −0.45 ± 0.43 mg/L, respectively) decreased significantly, and in a similar response. (p. 1443)

FINALLY (if you like) you can then compare your Discussion to their Discussion section by getting a copy of their article from the library: Fayh, A. et al (2013). Effects of 5% weight loss through diet or diet plus exercise on cardiovascular parameters of obese: A randomized trial. European Journal of Nutrition, 52(5) 1443-50. doi http://dx.doi.org.libproxy.csun.edu/10.1007/s00394-012-0450-1 

“I want RESULTS!”

(Analysis of Data to Answer the Hypothesis or Question)

The “Results” section of a research article tells you both 1) the characteristics of those who participated in the study (e.g., their gender, ethnicity, education, & so on); & 2) the data analysis used to answer the research question or hypothesis.   The Results section follows the methods section that is described in preceding blogs.

“Results” is where the author reports analysis of numbers data using statistics or analysis of word data by identifying common themes.  Don’t be afraid to read this section; & don’t let your eyes glaze over.   All this comes with practice.  Here are a few basics to get started.*

1st          The researcher has collected data (or measurements) about something in numbers (e.g., inches or test scores) or words (e.g., subjects’ descriptions of experiences) or data in both numbers and words.  The researcher will analyze numbers data using statistical tests and will analyze word data for recurring themes and ideas.  

2nd        The characteristics of the participants in the study will tell you whether the participants are similar to or different from those to whom you want to apply the results.

3rd         In statistical analysis when you see that a result is p<.05 this means that there is a 95% chance the result is right and a 5% chance it is wrong.  When you see p<.01, it means that there is a 99% chance the result is right and a 1% chance the result is wrong.

4th         In statistics the researcher will analyze number data to do at least one of these:

a.       Describe something (for example, What are RNs’ self-care practices);

b.      Find out whether two things are related to each other (for example, Is maternal age related to numbers of birth defects); or 

c.       Identify whether one thing is causing another (for example, Does ZMapp vaccine cause those with Ebola virus to get well).  

5th         Not surprisingly, statistical analysis that describes something is called descriptive statistics (4^th.a above). Examples are percents & averages.  In contrast, statistical analyses done to find relationships or cause and effect are called inferential statistics (4^th b.c. above).  Examples are correlation coefficients or t-tests.

6th          In word analysis, the researcher will be able only to describe something (e.g., what do RNs experience when returning to school).

*[For more on basic statistics see Halfens, R.J.G., & Meijers, J.M.M. (2013). Back to basics: An introduction to statistics. Journal of Wound Care, 22(5): 248-51.]

CRITICAL THINKING

1.       Is the following example, did Zerwekh et al do word analysis or statistical analysis?  Did they describe, correlate, or explain cause and effect? EXAMPLE: In Zerwekh et al (2002) study, analysis showed that barriers to pain management came from 5 sources: “within the patient, within the physician, within the family, within the nurse and within the healthcare organization” (p.85).  [Hint: see 1^st & 6^th above]

2.       In the following example, were Smith et al (2010) focusing on identifying relationships or cause and effect?  How might you describe the likelihood that they were right, based on the “p” levels?  EXAMPLE: “Better pain management was associated with increased emotional well-being (t = 2.11, p = 0.03). Number of hospitalizations was marginally associated with increased emotional well-being (t = 1.91, p < 0.06).” (p.83)

DATA COLLECTION SECTION!

(Methods in the Research Madness cont.)

Key point!  The data collection section of a research article includes: who collects what data when, where & how.

In previous blogs we’ve looked at title, introduction, and other elements of methods section (design, sample, & setting).   In this one let’s take a look at data collection.

Data are a collection of measurements.  For example, scores on a classroom test might be 97, 90, 88, 85, & so on.  Each single score is a datum; collectively they are data.

What data are collected is answered in this section.  The data (or measurements) can be numbers or words/themes.   For example, numbers data might be how many RNs in a hospital are men and how many are women.   An example of word data would be themes without any counting of things (e.g., in a study RNs may describe their roles as “caregiver” or “professional” or “interprofessional”; we would not count how many RNs used each word).   Sometimes a researcher collects both number and word data in the same study to give a more complete description.

How the data are collected includes what instrument or tool was used to gather data (e.g., observation, biophysical measure or self-report) and how consistently & accurately that tool measures what it is supposed to measure (e.g., reliability & validity).   Also included is who collected the data and the procedures that they followed—how did they obtain consent, interaction with subjects, timing of data collection and so on.

