3916_FM_i-xx 21/10/14 11:29 AM Page i

Bailey's
Research for
the Health
Professional
THIRD EDITION
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Bailey's Research
for the Health
Professional
THIRD EDITION

Angela N. Hissong, DEd, OTR/L, CMCP, CMMT

Program Director
Occupational Therapy
The Pennsylvania State University
Mont Alto, Pennsylvania

Jennifer E. Lape, OTD, OTR/L

Assistant Professor
Occupational Therapy
Chatham University
Pittsburgh, Pennsylvania

Diana M. Bailey, EdD, OTR, FAOTA

Professor Emerita, Tufts University
Medford, Massachusetts
3916_FM_i-xx 21/10/14 11:29 AM Page iv

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Library of Congress Cataloging-in-Publication Data

Bailey, Diana M., 1942- , author.

Research for the health professional / Angela N. Hissong, Jennifer E. Lape, Diana M. Bailey. — Third edition.
p. ; cm.
Preceded by: Research for the health professional / Diana M. Bailey. 2nd ed. c1997.
Includes bibliographical references and index.
ISBN 978-0-8036-3916-4 — ISBN 0-8036-3916-3
I. Hissong, Angela N., author. II. Lape, Jennifer E., author. III. Title.
[DNLM: 1. Research Design. 2. Data Collection—methods. 3. Data Interpretation, Statistical. 4. Publishing. 5. Writing. W 20.5]

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3916_FM_i-xx 21/10/14 11:29 AM Page v

For students, practitioners, and educators

embarking on the research journey . . .
It is easy to think of an idea.
It is challenging to make your idea a reality.
It is inspiring to see the idea change lives.

There are blue skies and

endless territory to explore.
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Preface
Research for the Health Professional was designed to be way. This text is appropriate for those just beginning
a practical and informative guide for research and in the research or evidence-based practice journey, but
evidence-based practice for a variety of healthcare stu- can also be an effective tool for more advanced stu-
dents and professionals. The text will guide you to: dents and practitioners or those needing a refresher
course. With these goals in mind, each chapter con-
1. Differentiate research from evidence-based
tains several features.
practice
First, Learning Outcomes define the chapter
2. Discriminate between quantitative, qualitative,
goals and let you know what you can expect to learn
and mixed methods research methodologies
in each chapter. Second, Skill-Building Tips are in-
3. Access and critically evaluate literature related to
cluded at the end of each chapter in bulleted format
your practice area
to summarize practical suggestions for understand-
4. Ignite your passion for your profession or chosen
ing and applying chapter content. These tips have
practice area to inspire participation in research
been accumulated through our experiences in con-
and evidence-based practice activities
ducting research and evidence-based practice and in
5. Apply principles of research and evidence-based
teaching others to do the same. These tips should
practice to design, implement, and evaluate
allow you to avoid some of the common pitfalls and
meaningful research studies or innovative
to move through the research process with greater
evidence-based practice projects
ease. Third, Learning Activities conclude each chap-
6. Share research and evidence-based practice
ter and provide opportunities for critical thinking
findings through a variety of methods
about the chapter content. These questions can serve
7. Engage in collaborative and self-directed learning
as a foundation for each phase of the research
activities to become researchers, evidence-based
process, by allowing you to consider chapter content
practitioners, and professional leaders
from the perspective of your clinic, practice, or re-
We have taken a straightforward, positive, and search situation. Finally, additional resources and
engaging approach to research and evidence-based templates are available within the chapters and in the
practice that draws upon our combined 25 years of online resources through DavisPlus to guide you
teaching experience, from the associate to doctoral through the research process. In addition, a variety of
levels. Understanding and engaging in research and examples from multiple disciplines have been in-
evidence-based practice can be challenging, but with cluded throughout the chapters to demystify more
use of a structured process and a passion for the cho- complex concepts.
sen topic, both can be extremely rewarding and en- Reviewing the chapters in chronological order
lightening. The philosophy of the text is to learn by reflects the approach we have found to be most effec-
“doing,” meaning that mastery of the content is facil- tive for research in traditional, online, and blended
itated via hands-on activities, engaging assignments academic settings. For those more interested in
and discussions, and collaboration with others. evidence-based practice, we recommend reviewing
Our intention was not to write a comprehensive re- sections in the following order: Section I, Section III,
search text, but rather to lead you through each phase Section II, Section IV. In either case, we hope this text
of the research process in a simplified and systematic will guide you to design and conduct a successful
vii
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viii Preface

study or project, and to pursue grant writing or to healthy and fulfilling life, and we remind our stu-
present and publish to share your work with others. dents of this frequently. The chapter photos were
One final feature that we chose to include is the in- taken throughout our writing journey for this book,
spirational quotes and photos that open each chap- as we tried to stay true to our own philosophy. We
ter to set the tone for a positive and engaging learning hope you enjoy the journey and embrace the joys of
experience. Research and evidence-based practice can research and conducting evidence-based practice! The
be challenging and time-consuming, but we believe process will surely change you if you let it!
that it can also be inspiring and fun with proper life
balance. Balancing competing activities and finding Angela N. Hissong
time to enjoy the simple leisures is fundamental to a Jennifer E. Lape
3916_FM_i-xx 21/10/14 11:29 AM Page ix

Reviewers
Diana M. Bailey, OTR, EdD, FAOTA Shirley J. Jackson, MS, OTR/L, FAOTA
Professor Emerita Associate Professor and Former Chairperson
Tufts University Department of Occupational Therapy
Medford, Massachusetts Howard University
Washington, District of Columbia
Joseph A. Beckett, EdD, ATC
Chair, Department of Sports Medicine & Frances E. Kistner, PT, PhD, CEAS
CAAHEP-accredited Athletic Training Education Assistant Professor
Program Director School of Physical Therapy
University of Charleston Massachusetts College of Pharmacy and Health
Charleston, West Virginia Sciences
Worcester, Massachusetts
Nicceta Davis, PT, PhD, MSPT, MPH
Associate Professor Rosemary M. Lysaght, PhD, OTR/L
Doctor of Physical Therapy Program Assistant Professor
Loma Linda University Department of Occupational Therapy
Loma Linda, California University of Utah
Salt Lake City, Utah
Deanna C. Dye, PT, PhD
Physical Therapist Cheryl A. Manthei, NCTMB, MT, MS-IDT,
Wound Care Department BBA, AAS MSG, AAS CHEM
Eastern Idaho Regional Medical Center Program Director, Therapeutic Massage and
Idaho Falls, Idaho Bachelor of Health Services Administration
Department of Health Sciences
Vickie S. Freeman, PhD Baker College of Allen Park
Department Chair and Professor Allen Park, Michigan
Department of Clinical Laboratory Sciences
University of Texas Medical Branch Kevin C. Miller, PhD, AT, ATC
Galveston, Texas Associate Professor
Department of Athletic Training
Rita M. Heuertz, PhD, MT(ASCP) Central Michigan University
Professor, Director of Departmental Research Mount Pleasant, Michigan
Clinical Laboratory Science, Doisy College of Health
Sciences
Saint Louis University
St. Louis, Missouri

ix
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x Reviewers

Maralynne D. Mitcham, PhD, OTR/L, FAOTA Holly Schmies, PhD, ATC

Professor and Director Assistant Professor
Occupational Therapy Educational Department Department of Athletic Training
Department of Rehabilitation Sciences School of Physical Education and Athletic Training
College of Health Professions University of Wisconsin—Stevens Point
Medical University of South Carolina Stevens Point, Wisconsin
Charleston, South Carolina
Karen Sladyk, PhD, OTR, FAOTA
Annie Morien, PhD, PA-C, LMT Professor and Chair
Lead Instructor Department of Occupational Therapy
Florida School of Massage Therapy Bay Path College
Gainesville, Florida Vernon, Connecticut

Stanley Paul, MD, PhD, OTR/L Frank B. Underwood, PT, PhD, ECS
Associate Professor Professor
Department of Occupational Science and Therapy Department of Physical Therapy
Keuka College, New York University of Evansville
Keuka Park, New York Evansville, Indiana

Kimberly S. Peer, EdD, ATC, FNATA Janet H. Watts, PhD, OTR, CRC
Athletic Training Education Program Coordinator Associate Professor and Director of
and Associate Professor Post-Professional Graduate Studies
School of Health Sciences Department of Occupational Therapy
Kent State University Virginia Commonwealth University
Kent, Ohio Richmond, Virginia

James R. Roush, PT, PhD, ATC Michael B. Worrell, PhD

Associate Professor Assistant Professor
Department of Physical Therapy Department of Occupational Therapy
Arizona School of Health Sciences Indiana University and University of Indianapolis
Mesa, Arizona Indianapolis, Indiana

Victoria Schindler, PhD, OTR, BCMH, FAOTA

Associate Professor
Department of Occupational Therapy
Richard Stockton College of NJ
Galloway, New Jersey
3916_FM_i-xx 21/10/14 11:29 AM Page xi

Acknowledgments
Our deepest gratitude goes to:
Joe and Jere, for understanding our need to flee to the woods, the ocean, or
the spa in order to make this book a reality. We couldn’t have done it with-
out you.
Our family and friends, for your concern and support along the way.
Our faithful and loving canines, Chloe and Sophia, who slept on our laps as we
wrote and gently reminded us to take time to enjoy the simple things in life.
Christa, Karen, and Liz, for believing in us and guiding us throughout the
journey.
Finally, to our students—past and present—who inspired us through their
journeys of research and evidence-based practice, to write a sensible and
lighthearted book to ease the process.

A special thank you from Angela to Dr. Julie Beck for contributing to the Adult & Trans-
formative Learning Influences on the Inquiry Process dialogue in Chapter 2.

xi
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3916_FM_i-xx 21/10/14 11:29 AM Page xiii

Photographs
The chapter opener photos taken during our writing journey are:
EPIGRAPH: The Cabin, Breezewood, Pennsylvania
CHAPTER 1: Harbor of Christiansen, St. Croix, U.S. Virgin Islands
CHAPTER 2: Breathe & Balance Lecture, Philadelphia, PA
CHAPTER 3: Seaside Mahoe Tree, Carambola Beach Resort, St. Croix, U.S.
Virgin Islands
CHAPTER 4: Osprey Nest, Westport, Ontario, Canada
CHAPTER 5: Grandfather Mountain, Linville, North Carolina
CHAPTER 6: Woody Pines—Whitetail Mountain Forest, Beech Creek,
Pennsylvania
CHAPTER 7: North Atlantic Ocean, Island of Bermuda
CHAPTER 8: Enchantment Resort, Sedona, Arizona
CHAPTER 9: Moais Stone Head, Valparaíso, Chile
CHAPTER 10: Cape Hatteras Lighthouse, Buxton, North Carolina
CHAPTER 11: Snowy Stream, Springwood Farm, Pennsylvania
CHAPTER 12: Butterfly, Dupont State Forest, North Carolina
CHAPTER 13: Bald Cypress Tree in the Bayou, New Orleans, Louisiana
CHAPTER 14: Wright Brothers National Memorial, Kill Devil Hills, North
Carolina
CHAPTER 15: Bee & Lily, Garrison Institute, New York
(Photos taken by Angela Hissong, Jennifer Lape, and Joe Lape.)

xiii
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Brief Contents
SECTION 1: Beginning the Journey 1 SECTION 4: Common Tasks Along the
CHAPTER 1: Concepts of Research: Journey 149
Embarking on the Journey 3 CHAPTER 11: Before Implementing Your
CHAPTER 2: Identifying a Topic: Purpose Plan: Important Steps and
Balanced With Passion 9 Considerations 151
CHAPTER 3: Reviewing the Literature for CHAPTER 12: The Art of Writing Up the Research
Research and Practice 17 Study or Evidence-Based Practice
CHAPTER 4: Refining the Topic of Interest Project 161
and Developing the Background CHAPTER 13: The Art of Presenting the Research
Story 27 Study or Evidence-Based Practice
Project 177
SECTION 2: Research Methodologies CHAPTER 14: The Art of Publishing the Research
and Designs 33 Study or Evidence-Based Practice
Project 193
CHAPTER 5: Getting Started in the Research
CHAPTER 15: Grant Funding:Insights and
Process 35 203
Approaches
CHAPTER 6: Quantitative Research
APPENDIX A Example of Mixed Quantitative–
Methodology and Design 45
Qualtitative Study 209
CHAPTER 7: Technical Aspects of Quantitative
APPENDIX B Example of Qualitative Study 221
Research 69
APPENDIX C Example of Evidence-Based
CHAPTER 8: Qualitative Research
Practice Project 233
Methodology and Design 95
APPENDIX D Outline for an Informed
CHAPTER 9: Technical Aspects of Qualitative
Consent 239
Research 115
APPENDIX E Guidelines for Informed
Consent for Human Subjects
SECTION 3: Evidence-Based Practice 123
in a Study 241
CHAPTER 10: Understanding the Triad of APPENDIX F Example of Informed
Evidence-Based Practice: Consent—Practitioner Study 245
Evidence; Practitioner Skills and APPENDIX G Example of Informed
Knowledge; and Client Goals, Consent—Student Thesis 247
Values, and Circumstances 125

xv
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xvi Brief Contents

APPENDIX H Example of a Permission Form for APPENDIX M Guidelines for Contributors

Photograghs and Other Media to American Journal of
Materials 249 Occupational Therapy 261
APPENDIX I Professional Journals and APPENDIX N Author Guidelines for
Publishers 251 International Journal of Yoga
APPENDIX J Indexes and Abstracts 253 Therapy 267
APPENDIX K Evidence-Based Practice APPENDIX O Outline of a Grant Proposal 269
Resources by Healthcare INDEX 271
Discipline 257
APPENDIX L Author Guidelines for Health
Professional Journals and
Publications 259
3916_FM_i-xx 21/10/14 11:30 AM Page xvii

