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Nursing Research In Canada: Methods, Critical Appraisal, And Utilization, 3rd Canadian Edition Lecture Notes

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    The Role of Research in Nursing CHAPTER OVERVIEW Chapter 1 examines the role of research in a practice discipline; the historical foundations of nursing research; the relationships among research, education, and practice; the roles of professional nurses in the research process according to their level of educational preparation; and future trends and priorities for nursing research. It introduces students to their role as research consumers and high- lights how consumers of research contribute to the development of evidence-informed nursing practice. The authors emphasize that baccalaureate graduates must be able to read research critically and determine when a body of research is ready for use in practice. Nurses prepared at the master’s or doctoral level conduct research and use its findings. In general, this chapter raises students’ awareness of their role as consumers of nursing research. It also fosters an appreciation of the historical evolution of nursing research, that is, where nursing has been and where it is projected to be in terms of research. LEARNING OUTCOMES After reading this chapter, you will be able to do the following: • State the significance of research to the practice of nursing. • Identify the role of the consumer of nursing research. • Discuss the differences in trends within nursing research in Canada. • Describe how research, education, and practice are related to one another. • Evaluate the nurse’s role in the research process as it relates to the nurse’s level of education. • Identify future trends in nursing research. • Formulate the priorities for nursing research in the twenty-first century. INSTRUCTOR'S MANUAL : C H A P T E R 1

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    2 CHAPTER 1 The Role of Research in Nursing TEACHING STRATEGIES As a teacher of nursing students, you can facilitate your students’ awareness of, interest in, and ap- preciation of research. The teaching strategies identified in this section are intended to assist you in helping students become aware of nursing re- search and its relationship to clinical practice. 1. Critical Thinking Challenges The following lists of questions are intended to facilitate review of chapter content and to foster the critical thinking skills needed to fulfill the role of research consumer: RECALL AND UNDERSTANDING • What is nursing research? • What is the meaning of the term consumer ? • What is the research role of the registered nurse? How does this role compare with that of a nurse who has a master’s degree? A doctorate? • How would you define evidence-informed practice ? ANALYSIS AND SYNTHESIS • How does nursing research differ from the research of other disciplines? • What does it mean to be a consumer of nursing research ? • How does nursing research contribute to the development of clinical skills, to the overall practice of nursing, and to professionalism? 2. Allaying Students’ Anxiety As stated in the Introduction to the Instructor’s Manual , students often approach a course in re- search with preconceived notions about the na- ture and difficulty of the subject. Therefore, you should establish a nonthreatening environment. It may help to begin by encouraging students to ex- press their concerns and anxieties about the sub- ject matter. Sharing the responses of students in your other classes can initiate such a discussion. This strategy helps students realize that they are not alone in their feelings and that you as the teacher are aware of their needs and are concerned about them. This type of open discussion also can give you an idea of students’ learning needs and major areas of potential difficulty. Through this discussion, misconceptions can be addressed and clarifi ed right away. 3. Making Research Relevant to Practice If research concepts have not been incorporated in previous courses, or even if they have, students may not be aware of the relationship between research and practice. A variety of teaching strat- egies can be used to facilitate this awareness. Students have found the use of numerous clin- ical examples during discussions of the role of research in nursing to be particularly enriching. For example, you might ask your students about the techniques they use to give intramuscu- lar injections. After several students describe their technique(s), you can ask them to discuss where they obtained their knowledge and whether they believe these techniques are valid. You might then explain that, although research supporting the theoretical principles related to the administration of intramuscular injections has existed for 20 years, findings have not been universally applied in nurs- ing practice. More specifically, the effect of pos- itioning (internal rotation of the femur for giving injections in the dorsogluteal site) was first stud- ied by nursing in 1979 by Kruszewski, Lang, and Johnson. Their study, titled “Effect of positioning on discomfort from intramuscular injections in the dorsogluteal site,” supported the hypothesis that “Patients who are placed in prone positions with femurs internally rotated while receiving an intramuscular injection in the dorsogluteal site will report less intense discomfort than patients placed in prone positions with femurs externally rotated” (Kruszewski, Lang, & Johnson, pp. 103–105).

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    CHAPTER 1 The Role of Research in Nursing 3 In 1982, Rettig and Southby supported the effect of proper positioning in reducing discom- fort from dorsogluteal injections. In more recent research, Cocoman and Murray (2008) completed a comprehensive review of the practice for intra- muscular injections and discuss the often contra- dictory available evidence. 4. Involving Guest Speakers You may want to invite a guest speaker who has a background in historical research or an in-depth knowledge of nursing history to address the his- torical evolution of nursing research. Such a per- son can make the subject matter come alive by, for example, interspersing little-known anecdotes about prominent nurses involved in the develop- ment of nursing research. 5. Providing Experiential Learning Activities a. The Evolution of Nursing Research: A Game The purpose of this learning activity is to inject some spice into what students generally perceive as a dry subject: the evolution of nursing research. Student objectives for the learning activity: • Relate an historical event to its time and place or person. • Recall milestones in the evolution of nursing research. Directions for implementation . This activity is a modified version of Jeopardy , a popular TV game show. Be sure to explain clearly how the game will be played before starting. Depending on the number of students in your class, you may have all students participate at once in teams or have some students act as the “audience” while others take the role of contestants. Form a panel of three students or three teams of students (a team may consist of two to four players). You will need index cards, four bells or buzzers, and a score sheet with marker or board with chalk. Create three sets of index cards: set 1 will contain the years that various historical events took place; set 2 will contain the events themselves; and set 3 will contain the places, per- sons, or outcomes related to those events. Each set of cards should be a different colour. Key the cards in each set to their related cards in the other two sets by marking them with the same numbers. As an example, in 1932 (date on card #23 in set 1) the Weir report was published (event on card #23 in set 2) and recommended changes in nursing education (outcome on card #23 in set 3). The instructor acts as game show host. Contestants take turns picking one of the three categories. The instructor holds up and reads a card from that pile. Contestants then have to provide an answer in the form of a ques- tion from the other two sets. For example, if the contestant picked the card from set 1 with the date “1932,” he or she could correctly respond in ques- tion form with the following: “In what year was the Weir report published?” If the contestant picked the card from set 3 with the outcome “Recommended changes in nursing education,” the response might be: “What was the recommendation from the Weir report? The game begins with the instructor picking a card and reading it. The contestant or team who presses the buzzer (or rings the bell) first is given the fi rst chance to respond. If that contestant or team provides the correct answer, another card is chosen and play continues. If, on the other hand, the contestant or team who buzzes in first gives an incorrect answer, the other contestants or teams are given a chance to answer correctly. Once the question is answered correctly, the game con- tinues as before. The instructor or another student may keep score on a flip chart or board. Score 1 point for each correct answer. The instructor and students should decide together on a prize before beginning the game.