Now you know!

Critical thinking question:  You are interested in the level of pain control among patients on your unit.  Think of a way to measure this with numbers data and also a way to measure this with word data.  Who would ask what, when, where & how?

METHODS in the Research Madness

Research article elements are: Title, Abstract, Introduction/background, Methods, Results, Discussion, & Implications/Conclusions

METHODS =

•       Design
•       Sample
•       Setting
•       Data collection/Instrument 

Sometimes there are sub-headings of design, sample, setting, & instrument.

Sometimes not.

•       Key point #1: Design= overall plan for answering the question or proving the hypothesis.  The 2 basic types of design are 1) experimental & 2) non-experimental.   In experimental, the researcher does something to the subjects and measures the effects of that something.  In non-experimental, the research merely observes and describes what is happening without doing anything to change it.  (Note: Quasi-experimental designs are a subset of experimental ones—the researcher just doesn’t control as many variables.)

•       Key point #2: Setting=where the study is conducted: home, hospital, office, classroom, on an ocean cruise, or other.

• Key point #3: Sample includes who/what subjects were in & excluded from the study; how many subjects were in the study; & whether subjects were selected using random methods or non-random methods.   In random selection every eligible subject has the same chance of being selected. That’s called probability sampling.  An example is drawing names from a hat.  In non-random selection only the most nearby subjects are asked to be in the study. That’s called non-probability or convenience sampling.  An example, using a clipboard to survey people who walk into a mall one day. [Note: Subjects can be people, animals, charts, hospitals, or nations.]

(Whew!....Enough for now.  In the next blog we’ll look at data collection methods.)

Critical Thinking Exercise:  Find the Design, Setting, & Sample in this excerpt of Methods from Mohammedkarimi et al, (2014): 

“A double-blind, randomized clinical trial (RCT) was performed among 90 adult patients with acute headache in Shahid Rahnemoon Emergency Center of Yazd city of Iran (45 patients in lidocaine group and 45 patients in placebo group). Patients with history of epilepsy, allergy to lidocaine, signs of skull base fracture, Glasgow Coma Scale (GCS) < 15, patients younger than 14 years and patients who had received any medication in previous 2 h were excluded.” 

Let Me Introduce You to INTRODUCTIONS!

(How to Read Research cont.)

In the last two blog entries we talked about what you can and cannot learn from research titles & abstracts. Now, let me introduce you to INTRODUCTIONS/BACKGROUND section of research reports.

  

The introduction/background

“[a] outlines the background of the problem or issue being examined,

[b] summarizes the existing literature on the subject, and

[c] states the research questions, objectives, and possibly hypothesis” (p. 6, Davies & Logan, 2012)

This is the very 1^st section of the body of the research article.  It may or may not have a heading of “Introduction” or “Background” or both.  Both Abstract and Introduction/Background include:

• ·         Problem that the research is investigating &
• ·         Research questions OR hypothesis

In the Intro/Background you will get a more full description of why the problem is a priority for research and what is already known about the problem (i.e., literature review).

Key point #1: Articles & research that are reviewed in the Intro/Background should be mostly within the past 5-7 years.  Sometimes included are classic works that may be much older OR sometimes no recent research exists.   If recent articles aren’t used, this should raise some questions in your mind.   You know well that healthcare changes all the time!!  If there are no recent studies the author should explain.

Key point #2:  The last sentence or two in the Intro/Background is the research question or hypothesis.  If you need to know the research question/hypothesis right away, you can skip straight to the end of the Intro/background—and there it is!

Key point #3: What is the difference between a research question and hypothesis?  A hypothesis is a predicted answer and focuses on one thing causing another thing (i.e., ASA lowers MI risk).   A research question is used when we don’t know enough to guess about the cause and effect, & merely want to describe something. A question may also be used when we want to establish whether 2 things are related to each other, but aren’t ready to identify one as causing the other (i.e., which came 1^st, the chicken or the egg?—these are related, but which was the cause?)

Critical thinking question: One of the following is a hypothesis & one is a research question.  Which is which?

1.   The purpose of this study was to describe the expectations for pain relief of patients with abdominal pain and how their communication with providers relates to their overall pain relief. (Yee et al 2006)

2.  We investigated whether a brief pain communication/education strategy would improve patient pain communication skills. (Smith et al, 2010)

Happy research reading!