Contents
SECTION 1: Beginning the Journey 1 How Long Should the Literature
Review Be? 23
CHAPTER 1: Concepts of Research: Points to Remember When Writing
Embarking on the Journey 3 the Literature Review 23
Introduction to Research 3 Chapter Summary 23
Journey of Exploration in Research 4
Estimate Time to Complete a CHAPTER 4: Refining the Topic of Interest and
Research Project 4 Developing the Background Story 27
Steps in the Research Process 5 Refine the Question and Develop
Research Process Challenges 6 the Background 27
Synopsis of This Book 6 Problem 27
Background 28
CHAPTER 2: Identifying a Topic: Purpose Purpose of the Study 29
Balanced With Passion 9 Importance of the Study 29
Identifying a Topic: Passion Within Research Question 30
One’s Profession 9 Chapter Summary 31
Adult and Transformative Learning
Influences on the Inquiry Process 10 SECTION 2: Research Methodologies
Educational Aims During the Inquiry
Process 13
and Designs 33
Developing a Topic of Interest 13 CHAPTER 5: Getting Started in the Research
Embracing and Situating the Purpose
Process 35
of the Inquiry 14
Therapeutic Intervention 15 Research Methodologies 35
Management of Healthcare Program 15 Comparison of Quantitative
Environmental and Technological and Qualitative Research 35
Adaptations for Clients 15 Purpose 35
Evaluation of Healthcare Evaluation Designs 35
Procedures 15 Subjects 36
Chapter Summary 15 Researcher’s Relationship With Subjects 36
Data Collection 36
CHAPTER 3: Reviewing the Literature for Data Generated 36
Data Analysis 36
Research and Practice 17 Outcomes 36
Reviewing the Literature 17 Potential Issues 37
How to Do a Literature Search 18 Mixed Methods Designs 37
The Electronic Catalog and Reference General Considerations for Any
Books 19 Research Study 39
U.S. Government Documents 19 Defining and Operationalizing Terms 39
Health Professional Databases, Assumptions 39
Indexes, and Abstracts 20 Scope of the Study and Guiding
Searching and Selecting Databases 21 Conceptual Framework 42
Locating Articles and Books 21 Limitations of the Study 42
Organizing the Material 22 Chapter Summary 43

xvii
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xviii Contents

CHAPTER 6: Quantitative Research Inferential Statistics 84

Methodology and Design 45 Statistical Software 90
Reporting Data and Drawing
Features of Quantitative Research 45
Conclusions 90
Manipulation 45
Chapter Summary 91
Control 46
Randomization 47
Experimental Designs 49
CHAPTER 8: Qualitative Research Methodology
Basic Experimental Design 49 and Design 95
Pretest–Posttest Design With Qualitative Research: Expectations,
Follow-Up 50 Potential, and Opportunities 95
Posttest-Only Design 50 Constructs of Qualitative Research 96
Solomon Four-Group Design 51 Naturalistic Settings 97
Factorial Designs 51 Local Groundedness 97
Quasi-Experimental Designs 52 Phenomenological Perspective 97
Quasi-Experimental Design Lacking Data as Thick Description 97
Control 53 Lived Experience 98
Quasi-Experimental Design Lacking Power of Qualitative Data 98
Randomization 54 Recurring Features of Qualitative
Cohort Designs 54 Research 98
Time-Series Designs 55 Qualitative Strategies 98
Nonexperimental Designs 57 The Ethnographic Research Design 99
Correlational Research 57 The Case Method Research Design 100
Survey Research 57 The Historical Research Design 100
Quantitative Case Study Research 58 The Narrative Analysis Inquiry
Methodological Research 61 Research Design 101
Evaluation Research 62 Preparing for a Qualitative Research
Validity and Reliability of Study 101
Quantitative Research 62 General Components of Qualitative
Validity 63 Research 102
Reliability 64 The Problem 102
Chapter Summary 65 Theory 102
Research Questions 103
CHAPTER 7: Technical Aspects of Quantitative Participant Selection 104
Research 69 Data Collection 105
Data Analysis 105
Considerations in Quantitative
Report Writing 105
Research 69
Qualitative Research Designs 106
Subject Inclusion and Exclusion Criteria 69
Research Design: Ethnography 106
Subject Recruitment 70
Research Design: The Case Study
Sampling 70
Method 109
Sample Size 71
Research Design: Historical 110
Data Collection Techniques 72
Research Design: Narrative Analysis 112
Observation 72
Chapter Summary 113
Interview 72
Surveys 73
Record Review 77
CHAPTER 9: Technical Aspects of Qualitative
Equipment Used in Research 78 Research 115
Tests, Assessments, and Inventories 78 Establishing Boundaries for the
Analyzing Quantitative Data 80 Qualitative Research Study 115
Consulting a Statistician 80 Assumptions and Limitations 115
Descriptive Versus Inferential Statistics 81 Participant Criteria and Selection 116
Types of Data 81 Data Collection Procedures for
Descriptive Statistics 84 Qualitative Research 117
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Contents xix

Validity 118 Chapter 1: Introduction and

Reliability 119 Overview of the Topic of Interest 161
Analyzing, Reporting, and Drawing Chapter 2: Literature Review 162
Conclusions About Qualitative Data 121 Describing and Synthesizing the
Literature 163
SECTION 3: Evidence-Based Practice 123 Chapter 3: Methodology 163
Subject or Participant Recruitment
CHAPTER 10: Understanding the Triad of & Selection 164
Evidence-Based Practice: Evidence; Chapter 4: Implementation and Results 164
Describing Subjects or Participants 164
Practitioner Skills and Knowledge;
Reporting Results 164
and Client Goals, Values, and Chapter 5: Evaluation, Discussion
Circumstances 125 and Conclusions 170
What Is Evidence-Based Practice? 125 What If Results Do Not Support the
Client-Centeredness 126 Project Question or Hypothesis? 170
Evidence-Based Practice Versus Research 127 Limitations 170
Why Is Evidence-Based Practice Needed? 127 Future Implications 171
Challenges to Evidence-Based Practice 127 The Abstract 171
Steps in Conducting an Evidence-Based Scientific Writing Styles 171
Practice Project 129 Becoming a Better Writer 172
Identifying a Need and an Evidence-Based Use of an Outline 172
Practice Question 129 Grammar and Organization 172
Searching the Evidence 131 Use of Software Features 173
Appraising and Synthesizing the Evidence 133 Chapter Summary 174
Applying the Evidence 136
Evaluating the Project 141 CHAPTER 13: The Art of Presenting the
Stories of Evidence-Based Practice 142 Research Study or Evidence-
Program and Protocol Development 142
Based Practice Project 177
Guidance for Unique Clinical Scenarios 143
Why Present? 178
Justifying the Need for Staff, Equipment,
What Is a Presentation? 178
or Services 144
Learning Styles 179
Mentoring, Teamwork, and Motivation 145
Oral Presentations 179
Chapter Summary 146
Visual Support for Oral Presentations 179
Oral Presentation Etiquette 182
SECTION 4: Common Tasks Along the Practice 182
Journey 149 Poster Presentations 183
Poster Design 183
CHAPTER 11: Before Implementing Your Printing and Transporting the Poster 185
Plan: Important Steps and Poster Etiquette 186
Considerations 151 Cyber Presentations 187
Important Preparations 151 Presentation Tools/Platforms for Cyber
Human Participants Committee Presentations 188
Procedures 151 Chapter Summary 189
Healthcare Research Ethics 154
The Pilot Study: A Helpful Measure CHAPTER 14: The Art of Publishing the
of a Researcher’s Readiness 155 Research Study or Evidence-
Implementing the Project 157 Based Practice Project 193
Chapter Summary 157 Why Publish? 193
Defining Publishing Goals 193
CHAPTER 12: The Art of Writing Up the Choosing a Publication 195
Research Study or Evidence- Peer-Reviewed Journals 195
Based Practice Project 161 Non–Peer-Reviewed Publications 196
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xx Contents

Author Guidelines 196 APPENDIX I Professional Journals and

Format of the Article 197 Publishers 251
Peer-Reviewed Articles 197
Non-Peer-Reviewed Articles 199 APPENDIX J Indexes and Abstracts 253
Publication Procedures 200
Revising 201 APPENDIX K Evidence-Based Practice
What If My Article Is Rejected? 201
Resources by Healthcare
Article Acceptance 202
Chapter Summary 202
Discipline 257
General Healthcare 257
CHAPTER 15: Grant Funding: Insights Health and Fitness or Sports Medicine 257
Laboratory Science 257
and Approaches 203
Massage Therapy 257
Charge to Engage in Grant Writing 203
Nursing 257
Grant Writer’s Skills and Knowledge 204
Occupational Therapy 257
Grant Writing 101 205
Physical Therapy 258
Enablers and Barriers 205
Physician Assistant 258
Chapter Summary 207
Radiologic Science 258
Social Work 258
APPENDIX A Example of Mixed Quantitative–
Qualitative Study 209 APPENDIX L Author Guidelines for Health
Professional Journals and
APPENDIX B Example of Qualitative Study 221
Publications 259
APPENDIX C Example of Evidence-Based Athletic Training 259
Clinical Laboratory Sciences 259
Practice Project 233
Massage Therapy 259
Nursing 260
APPENDIX D Outline for an Informed Consent 239 Occupational Therapy 260
Physician Assistant 260
APPENDIX E Guidelines for Informed Physical Therapy 260
Consent for Human Subjects Radiologic Technology 260
in a Study 241 Social Work 260
General Information 241 Yoga and Bodywork 260
A. Written Informed Consent 241
1. Description and Explanation APPENDIX M Guidelines for Contributors
of Procedure 241 to American Journal of Occupational
2. Risks and Discomforts 242 Therapy 261
3. Potential Benefits 242
4. Alternative 242 APPENDIX N Author Guidelines for International
5. Consent 242 Journal of Yoga Therapy 267
B. Other Types of Consent 243
C. Participation of Children in APPENDIX O Outline of a Grant Proposal 269
Consent Process 243
Grant Proposal Format 269
A. ABSTRACT 269
APPENDIX F Example of Informed Consent—
B. NARRATIVE 269
Practitioner Study 245 C. ATTACHMENTS 269
APPENDIX G Example of Informed Consent— INDEX 271
Student Thesis 247

APPENDIX H Example of a Permission Form

for Photograghs and Other
Media Materials 249
3916_Ch01_001-008 20/10/14 10:47 AM Page 1

Section 1

Beginning the
Journey
3916_Ch01_001-008 20/10/14 10:47 AM Page 2
3916_Ch01_001-008 20/10/14 10:47 AM Page 3

Chapter 1

Concepts of Research:
Embarking on the
Journey
The universe is full of magical things, patiently waiting for
our wits to grow sharper.
—Eden Phillpotts

reviewing numerous sources of literature on a given

LEARNING OUTCOMES
topic and drawing new conclusions about that topic,
The information provided in this chapter will assist the
manipulating certain variables to see what happens
reader to:
to other variables, or searching for the meaningful-
■ Understand the components of engaging in the ness of a variable to an individual or group.
research process. Systematic investigation involves the process of
■ Define the steps required to complete a logic, often called deductive and inductive reasoning.
research process. Deductive reasoning starts with a general theory and
■ Identify potential challenges in the research ends with a specific conclusion; this is sometimes
process. called a “top-down” approach. For example, the re-
searcher starts with a general theory, forms a hypoth-
esis based on the theory, tests the hypothesis, assesses
Introduction to Research
the results, and forms a conclusion (Box 1-1).
Research can be an enjoyable, stimulating, and fasci- Inductive reasoning starts with a specific observation
nating activity to engage in along one’s professional that eventually forms a general theory; this is sometimes
journey. Often anyone who is required to write a called a “bottom-up” approach. In this type of reason-
research thesis starts out overwhelmed by the idea, yet ing, the researcher starts with an interesting observation,
comes to enjoy the challenge and ends up feeling then looks for a pattern of similar observations. From
proud of the results. Great satisfaction can be derived this pattern, the researcher develops a hypothesis, which
from completing this exacting, often complex, and forms the basis of a general theory (Box 1-2).
always stimulating process. When using inductive reasoning, one accepts or
Unfortunately, some people avoid research because believes a finding about a situation and then applies
of their preconceived notions. Research is the system- that belief to all similar individuals, assuming that the
atic investigation of a problem, issue, or question un- finding will be true for all. For example, if a healthcare
dertaken to increase our knowledge. This includes practitioner finds that having clients complete a

3
3916_Ch01_001-008 20/10/14 10:47 AM Page 4

4 Section 1 ■ Beginning the Journey

that the principle will probably not apply to all other

BOX 1-1 ■ Deductive Reasoning cases that follow.
Theory → Hypothesis → Observations →
Conclusion Journey of Exploration in Research
An occupational therapist believes that posi- Research in the health sciences is a challenging task;
tive encouragement improves patient out- however, it can be accomplished with the proper tools
comes (general theory) and hypothesizes and guidance. Human behavior is extremely complex
that positive reinforcement will decrease and, therefore, difficult to isolate and measure. Be-
stroke recovery time. The therapist tests the cause we are working in the health field, added di-
hypothesis on 100 patients and finds that mensions must be considered when working with and
stroke recovery time decreased by 50% (ob- conducting research with clients. These may include
servations). The therapist concludes that time constraints of the client and the healthcare prac-
positive reinforcement decreases stroke re- titioner, complicated medical diagnoses, working
covery time (conclusion). This confirms the within the many layers of the healthcare system, and
original theory. the numerous ethical issues involved when doing re-
search with people. With that said, we are nonetheless
seeing more support for healthcare practitioners as
BOX 1-2 ■ Inductive Reasoning they conduct research in the community setting with
a focus on preventative or wellness programs.
Observation → Pattern → Hypothesis → When considering your research agenda, keep the
Theory following six points in mind:
An occupational therapist observes that a ■ First and foremost, explore and understand the
patient’s ability to climb stairs improves when types of research and determine which type best
preceded by a balance task (e.g., standing on fits the question you are pondering (Table 1-1);
one leg with eyes closed). Over the next sev- ■ Be aware that finding collaborators who are inter-
eral months, the therapist looks for a pattern ested in your research is time-consuming;
whether the balance task causes improve- ■ Give considerable thought to the type of research
ments in other areas (cognition, motor skills, project you want to engage in;
etc.). After observing improvements in other ■ Learn as much as you can about the embedded
areas, the therapist believes that the balance systems or structural rules that will affect, and at
task should be performed at the beginning of times overrule, how you conduct your research;
every occupational session (hypothesis) and ■ Be willing to compromise and accept that perse-
implements this as standard protocol for all verance is a key asset during the research process;
therapists (theory). ■ Finalize your research question, then sit down
and write up a time line (Figure 1-1).

specific questionnaire about their health history is

beneficial during an initial evaluation, the practitioner
Estimate Time to Complete a Research
may choose to give all subsequent clients the question-
Project
naire to fill out. Practitioners often ask, “How long will it take to com-
The point of consideration with deductive reason- plete a research study?” or “How long should I devote
ing is that, although the principle is usually true, there to conducting research each day or week?” In my expe-
may be exceptions. The point of consideration with rience in advising graduate occupational therapy stu-
inductive reasoning is that the individual upon whom dents in their thesis preparation and writing, the time
you have based the principle may be the exception, so frame is an average of 6 to 12 months. This includes
3916_Ch01_001-008 20/10/14 10:47 AM Page 5

Chapter 1 ■ Concepts of Research: Embarking on the Journey 5

Table 1-1 ■ Description of Categories of Research

A Basic Applied
Abstract, general, and concerned with generating Designed to answer a practical question to help people
new theory and gaining new knowledge for knowl- do their jobs better.
edge’s sake.

B Experimental Descriptive
Manipulate a variable to see its effect on another Describe a group, a situation, or an individual to gain
variable, control for as many other variables as knowledge that may be applied to other groups or
possible, and randomly assign subjects to groups. situations, as in case studies or trend analyses.