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    4 CHAPTER 1 The Role of Research in Nursing BOX 1-1

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    Theoretical Framework CHAPTER OVERVIEW Chapter 2 introduces students to the nature of knowledge, both from nursing and other disciplines, discussed within the context of worldview. Philosophies of research and science are shown to form the basis for beliefs and assumptions that guide the selected approach to studying research problems. The link to research is demonstrated through a critical thinking decision path. Next, students are introduced to frameworks for research, providing at the outset an example of a clinical situation that clearly shows the relationship between practice and research. This is fol- lowed by a section that illustrates how theory links research and practice. Inductive and deductive approaches to science are described, using the earlier clinical example. Models are described as a way to connect concepts and develop hypotheses. Reference is made to the idea of a “ladder of abstraction” that can be used to gain a research perspective and relate concepts, theories, and frameworks. Theory is defined, and the purpose of a theoretical rationale is conveyed as a context in which to examine problems. More specifically addressed are types of theories—grand, midrange, and microrange—to introduce readers to theory as a framework to answer nursing questions. A focus on nursing knowledge and nursing theory development can provide students with the frame of reference that is so necessary to help nursing continue to define what it is, how it is unique, and how it differs from other disciplines. Conceptual and theoretical frameworks are differentiated, and conceptual and operational def- initions are illustrated for six different concepts. Criteria for critiquing a theoretical framework are identified to assist students in the development of their roles as research consumers. INSTRUCTOR'S MANUAL : C H A P T E R 2

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    6 CHAPTER 2 Theoretical Framework LEARNING OUTCOMES After reading this chapter, the student should be able to do the following: • Define key concepts in the philosophy of science. • Identify and differentiate between theoretical/empirical, aesthetic, personal, sociopolitical, and ethical ways of knowing. • Identify assumptions underlying the post-positivist, critical, and interpretive/constructivist views of research. • Compare inductive and deductive reasoning. • Differentiate between conceptual and theoretical frameworks. • Describe how a framework guides research. • Differentiate between conceptual and operational definitions. • Describe the relationships among theory, research, and practice. • Discuss levels of abstraction related to frameworks guiding research. • Describe the points of critical appraisal used to evaluate the appropriateness, cohesiveness, and consistency of a framework guiding research.

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    CHAPTER 2 Theoretical Framework 7 TEACHING STRATEGIES The research consumer role should be expanded in discussions about the development of nurs- ing knowledge. At this point, students can begin to engage actively in the consumer role to “test the waters” in relation to the critical appraisal of knowledge derived from various sources. 1. Critical Thinking Challenges a. Stimulating Critical Thinking The following questions may serve to stimulate critical thinking about material related to various sources of knowledge: RECALL AND UNDERSTANDING What are the two main paradigms of research? • What are the major sources of human knowledge? • How do qualitative and quantitative approaches to research differ? • How are practice and research linked? • What is the difference between induction and deduction? • How would you define model ? • How would you define theory ? ANALYSIS AND SYNTHESIS • What are your beliefs about nursing? About health? About human behaviour? Give ex- amples of how you think these beliefs influ- ence your clinical practice. • What scientific paradigm do you feel most comfortable with? Why do you feel that way? • Consider a nursing intervention you have used. On what assumptions is it based? • What are your beliefs about nursing? About health? About human behaviour? Give ex- amples of how you think these beliefs might influence your approach to research. • How does theory influence the selection of study design? b. Use of Discussion Questions The use of discussion questions can foster critical thinking in relation to the parameters of a well- supported, logical, and clearly articulated theor- etical framework. It also can serve as a means by which to meet the learning outcomes identified for Chapter 2. The following questions can be used to guide the discussion: RECALL AND UNDERSTANDING • What is the most prominent type of research conducted until recently in nursing research? • How would you differentiate a conceptual from an operational definition? • What is an assumption? • What is the purpose of a theoretical frame- work? • What is the ladder of abstraction? • What are the central phenomena of concern to nursing? ANALYSIS AND SYNTHESIS • What nursing theories or models have you heard or learned about? • How useful are they for practice? • How would you evaluate the appropriateness of a particular operational definition? • How are hypotheses related to models and theories? 2. Using the Learner’s Previous Experience a. Everyday Experiences as a Consumer A “warm-up” exercise used with beginning re- search students involves an everyday experience, for example, how one determines which sham- poo to purchase. The purpose of this exercise is to show that different sources of information support how decisions are made. Students are asked what factors go into making this decision, and a list is written on a chalkboard, overhead