Abstracts Are Not Enough! :-)

My last blog post listed the usual sections of a research report (title, abstract, introduction, methods, results, & discussion/conclusion); and I illustrated the amazing things you can learn from only an article title!

This week? Abstracts.   Abstracts are great; abstracts are not enough!

An abstract will not give you enough information to accurately apply the study findings to practice.  An abstract typically summarizes all the other sections of the article, such as  the question the researcher wanted to answer, how the researcher collected data to answer it, and what that data showed.  This is great when you are trying to get the general picture, but you should Never assume that the abstract tells you what you need to know.

Abstracts can mislead you IF you do not read the rest of the article.  They are only a short 100-200 words and so they have to leave out key information.   You may misunderstand study results if you read only the abstract.   An abstract's 33,000 foot level description of a study, cannot reveal the same things that can be revealed in the up-close & personal description of the full article.

So...what is the takeaway?  Definitely read the abstract to get the general idea.  Then read the article beginning to end.  Don't give up reading the full article just because some parts of the study may be hard to understand.  Just read and get what you can. Then try a re-read or get some help understanding any difficult sections.   This is an important step toward EBP.

“IT’S ALL IN THE NAME”
Research articles have relatively standardized sections:
• Title
• Abstract (overview of project that is somewhat incomplete)
• Introduction (purpose, problem, & background)
• Methods (sample, setting, measurements collected)
• Results (data analysis from measurements), &
• Discussion/conclusions (what the data analysis tells us about the original purpose & problem)
These may vary a little from article to article.

Let’s look at the TITLE for a minute. A good title is a mini-abstract. A good title will include:
• Key variables (remember a variable is something that varies, such as fatigue or satisfaction)
• Population studied
• Setting of study
• Design of study

For example take this research article title “What patients with abdominal pain expect about pain relief in the Emergency Department” by Yee et al in 2006 in JEN.
• Key thing that varies? Expectations about pain relief
• Population studied? ED patients with abdominal pain
• Setting? May be the ED
• Design? (not included, but those with experience in reading research would guess that it is probably a descriptive study—in other words it just describes the patients’ expectations without any intervention.)

There you have it! Now you know about TITLES!!

When you have a great project, take credit for your ideas by submitting an abstract to a conference!

Right Writing
"You will not learn to write well by talking – to me, or to anyone else – about writing; you will learn to write well by writing. Talking about writing is like talking about carpentry, or about playing the piano, or about riding a bicycle – interesting, perhaps, but of little help in actually learning how to do any of these things. To learn how to do them, you have to do them, over and over and over. It’s called “practicing.” It’s the same with writing; actually practicing the skill…. I’m not suggesting that I’m not happy to talk to you about your project. But talking to me is much less valuable than you (and most students) think it is.” – D.G.Post (August 2010)

Steps of Writing
 Pre-Writing = Just getting all your ideas down on paper. Order doesn’t matter. (See http://www.studygs.net/writing/prewriting.htm for strategies to start.)
 Writing = Organizing your ideas into paragraphs that communicate
 Re-writing = Editing accuracy of facts, content, grammar, spelling, etc. Make it “sing” (Plan to write your title & introduction during this phase.

Rules of Writing Well
#1 Writing is Re-writing
#2 Writing is Re-writing
#3 Writing is Re-writing

1. Research = Creating new evidence, such as developing a new drug that is needed.

2. Evidence-based practice = using research evidence, such as the RN administering a drug.

From PubMed database. Full text available through that site.
O'Horo JC, Silva GLM, Silvia Munoz-Price L, Safdar N. The efficacy of daily bathing with chlorhexidine for reducing healthcare-associated bloodstream infections: a meta-analysis. Infection Control and Hospital Epidemiology 2012; 33(3): 257-267.

Abstract
DESIGN: Systematic review and meta-analysis of randomized controlled trials and quasi-experimental studies to assess the efficacy of daily bathing with chlorhexidine (CHG) for prevention of healthcare-associated bloodstream infections (BSIs).

SETTING: Medical, surgical, trauma, and combined medical-surgical intensive care units (ICUs) and long-term acute care hospitals.

PARTICIPANTS: Inpatients.

METHODS: Data on patient population, diagnostic criteria for BSIs, form and concentration of topical CHG, incidence of BSIs, and study design were extracted.