C Clinical Laboratory
Performed in the “real world” where control over Performed in laboratory surroundings that are con-
variables is quite difficult. trolled.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Prepare research project

Intervention

Analyze & interpret data

Write up results & publish

Figure 1-1 Time Line for Tasks of a Research Project

conceptualizing the issue to be studied, carrying out therapists enough free time during the day to do the
the project, and writing the study. Students are usually extra work required to complete a research study.
not carrying a caseload of clients or tied to a 40-hour
work week; however, they do have classes to attend and
Steps in the Research Process
often are working full-time on an affiliation.
Research conducted by practitioners tends to take It is helpful to remember that research is a circular
longer—about 1 year to 18 months—with some time process. The researcher starts with a question in
spent on the project each week. Of course, different mind, goes through the investigative stages, and
phases of the research demand more or less input. For ends up with an answer to the question. More often
example, if a new treatment approach is being investi- than not, further questions arise during the analysis
gated, the practitioner must adhere to the number and and interpretation of the data, leading to yet more
length of treatment sessions stipulated in the research research ideas.
protocol and put time into preparation and record- There are different points of entry into the research
keeping. Activities such as reading the literature and process. Some people enjoy starting afresh at the
writing the results are done on one’s own time and on a question identification stage; others may discover
less precise schedule. A therapist who works from 9 to some study results that they question and feel they
5 should plan on reading and writing in the evening would like to investigate for themselves. Still others
and on weekends because few clinical situations afford enter at various phases along the way. Whatever the
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6 Section 1 ■ Beginning the Journey

entry point, the steps required to complete a research ■ Understand the reality that your social life will be
project follow a logical sequence: limited secondary to engaging in a research in-
1. Identify a problem that needs to be solved or a quiry.
question that needs to be answered.
■ Construct support systems to help you complete
2. Review the existing literature related to the prob- the research agenda in a timely and cost-effective
lem or question. manner.
3. Formulate a question or hypothesis about the
Synopsis of This Book
problem based on the literature.
4. Design a procedure that will address the question The following is a picture in preview of the forth-
or hypothesis. coming chapters of this book. You have just read
5. Carry out the procedure. Chapter 1, which gives you an overview of how you
6. Collect and interpret the findings. should approach your research journey. The four
7. Present findings to one or more committees. chapters in Section I will assist you in beginning
8. Publish your research so that others may benefit the research process. Section II of the book
from the identified knowledge. It is very helpful to addresses research methodologies and designs,
talk to your committee and peers about where to whereas Section III addresses evidence-based prac-
publish your research. tice. Section IV gives you detailed information
This process will be addressed step by step later in regarding common tasks along the journey related
this text. As each step is explored, practical hints are to preparing to implement your project, analyzing
offered that explain each step, along with suggestions your findings, presenting the research to commit-
on how to get over the hurdles that frequently present tees, and finally publishing and presenting the
themselves. knowledge to the larger community.
Remember that, if you persevere, you can carry out
a research project from its inception to publication SKILL-BUILDING TIPS
by using this book as your step-by-step guide. This ■ As you begin to navigate and negotiate through
book is designed to guide you through each stage of various research processes, do not fault yourself or
negotiation and navigate through your own and others.
other people’s questions about the research process.
■ Remember that others around you may not be as
Research Process Challenges passionate about your topic as you are and that
they may not understand the research process or
When one begins with a research project there is a your research project. It isn’t their fault. Be kind to
time of balancing out new tasks with everyday activi- them and yourself.
ties. We have compiled a list of common challenges ■ Don’t worry too much about the rules when you
that may be encountered prior to starting and/or in begin the research. You will not do everything cor-
the initial stages of the research process: rectly the first time and will have to go back and
■ Balance commitments to allow for time to com- redo a few things. This is part of the learning
plete all stages of a research inquiry. process.
■ Underestimate how much assistance or coopera- ■ Be humble and honest during the process from
tion you may need from all the people involved in start to finish. If you need help, ask for it.
the research inquiry.
■ Keep excellent notes.
■ Sort out how much time you need to complete
each phase of the project. ■ Find these four key people to assist you with the
■ Say no to “tempting” opportunities that come up following tasks:
while you are engaged in the research inquiry that ■ A person who understands the technical aspects
you really want to do. of your research
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Chapter 1 ■ Concepts of Research: Embarking on the Journey 7

■ A person who is familiar with various writing

styles such as APA (American Psychological Asso- LEARNING ACTIVITIES
ciation) or MLA (Modern Language Association) 1. What is your mission statement (i.e., why do
■ A person who will read your manuscript and cor- you want to complete your research project at
rect grammar and spelling (that’s right, the com- this point in time)?
puter still does not pick up everything!) 2. Are you ready to give up social time for re-
■ A kind person who will take you out for dinner, search time? If the answer is yes, how will you
bring you a chocolate cupcake, or sign you up accomplish this? For example: Rather than
for a massage when you most need a break going out for dinner with friends three nights
from your research project a week, you might go out only on Friday night.
3. List five reasons why you are passionate about
completing your research study at this point in
time.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
3916_Ch01_001-008 20/10/14 10:47 AM Page 8
3916_Ch02_009-016 20/10/14 10:22 AM Page 9

Chapter 2

Identifying a Topic:
Purpose Balanced With
Passion
The shape of one’s knowing becomes the shape of one’s
being, doing, and becoming.
—Unknown

as a student or practitioner. Ironically, this grounding

LEARNING OUTCOMES experience will not only guide your inquiry, but will
The information provided in this chapter will assist the
also fuel your passion to plan and execute your in-
reader to:
quest. It will truly assist you in coming to know, un-
■ Explore the process of identifying topics that derstand, and engage in evidence-based practice and
elicit a professional passion for inquiry. inquiry.
■ Appreciate the influence adult and transfor- Post the process of looking within to discern what
mative learning provide when aligned with you want to study, and take time to consider the many
the processes of engaging in an inquiry. philosophies and pedagogies of practice that you have
■ Acknowledge the need for a balance of personal been exposed to over the years. First, philosophical
and professional obligations while engaged in perspectives of evaluation, intervention, and care have
an inquiry. helped shape and guide your practice more than you
may think about on a daily basis, secondary to them
becoming engrained in your work and second nature.
Next, consider the experience you have in practice with
Identifying a Topic: Passion Within
your clients in terms of the teaching–learning process.
One’s Profession
Each time we engage in practice with clients there is a
An idea for an inquiry project typically begins from a teaching–learning component to the session. A few
grounding experience you have had in your field of pedagogical methods for any given session may in-
study, although it may start anywhere. One key start- clude collaboration, critical reflection, transforma-
ing point to remember, and one that will consistently tion, and replication of a therapeutic modality or
guide you through the inquiry process, is to begin exercise. Again, it is very important to take time to
with, maintain, and end with a passion for what you ponder the philosophical and pedagogical perspec-
are studying. Think about a professional grounding tives and notions that have influenced and enlight-
experience that has been a guiding force in your life ened you on areas of practice that you want to explore

9
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10 Section 1 ■ Beginning the Journey

further. Note that coming to know and understand look at your calendar and determine what social
why and how these notions fit into your agenda may events, family gatherings, and vacations you are going
take some time, but giving them deep thought and the to forgo to conduct and complete the inquiry. The
courtesy to form a base for your inquiry is time well ole’ saying, “Something’s got to give,” applies to any-
spent. Once you have established the role these two one who decides to engage in a small or large scale in-
points will play in your inquiry, the next step is to con- quiry. It is next to impossible to balance both, so
sider how your learning is situated in the process. some things need to wait or be significantly reduced
in order to accomplish your goal. Looking forward a
bit, Table 2-1 is a typical time line for the final four
Adult and Transformative Learning months of a small scale inquiry.
Influences on the Inquiry Process As noted by Mezirow (2000) and Taylor (2007),
adults who engage in a significant transformative
Adult education theorists—extrapolating from and
learning experience will exhibit the following charac-
building upon cognitive, social, behavioral, and hu-
teristics: (1) display a sense of selves; (2) be intricately
manist learning, as well as developmental theories—
influenced by their professional identities and levels
highlight the diversity and complexity of adult
of social, emotional, and cognitive development;
learning needs as well as environmental influences
(3) bring a wealth of personal and clinical experience;
upon these needs (Kasworm, Rose, & Ross-Gordon,
(4) seek refinement of knowledge and attitudes;
2010). Historically, Knowles (1984) emphasized the
(5) search for immediate applicability of newly acquired
impact of self-concept, orientation to learning, expe-
skills; (6) juggle multiple personal and professional
rience, time perspectives, and motivation on adult
responsibilities; (7) undergo stages of perspective trans-
learning processes, whereas Mezirow (2000) ex-
formation; and (8) desire active participation in direct-
pounded upon the importance of critical reflection,
ing their own learning experiences. Adults’ particular
as influenced by cultural beliefs and attitudes, on the
learning styles and stages of development should
transformation of perspectives and the development
mold to the styles of their active participation and di-
of new understanding. He believes adults resolve con-
rection of learning. Again, in order to accommodate
tradictions and move to more progressive conceptual
this diverse and complex learning, the inquiry process
constructs by:
should be designed to invoke enthusiasm and passion
■ Becoming disoriented with existing beliefs alongside its method for achieving the stated objec-
■ Self-examining and critically assessing assump- tives outlined by the investigator. For your first in-
tions and knowledge quiry, you should select a topic and formulate an
■ Searching for new roles agenda that not only fulfills a need in your practice
■ Acquiring new knowledge and skills area, but touches your heart.
■ Building competence and confidence in these new Furthermore, when you begin to consider engaging
roles in inquiry, it will take time away from your other daily
■ Reintegrating the components of life in response tasks. This can’t be overstated or pointed out more in-
to these transformed perspectives tently, because this is a common downfall to complet-
Developmental theories explore the diversity of ego ing the inquiry. Therefore, give yourself permission to
and moral development, learning preferences, life stop and pause in order to explore the space between
events, and neurophysiological changes on the readi- your professional and personal life. You must be hon-
ness, willingness, and selectivity of adults to engage est with yourself and discern how important it is for
in learning activities. A firm and steady level of com- you to engage in an inquiry. It is important to look in-
mitment to embark upon the inquiry, aligned with ward and consider the pace of your current day and
the establishment of a time line, may seem like a small determine how you are going to balance an inquiry
feat, but it is essential to your success. Even during with all of your other responsibilities. In addition, you
the brainstorming stage of the process, it is wise to must be prepared to be changed by the experience and
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Chapter 2 ■ Identifying a Topic: Purpose Balanced With Passion 11

Table 2-1 ■ Example of Daily Tasks During Implementation and Evaluation Inquiry Stages
Date Specific Task Date Specific Task
Sept 1 Final Review of Outline of Implementation Oct 4/5

Sept 2 Week 1 Implementation Oct 6 Week 6 Implementation

Sept 3 Conduct and Write Oct 7 Conduct and Write

Sept 4 Oct 8

Sept 5 Oct 9

Sept 6/7 Oct 10

Sept 8 Week 2 Implementation Oct 11/12

Sept 9 Conduct and Write Oct 13

Sept 10 Oct 14 Write Final Implementation Section

Sept 11 Oct 15

Sept 12 Oct 16

Sept 13/14 Oct 17

Sept 15 Week 3 Implementation Oct 18/19

Sept 16 Conduct and Write Oct 20 Oct 20 Submit the following:

Implementation Section
Sept 17
Implementation PowerPoint Slides (3–4)
Sept 18
Oct 21 Week 1 Evaluation of Inquiry
Sept 19
Oct 22
Sept 20/21
Oct 23
Sept 22 Week 4 Implementation
Oct 24
Sept 23 Conduct and Write
Oct 25
Sept 24 Conduct and Write
Oct 26/27
Sept 25
Oct 28 Week 2 Evaluation of Inquiry
Sept 26
Oct 29
Sept 27/28
Oct 30
Sept 29 Week 5 Implementation
Oct 31
Sept 30 Conduct and Write
Nov 1
Oct 1
Nov 2/3
Oct 2
Nov 4 Week 3 Evaluation of Inquiry
Oct 3

Continued
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12 Section 1 ■ Beginning the Journey

Table 2-1 ■ Example of Daily Tasks During Implementation and Evaluation Inquiry
Stages—cont’d
Date Specific Task Date Specific Task
Nov 5 Nov 27

Nov 6 Nov 28 Happy Thanksgiving—Day Off!

Nov 7 Nov 29

Nov 8 Nov 30/Dec 1

Nov 9/10 Dec 2 ■ Last Day to Get Paper and Poster to

Printers
Nov 11 Week 4 Evaluation of Inquiry
■ Start Gathering Things Needed for

Nov 12 Formal Presentation of Inquiry

Nov 13 Dec 3

Nov 14 Dec 4

Nov 15 Dec 5

Nov 16/17 Dec 6

Nov 18 Week 5 Evaluation of Inquiry Dec 7/8 Last Day to Submit PowerPoint via
Moodle Dropbox
Nov 19
Dec 9
Nov 20
Dec 10 Last Day to Submit Article or Grant
Nov 21
via Moodle Dropbox
Nov 22
Dec 11 Travel to All-State University
Nov 23/24 Final Week of Evaluation of Inquiry Celebration Begins
Nov 25 ■ Finish PowerPoint Dec 12 ■ Poster Set-up Starting @ 10 a.m.
■ Evaluation (2–3 slides) Summary ■ 4:00–5:30 p.m. Poster Round Robin
(1–2 slides) to Healthcare Practitioner Community
■ Design and Finish Poster