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    8 CHAPTER 2 Theoretical Framework projector, or easel. Common responses focus on ingredients, media promotion, bottle colour, smell, cost, and goal for use (e.g., dandruff re- moval, conditioning). The use of personal know- ledge derived from various sources to make deci- sions is related to problem solving typically used in research. b. Comparing and Contrasting Processes Used to Generate Knowledge Although students can identify how they make decisions in personal and clinical situations, they are less familiar with the scientific or research approach to generating knowledge. Comparing and contrasting the research process with the problem-solving process, which is familiar to students, is a strategy we have used to facilitate learning this content. An overhead or handout can be used to show the steps typical of these processes. (1) First, the problem-solving process is presented to students with specific emphasis on its relation to the nursing process, as follows: PROBLEM-SOLVING PROCESS • An obstacle to goal achievement is perceived. • The underlying difficulty is identified and stated. • Additional data are collected to validate the difficulty. • Possible solutions are suggested and evaluated. • The most plausible solutions are attempted. • The solution is evaluated in relation to elim- ination of the original obstacle. NURSING PROCESS • An assessment of data is made. • A patient health problem is identified, and a nursing diagnosis is formulated. • Additional data are collected to validate the diagnosis. • Possible interventions are suggested and evaluated. • The most plausible interventions are imple- mented. • The patient’s response is evaluated in relation to his or her goals. (2) Next, the following characteristics of the scientific method and the problem-solving process are compared and contrasted: SCIENTIFIC METHOD • Control of extraneous influencing factors • Problem solving • Evidence based on “objective” reality • Purpose—to make a contribution to general knowledge PROBLEM SOLVING • No control of extraneous influencing factors • Does not necessarily involve research • May include subjective bias in investigation of problem • Concerned with a situation-specific solution (3) Finally, a clinical situation is used to emphasize the difference between problem solving and using research to generate knowledge. For example, a nurse may notice that Mrs. X has a pressure ulcer. Her statement of the situation- specific problem might be as follows: “How can further development of the ulcer be prevented, and how can the ulcer be healed?” If the nurse observes the development of pressure ulcers in many patients over time, he or she may ask the research question, “What is the most effective method for preventing pressure ulcers?” 3. Providing Experiential Learning Activities a. Identifying the Basis of Nursing Techniques/ Protocols This learning activity provides students with an opportunity to question the theoretical basis of standard nursing interventions.

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    CHAPTER 2 Theoretical Framework 9 Student objectives for the learning activity: • Based on the findings of this clinical exercise, identify the bibliographical sources used in the development of a selected nursing technique/ protocol. • Determine whether or not the nursing tech- nique/protocol was based on research. • Suggest potential problems that may arise from using non–research-based nursing tech- niques/protocols. Directions for implementation . Assign this exer- cise at the beginning of the course. Have students select a nursing protocol/technique (such as urinary catheterization or intravenous maintenance) from a clinical agency’s policy and procedure manual. (Explain that they may obtain a copy of the select- ed protocol from the agency’s nursing or nursing education office.) Ask them to determine by whom the protocol (procedure) was written. This infor- mation may be obtained from an in-service edu- cator or nursing administrator. Direct students to request an interview with one or more individuals who are involved in developing practice protocols for the agency. The purpose of the interview is to determine the basis for the existing protocol. Sug- gested interview questions include the following: • Can you explain how protocols are written in your agency? • On what information was this specific protocol based? • Are there any references that will give me a better understanding of the rationale for the practices included in the protocol? After the interview, students should submit a brief paper that describes the experience and states a conclusion about whether or not the protocol is research-based. On completion of the clinical exercise, stu- dents may also be asked to present their findings in class. During the discussion period it is important to consider the following questions: • Was any reference to research made, either by the interviewee or in the protocol itself? • If no reference is made or if the reference is a non-research source, how does one know that the selected technique/protocol is valid? • What then is the basis of the selected practice? • What is the value of research support of the se- lected technique/protocol or for any technique/ protocol? 4. Using Diagrams to Show Relationships Students respond to visual representations be- cause diagrams often clarify a potentially confus- ing topic. When using examples in discussions about concepts, theory, research, and hypothesis development, you should map out specific rela- tionships. Diagrams that clearly identify the vari- ables being studied and the relationships between them will enhance students’ understanding of the process used to summarize literature and arrive at hypotheses. In Figure 2-5 below, the link be- tween the independent variables (stress, social support, coping) and dependent variable (health outcomes) is illustrated. The figure outlines the process through which a supportive interven- tion influences the health outcomes of homeless youth. Locate the article and work with the stu- dents to understand how the framework informed the hypothesized relationships. 5. Providing Experiential Learning Activities FORMULATING DEFINITIONS This learning activity is designed to give stu- dents experience in developing operational definitions in an effort to increase their ability to critique the definitions they read in research reports.

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    10 CHAPTER 2 Theoretical Framework Student objectives for the learning activity: • Construct a conceptual definition. • Construct an operational definition. • Evaluate an operational definition in terms of clarity and inclusion of an index of measurement. Directions for implementation . Identify or ask stu- dents to name concepts. Select four to six of these concepts for students to define, both conceptually and operationally, using a library and other resour- ces. Students can start with a dictionary definition and then read the work of a theorist who has exam- ined the concept. To make this activity manageable for students, you can have each choose one of the identified concepts to define. Another option is to have only some students (equal to the number of concepts to be defined) involved in this particular learning activity, while others can be engaged in different learning activities at other times in the re- search course. This activity also can be a written assignment completed out of class and then shared at a subsequent class session. You can also include the construction of an operational definition as an item on an examination. Guidelines for discussion . After students share their defi nitions with the class, you can focus on the evaluation of each definition. Of course, stu- dents should be actively involved in the evalua- tion discussion. You can prompt students by asking them whether each definition is clear and unambiguous and to identify the specific index of measurement that operationalizes the definition. FIGURE 2-5 Model of conceptual foundation. From Stewart, M., Reutter, L., Letoumeau, N., & Makwarimba, E. (2009). A support intervention to promote health and coping among homeless youths. Canadian Journal of N ursing Research, 41(2), 54–77.

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    INSTRUCTOR'S MANUAL: C H A P T E R 3 Critical Reading Strategies: Overview of the Research Process CHAPTER OVERVIEW Chapter 3 begins by emphasizing the need to use critical thinking and critical reading skills when reading a research article. Both concepts are defined and discussed as a means to help students more effectively read and understand research articles. The authors separate the process of critical reading into four levels, or stages, of understanding: preliminary, comprehensive, analysis, and synthesis. Strategies to facilitate each stage of understanding are presented. A section of Chapter 3 addresses and validates the difficulties perceived by a novice reader of research. A major portion of this chapter is devoted to describing the format and style of research reports. The authors walk the reader through each step of the research process, indicating how and where to find related content in published research and in this textbook. Examples from published studies are presented to bring abstract discussion to a concrete level. LEARNING OUTCOMES After reading this chapter, the student should be able to do the following: • Identify the steps that researchers use to conduct quantitative and qualitative research. • Identify the importance of critical thinking and critical reading for the reading of research articles. • Identify the steps associated with critical reading. • Use the steps of critical reading to review research articles. • Use identified strategies to critically read research articles. • Use identified critical thinking and critical reading strategies to synthesize critiqued articles. • Identify the format and style of research articles.