RESULTS: One randomized controlled trial and 11 nonrandomized controlled trials reporting a total of 137,392 patient-days met the inclusion criteria; 291 patients in the CHG arm developed a BSI over 67,775 patient-days, compared with 557 patients in the control arm over 69,617 catheter-days. CHG bathing resulted in a reduced incidence of BSIs: the pooled odds ratio using a random-effects model was 0.44 (95% confidence interval, 0.33-0.59; [Formula: see text]). Statistical heterogeneity was moderate, with an I(2) of 58%. For the subgroup of studies that examined central line-associated BSIs, the odds ratio was 0.40 (95% confidence interval, 0.27-0.59).

CONCLUSIONS: Daily bathing with CHG reduced the incidence of BSIs, including central line-associated BSIs, among patients in the medical ICU. Further studies are recommended to determine the optimal frequency, method of application, and concentration of CHG as well as the comparative effectiveness of this strategy relative to other preventive measures available for reducing BSIs. Future studies should also examine the efficacy of daily CHG bathing in non-ICU populations at risk for BSI.

Dignity Health Northridge Hospital Staff & Cal State Univ Northridge BSN students create a history of sharing their evidence-based practice projects in an Annual Collaborative EBP Day.

“Hospitals’ relative standing [in HCAHPS scores] with respect to doctor communication, nurse communication, and pain control outcomes vary the most across patient subgroups (e.g.,1.8-2.8 hospital-level standard deviations for excellent vs. poor health; 1.5-2.2 for American Indians/Alaska Natives vs. non-Hispanic White; 0.7-0.9 for third language vs. English, and for Asian vs. non-Hispanic White).”

 

Do Hospitals Rank Differently on HCAHPS for Different Patient  Subgroups?
Med Care Res Rev 2010 67: 56 originally published online 15 July 2009
Marc N. Elliott, William G. Lehrman, Elizabeth Goldstein, Katrin Hambarsoomian,
Megan K. Beckett and Laura A. Giordano

Keep up the good work, Californians!   Keep that body weight in control.  Eat those veggies & fruits.

Mississippians Most Obese, Montanans Least Obese

Chronic diseases are more prevalent in the most obese states.   

http://www.gallup.com/poll/167642/mississippians-obese-montanans-least-obese.aspx

What is evidence-based practice?

It is not merely finding the research.  It is combining the research with your clinical expertise in light of patient & family preferences & values.

Check out this quick overview:
http://guides.mclibrary.duke.edu/content.php?pid=431451&sid=3529499

Want empowerment? Decreased LOS & Falls?

Want to ….
1.Empower yourself?
2.Shorten LOS?
3.Reduce falls?

Various research studies show that RN CERTIFICATION is related to
1.Nurse empowerment (p<.05)
2.Shorter LOS (p<.001)
3.Fewer falls (p<.04)


Source: Krapohl, G. Manojlovich, M. ,Redman, R., & Zhang, L. (2010). Nursing specialty certification & nurse sensitive patient outcomes in the intensive care unit. American Journal of Critical Care, 19(6), 490-499.
http://www.aacn.org/WD/CETests/Media/A1019063.pdf

Facial features to be used to diagnose pain in dementia sufferers

Facial features to be used to diagnose pain in dementia sufferers

Undiagnosed pain of dementia sufferers could soon be measured by facial recognition technology, as part of an Electronic Pain Assessment Tool (ePAT) being developed at Curtin University.  The ePAT, which is linked to the camera on a smart phone or tablet, is designed to quickly and accurately detect, evaluate and document the severity of pain in non-communicative patients with dementia.
http://healthsciences.curtin.edu.au/news_facial-features-used-to-diagnose-pain-in-dementia-sufferers.cfm

Enjoy the holidays free from luggage-related injuries
November 12, 2013 Source: American Academy of Orthopaedic Surgeons

Holiday travel can mean long lines and hurried sprints through sprawling terminals. It also can mean neck, wrist, back and shoulder pain, and even injury, from carrying and lifting heavy luggage. In fact, according to the U.S. Consumer Product Safety Commission (CPSC), there were 53,790 luggage-related injuries in 2012. The American Academy of Orthopaedic Surgeons offers these tips for safely lifting and carrying luggage.

See https://members.aapainmanage.org/aapmssa/ecmssamsganalytics.click_through?p_mail_id=E79650A17510607B1C53110 for tips!