■ Finish Article or Grant Proposal

Dec 13 ■ 10 a.m. Present PowerPoints
■ 5 p.m. All-State University Celebration
(3–20 pages; depends on what you
■ Dinner or Celebrate Downtown at
are doing—can copy and paste a lot of
Elbow Room!
information)
Dec 14 Ah—Feel the Glow!
Nov 26

notice how you are changing alongside the inquiry the work is changing you as a practitioner. Because
processes. As noted in the previous paragraph, the this is very important, let’s take a bit more time to
process will more than likely be a transformative learn- appreciate transformative learning.
ing experience for you; therefore, you should not only Mezirow, Taylor, and associates (2009) note that
pay attention to the work you are doing, but also how transformative learning can be broken down into
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Chapter 2 ■ Identifying a Topic: Purpose Balanced With Passion 13

two fundamentally different views. One viewpoint come to understand and engage in an inquiry in order
stresses the personal transformation that focuses on to (1) critically assess inquiry literature influencing
the individual. This view looks at the person’s growth practice; (2) develop strategies for conducting in-
through reflection and self-critique but it does not quiries; (3) determine the effectiveness of their own
look at the impact that the social context has on the theoretical constructs and practices; and (4) critique
learner at all. The other viewpoint sees transforma- interprofessional collaborative practice techniques.
tive learning essentially linked to social change and Additionally, through the inquiry process, practition-
awareness of power within the purview of the learner. ers develop clearer and more concise writing skills con-
It is further noted by Mezirow, Taylor, and associates sistent with accepted healthcare practices. Professional
(2009) that “transformative learning may be defined engagement in an inquiry also helps when communi-
as learning that transforms problematic frames of reference cating to other professionals and consumers about the
to make them more inclusive, discriminating, reflective, analyses of the research and evidence-based outcomes
open, and emotionally able to change” (p. 22). It is very related to their evaluation or intervention protocols.
important for the practitioner to embrace and ac-
knowledge how his or her previous knowledge is
Developing a Topic of Interest
dovetailing with new knowledge. Southern (2007)
further explains the transformational learning envi- To develop a topic and align its purpose with a pro-
ronment as follows: fessional passion, you should formulate a question
that you are excited about. What do you really want
Once we accept the invitation to participate in new
to investigate? Start by thinking about your every-
ways, we create the possibility to become fully engaged in the
day work. What issue or problem keeps coming up
process. When this engagement leads us to question assump-
during your daily practice? Is there an area of prac-
tions and see the limitations of old thinking and the opportu-
tice that you are not involved in that you would like
nities in new possibilities, creative energy is set free; students
to explore? Maybe there is a group in your commu-
and teachers alike begin to share the learning space, taking
nity you would like to explore practice options with,
responsibility for creating the necessary conditions to become
or an area of inquiry that you explored earlier with
a true learning community. Those conditions include mean-
someone and now you would like to revisit the topic
ingful relationships, purposeful work, shared leadership, and
to dive deeper into the literature and engage in an
communicative and cultural competence. (p. 332)
inquiry agenda. Begin by pondering an inquiry
The shared experiences with peers, mentors, and agenda by writing down words that are part of the
clients during the inquiry process will be the changing question you are seeking and then begin to formu-
agent or significant learning process that will trans- late draft questions (Box 2-1).
form the way you view and conduct practice from that Once you have brainstormed key words and possi-
juncture forward. Once you have gathered the litera- ble inquiry questions, you should then go to a litera-
ture, facilitated a therapeutic experience for individuals ture database. Type these words and your draft
or a group, compared it to your personal knowledge, questions into the query to seek out available infor-
and illuminated perspectives, your professional and mation. As Creswell (2014) notes, “A common short-
personal journey will be transformed. coming of beginning inquirers is that they frame their
study in complex and erudite language . . . good,
sound inquiry projects begin with straightforward,
Educational Aims During the Inquiry uncomplicated thoughts, easily read and understood”
Process (p. 2). He further suggests the following questions:
You are more than likely reading this book because ■ Is the topic inquiry able, given time, resources,
you are involved in a formal education process or tak- and availability of data?
ing on an inquiry process for your own educational ■ Is there a personal interest in the topic in order to
benefit. From an educational perspective, practitioners sustain attention?
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14 Section 1 ■ Beginning the Journey

■ Who do you want or need to engage in the

BOX 2-1 ■ Example of How to Ponder an process with you?
Inquiry Using Key Words to ■ What is the true question you are trying to answer?
Formulate Questions Is it more about the clients, the practice area, the
Key Words environment, or a particular intervention?
■ What resources do you have available to you to
■ Adolescents With Disability or Involved
carry out the inquiry?
Disease Process ■ Who do you want to influence, assist, or affect by
■ Social Justice
engaging in the inquiry?
■ Self-Advocacy
■ How much time do you have to invest in the process?
■ School-Based Practice
What is the time line and are there financial implica-
■ Occupational Therapy
tions if you take longer than the allotted time?
■ Counseling
Once you have answered all of these questions, you
Draft of Inquiry Questions can situate the purpose of the inquiry.
■ How do adolescents with a disability or

disease process learn to self-advocate for

accommodations or adaptations during
Embracing and Situating the Purpose
the transition planning process of their
of the Inquiry
academic career? The purpose of the inquiry is different for every in-
■ How does occupational therapy assist quiry; however, the journey of the process is a way of
adolescents with a disability or disease learning and coming to know more about a topic of
process in understanding social justice in interest. To some extent, all of us conduct informal
the educational environment, in order for inquiries every day, so we are familiar with the
them to learn how to self-advocate for processes of investigations and conclusions. It is ex-
accommodations or adaptations? tremely important to stay in the moments of the process
and to document them so you can learn even more
from the process when you review the notes. Also, re-
member to seek wisdom along the way when you need
it from friends, colleagues, and resources. Try not to
■ Will the results from the study be of interest to
just walk through the experience, but embrace it, get
others (e.g., in the local region, state, region,
excited about it, and consistently move forward with
nation, global)?
your agenda. You will be in the inquiry-space for
■ Is the topic likely to be publishable in a scholarly
months and sometimes years, so it is important to
journal? (or attractive to a thesis committee)?
find enjoyment during the time. It is common, while
■ Does the study (1) fill a void, (2) replicate, (3) extend,
gathering data and then writing the evaluation of the
or (4) develop new ideas in the scholarly literature?
inquiry, for people to get bored, complacent, and
■ Will the project contribute to career goals?
lonely. Therefore, it is essential for you to reach out
You have almost arrived at discerning what you want to people who will support you during the experience.
to do for your inquiry. To finish, consider the processes Further, during the engagement phase, people tend
and needs of engagement in a research or evidence- to be stressed by managing all the components and
based inquiry by answering the following questions: time lines and tending to the participants’ needs;
■ Is there something from your past experience, however, this time tends to be the most uplifting and
current interest, or an area of practice you want to collaborative time of the inquiry. Now that you know
move into that is influencing the route you are to stay in the moments as you move through the in-
following? quiry process, let’s take a look at how to situate your
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Chapter 2 ■ Identifying a Topic: Purpose Balanced With Passion 15

inquiry. There are endless options, but here are a few Evaluation of Healthcare Evaluation
that make the most sense in healthcare practice. Procedures
Therapeutic Intervention Through a quantitative methods inquiry, you can de-
termine the expansion of:
Through an action inquiry, you will expand your
knowledge of: ■ Knowledge of appropriate evaluation procedures
for the site’s client population.
■ Assessing client and facility programming needs.
■ Knowledge about the level of expertise required to
■ The process of implementing a therapeutic pro-
administer the selected evaluation procedures.
gram or project.
■ Ability to determine the strengths and limitations
■ The compatibility of the recommended program
of the selected evaluation procedures.
with the overall objectives of the client(s) program.
■ Competency skills in administering the selected as-
■ The strengths and limitations of the recom-
sessment tools included in the evaluation process.
mended program or project.
These are just a few of the thousands of options
Management of Healthcare Program available to situate the purpose and plan for your re-
Through a narrative inquiry, you will glean a better search or evidence-based practice inquiry. As previously
understanding of: noted, you must start from a place of passion when en-
gaging in an inquiry. If you are not vested in the topic
■ The mission and goals of the facility.
from the start, it will be difficult to stay motivated to
■ Staffing issues relevant to the project.
engage in and complete the task. Good luck, and most
■ Knowledge of the legal issues involved in the pro-
of all—enjoy the moments along the journey of inquiry.
vision of services at this facility.
■ Assessment of the impact of recent changes in
delivery systems of this facility. (These might Chapter Summary
include health care, education, welfare, penal
This chapter gives the reader insight into the needs
systems, etc.)
of preparing for a research inquiry. The transforma-
tive nature of adult learning, which typically takes
Environmental and Technological Adaptations
place during the research process, is explained to as-
for Clients
sist the reader in understanding the feelings, emo-
Through a participatory action inquiry, you can gain tions, and learning they may encounter along the
a better understanding of the: journey. It explains the learning path that led to and
■ Expansion of knowledge of appropriate environ- contributes to the process, as well as ideas of how to
mental and technological adaptations for the client balance one’s time and energy alongside of an inquiry.
population.
■ Expansion of knowledge in identifying environ-
mental and technological adaptations appropri- SKILL-BUILDING TIPS
ate to the client population’s lifestyle and
■ Explore everything that fills you with passion in
values.
practice before you begin the inquiry. Don’t settle
■ Ability to determine the strengths and limitations
on something just because you are able to easily
of the environmental and technological adapta-
find a literature base to support your efforts.
tions used or proposed.
Explore–pause–ponder–pause–then make the final
■ Ability to identify funding issues relevant to the
decision on your topic.
populations served and at the site.
■ Ability to provide clients and staff with new ■ Your project will not flourish if you do not take
knowledge on environmental and technological risks and move forward every day.
adaptations. ■ You can’t enjoy what you don’t work for.
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16 Section 1 ■ Beginning the Journey

■ Don’t delay pieces you feel are going to be difficult. REFERENCES

Make sure to put a pen to paper or fingers to key- Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed
board every day for at least an hour while engaged methods approaches. Thousand Oaks, CA: Sage.
Kasworm, C., Rose, A., & Ross-Gordon, J. M. (Eds.). (2010). Handbook of
in an inquiry. adult and continuing education (2010 ed.). Thousand Oaks, CA: Sage.
■ The average person wastes 2 hours per day procras- Knowles, M. (1984). Andragogy in action. San Francisco: Jossey-Bass.
tinating. If you get stuck, figure out some way to Mezirow, J. (2000). Learning to think like an adult: Core concepts of trans-
formation theory. In J. Mezirow (Ed.), Learning as transformation: Critical
create a shift in your mindset so that you can move perspectives on a theory in progress (pp. 3–33). San Francisco: Jossey-Bass.
forward quickly and swiftly. Mezirow, J., Taylor, E., & Associates. (2009). Transformative learning in prac-
tice: Insights from community, workplace, and higher education. Jossey-Bass:
San Francisco.
Southern, N. L. (2007). Mentoring for transformative learning: The
importance of relationship in creating learning communities of care.
LEARNING ACTIVITIES Journal of Transformative Education, 5, 329.
Taylor, E. W. (2007). An update of transformative learning theory: A
1. Write your professional mission statement on critical review of the empirical research. International Journal of Lifelong
engaging in an inquiry. Why is it important to Education, 26(2), 173–191.
you personally and professionally?
2. List at least 10 ideas you have for an inquiry.
Now write a defense for each one—why do you
want to explore more about this topic? Select
two of your ideas and write a question of in-
quiry for each. Write down why you are pas-
sionate about these two topics. Lastly, sit back
and ponder—which one fits you best at the
moment?
3. Write down 10 reasons why you are committed
to engaging in an inquiry.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
3916_Ch03_017-026 20/10/14 10:48 AM Page 17

Chapter 3

Reviewing the Literature

for Research and Practice
When nothing is sure, everything is possible.
—Margaret Drabble

your time and that of your subjects by repeating

LEARNING OUTCOMES what has already been reasonably well researched.
The information provided in this chapter will assist the ■ Perhaps someone has tried to investigate your
reader to: question or one very similar and met with insur-
■ Understand the process of approaching and mountable problems (e.g., not finding a test in-
undertaking a literature review. strument sensitive enough to measure one of the
■ Identify potential resources to facilitate the crucial variables or not being able to prompt ade-
research or evidence-based practice literature quate narratives to show the depth and breadth of
review process. your question). This information would be useful
■ Conduct a literature search. before embarking on a similar project.
■ Organize self and material in order to write a ■ Perhaps someone has investigated your question
literature review. or a very similar one, but not in the same way that
you intend to investigate it. You may plan to use
Reviewing the Literature slightly different methods or subject characteris-
tics. You would, however, want to benefit from
Now that you have explored some research questions the information that could be gleaned from the
and settled on one that you would like to answer, the previous study.
next step is to conduct an overview of your topic to ■ Someone may have already studied one compo-
determine if the question has already been adequately nent of the topic, and you can build on that
addressed. If so, then you need to modify your ques- research, thus saving yourself time and energy.
tion. If not, then your process moves into a review ■ You might wish to place your study in context
of the literature. Many novice researchers ask, “Why with similar studies so that the reader will know
is this necessary? Why can’t I just start in on my how to perceive your work.
project?” There are several reasons: ■ You must place the study within the theoretical
■ Perhaps someone has already researched your ques- base that informs the question(s) from the per-
tion, or one just like it, and the answer is already spective that you feel gives the optimal insight to
published. You certainly would not want to waste the problem (e.g., biomechanical, occupational
17
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18 Section 1 ■ Beginning the Journey

science, or social constructivist theory). An

increased understanding of the topic and the BOX 3-1 ■ Statement of Research
literature will assist you in the process. In studying the temporal adaptation of individ-
■ It will be reassuring if you find reasons in the uals who have chronic psychiatric conditions,
literature to suggest why the study you propose therapists reviewed literature in the areas of use
will address the problem and how your study is of time in the “normal” population and in the
capable of solving the problem or answering the chronic psychiatric population. Areas ad-
question. dressed were the human drive to explore and
■ While searching the literature, you will likely to master the environment, purposeful activity,
find evidence that will prompt you to revise or the environment, demographics of people sim-
change your question. It may need a different ilar to those in the sample, and methods of
emphasis; for example, you may decide to look measuring temporal adaptation.
for a correlational effect rather than a cause-
and-effect or you may refine your prompting
questions.
In any profession, there are strongly held impres- BOX 3-2 ■ Research Abstract on
sions about various areas of practice, things with Improving Healthcare
which most practitioners would agree. However, im- Quality and Safety
pressions are not enough. A basis for research and In a study by McCrory (2012) on improving
documentation of these beliefs through the litera- healthcare quality and safety, you can see the
ture is constantly needed. Furthermore, a thorough depth and breadth addressed and gleaned
review of written material on the proposed topic of from an excerpt from the abstract: The exper-
study is essential if the researcher is to design a rel- imental results of four studies used to develop
evant, original, and timely research study. In addi- and assess laparoscopic surgery instrumenta-
tion to articles and books that pertain strictly to tion, practices, and procedures were ad-
your chosen subject, it is important for you to read dressed. In the first experiment, a novel
related material and to be well-versed in the topic hand-controlled electrosurgical laparoscopic
being studied. Some examples of such reading are grasper was developed and evaluated to elim-
given in Boxes 3-1, 3-2, and 3-3. From these exam- inate the use of foot pedals, reduce surgery-
ples you can see that breadth of reading is as impor- related discomfort, and minimize the risk of
tant as depth of reading in preparing an effective actuation errors. The final three studies com-
research proposal. We typically tell our students pared the emerging technique of single-inci-
they will actually spend 70% of their time research- sion surgery to conventional laparoscopic
ing and reading, then spend 30% of their time writ- surgery to determine whether there were any
ing, while doing the entire study–literature review. technical, physical, or subjective performance
We get some raised eyebrows when we make this differences across the two surgical techniques.
statement, but it’s knowledgably based on supervis- In all, these studies contribute toward the im-
ing hundreds of successful research and evidence- provement of the quality and safety of mini-
based projects. mally invasive surgery.