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    12 CHAPTER 3 Critical Reading Strategies: Overview of the Research Process TEACHING STRATEGIES Because practice is required to develop skill in the use of critical thinking and critical reading, it is essential to engage the learner in dialogue and experiential learning activities. Clarification of these concepts through discussion should there- fore be followed by in-class practice, so that you can facilitate students’ use of these essential skills. 1. Critical Thinking Challenges The following discussion questions provide a guide for reviewing the content of Chapter 3 and helping students to think about their past use of critical thinking and reading skills: RECALL AND UNDERSTANDING • What is critical thinking? • What is critical reading? • How would you define the stages of critical reading? • What strategies facilitate comprehensive under- standing of a research report? • What questions are helpful to ask when ana- lyzing a research report? • What are the main sections of a research report? How do you know them when you see them? ANALYSIS AND SYNTHESIS • How have you used critical thinking skills in the past? • What general assumptions have you made about the literature you have read for other courses? • Compare and contrast critical reading with reading for pleasure. • How does a dialogue with the text enhance your ability to understand its meaning? 2. Questioning by the Socratic Method Socratic questioning involves challenging stu- dents to find their own answers to a dilemma and helping them accept that not all questions have “right” answers. It goes beyond recall of facts or descriptions of concepts by encouraging students to think critically about their own ideas as they are challenged by opposite points of view. This is a classic technique and was first applied to teach- ing nursing research by Sakalys (1985). She sug- gested that the questions asked in the Reflective Judgment Interview (RJI), developed by King and Kitchener, are consistent with questioning by the Socratic method. The RJI poses dilemmas with two conflicting statements, followed by stan- dard questions that are intended to elicit students’ opinions about the issue and their rationale for the stand they take. The dilemmas contained in the RJI are not clin- ically oriented, but you can develop ones that are relevant to the research consumer role. A dilemma should be read aloud to the class while students read along from a copy. The questions are then posed, and students are encouraged to share their beliefs, opinions, and hypotheses relevant to the issue. 3. Providing Experiential Learning Activities a. Developing Critical Reading Skills The purpose of this in-class group exercise is to actively engage students in critical dialogue about written material. Based on the Intra-Act procedure for critical reading (Hoffman, 1979), this learn- ing activity fosters “… problem-solving, critical analysis, and metacognitive awareness while at- tending to course content” (Van Dyk & Jensen, 1990). Student objectives for the learning activity: • Identify the main ideas of a text selection. • Engage in the process of valuing by forming opinions about the selection. • Differentiate quickly formed opinions from those arrived at by critical analysis of the text and dialogue with peers.

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    CHAPTER 3 Critical Reading Strategies: Overview of the Research Process 13 Directions for implementation . Choose a rela- tively simple research report for in-class reading. The report should be no more than four to five pages and should be simple versus complex in its presentation. Form small groups (four to six stu- dents) and appoint a student from each group to be the leader. In choosing a group leader, keep in mind that he or she should possess the ability to initiate and sustain discussion. Provide a copy of the report to each study. Provide a handout for students that includes a description of the Critical Reading Process (see Table 3-1 in the core text), the appropriate critical appraisal table (18-1 or 19-1 in the core text), and the Intra-Act sheet (see sample below). Explain the purpose and methods of the exercise before proceeding with the follow- ing phases. Comprehending Research Articles Begin this activity by instructing students to use the highlights of critical reading process strat- egies to read the article. The focus will be on preliminary and comprehensive understanding, as this phase of the activity is intended to help students build a frame of reference for the text. The group leader’s responsibility is to summar- ize the text, encourage group members to contrib- ute additional information about what was read, or ask questions to clarify the main ideas of the selection. This phase should be limited to 15 to 20 min- utes for reading and 10 minutes for discussion. Step 1: Strategies for preliminary understanding • Review critiquing guidelines from your text and keep these in mind as you read. • Review the title, headings, and subheadings, cap tions under pictures, charts, graphs, or maps. • Turn each heading into a question that you attempt to answer. • Read the introduction and discussion sec- tion of the article. • Highlight or underline on the photocopy any new terms, unfamiliar terms, and sig- nifi cant sentences. • Look up the definitions of new terms, and write them on the photocopy. • Highlight or underline identified steps of the research process. Step 2: Strategies for comprehensive understanding • Identify the main idea or theme of the arti- cle; state it in your own words in one or two sentences. • Before critiquing the article, make sure you understand the main points of each re- ported step of the research process that you identified. Step 3: Group Think The leader should next shift the discussion from the ideas contained in the text selection to the group’s personal reactions and values related to the content of the reading material. (This shift often occurs nat- urally.) All members should be encouraged to share their personal impressions and opinions. This phase should be limited to 10 minutes. Step 4: Valuation phase Each class member is then asked to remove an Intra-Act sheet that contains four value statements that you previously wrote about the research article (see sample below). These statements should reflect opinions about the article and/or be a vehicle for providing new insights about its meaning of the findings from the article. Instruct students to mark either A (agree) or D (disagree) for each statement under their own name. This phase is intended to help students derive and integrate the personal meaning that the text has for them. When critiquing the theoretical framework for a quantitative article, one example may include: The framework of this article is not consistent with a nursing perspective or It is difficult to link the frame- work to the hypothesis outlined by the author(s) .