How to Do a Literature Search

You are likely to find material relevant to your topic educational, anthropological, psychological, and
in journals, books, global websites, and government engineering sciences, the best place to locate material
documents. Because much of the material relevant to is in institutional libraries, such as those found in
healthcare professions is found in the medical, social, universities, postgraduate medical centers, training
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Chapter 3 ■ Reviewing the Literature for Research and Practice 19

The next step is to search the online databases and

BOX 3-3 ■ Research Abstract Related electronic references on your topic. These may include
to Physical Therapy and the following:
Prosthetic Use ■ Electronic card catalog and reference books
In a study related to physical therapy and ■ U.S. government documents
prosthetic use by older adults, the literature ■ Online databases that index journal articles and
survey may include statistics on the whole other materials relevant to your topic
population, followed by those in the elderly ■ Healthcare databases such as CINAHL (Cumulative
population who are undergoing amputations; Index to Nursing and Allied Health Literature) and
conditions commonly leading to amputa- PubMed
tions; and review of the literature concerning ■ Health profession-specific resources within the
whether or not to fit elderly amputee patients library’s database or in the general media
with prostheses. Topics may include costs ver-
The Electronic Catalog and Reference Books
sus benefits, physical limitations, motivation,
training time, and the likelihood of patients There is a record (or computerized entry) in the
using the prostheses upon discharge; and library catalog for every item housed in the library,
finally, an overview of studies describing func- except for individual journal articles. There are three
tional outcomes of prosthetic use by elderly main types of entries for each item: author’s last
people. Additionally, the authors stated that name, title, and subject(s). If you are aware of leading
they had limited their literature search to the authorities in your topic area, such as A. Jean Ayres in
past 15 years because of recent changes in the area of sensory integrative techniques or Singe
surgical procedures and rehabilitation care Brunnstrom in kinesiology, you can search for those
and improvements in prostheses. authors’ names and review titles to find appropriate
books. If you are not aware of experts in the field, the
subject index and database can be used to find appro-
priate books or journals. Unfortunately, searching for
institutions for healthcare professionals, and other books by subject can be somewhat frustrating if you
institutions of higher learning. Although this may are not aware of how the subject terms are chosen. An
cause a minor problem for the practitioner who is important point to keep in mind is that the catalog
isolated geographically, frequently material can be or database makes use of a specialized vocabulary,
found through the public library by using the services sometimes in contrast to the terms used in everyday
of interlibrary loan. Most of the information found language. A specialized vocabulary list may be re-
can be accessed online and in full-text via e-mail or ferred to as a thesaurus, medical subject headings,
electronic warehouses. You may be able to gain access descriptors, or subjects, depending on the database
to information by becoming a member of your uni- searched. See Table 3-1.
versity alumni association. Many universities offer
use of the library as a guest when you join the alumni U.S. Government Documents
association. Select libraries around the country are depositories
Once you have found a well-stocked library and for U.S. government publications. This collection is
a helpful librarian, you need to conduct a computer arranged by the Superintendent of Documents’ clas-
search of the literature. Occasionally, it may be nec- sification scheme and is updated monthly. It lists
essary to search printed indices and catalogs, espe- publications issued by all branches of the U.S. gov-
cially if the topic is of an historical nature. In this ernment, including congressional, department, and
case, enlist the help of a health information profes- bureau publications. Issues are indexed in separate
sional or librarian in locating the best sources of volumes for authors, titles and key words, subjects,
evidence. and series or report titles. The types of documents
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20 Section 1 ■ Beginning the Journey

ProQuest Dissertations
Table 3-1 ■ Specialized Vocabulary List This online database of dissertations and theses from
around the world dating from 1861 to the present can
Health-Based Catalog
be accessed from ProQuest. Most of the dissertations
Everyday Language or Database Language
and theses indexed can be purchased in electronic,
Injury Fracture, Open Wound hard copy, or microform formats through companies
Massage Craniosacral, Myofascial listed in the database. The price varies according to
Release the format. Many of the dissertations and theses
can be ordered through interlibrary loan from an
Dressing Donning, Doffing academic or public library. However, the database
includes comprehensive abstracts of the studies,
which may be sufficient for your purposes.
likely to be useful to therapists include amendments PubMed
to Medicare, Americans with Disabilities Act (ADA), PubMed contains more than 21 million citations to
Individuals with Disabilities Education Act (IDEA), biomedical research articles dating from 1948 and
Equal Educational Opportunities, and the Report of includes worldwide coverage. Consult the MeSH
the President’s Commission on Mental Health. (Medical Subject Headings) to identify the most
appropriate subject headings pertaining to your topic.
Health Professional Databases, Indexes, and
Abstracts OT Search, the Occupational Therapy Bibliographic
To use health profession-based online databases, in- System (formerly OT BibSys)
dexes, and abstracts, you must identify appropriate OT Search is a comprehensive database of literature
subject terms or know the authors of specific articles. and audiovisual material related to occupational
It is necessary to define the subject being researched therapy along with information directly related to lit-
carefully in order to locate relevant articles because erature in rehabilitation, education, psychiatry, psy-
terminology can be specific to the field and can vary chology, healthcare delivery, and administration. The
from field to field (e.g., one index may use the term actual material is contained in The Wilma L. West
adolescent, whereas another uses teen or teenager). There Library of the American Occupational Therapy Asso-
are user guidelines and tips for all of the following ciation in Bethesda, Maryland. Items indexed date
commonly used health profession databases, indexes, from the 1890s to the present.
and abstracts.
ERIC
The Cumulative Index to Nursing and Allied Health A database sponsored by the U.S. Department of
Literature (CINAHL) Education indexes education-related material, includ-
This resource indexes more than 3,000 journals on top- ing journal articles, conference proceedings, govern-
ics like occupational, physical, and speech therapy, as ment documents, and more.
well as 12 other rehabilitation disciplines. Therapy
students and practitioners find this an extremely well- PsycINFO
organized and useful database. It includes related This database, produced by the American Psycholog-
books, book chapters, conference proceedings, audio- ical Association, uses a content classification scheme
visuals, and educational software. Enhanced versions that divides the field of psychology into 16 major cat-
of CINAHL provide access to online full-text versions egories and 64 subcategories. It is well-organized, con-
of a large host of journals and books. Identify your sub- taining more than 3.3 million citations, primarily to
ject terms by utilizing the “CINAHL Headings” search peer-reviewed journal articles and books pertaining
function. These headings include both CINAHL sub- to behavioral sciences and mental health. Coverage
ject terms and MeSH (Medical Subject Headings). begins in 1597, but primarily focuses on the 1880s to
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Chapter 3 ■ Reviewing the Literature for Research and Practice 21

the present. A well-developed thesaurus of psychology

terms used to index citations is available through BOX 3-4 ■ Specialized Terms to Use When
the database. Searching a Database

Additional Indexes In a study on recruitment and retention issues

■ Resources in Education (RIE) for occupational therapists in mental health
■ Current Index to Journals in Education (CUE) practice (Scanlan, Still, Stewart, & Croaker,
■ Exceptional Child Educational Resource (ECER) 2010), the researchers identified terms such
as job satisfaction, attitude of occupational thera-
The RIE abstracts educational research reports
pists, career mobility, career planning, employee
(from 1975) by subject, author, and institution, and
attitudes, retention, and occupational stress.
most reports are available on microfilm. The CUE and
These terms were found in the thesauruses of
ECER abstract articles in education and education-
PubMed, PsycINFO, and OT Search. As men-
related journals by subject, author, and journal con-
tioned previously, different indexes and ab-
tent and are companions to the RIE. A thesaurus of
stracts use different terms to identify similar
terms accompanies these indexes.
subjects. For example, one index used the
term occupational therapy personnel, whereas
Searching and Selecting Databases another used occupational therapists.
Give careful consideration to how far in the past you
want to review your topic. If the subject is rapidly
developing or changing a great deal, or is currently to look through the list of terms in the accompanying
being written about (e.g., autism, occupational thesaurus than ponder alternative words.
health systems, surgical procedures in orthopedics), Selecting the database to be searched (e.g., PubMed
then 2 to 5 years may be sufficient to give you a great or ERIC) will depend on which field you think will con-
deal of material on the most up-to-date thinking. tain material relevant to your project, such as medicine,
If the subject has been developed over many years sociology, or education. Once the terms are entered,
(topics such as the development of personal values the computer will scan all the material in that database
or carpal tunnel syndrome) and has remained fairly for literature keyed in with those words for as far back
stable in content since the original work, it may be as you wish or is available in the database. Terms can
wise to go back to the time of most plentiful writing be combined with one another using the connector
on that topic, sometimes as many as 20 or 30 years, AND so that you receive only those articles keyed in
to find the classic works. If one or two articles or with both terms (e.g., arthritis AND joint protection).
books are constantly referred to in more recent You can search for three or four terms to be listed for
works, they are probably the classic and important each literature source, but likely you will get very few
writings related to that topic; therefore, it would be responses when being this specific. Synonymous terms
worthwhile to read them for a more thorough under- should be searched using the OR connector. It is often
standing of the topic. simpler and more cost-effective to print titles out at
When beginning a computerized search of any first, so that the items that appear most promising can
database, the user should have a well-developed be selected before purchasing or obtaining the full-text
research question and official subject terms (usually artifact (i.e., book, article, dissertation).
called subjects, descriptors, or MeSH headings) iden-
tified. The terms come from the thesaurus that ac-
Locating Articles and Books
companies each index (Box 3-4). If you cannot find the
topic under one heading, try finding a similar or re- Once a list of artifacts has been generated from a
lated term. Look for broader or narrower terms than search, the abstracts need to be reviewed to see if they
the original one used for searching. It is more efficient appear relevant to the study. Numerous books and
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22 Section 1 ■ Beginning the Journey

articles are available in full-text online. The cost of As soon as you have read and prepared cards or
obtaining copies depends on many factors, including computerized notes on all the artifacts, you are ready
publishers’ willingness to offer free access and your to write the review. Start by reviewing the subject
own affiliation with libraries that might own items headings and putting them in a logical sequence
or subscribe to databases. For print copies, you must (Box 3-5). In this way, the reader is carried through
go to the book stacks, the periodical room, or the a progression of topics pertinent to the study or
government documents depository to find the items. evidence-based practice experience. By the end of the
If an article is only peripherally related to your topic, literature review, the reader should understand why
you can jot down the relevant points together with the project was being undertaken.
the complete reference while you are in the library. Next, concentrate on one grouping of the literature
However, it will probably be preferable to make copies base at a time. Look for common themes that run
of the most pertinent articles or to borrow the most through the various authors’ research, and make a
relevant books, so that it is possible to study them at note of the themes. If a sole author makes a point you
your leisure. would like to include, mark it. Now look at these
themes and important points. Do they fall into a log-
Organizing the Material ical sequence? Do they flow from one to the other,
making the progression of ideas you want to convey
Some people feel comfortable organizing the literature to the reader? Write these ideas down in sequence and
directly on their computers or handheld devices, see if any steps are missing. If so, add them in your
whereas others still prefer hard copy methods. There is own words. When you are satisfied that you have
an endless choice of programs that make this a simpler stated the important issues about this topic in a clear,
task. However, some still find index cards useful in concise manner, add the authors’ names whose ideas
keeping information manageable and retrievable. You you have cited, together with the year of publication,
may find that a combination of filling out index cards in parentheses, after each idea. You are now ready to
and keeping data on your handheld device works best. move on to the next major subject area of your liter-
Whatever method you use, devise a system early on that ature review and to repeat the process.
will help you organize the large amount of information It is a true challenge to write a literature review
you will gather while engaged in a research study or an well. Try to avoid starting every sentence with “Smith
evidence-based practice experience.
Again, as committee members for hundreds of
research and evidence-based agendas, we have found
BOX 3-5 ■ Logical Sequence of Information
that, given the sheer volume of material that a stu-
dent collects, the student must have an organiza- If you were writing a review of the study
tional plan early on in the process. Those who prefer concerning prostheses mentioned earlier, it
to organize the information from their literature would be logical to order the literature re-
search directly on the computer may choose to use a view in the following way:
simple coding program to cross-reference materials. 1. Causes and incidence of amputation in
Software programs are readily available to help the re- elderly people
searcher organize and annotate citations. It is wise to 2. Decision to fit the elderly patient with a
enlist the help of a friend, peer, or the student learn- prosthesis
ing center at the institution you are attending to re- 3. Types of prostheses
view the various options available to you. All of these 4. Costs versus benefits
programs provide an efficient way to organize mate- 5. Physical limitations and motivation
rial because a single file or a collection of files can 6. Training procedures
eventually be used to construct the actual literature 7. Functional outcomes
review section of the article.
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Chapter 3 ■ Reviewing the Literature for Research and Practice 23

(2012) says . . .” or “Brown (2013) feels that. . . .” Read The Publication Manual of the American Psychological
through some literature sections in published articles Association (2010) offers helpful guidelines for what to
to get some ideas for imaginative ways to start sen- include in the background or literature review section
tences and ways to incorporate several authors’ ideas of your work.
and findings in one or two sentences. There are space At this juncture you know that completing the lit-
constraints in journals, so you will not be able to erature review is a major step in the right direction. It
devote many paragraphs to the literature summary. does not have to be written in final form at this stage
In fact, you will probably read many more articles and of the project, of course, but it is certainly a potential
books than you will be able to include. Restrict your- hurdle and it is a good idea to get the writing accom-
self to the most important and convincing work on plished as soon as possible. You are now ready to re-
the points you wish to make. Do a search to find three fine your research or evidence-based practice question
to four well-written literature reviews and use them and to develop the background material for your
as a guide, incorporating the best of each into your study based on what you have read.
own work. Also, remember that the format used to
cite references in the literature review is very specific,
Points to Remember When Writing
so try to find literature reviews that are cited and
the Literature Review
written in the format that you need to write in. Styles
will be addressed in detail in Chapter 14, which will Although it is important to discuss the literature, you
address publishing your work. do not need to include an exhaustive historical review
of your topic. Assume that the reader has knowledge
in the field for which you are writing and does not re-
How Long Should the Literature
quire a complete digest. A scholarly review of earlier
Review Be?
work provides an appropriate history and recognizes
We are asked this question a great deal, and the bot- the priority of others’ work. Citation of and specific
tom line is that your literature review needs to be credit to relevant earlier works is part of the author’s
expansive enough so you and the reader have a clear scientific and scholarly responsibility. Although it
understanding of what has informed the research is essential for the growth of cumulative science,
project or evidence-based practice project you are cite and reference only works pertinent to the spe-
about to embark upon. The length of a literature re- cific issue and not works of tangential or general
view varies greatly depending on the type of docu- significance. If you summarize earlier works, avoid
ment being produced. For the student writing a nonessential details; instead, emphasize pertinent
thesis, the literature review should be comprehensive findings, relevant methodological issues, and major
and demonstrate that a great deal of literature rele- conclusions. Refer the reader to general surveys or
vant to the study has been examined to assure the reviews of the topic if they are available.
reader that the most important material has been Demonstrate the logical continuity between pre-
analyzed. A large amount of literature should be ex- vious and present work. Develop the question with
amined that explains the issue, suggests why your enough breadth and clarity to make it generally
study is appropriate to it, describes your study’s understood by as wide a professional audience as
capability for informing the issue, and relates to any possible. Do not let the goal of brevity mislead you
other studies or evidence-based interventions that into writing a statement intelligible to only an expert
have attempted to solve the issue. in the field.
The literature review for a journal article, on the
other hand, tends to be brief and to the point. This is
Chapter Summary
because space constraints are imposed by journal
editors and there is often a requirement that an entire This chapter explores the task of conducting a litera-
article be kept within five to seven printed pages. ture review to inform the path of an inquiry. Before
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24 Section 1 ■ Beginning the Journey

any inquiry is initiated there is a need to explore the ■ Your topic does not make sense. No one has writ-
dialogue that has or has not occurred in relation ten in this area because it is not logical and there
to the subject matter that is going to be addressed. is nothing there to research.
Furthermore, it explores the process of approaching ■ You are looking in the wrong database (e.g., you
and undertaking an investigation of the literature are looking in medicine and should be looking in
that is pertinent to the inquiry. Collectively, the vocational services).
bodies of literature create the background for in- ■ You have chosen new territory; research has
depth understanding of the issues related to the topic
not been conducted in your area. This is very
of inquiry. The chapter highlights the fact that the
exciting—go ahead!
analysis of the literature acknowledges and brings to
■ Because many people find writing literature reviews
the forefront the limitations of existing research, pro-
viding justification of an inquiry and its research a tiresome task and one that they put off as long as
methodology. Lastly, it identifies potential resources possible, promptness is definitely the best policy
to facilitate the literature review process. and possibly the only policy that will ensure the
completion of your work. Besides, it is easier to
SKILL-BUILDING TIPS write a review with the material fresh in your mind
and while inspiration is still present. Sometimes
■ By documenting all points of the reference informa- your only stumbling block is active engagement in
tion immediately as you prepare your hardcopy or conducting the literature review. It is easy to do all
computer-based source index, you will save yourself the reading and take all the notes, but sometimes
time and trouble when you are ready to organize it is difficult to get around to synthesizing and
the reference list. When organizing the reference writing the literature review. It is a difficult and
list, you may find that you have: time-consuming task, but stay focused and you will
■ Lost the article be successful.
■ Returned the book
■ Loaned the article to someone else
■ Spilled coffee on the volume number
LEARNING ACTIVITIES
■ When you are immersed in piles of journals, books,
1. Locate a local library or visit the institutional
computer files, or copies, it is common to lose sight
library to which you are connected. Spend
of the primary topic and to get sidetracked into
some time in the library and familiarize your-
other interesting areas. We find it helpful to have a
self with the following:
sticky note in front of us containing our research
■ Online catalog
or evidence-based question and a list of the major
■ Reference librarian
areas for which we are searching. When we feel as if
■ Interlibrary loan services
we may be straying too far from the original intent
■ Online databases
of our inquiry or have forgotten the major issues
■ Reference section
(which does happen when you are reviewing
■ Periodical room
2,000–3,000 pages of information), we glance at the
■ List of periodicals and journals stocked by
sticky note and it gets us back on track.
that library
■ Ifduring a computer search you cannot find ■ Location of copying machines
any sources or very few sources relevant to your ■ Location of nearest depository of government
topic, there are several possibilities for what may be documents
happening:
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Chapter 3 ■ Reviewing the Literature for Research and Practice 25

REFERENCES
2. Complete an online catalog and database American Psychological Association. (2012). Publication manual of the
search for a topic of interest. American Psychological Association (6th ed.). Washington, DC: Author.
McCrory, B. J. (2012). Improving health care quality and safety: The development
Decide on the database most appropriate for and assessment of laparoscopic surgery instrumentation, practices and proce-
your subjects (discuss with the librarian) and dures. The University of Nebraska–Lincoln. ProQuest Dissertations and
Theses, 127. Retrieved from http://search.proquest.com/docview/
peruse the thesaurus for terms. 1010422327?accountid=13158
Database: Database: Scanlan, J. N., Still, M., Stewart, K., & Croaker, J. (2010). Recruitment
Terms: Terms: and retention issues for occupational therapists in mental health:
Balancing the pull and the push. Australian Occupational Therapy
Journal, 57, 102–110.
When the search has been completed, review the
list of titles and abstracts generated by the com-
puter and check off those you wish to locate.
Find books, articles, or dissertation abstracts
and complete index cards on peripheral sub-
jects at the library.
3. Write a rough outline for your literature review.
4. Locate at least four literature reviews that can
inform your work and are well-written.
5. Develop an online database for your topic and
catalog articles on your computer.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
3916_Ch03_017-026 20/10/14 10:48 AM Page 26
3916_Ch04_027-032 20/10/14 10:23 AM Page 27

Chapter 4

Refining the Topic of

Interest and Developing
the Background Story
When you go out on a limb, that’s when you really know
you’re living.
—Robin Quivers

LEARNING OUTCOMES Problem

The information provided in this chapter will assist the The heart of the study is the problem statement,
reader to: from which all other elements will flow. This is the
■ Understand the initial phases of the research reason for undertaking the study; it is the problem
process. or question that caught your interest in the first
■ Consider all the facets of a problem statement. place—the issue you wanted to solve in your clinical
■ Identify the background, purpose, and signifi- practice. After reviewing what has been written about
cance of a research study. the topic, you should be able to write about the prob-
lem comprehensively. At this point stop and ponder
this thought, “Is it a problem for many healthcare
professionals?” or “Am I going to write from a space
Refine the Question and Develop
I have been having difficulty with over the years or
the Background
an area I want to know more about?” Have others
As a way of refining the research question and de- identified the problem and tried to do something
veloping the background, it is helpful to start writing about it? Were their attempts successful or unsuc-
about the project at this juncture. Information from cessful? What will you do differently in your attempt
the literature search is still fresh in your mind, and to solve the problem? Or are you merely trying to
most of the literature findings will be incorporated gather more data about it? (See Box 4-1.)
into the early parts of the research manuscript. The research is usually driven by an action, such as
Writing the initial sections makes preparation for carrying out research by identifying something that
publication easier when that time comes. is wrong or something that needs attention, or by old

27
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28 Section 1 ■ Beginning the Journey

BOX 4-1 ■ Statement of Study Problem BOX 4-2 ■ Statement of Study Problem
Phipps and Roberts state the underlying Wideman and Sullivan state the problem for
problem for their study: their study in the following sentence:
Because of the challenging clinical presen- This study was conducted to determine
tation in children, adolescents, and young whether the level of risk for problematic recov-
adults with cerebral palsy (CP), occupational ery following work-related injuries is associ-
therapy practitioners and other health care ated with the number of elevated psychosocial
providers must use the best available evi- factors.
dence to optimize functional outcomes for They elaborate on the study’s objective
these clients. Yet, the base of evidence for through two more concise sentences:
predicting self-care, mobility, and social Psychosocial variables such as fear of move-
function is limited to a few research studies, ment, depression, and pain catastrophizing
many with small sample sizes. The current have been shown to be important prognostic
study includes 2,768 children, adolescents, factors for a wide range of pain-related out-
and young adults ages 0–19 yr to provide comes. The potential for a cumulative relation-
needed evidence for optimal therapy treat- ship between different elevated psychosocial
ment planning, caregiver education, and clin- factors and problematic recovery following
ical resource allocation. (Phipps & Roberts, physical therapy has not been fully explored.
2012, pp. 422–423) (Wideman & Sullivan, 2012, p. 58)

ideas or methods that are no longer adequate. The para- in the background material when it relates to the im-
graph stating the problem should be brief and to the portance of the problem (e.g., a leader of your na-
point. Tell the reader what is wrong, what has failed, tional association may believe that a certain stance on
what is missing, what current ideas are presumed true the issue you are researching is of primary impor-
that you wish to challenge, or what program needs to tance; therefore, you can quote her or him if it lends
be scrutinized. Write two or three sentences about the credence to your problem statement).
problem and read them to a colleague. If he or she In preparing this section of your research for pub-
misses the point, try again. Listen to yourself as you lication, try to make it interesting to readers. It
read. Is this really the problem you want to do some- should capture their attention and leave them agree-
thing about? See another example in Box 4-2. ing that the problem is important and worthy of
investigation. If readers are not captivated by this
section, they may not read any further.
Background
If, during your literature search in government pub-
Once you are satisfied with the wording of the prob- lications, you found general statistics related to your
lem, you are ready to address the background of your topic, now is the time to use them. More often than
study. The background answers the questions, “Why not, these types of data offer additional background
is this problem of concern?” “Why is it of theoretical information about the problem but do not have direct
interest?” Based on your reading, you should mention bearing on the specific clinical situation under inves-
why other people think the problem is important and tigation. For example, if the central problem concerns
needs work, but most important is background ma- insufficient subsidized health care for persons living
terial and your extensive literature review of the topic in rural America, statistics on how many people are
which supports the study you are going to embark without health care in the United States, and the dol-
upon. As noted, opinion as well as fact can be given lar amount of the rural poverty line as defined by the
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Chapter 4 ■ Refining the Topic of Interest and Developing the Background Story 29

government, may be included in the background. How- that the purpose be nearer the beginning of the re-
ever, the study itself might be concerned specifically search manuscript, in which case you can insert it im-
with access as a partial solution to the problem. In an- mediately after the problem statement and before the
other example, you might be studying the specific issue background. The purpose should tell the reader what
of falls experienced by elderly persons that result in you hope to accomplish regarding the problem by car-
femur fractures. In this case, it would be useful to men- rying out your study. Be clear about this by starting
tion the number of falls by elderly persons each year, the sentence, “The purpose of the research was . . . .”
the cost of medical treatment for these traumatic Then describe your intentions. The purposes of vari-
events, and the percentage of elders who are unable ous studies are illustrated in Boxes 4-4 through 4-6.
to return to their homes as a result of the fall. See the At this point in your manuscript, the reader should
expanded example in Box 4-3. be able to understand what you intend to accomplish
within your research and will later judge whether your
methodology is likely to achieve it.
Purpose of the Study
A clear statement of the study’s purpose should fol-
Importance of the Study
low the background material. Some advisors prefer
Another section of the manuscript that can be written
as a result of the literature review is the importance
of the study. The significance elaborates on what
BOX 4-3 ■ Statement of Background
of Study
In their 2011 research article entitled Stability BOX 4-4 ■ Statement of How the Problem
of Measurement Outcomes for Voluntary Task of the Study Will Be Addressed
Performance in Participants With Chronic Ankle The purpose of the study is to describe three
Instability and Healthy Participants, Van Deun measures of incidence used in sports injury
et al. described the following: epidemiology.
Background: Ankle sprains are among the
most common injuries seen in daily life and
sport activities. Approximately 40% of the
patients who have a lateral ankle sprain de- BOX 4-5 ■ Statement of How the Problem
velop chronic ankle instability (CAI). In the of the Study Will Be Addressed
literature, little attention was paid to the sta-
bility of measurements of electromyography The purpose of this study is to assess if
(EMG) for the ankle region. the inclusion of the additional x-ray projec-
Context: Acceptable measurement stability tions altered the sensitivity of bony injury
during data collections was critically impor- detection.
tant to research. The purpose was to inter-
pret differences in measurement outcomes
among participants or changes within partic-
BOX 4-6 ■ Statement of How the Problem
ipants after an intervention program. We
of the Study Will Be Addressed
need to know whether the measurement is
stable and consistent. The purpose of the study is to determine
Setting: Musculoskeletal laboratory. when (in minutes) a client can identify the
(Van Deun, Stappaerts, Levin, Janssens, & mind, body, and spiritual benefits after a
Staes, 2011, p. 366) 90-minute bamboo massage.
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30 Section 1 ■ Beginning the Journey

your study will do to affect the problem and why you a glimpse at methodology, the reality of how you
your study is important. It tells what makes your pur- will accomplish your purpose. Different methods for
pose worth pursuing. There are many ways to address conducting studies are discussed in later chapters.
a problem—for example, why did you choose your
particular purpose? This section will justify your Research Question
search. For example, there may be other studies ad-
dressing the issue, but you have a different purpose As a result of the writing that has been done so far, the
in mind (e.g., a group of individuals may have been original research question should have become clearer.
overlooked by other studies, and you wish to address This is the time to refine and reshape it. For example, what
their needs). The significance paragraph says that may have started out as the global question, “What
your study is appropriate for the research problem causes physician assistants to leave suburban prac-
and that some important benefits will occur if you do tices?” now becomes, “Physician assistants are leaving
it. This is the answer to the question, “So what?” It their suburban practices because they want to move to
gives you the chance to provide a persuasive, rational urban or rural areas to expand their practice interests
response (Box 4-7). and enhance their level of advancement.” Rework your
In writing these four sections—the problem, back- research question until it contains all the variables you
ground, purpose, and significance—you have engaged wish to study and puts them in a relationship with one
in expansive thinking, using global and far-reaching another that is supported by the literature. They may
ideas. Now is a good time to pull back into micro- have a cause-and-effect relationship; that is, one vari-
scopic thinking and ask yourself, “How would I go able causes something else to happen. Or they may
about achieving all this? Is it feasible?” This will give merely be correlated; that is, if one happens, the other
is more (or less) likely to happen in its presence.
In a directional research question, you are predicting
that by manipulating or adding a variable there will be
BOX 4-7 ■ Statement of the Importance a negative or positive outcome. On the other hand, for
of the Study a nondirectional research question, you are not going
Ried and Chiu note the importance of con- to be able to state or predetermine if the outcome
ducting occupational therapy research with will be positive or negative. Whether you choose to
culturally diverse mothers of premature infants: pose your research question in the directional or
Researchers need to be sensitized to the nondirectional format will depend on your clinical ex-
Western cultural values upon which most re- perience, what you want to investigate, and the out-
search designs and instrumentation are con- come of the literature review. If most of the literature
structed. Involvement of a culturally diverse leaned in a specific direction, it would be appropriate
research team, openness to feedback, adapt- to frame your question in that direction. If the material
ability, and critical reflection on what is im- was noncommittal, it would be appropriate to form a
portant to the cultural groups are among the nondirectional question. Alternately, sometimes there
suggestions for researchers planning home- is no-minimal literature regarding a question that a re-
based occupational therapy research with searcher wants to investigate. In this case, the research
culturally diverse populations. Furthermore, question should be framed and written according to
the objective of the research was to share les- what you want to investigate, identify, or prove.
sons learned in conducting home-based oc- When you feel pleased with your research question,
cupational therapy research with Canadian, go back to Chapter 2 and review the items that make
immigrant South Asian, and Chinese mothers a question realistic and researchable to be sure that
of premature infants in a large Canadian city. yours still meets the criteria. Perhaps you will find
(Reid & Chiu, 2011, p. 173) that you now need different resources or a more
refined selection of participants.
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Chapter 4 ■ Refining the Topic of Interest and Developing the Background Story 31