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    14 CHAPTER 3 Critical Reading Strategies: Overview of the Research Process Students should next engage in discussion about the statements on the game sheet (approxi- mately 10 minutes). Based on the discussion, students should then be asked to predict how each of the other group members responded to the value statements by placing an A or D under each person’s name for each statement. Step 5: Reflective phase Begin this phase by having students score the game sheets. Group members should then take turns sharing how each responded and how each predicted the others would respond. As the dis- cussion takes place, students should check wheth- er their predictions agreed with other members’ actual responses. During this phase, your role is that of a facilita- tor, rephrasing students’ comments for validation, summarizing how students responded, but not making value judgments about students’ opinions or comments. This is a time to allow students to reflect on what they have learned in terms of content and process. Step 6: Debriefing phase Afterward, debrief the class by posing the follow- ing questions: • What did you learn from participation in Intra- Act? • Why must all group members participate? • How might discussion improve the next time we use this method? These questions attempt to sensitize students to the purpose of the exercise (critical reading) and to the role that collegial dialogue plays in help- ing an individual to clarify his or her own ideas. Intra-Act Activity Sheet Name: Date: Total Score: Percentage of Correct Predictions: Directions: Write the names of all members of the group, including yourself, in the boxes at the top of the columns (one name per column). Then read the statements. Indicate whether you agree or disagree with the statement by circling either (A) for agree or (D) for disagree. Then predict the responses of the other members of your group by doing the same thing. Once all members of your group are finished, score the sheets and discuss why you agreed or disagreed with the statements. Name Statement A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D A D

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    CHAPTER 3 Critical Reading Strategies: Overview of the Research Process 15

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    INSTRUCTOR'S MANUAL: C H A P T E R 4 Developing Research Questions and Hypotheses CHAPTER OVERVIEW Chapter 4 first addresses the development of a research question and hypotheses, including numerous examples of how practical experience leads to the identification of a clinical question, and the scientific literature enables refinement of that question. Also provided are examples of problem statements taken from the research literature. It is important for students to understand that the research question or research problem will drive the design of the research, and the development of a hypothesis heralds quantitative research design. Second, this chapter provides an extensive examination of the nature, depth, and scope of research questions and hypotheses. Characteristics of a hypothesis statement are discussed in detail and include a relationship statement, the nature of the relationship, testability, and theory base. Examples are provided of hypotheses that meet and fail to meet these characteristics. In addition, research questions are discussed in terms of the kinds of studies and conditions in which they commonly are posed. Perhaps the most salient aspect of this chapter is the critiquing process involved in evaluating the soundness of a stated research question and the strengths and weaknesses of a hypothesis statement. Three key elements are highlighted for evaluating a research question for quantitative research: 1. Does the research question express a relationship between two or more variables, or at least between an independent and a dependent variable? 2. Does the research question specify the nature of the population being studied? 3. Does the research question imply the possibility of empiric testing?

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    18 CHAPTER 4 Developing Research Questions and Hypotheses Students are shown, through discussion and example, how to examine a hypothesis to determine (1) its ability to answer the research problem directly; (2) its clarity, succinctness, and objectivity; (3) whether it expresses the relationship between key variables, and (4) whether it is understandable to the reader. LEARNING OUTCOMES After reading this chapter, the student should be able to do the following: • Describe how the research question and hypothesis relate to the other components of the research process. • Describe the process of identifying and refining a research question. • Identify the criteria for determining the significance of a research question. • Discuss the purpose of developing a research question. • Discuss the appropriate use of the purpose, aim, or objective of a research study. • Discuss how the purpose, research question, and hypothesis suggest the level of evidence to be obtained from the findings of a research study. • Identify the characteristics of research questions and hypotheses. • Describe the advantages and disadvantages of directional and nondirectional hypotheses. • Compare the use of statistical hypotheses versus research hypotheses. • Discuss the appropriate use of research questions versus hypotheses in a research study. • Discuss the differences between a research question and a clinical question in relation to evidence- informed practice. • Identify the criteria used for critiquing a research question and a hypothesis. • Apply the critiquing criteria to the evaluation of a research question and a hypothesis in a research report.

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    CHAPTER 4 Developing Research Questions and Hypotheses 19 TEACHING STRATEGIES Strategies for facilitating learning of the research question and hypothesis are described separately. The first group of teaching strategies focuses on the research question, and the second group focuses on the hypothesis. A. The Research Question In relation to developing and evaluating research questions, teaching strategies should routinely include examples that students can relate to their clinical experience. Such an approach can facili- tate meaningful discussions about the relationship between the study of research questions and nurs- ing practice. The following teaching strategies are designed to incorporate this approach and en- hance the nursing student’s acuity in recognizing and judging the merits of research questions. 1. Critical Thinking Challenges To stimulate critical thinking about researchable research questions and the question itself, the fol- lowing questions are proposed: RECALL AND UNDERSTANDING • How is a research question identified? • Define the terms independent variable and dependent variable . • How is the research question refined? • What are research and statistical hypotheses? • What are the components of a research question? ANALYSIS AND SYNTHESIS • How might you go about developing a research question to address anorexia in adolescents? • What is the relationship between the literature review and the research question? • Why is potential significance to nursing an important attribute of a research question? 2. Identifying Relational Statements One of the criteria for evaluating a research ques- tion is the expression of a relationship between key variables. It has been our experience that stu- dents have difficulty identifying the terms that ex- press a relationship between variables. In the past, students have confused the predictive terminol- ogy used in hypotheses with the relationship cri- teria for research questions and have, therefore, critiqued the latter statements inappropriately. A possible way of clarifying the identification of a relational statement in the research question is to share with students examples of different termin- ology used by researchers to convey relationships between variables under study. Several of these examples follow. (The relational terms are itali- cized.) • What is the relationship between preopera- tive anxiety and postoperative pain in patients undergoing elective cholecystectomy? • What is the effect of a prenatal nutrition pro- gram on the rate of premature delivery in pri- miparous Aboriginal women? • What is the difference in the incidence of falls in elderly patients in relation to the use of side rails? 3. Using Examples to Point out Different Forms of the Research Question Because research questions are stated in both in- terrogative and declarative forms, it is important that this be clearly conveyed to students to avoid unnecessary confusion or misinterpretation when they are evaluating research reports. It is helpful to present students with a number of examples of how an interrogative form (a question) can be phrased in declarative form (a statement) with- out changing the content of the inquiry and vice versa. Two such examples follow: INTERROGATIVE FORM • Is there a relationship between the physical symptoms of pregnancy and maternal–fetal attachment in primigravidae? • What is the difference in the incidence of contractures in comatose patients in relation to frequency of positioning?