Chapter Summary your ideas to print: type on the computer, use

notecards, buy a nice notebook and divide it into
It is quite common for you, as the researcher, to con- chapters. When you come up with a thought for
fuse the problem, purpose, and significance of a a chapter, go to that section and write down your
study. Remember: thoughts.
■ The problem is the larger issue. ■ Enlist a peer. Tell the peer your problem statement.
■ The purpose is what you hope to accomplish Did the peer understand it? Ask the peer if it
as a result of your contribution to the larger makes sense to research this issue and do some-
problem. thing about it.
■ The significance is the importance of your
■ Remember that the question you think you are
particular study and what it will do to help
starting with will most likely evolve into something
solve the larger problem. It is the “So what?”
else. The concepts will stay the same, but the ques-
part of the study.
tion may look different. Write down many versions
These sections of your research manuscript may of the same question and just sit with them to
change several times, so do not get anxious or upset see where the literature leads you.
about a particular component of the process.
Remember, this is a learning process. There may be
steps of the research study that do not go as
planned. You must simply document these steps as LEARNING ACTIVITIES
you go along in order to make an accurate and hon- 1. Write down your original research question.
est account of events. This allows you to go back
2. State the general topic area of your project. What
and determine the factors that led to your change
is the specific problem you plan to address?
in plans. There will come a point when everything ■ Is there something wrong?
is as perfect as it can get. Just remember that when ■ Does something need attention?
pieces begin to blur together, it is very helpful to ■ Who is the individual, group, or community
stay focused on your question and come back to it
that will engage in the study?
as often as needed as your guide. Advice: Put your ■ Is something missing?
question on post-it notes and place them throughout your ■ Do old ideas need to be revisited?
home, work, and daily agendas for several months to en-
sure every minute you are doing research your focus is on 3. Practice writing your question several different
THE question. ways to expand or limit the options of your
research.
SKILL-BUILDING TIPS 4. Give at least three reasons why your research
agenda is important and valid to you, to soci-
■ Find at least 10 topic-related abstracts before ety, and to your profession. Why is your study
writing your own. The abstracts typically list important?
the problem, background, purpose, and signifi- ■ What can happen that will be beneficial if the
cance of the research study and can be invaluable study is done?
in helping you focus on your own work. Abstracts ■ What is the benefit of this study? Who bene-
from other studies are a quick way to get a fits from the findings?
handle on what was done in a study and they are ■ What might happen if the study is not
helpful in guiding you through your own inquiry done?
without the burden of reading the entire research ■ Write a significance statement.
manuscript.
5. State what you hope to accomplish regarding
■ Don’t feel pressured to write everything perfectly the research you are going to engage in.
the first time. Also, try different ways to get
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32 Section 1 ■ Beginning the Journey

REFERENCES
6. What do you hope to accomplish regarding Phipps, S., & Roberts, P. (2012). Predicting the effects of cerebral palsy sever-
the problem by carrying out your research ity on self-care, mobility, and social function. American Journal of Occupa-
tional Therapy, 66, 422–429. http://dx.doi.org/10.5014/ajot.2012.003921
agenda? Reid, D. T., & Chiu, T. M. L. (2011). Research lessons learned: Occupational
■ Who are the individuals, groups, or commu- therapy with culturally diverse mothers of premature infants. Canadian
nity members this research will impact in a Journal of Occupational Therapy, 78, 173–179. doi: 10.2182/cjot.2011.78.3.5
Van Deun, S., Stappaerts, K., Levin, O., Janssens, L., & Staes, F. (2011).
positive way? Stability of measurement outcomes for voluntary task performance
■ Will you change something? in participants with chronic ankle instability and healthy participants.
■ Will you understand something? Journal of Athletic Training, 46(4), 366–375.
Wideman, T. H., & Sullivan, M. J. L. (2012). Development of a cumulative
■ Will you interpret something differently?
psychosocial factor index for problematic recovery following work
related musculoskeletal injuries. Physical Therapy, 92, 58–68.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
3916_Ch05_033-044 20/10/14 10:23 AM Page 33

Section 2

Research
Methodologies
and Designs
3916_Ch05_033-044 20/10/14 10:23 AM Page 34
3916_Ch05_033-044 20/10/14 10:23 AM Page 35

Chapter 5

Getting Started in
the Research Process
All glory comes from daring to begin.
—Eugene F. Ware

answered using both of these methods simultane-

LEARNING OUTCOMES ously, which is referred to as a mixed methods design.
The information provided in this chapter will assist the
In order to decide on a study design, the features of
reader to:
each type of research are considered.
■ Differentiate between quantitative, qualitative,
and mixed methods research designs.
■
Comparison of Quantitative
Construct operational definitions of key study
and Qualitative Research
terms.
■ Examine assumptions made related to the study Purpose
population, testing measures, and procedures. The purpose of quantitative research is theory-testing:
■ Select an appropriate conceptual framework to establish facts, show causal relationships between
to guide the study and adequately define the variables, allow prediction of outcomes, and strive for
scope of the study. generalizability. Conversely, the purpose of qualitative
■ Discern conceptual and procedural limitations research is to cultivate an understanding of cultures, en-
within a study and their impact on the results. vironments, or groups of people; to develop grounded
theory; and to describe views, experiences, and beliefs.
Designs
Research Methodologies
Quantitative research designs, which are explored in
After you have committed to the research process, detail in Chapter 6, are predetermined and struc-
identified a topic of interest, refined your research tured, and do not change during the course of the
question, and explored the background literature, you study; the plan is formal and objective. Qualitative re-
are ready to consider the research methodology that search designs, which are discussed in Chapter 8, fall
will be used to investigate your research question. at the other end of the spectrum. The procedures are
Some questions are best answered with quantitative more general in nature and tend to evolve throughout
research designs, whereas others are more appropriate the study. They also guide progression of the study
for qualitative ones. Moreover, some questions may be and can be modified as necessary.
35
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36 Section 2 ■ Research Methodologies and Designs

Subjects open-ended interviews, and focus groups. In a qual-

In quantitative studies, the subjects are typically re- itative study, the researchers are often the only “tool”
cruited based upon specific inclusion and exclusion for data collection. Credibility is determined by the
criteria, and then randomly selected and randomly researcher’s skill, competence, and rigor. He or she
assigned to study groups. Subject samples tend may use guiding questions to elicit responses during
to be large in an effort to accurately represent an interview, as well as audio or video recorders,
the larger population of interest from which the translators, and transcribers to document responses
sample was drawn. In their most simplistic form, for later analysis. Using more than one data collec-
quantitative studies usually include at least two tion method within a research design, referred to as
study groups—an experimental group and a control triangulation, can help the researcher confirm the
or comparison group, with the control or compari- validity of the results.
son group serving to control for extraneous vari-
ables that could impact study results. Other variations Data Generated
of this design are discussed in Chapter 6. In qualitative The data gathered in quantitative research designs are
studies, the subject sample is small and may be non- quantifiable and statistical, using counts and meas-
representative of the larger population. Subjects are ures. Data are collected and managed according to
also selected based upon their roles, culture, or envi- very specific procedures developed before initiation
ronment, depending on the purpose of the study, and of the study. Data gathered in qualitative designs are
there is no need for randomization or a control or descriptive and deal with qualities. They may consist
comparison group. of field notes, artifacts, people’s own words, personal
records, recordings, or official documents. Qualita-
Researcher’s Relationship With Subjects tive data are extensive and can be difficult to manage.
Quantitative researchers typically have limited con- As noted in the following section, specific procedures
tact with the subjects on a short-term basis. They are used to process qualitative data.
are detached and distant, keeping the roles of re-
searcher and subject distinct. The researcher’s role Data Analysis
is to observe and measure; as the researcher must be Perhaps the greatest difference in the two styles of re-
objective, care is taken to prevent the researcher search is in how the data are analyzed. Data analysis
from influencing the data through personal in- occurs at the conclusion of data collection in a quan-
volvement with the research subjects. In contrast, titative study. It tends to be deductive and uses statis-
during a qualitative study, researchers usually have tical manipulation as planned in the study design
intense contact with subjects over an extended phase. It is a straightforward operation that is often
period of time. There is an emphasis on trust. The completed rather speedily. On the other hand, data
subjects are viewed as participants in an egalitarian analysis is ongoing throughout qualitative studies,
relationship, and the researcher may empathize using a constant comparison method. Data are ana-
with the subjects and their situations. lyzed as they are gathered, then reanalyzed in light of
new information, in a recursive manner. Qualitative
Data Collection data analysis is inductive in nature and addresses
Data collection tools and techniques used in quan- models, themes, and concepts. Techniques such as
titative and qualitative research vary greatly. In quan- coding, memoing, event listing, pattern-matching,
titative research, data collection methods can include charting, matrices, and triangulation may be used.
structured observation, interviews, surveys, record
review, hardware and equipment use, or standardized Outcomes
and nonstandardized assessments and tests. Tech- The outcomes of quantitative and qualitative research
niques used in qualitative research can include can be quite different. Quantitative research studies an-
observation, review of documents and artifacts, swer specific research questions by producing statistical
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Chapter 5 ■ Getting Started in the Research Process 37

evidence to prove or disprove hypotheses that were de- a combination of both designs, often referred to as a
veloped before the study. Although the researcher can mixed methods design. Some of the reasons to use
certainly discuss the findings, there is a common saying a mixed methods design are:
that the data, meaning the statistical outcomes, speak
■ To investigate a research question that cannot be
for themselves. The outcome of qualitative research,
effectively answered by quantitative or qualitative
more often than not, is a lengthy descriptive document,
methods alone
presenting the data in words rather than numbers. The
■ To strengthen a study so that methods complement
report is rich, textural, anecdotal, and full of thick
each other and increase confidence in the findings
description in narrative form. The final analysis pro-
■ To gain a comprehensive understanding of a
vides either verification of an existing theory or new
phenomenon by uncovering different dimensions
grounded theory, together with well-formulated re-
with different techniques
search questions that now need to be investigated.
■ To compensate for the weaknesses of one design
with the strengths of another
Potential Issues ■ To achieve triangulation. Triangulation is a
Although each type of research has definitive advan- technique that involves the use of two or more
tages, issues may be encountered in conducting either separate research methods or data collection tech-
type. Problems in quantitative studies could include: niques to confirm study results. When similar
■ Difficulty isolating or controlling variables that
results are obtained via multiple methods or
will affect the study techniques, the researchers have increased confi-
■ Difficulty recruiting an adequate number of
dence that their findings are valid.
appropriate subjects Box 5-1 provides an example to further distinguish
■ Questionable validity of the study, as some critics
between quantitative, qualitative, and mixed methods
feel that highly controlled experimental studies approaches.
have little relevance to real life It is important to understand the basic tenets that
■ Obtrusiveness of the researcher and data collec-
define quantitative and qualitative research including
tion methods that may affect the subjects or their purpose, methodologies, and outcomes. The
environment goal of quantitative research is to answer a specific re-
■ Ethical concerns regarding provision of experi-
search question via use of statistical evidence, whereas
mental treatments on human subjects qualitative research aims to verify or generate descrip-
Problems in qualitative research include: tive theory. To achieve these goals, the researchers
■ Nonstandardization of procedures approach the study in very different ways. The quan-
■ Difficulty of managing large amounts of data and titative researcher begins the study with a theory and
data reduction methods very specific hypotheses that address one defined
■ Extremely time-consuming nature of the whole issue, whereas the qualitative researcher begins with
process multiple vague research questions on a broad topic.
■ Difficulty of using naturalistic methods to study The questions may change throughout the qualita-
large populations tive study process, and the project ends by posing
■ Difficulty generalizing results to the larger popu- some specific hypotheses and grounded theory. In
lation of interest both cases, the methodologies to achieve these out-
comes are significantly different, with quantitative
designs employing rigorous formalized procedures,
Mixed Methods Designs
and qualitative designs using more general evolving
Although the two styles of research are presented as ones. When the principles and activities of both meth-
if they were mutually exclusive, in reality, the designs ods are fully grasped, the researcher can become adept
may be integrated and many research projects employ at using the methods independently or together. For
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38 Section 2 ■ Research Methodologies and Designs

BOX 5-1 ■ Example to Highlight Quantitative, Qualitative, and Mixed Methods Designs
Three groups of researchers were asked to de- a variety of practice settings to assess their
sign a study that would investigate the research opinions on evidence-based practice. Questions
question: Are healthcare practitioners increasing included:
their use of evidence-based approaches in daily ■ How do you feel about engaging in evidence-
practice? Teaching of evidence-based practice based practice activities?
has become commonplace in educational pro- ■ What value do you place on the use of
grams because of changes in education stan- evidence-based practice related to your
dards. Many disciplines have committees and daily work?
publications devoted specifically to evidence- ■ How prepared do you feel to engage in
based practice, and patients and third-party evidence-based practice activities?
payers are beginning to demand it. But have all This group of qualitative researchers felt that
these factors led to actual changes in the health- gathering sufficient data on the general topic
care practice? This question can be addressed in to propose hypotheses was more important
several ways. than answering the assigned research question.
The first group of researchers felt that an an- The third group chose a mixed approach,
swer could be found by asking experienced which involved asking 45 practitioners to quan-
practitioners to complete a quantitative survey tify the percentage of time that they engaged in
in which they reported the percentage of time evidence-based practice activities over the last
spent on evidence-based practice activities, month. However, the researchers also chose to
such as searching for evidence or participating interview a subset of this group, which included
in a journal club, each day. Fifty practitioners 20 practitioners, to supplement the numerical
were asked to quantify the percentage of time data with additional qualitative data. Interview
in the work day that they engaged in the out- questions included:
lined evidence-based practice activities 5 years
■ Why do you engage in evidence-based prac-
ago and then in their current practice. The re-
searchers set out to answer the research ques- tice activities?
■ What barriers have you encountered when
tion quantitatively, by comparing numerical
data indicative of practice 5 years ago and at engaging or attempting to engage in evidence-
the present time. based practice?
■ How has your practice changed related to
A second group elected to garner opinions
from practitioners regarding the topic of the evidence-based practice movement?
evidence-based practice and its use within their This group felt it was ineffective to look
specific discipline from a qualitative perspec- at the time spent engaging in evidence-based
tive. These individuals felt it was important to practice activities without investigating the mo-
investigate the whole notion of evidence-based tivations and barriers to engagement. Using
practice in order to make some substantiated both quantitative and qualitative methods gave
guesses about whether evidence-based practice them a more comprehensive picture of the phe-
was gaining momentum in recent years. The nomenon than either of these methods used
researchers interviewed 35 practitioners from alone.
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Chapter 5 ■ Getting Started in the Research Process 39

this reason, quantitative and qualitative research the problem statement, the purpose of the study, and
methods are treated separately in the next chapters. the research questions or hypotheses because a misun-
derstanding here could threaten the reader’s grasp of
the entire study. Definitions may come from sources
General Considerations for Any
such as dictionaries, medical textbooks, lists of syn-
Research Study
onyms, and glossaries, and may range from just a few
Regardless of the research method that you choose, words to elaborate explanations several paragraphs
in order to enable others to understand and apply long. Researchers may also use existing definitions
your research, you will need to consider and identify from authorities and cite the authors.
the following: When beginning a research project, some terms
■ Definitions and operationalization of all key may also need to be operationalized. Operationaliz-
terms if the meanings are not obvious ing involves strictly defining concepts in terms of
■ Assumptions about underlying principles of the how they are measured so that their meaning cannot
study be misinterpreted. For example, researchers interested
■ Conceptual or theoretical framework used to in studying the effect of a multisensory treatment
guide the study environment on negative behaviors in clients with
■ Scope of the study (how it fits into the scheme of dementia would need to operationally define multi-
existing professional literature) sensory treatment environment, negative behaviors, and de-
■ Limitations that are likely to influence results or mentia. Clearly describing the treatment environment
their interpretation allows the reader to fully understand the intervention
Each of these topics will be covered in greater being provided. Negative behaviors could include ag-
depth here. gression, agitation, or lethargy, to name a few. How
will these behaviors be quantified and documented?
Defining and Operationalizing Terms Furthermore, several types of dementia exist and the
Some of the terms in the study need to be defined, severity can be rated on a number of scales. Is the re-
whereas others need to be operationalized. In both searcher interested in presenile dementia, multi-
cases, the specific meanings of the terms in your study infarct dementia, or Alzheimer’s dementia, for ex-
need to be made clear to the reader. First, let’s con- ample? Specifying these aspects will facilitate appro-
sider the simple definitions. priate application of the study results as well as
People who read your study may come from a vari- replication in future studies. Operational definitions
ety of professional backgrounds and may not be famil- may apply not only to measurable items, such as
iar with terms specific to your discipline or specialty. degrees of flexion or percentage of oral intake, but
Defining your terms will help the reader know their also to more abstract concepts, such as independence
precise meaning in the context of the study. Some or self-esteem. See Box 5-2 for an example of defining
terms that need defining include those specific to your and operationalizing study terms and concepts.
field or which have everyday language counterparts
with which they might be confused. One example is the Assumptions
word grounded, which has a meaning in ethnography Next, you need to consider your own assumptions re-
that is quite different from its nautical or electrical garding the study and the premises upon which the
meanings. Another is the term occupation, which is used study is designed. Assumptions are underlying prin-
frequently in the occupational therapy literature to ciples that the researcher believes or accepts but that
refer to all of life’s meaningful activities including self- are difficult to prove in any concrete way. They are fre-
care, productive work, and leisure. Those outside the quently untested and untestable hypotheses, basic
discipline associate this term with paid employment. values, or views about the world. They include such
It is especially important to define terms that occur in values as the notion that people are basically good or
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40 Section 2 ■ Research Methodologies and Designs