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    20 CHAPTER 4 Developing Research Questions and Hypotheses DECLARATIVE FORM • The purpose of this study is to investigate the relationship between the physical symptoms of pregnancy and maternal–fetal attachment in primigravidae. • This study investigates the difference in the in- cidence of contractures in comatose patients in relation to frequency of repositioning. 4. Providing Experiential Learning Activities a. Critiquing Research Questions or Statements The purpose of this exercise is to provide students with an opportunity to critique the research ques- tions/statements of research studies using the criteria presented in Chapter 4. Student objectives for the learning activity: • Identify the research question of a clinical nursing study. • Evaluate the strengths and weaknesses of the statement. Directions for implementation . Have students read Chapter 4 with emphasis on “Critiquing Criteria.” Select two clinical research stud- ies (from the appendix in the text or one of the studies listed below) and ask students to read the introduction and literature review of the selected studies before class. Suggested studies follow: Study 1: Christman, S. K., et al. (2000). Continuous handrail support, oxygen uptake, and heart rate in women during sub- maximal step treadmill exercise. Research in Nursing and Health, 23 (1), 35–42. Study 2: Wilson, D. (2002). The duration and degree of end-of-life dependency of home care clients and hospital inpatients. Advanced Nursing Research, 15 , 81nced Study 3: Watt-Watson, J., Garfinkel, P., Gallop, R., Stevens, B., & Streiner, D. (2000). The impact of nurses’ empathic responses on patients’ pain management in acute care. Nursing Research, 49 (4), 191–200. In seminar, students present their evaluations of the research question of each study. Encourage students to discuss their evaluations with each other and to reach a consensus on whether the problem statement meets each of the criteria listed in Chapter 4 of the textbook. Allow 30 to 45 minutes for this exercise. b. Analyzing Research Questions The purpose of this exercise is to provide students with an opportunity to analyze the researcher’s development of a research question (see Chapter 4 in the textbook). Student objectives for the learning activity: • Analyze the relationship between the research question and the literature review. • Evaluate the researcher’s discussion of the question’s significance. Directions for implementation . This is a continu- ation of learning activity a , “Critiquing Research questions.” Using the same three studies, have students first determine the variables presented in the literature review. Then ask students to identify whether relationships between these variables are presented and, if so, with what degree of clarity. Afterward, encourage students to discuss the con- nections between the problem statement and the literature review. Questions that may be used to initiate discussion include the following: • Are all the variables contained in the research question presented in the literature review? • Are there any gaps between previous research contained in the literature review and the ques- tion under study? Once the relationship between the research ques- tion and the literature review has been analyzed, have students determine whether the researcher

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    CHAPTER 4 Developing Research Questions and Hypotheses 21 has discussed the significance of the question to nursing. If a discussion of the question’s significance is present, encourage students to evaluate the validity of the researcher’s presen- tation. If not, have students explore their own thoughts about the question’s significance. Allow 30 to 45 minutes for this exercise. c. Developing a Research Question The purpose of this activity is to give students an opportunity to formulate a research question or a clinical nursing study. Student objectives for the learning activity: • Identify a clinical nursing question. • Formulate a research question that is related to a clinical nursing situation. • Evaluate the formulated question according to the criteria presented in Chapter 4 of the textbook. Directions for implementation . Ascertain the clin- ical interests of your students; then divide them into small groups (four or five students per group) based on those interest areas. Ask the groups to develop a research question for a nursing study. Allow about 30 minutes for this portion of the ex- ercise. Have each group then present its research question to the entire class. Instruct students to evaluate each statement presented and to share their comments with their peers. The time needed for this portion of the exercise will depend on the number of groups involved. Allow 5 to 10 minutes for discussion of each group’s research question. B. The Hypothesis As stated in the textbook, hypotheses are an attempt to answer the posed research questions. They are critical to testing the validity of the as- sumptions of the stated theoretical framework. The teaching strategies that follow are designed to facilitate students’ understanding of movement within the research process from assumptions to theoretical framework to hypothesis formulation and to provide an opportunity to write and cri- tique hypothesis statements. 1. Critical Thinking Challenges To stimulate critical thinking about the hypoth- esis, the following questions are proposed: RECALL AND UNDERSTANDING • What are the characteristics of a hypothesis? • What are the different types of hypotheses? • How are hypotheses derived? • What must occur for a hypothesis to meet the criterion of testability? • What are hypotheses actually testing? ANALYSIS AND SYNTHESIS • In what situations would research be con- ducted to generate hypotheses? • In what situations would research be con- ducted to test hypotheses? • How do research questions differ from hypoth- eses, and in which instance is each appropriate? • What does it mean to have a hypothesis sup- ported? Rejected? 2. Using Examples to Reinforce the Connections between Prior and New Learning A technique often used in teaching is reinforcement of previous learning. Reinforcement is used to strengthen a particular behaviour—in this case, knowledge of the research process. It can also serve as a precursor to making new connections to previous learning. The following teaching strategy can be used to reinforce learning about assumptions, the theoretical framework, and their connection, while at the same time reinforcing the connection between the hypothesis statement and the steps that precede its formulation. Students should read the following studies before class: Study 1: Bliss, D. Z., et al. (2001). Supple- mentation with dietary fiber improves fecal

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    22 CHAPTER 4 Developing Research Questions and Hypotheses incontinence. Nursing Research , 50 (4), 203–213. Study 2: LeFort, S. M. (2000). A test of Braden’s self-help model in adults with chronic pain. Journal of Nursing Scholarship , 32 (2), 153–160. After briefly reviewing key information about what an assumption is (Chapter 3), the nature and development of a theoretical framework (Chapter 2), and hypothesis development (Chapter 4), use Study 1 to reinforce learning about the connec- tions among these three aspects of the scientific approach. As you will note, the connections are logical and the students should be able to understand them readily. Once you determine that they have grasped the interrelationships of Study 1, move on to Study 2. Draw Figure 4-2 on the blackboard and ask students to identify the assumptions, theoretical rationale, and hypothesis of Study 2. If students have a good grasp of what these three aspects are and how they are connected, they should be easily able to fi ll in the blanks. 3. Providing Experiential Learning Activities a. Examining Sources Used to Support Hypotheses This learning activity enables the student to examine more closely some of the research cited in a literature review in support of study hypotheses. Student objectives for the learning activity: • Identify how a specific hypothesis is sup- ported, based on the conceptual (theory-based) literature of a selected research study. • Identify how a specific hypothesis is supported, based on the data-based (previous research in the area) literature of a selected research study. Directions for implementation . Students can read any of the studies listed in a previous learning ac- tivity, paying particular attention to the literature review, hypothesis statement, and findings. Stu- dents should focus on the specific theory refl ected by the hypothesis statement. They should select one or two primary and one or two secondary FIGURE 4-1. Study No. 1 (Refer to Bliss, D.Z., et al. (2001). Supplementation with dietary fiber improves fecal incontinence. Nursing Research, 40, 203–213.)

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    CHAPTER 4 Developing Research Questions and Hypotheses 23 sources listed in the bibliography of the article that pertain to one of the study hypotheses. While reviewing these sources, students should exam- ine their relevance to the hypothesis statement. They should take a position—pro or con—as to whether the sources support the hypothesis and defend that position. b. Differentiating Between Dependent and Independent Variables Many students fi nd it difficult to differentiate between dependent and independent variables. After reviewing Table 4-4 (p. 79) in the textbook, have the students list a variety of variables, (age, weight, gender, GPA, satisfaction, blood pressure, and so forth). Ask them to construct a variety of hypotheses from the list of variables. Challenge them to have statements in which one variable (e.g., blood pressure) is a dependent variable and then an independent variable. c. Constructing Hypothesis Statements This learning activity is designed to give students experience in writing hypothesis statements so they will have a better understanding of what constitutes an appropriately written hypothesis. Ultimately, the student can use this information to evaluate hypotheses. Student objectives for the learning activity: • Construct a hypothesis statement. • Identify the characteristics of hypothesis state- ments that appear in the constructed hypothesis. • Identify the characteristics of hypothesis state- ments that do not appear in the constructed hypothesis. Directions for implementation . Ask students to read just the literature review of either Appendix A or C. This should be a pre-class assignment. In class, you may want to review briefly the characteristics of a hypothesis statement to reinforce prior learning. In class, ask the students, without reading further in the study, to develop a hypothesis state- ment based on the theoretical rationale they have read. (You can suggest that they construct an in- ventory of relationships to get them started.) Guidelines for discussion . After the experiential ac- tivity, students can either independently or through FIGURE 4-2. Study No. 2

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    24 CHAPTER 4 Developing Research Questions and Hypotheses class discussion identify the characteristics that ap- pear in their hypotheses; they should also identify those that do not appear. Taking this a step further, to enhance students’ ability to construct hypothesis statements, you may want to have them reconstruct their statements to include any omitted character- istics. Then have the students compare their state- ments to the hypothesis stated in the article. d. Critiquing Hypothesis Statements The purpose of the following learning activity is to enhance students’ ability to evaluate the structural aspects of a hypothesis statement, using criteria 1 through 11 identified under “The Hypotheses” in the Critiquing Criteria box (p. 87 in the textbook). Student objectives for the learning activity: • Use criteria 1 through 11 (see Critiquing Cri- teria box) to critique a hypothesis statement. • Evaluate the structural aspects of a selected hypothesis statement. Directions for implementation . Examples of hypotheses that can be used for this learning activity can come from a variety of other studies listed in either the textbook or the Instructor’s Manual that accompanies it. To reinforce prior learning, the students should review criteria 1 through 11. After the review, present several hy- pothesis statements (a list of four to six should suffice) in class. Students can refer to the text- book for information about the criteria, or the Critiquing Criteria can be duplicated and distrib- uted for use during the actual critique. Groups of three or four students should select two or three hypothesis statements and discuss them, using critiquing criteria 2 through 8. Small group dis- cussions should last about 10 minutes per hy- pothesis. An example of this activity is provided on the Evolve site (see Critical Appraisal Activ- ity, Chapter 4). Guidelines for discussion . Each group can se- lect one or two of the hypotheses evaluated and share the evaluation with the rest of class. As the instructor, you will embellish the students’ cri- tiques, reinforcing their appropriate responses. Your role also may consist of clarifying the estab- lished criteria.

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    INSTRUCTOR'S MANUAL: C H A P T E R 5 Finding and Appraising the Literature CHAPTER OVERVIEW Chapter 5 introduces the student to the process of conducting a search and review of the literature for a research study. The overall purposes of a literature review are described for quantitative and qualitative research designs. Discussed in detail is the use of the literature review from the perspec- tive of the investigator and the consumer, as well as the relationship of the literature review to the following steps of the quantitative research process: (1) theoretical or conceptual framework, (2) research question and hypothesis, (3) design and method, and (4) outcome of the analysis. Both conceptual and data-based literature are discussed. Literature retrieval methods and schol- arly research publications are also discussed, with emphasis on computer-generated strategies. Numerous examples of primary and secondary journal articles, books, book chapters, and docu- ments are provided. Extensive discussion is devoted to various databases and online resources, including selected Web sites and the possible outcomes of using these sites. Also addressed are the ways to begin and complete a literature search. Recognizing the role of the nurse in research, the section on critiquing emphasizes the consumer perspective and quantitative research, although reference is made to qualitative studies and the different nature of the literature review for this kind of design.

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    26 CHAPTER 5 Finding and Appraising the Literature LEARNING OUTCOMES After reading this chapter, the student should be able to do the following: • Discuss the relationship of the literature review to nursing theory, research, education, and practice. • Discuss the purposes of the literature review from the perspective of the research investigator and the research consumer. • Discuss the use of the literature review for quantitative designs and qualitative methods. • Discuss the purpose of reviewing the literature in the development of evidence-informed practice. • Differentiate between primary and secondary sources. • Compare the advantages and disadvantages of the most commonly used online databases and print database sources for conducting a literature review. • Identify the characteristics of an effective electronic search of the literature. • Critically read, appraise, and synthesize primary and secondary sources used for the development of a literature review. • Apply critiquing criteria to the evaluation of literature reviews in selected research studies

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    CHAPTER 5 Finding and Appraising the Literature 27 TEACHING STRATEGIES Although students are not expected to develop an extensive literature review during their research course, they will need to be prepared to think crit- ically and make judgements as to the merit of the literature reviews they read in the professional lit- erature. Therefore the nature and process of the literature review form the basis for the following teaching strategies. 1. Critical Challenges For purposes of general discussion and critical thinking, the following questions can be used: RECALL AND UNDERSTANDING • What are the purposes of a literature review for research investigator and research consumer activities? • What are conceptual and data-based literature? • What are the differences between primary and secondary sources of information? • What are the characteristics of a written, rel- evant literature review? • What is the role of electronic databases in a literature review? ANALYSIS AND SYNTHESIS • How does the literature review enable the researcher to estimate the potential for success of a study? • How do you know that sufficient literature has been reviewed? • How is a literature review used in quantitative versus qualitative research studies? • How can you be sure that a literature review has been approached critically? You can engage students in a variety of discus- sions based on the literature review of an assigned article. These may include the following basic questions: • What is known about this problem? • Does the literature review uncover knowledge? • Does the literature review support the hypoth- eses or research question(s)? • Does the literature review uncover research find- ings that support evidence-informed practice? • What is the overall value of the literature review in developing the knowledge base ne- cessary to carry out the research? Your goal here is to help students understand the status of research in the identified problem area. 2. Introducing Students to the Library In an effort to bring meaning to the experience of conducting a literature review, a trip to the library is recommended. The reference librarian can be tremendously helpful in providing explanations about nursing and non-nursing indexes, what they consist of, where to find them, and how to use them. This person can field questions pertaining to primary and secondary sources of information. It may be advantageous to speak with the librarian in advance of the library class to discuss the sub- stance of the orientation and the students’ back- ground in research. To be included is information about how to conduct a computer search, where measurement tools can be found, and how to use a thesaurus for indexes. It also is helpful if the librarian can demonstrate a search using one or more electronic databases, using actual variables pertinent to a clinical problem that you identify. The library introduction should take 1-1/2 to 2 hours, or approximately one class session. After the formal introduction by the librarian, students should be encouraged to examine one or more of the indexes relevant to nursing research. If pos- sible, book a computer lab to allow the students to access the electronic databases and practice searching after the presentation.

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    28 CHAPTER 5 Finding and Appraising the Literature 3. Providing Experiential Learning Activities a. Identifying Strong and Weak Areas of a Literature Review The purpose of this learning activity is to help stu- dents identify strong and weak areas of a selected literature review. It gives students an opportunity to critically appraise the content and style of at least one published research report. Student objectives for the learning activity: • Identify all relevant variables discussed in the selected literature review. • Determine whether the essential variables are discussed in the review. • Determine the ratio of primary sources to sec- ondary sources cited. • Evaluate the review for completeness and evi- dence of bias. Directions for implementation . Students should review Chapter 5 in the textbook. In addition, as- sign a study for in-depth discussion and analysis by students. Use one of the studies from the ap- pendix of the textbook. Based on the assigned study reading, ask students to do the following: • For quantitative articles, identify all the rel- evant variables in the research question and determine whether each was addressed in the literature review. For qualitative articles, does the literature review describe what is known about the phenomenon under study? • Determine what proportion of the bibliographic citations in the literature review were primary sources. • Critically evaluate the literature review for evi- dence of completeness and bias. • Evaluate whether the literature review reflects analysis and synthesis of material. Guidelines for discussion . Engage students in a discussion of the literature review presented in the assigned paper. Students should use as a basis for evaluating the adequacy of the review or the critique criteria presented in Chapter 5 of the text- book. b. Primary and Secondary Sources of Information This learning activity gives students an opportun- ity to develop skill in differentiating primary from secondary sources of information. Although a sample reference list is provided in this exercise, any list can be substituted. Student objectives for the learning activity: • Identify primary and secondary sources from a reference list derived from a research report. • Evaluate the adequacy of primary sources from a reference list derived from a research report. Directions for implementation . Hand out the one-page activity (Figure 5-1 Primary and Sec- ondary Sources of Information) found at the end of this chapter, for completion in class. After everyone has completed the activity, discuss the students’ choices for each source and whether the number of primary sources used is adequate. Ask students to provide their rationale for each response made. c. Doing a Bibliographic Computer Search • The purpose of this activity is to give students an opportunity to conduct a computer search of the literature. Student objectives for the learning activity: • Conduct a computer search. • Compare two computer search methods and a print resource.

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    CHAPTER 5 Finding and Appraising the Literature 29 Directions for implementation . Help students choose two variables of interest or assign group projects to develop research-based clinical proto- cols. The variables (or protocol topics) may be ones you have previously discussed in class or ones that students have as an assignment for another course. After the variables (or protocol topics) have been selected, students should do the following: • Spend 2 hours in the library doing a search of the literature. • If you used strategy 2 above, “Introducing Students to the Library,” students should be familiar with the librarians who can assist them. If you have not used that strategy, inform students of the appropriate reference librarian to contact. The search should be limited to the past 3 years, because computer time can be expensive and a 3-year period is adequate to make the point. Ask students to note how long it takes the computer to process the search, in- cluding printing out the references. Guidelines for discussion . The following ques- tions are suggested to stimulate discussion after students have conducted their own computer search: 1. How did you find key terms to begin the search? 2. What tactics were effective? 3. How did you maximize results? Limit results? 4. How do you determine whether the results were useful? 5. How do you access the full text? 6. Are accessing and reading full abstracts useful?

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    30 CHAPTER 5 Finding and Appraising the Literature FIGURE 5-1 . Primary and Secondary Sources of Information. (Partial reference list from: Mahon, N.E., Yarcheski, A, & Yarcheski, T.J. (2000). Positive and negative outcomes of anger in early adolescents. Research in Nursing & Health, 23, 177–24.)

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