BOX 5-2 ■ Example of Defining and Operationalizing Study Terms and Concepts
In an occupational therapy study, Chippendale They go on to describe the 90-minute writing
and Bear-Lehman (2012) explored the impact sessions conducted in the study, including the
of life review via therapeutic writing on re- prompts and additional questions raised to
ported symptoms of depression for adults in participants.
senior living communities. They provided the Next, they defined depressive symptoms in
following definition of therapeutic writing in terms of their impact on quality of life and
their article: functional independence in the aging popula-
Therapeutic writing, a form of expressive therapy tion. A review of current literature provides
that uses the act of writing and processing the the rationale for this study; therefore, depres-
written word, can take several forms. Emotional sive symptoms must be operationalized in
disclosure includes writing about emotional order to determine the effect, if any, life review
or traumatic life events without additional writing has on these symptoms. The authors
prompts, whereas guided autobiography, or life resolved to measure depressive symptoms
review through writing, includes written or ver- with the 30-item Geriatric Depression Scale
bal prompts to encourage writing about one’s (Lelito, Palumbo, & Hanley, 2001), which has
life in a systematic, chronological way irrespec- been recognized as a valid and reliable tool
tive of emotional content. (p. 439) with the chosen population.

that people want to function independently in their regular participation may reduce the cost of medical
day-to-day activities. These ideas would be very diffi- care for adults in subsidized housing and on govern-
cult to prove with the population at large or even with ment medical plans.
a small research group. The two researchers are likely to adopt different
Two kinds of assumptions need to be examined: study methods when addressing the impact of thera-
first, assumptions about the ideological principles peutic writing on depressive symptoms in adults in
upon which the study is based, and second, assump- senior living communities. The client-centered re-
tions that are made concerning the procedures used searcher would probably investigate the impact of the
in the study. We all adhere to certain ingrained prin- therapeutic writing on the well-being and quality of
ciples that will affect the way we approach situations life of the subjects, whereas the financially-oriented
and therefore the way we design research studies. researcher might investigate the results of the thera-
For example, in following their ideological princi- peutic writing on the health status and resulting
ples, a client-centered researcher and a financially- healthcare costs of the subjects.
oriented researcher might approach Chippendale The second type of assumption relates to the pro-
and Bear-Lehman’s (2012) study about the use of cedures used during the research study. Usually
therapeutic writing with adults in senior living com- these pertain to the instruments used and the will-
munities from quite different viewpoints. The client- ingness of subjects to participate in the study. For
centered researcher might hold the assumption that instance, researchers are often obliged to assume
as adults age, everything should be done to preserve that the measuring instrument being used is valid
their quality of life and to minimize depressive symp- and reliable because, at least in human subject re-
toms. Therapeutic writing might be one tool to ac- search, it is often difficult to prove validity and reli-
complish this. The money-conscious administrative ability conclusively. The most notoriously unreliable
researcher might feel that therapeutic writing con- instruments (in experimental research when replica-
tributes to improved mental well-being and that tion is desirable) are interviews and questionnaires,
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Chapter 5 ■ Getting Started in the Research Process 41

yet it is sometimes impossible to conduct a quanti- issues related to the research and where they should
tative study without them. keep a critical eye on procedures.
There are other basic assumptions associated To further clarify, people often make the mistake
with the use of measuring instruments, such as as- of including in their assumptions those notions that
suming that the subjects will answer questions hon- can be proven; in other words, ideas that are referenced
estly and respond to tests of skill to the best of their in scientific literature. If an idea can be proven scien-
abilities. In designing study procedures, the re- tifically, it need not be presented as an assumption but
searcher must consider, in advance, events that may rather should be presented in the literature review as
occur during the study and must try to control for part of the reason for conducting the study in a certain
those events to avoid having to make procedural manner. Only beliefs that are difficult to prove con-
assumptions about them. For example, in some cretely, those that are untested or untestable, or those
studies in which performance of a skill is being assimilated from a variety of sources should be in-
measured, it is imperative for the study that sub- cluded in the assumptions section.
jects try as hard as they can on the test. To ensure Researchers routinely examine their assumptions
this, some researchers have devised reward systems carefully and state them to the reader near the begin-
to compensate subjects according to their motiva- ning of the study. Readers need not agree with the as-
tion level. When these types of strategies are used, sumptions put forth by the researcher but they should
assumptions need to be made less frequently and be able to follow the logic of the propositions and un-
only for items beyond the researcher’s control and derstand why the researchers approached the study as
ingenuity. Making your assumptions known is im- they did. Box 5-3 illustrates how one author clearly dis-
portant so that readers know where you stand on cussed important assumptions in her doctoral project.

BOX 5-3 ■ Example of Assumptions in Research

For her doctoral thesis, Trickey-Rokenbrod treatment time and in following through
(2011) studied the driving skills of community- outside of therapy to make progress toward
living elderly adults. Being employed in an out- the established goals related to driving. This
patient setting, she was specifically concerned assumption is partly based on confidence in
with what clinic-based interventions would be the skill the author has in establishing ther-
most effective for improving driving subskills apeutic rapport with new clients.
and self-awareness of driving performance in A major assumption underlying this project
this population. She clearly and concisely artic- is that driving performance can be influ-
ulated her assumptions in designing her inter- enced by in-clinic remediation of subskills and
vention as follows: increased older-driver self-awareness. While
Before conducting a literature review the au- there have been indications of this [outcome]
thor of this project had a general assump- (Sivak et al., 1984; Caragata et al., 2009;
tion that all elderly drivers want to continue Marottoli et al., 2007) many studies have been
to drive. This impression comes from expe- inconclusive or have limitations in size, popu-
rience working and interacting with elderly lation or methodology that limits generaliza-
clients as well as older family members that tion to the proposed setting. A last assumption
drive. Another assumption is that clients in is that without an on-road assessment method,
the outpatient OT clinic will want to work the proposed assessment tools will be sensitive
on driving as a part of therapy, and will put enough to pick up progress made toward
forth significant effort both during clinic driving- related goals. (pp. 60–61)
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42 Section 2 ■ Research Methodologies and Designs

Scope of the Study and Guiding The scope tells the reader the study’s focus, what
Conceptual Framework will be covered in the project, and what will not be in-
The scope of a study includes a clear explanation of cluded. For instance, if a sensory integrative approach
the study’s area of focus, purpose, and relationship will be taken in a study, it is unreasonable to expect
to existing literature. Conceptual frameworks, also the researcher to cover the possibilities of what might
known as models of practice, are theoretical explana- happen to subjects if a behavioral approach had been
tions of functioning that can guide practitioners in used. Informing the reader of the background and
their treatment approach with clients or researchers any guiding principles puts the study in context
in their approach to a study. Some examples of these within the work that was previously accomplished on
frameworks include a behavioral approach, a biome- the topic. In this way, it is immediately apparent to
chanical model, a sensory processing model, or a readers how the current study can add to the existing
model of change. These models can be individualized body of literature on the subject.
to specific disciplines or applied across disciplines.
In some cases, the description of the scope is elabo- Limitations of the Study
rate and meticulously presented, perhaps in instances In setting forth your study’s limitations, you should
when the researchers are presenting a new treatment include conceptual and methodological shortcom-
choice for a particular client population. Detailed ex- ings that cannot be overcome in the study design.
planations of the background and the guiding frame- Limitations in experimental research may include the
work may be necessary for the reader to fully grasp the inability to randomly select the subjects, or to include
logic and meaning behind the study. In another study, a control group, or the lack of a standardized instru-
where the purpose and approach are more easily un- ment to measure variables. Nonexperimental research
derstood, it might be appropriate to explain the scope may have insurmountable methodological problems,
and conceptual framework within one paragraph. such as lack of an appropriate mailing list of the
For example, the purpose of Carnaby-Mann and people you want to poll in an attitude survey, which
Crary’s (2008) study was to determine the effect of could force you to make do with an over-inclusive or
adjunctive neuromuscular electrical stimulation on the under-inclusive list. Conceptual limitations could
treatment of pharyngeal dysphagia, or difficulty swal- include such problems as an underlying principle of
lowing. Although other techniques—such as thermal the study not being widely accepted outside your
stimulation and oral motor exercises—may improve professional specialty.
swallowing function, these interventions were beyond Naturally, listing a study’s limitations does not ex-
the scope of the study. The researchers reviewed the ex- cuse you from making all possible attempts to over-
isting literature on use of neuromuscular electrical come the problems. After all possible improvements
stimulation, noting 11 other studies completed thus in study design have been made, pointing out the
far with affirming results; however, they also noted remaining limitations shows that you are aware of
that this approach to treatment was still not well- them and will consider them when discussing the
defined. In order to expound on this prior research, results. Although some researchers may be tempted
the authors made it clear to readers that they were ap- to give litanies of limitations, doing so may discount
plying the first of Robey’s five-phase model for clinical- the fact that the research may still prove useful in ad-
outcome research (Robey, 2004). This model, typically vancing knowledge in the area of study. There is a
used to comprehensively describe a therapeutic inter- middle ground to be achieved between listing every
vention and evaluate its outcomes, usually involves conceivable problem and quirk in a study and being
case study, case series, or retrospective designs. Thus, fair with the reader and presenting those things that
Carnaby-Mann and Crary (2008) chose a prospective could truly bias the results. Knowledgeable readers
case series design, defined their population precisely, will pick up obvious limitations but will respect an
and explained the rationale for the study. author who acknowledges problems and considers
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Chapter 5 ■ Getting Started in the Research Process 43

them in the interpretation of the findings. Box 5-4 of- Chapter Summary
fers an example of how a group of physical therapists
made clear the important limitations in their study. In this chapter, you were provided with foundational
knowledge regarding research methodologies, and
you may now have some early ideas about which
type of design might be suitable for your research
BOX 5-4 ■ Example of Study Limitations question. Considering your research question, cir-
cumstances, and objectives is the first step in making
A group of physical therapists from Loma this decision. Chapters 6 and 7 provide additional
Linda University in California studied the information and support for conducting quantitative
effects of virtual reality gaming on dynamic research, and the corresponding information on qual-
balance and strength in older adults (Rendon itative designs can be found in Chapters 8 and 9.
et al., 2012). Because of the increased inci-
dence of falls in this population, finding in-
terventions that effectively improve mobility SKILL-BUILDING TIPS
and balance was critical. Although the study ■ Consider a quantitative study if you:
supports the use of virtual reality gaming in ■ Want to support a hypothesis
this endeavor, these findings must be applied ■ Want to look for the effect of one variable upon
with consideration of the study’s limitations
another
as reported:
■ Are interested in the relationship between two or
There were several limitations in this investi-
more variables
gation. No participant was able to complete
the entire series of exercises without the use ■ Want to find out some specific facts about a large
of the assistive devices at least one time. This group of people
fact is cause for concern for potential injury ■ Have access to a large group of people who meet
in regard to independent practice devoid of your criteria
supervision. Review Chapters 6 and 7 for more details if you feel
Also, the sample pool from which the par- a quantitative design may fit your goals.
ticipants were selected from is a limiting fac- ■ Consider a qualitative study if you:
tor in terms of generalising [sic] the outcome
■ Want to generate a new theory
measures. All participants were veterans or
spouses of veterans from the US military, ■ Want to generate new hypotheses to be tested
which created a specific mindset of account- later
ability of appointment keeping and exercise ■ Are interested in exploring the thoughts, feelings,
rigour [sic], which is possibly higher than the and beliefs of a small group of people
average population. Another potential limi- ■ Want to gather data in a naturalistic setting
tation is that this intervention was not com- ■ Have access to a natural setting and the ability to
pared with any other form of traditional spend large amounts of time there gathering data
physical therapy balance training program. from individuals, groups, and records
Additionally, we did not have the control
group perform the warm-up and cool-down Review Chapters 8 and 9 for more details if you feel
exercises and therefore cannot say with cer- a qualitative design may fit your goals.
tainty that the intervention group benefits ■ Mixed methods designs may require advanced
were not due to the warm-up/cool-down knowledge, skills, and time, and more in-depth ex-
routines. (Rendon et al., 2012, pp. 551–552) planation is beyond the scope of this text. If you feel
this approach may suit your purposes, be sure to
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44 Section 2 ■ Research Methodologies and Designs

seek assistance from a research advisor at your

facility or institution, or review some of the addi- the variables and phenomena in question, and
tional resources provided at the end of this chapter. any treatments or interventions provided.
■ Once
3. What assumptions have you made in contem-
you have decided upon a methodology, find
three studies in the literature that employed this plating your study? Make a list of assumptions
methodology. Reviewing these studies will help you regarding your population, testing instruments
to determine if your topic and goals will be sup- and procedures, and the study environment,
ported by the chosen method. as well as your rationale for assuming these
things.
■ Choose a topic that you have some experience with
4. What is the underlying framework or scope of
and feel passionate about. Without these two crite-
ria, you will spend much time establishing baseline your study?
knowledge to formulate a research question, and 5. What conceptual and procedural limitations
your motivation for the project may fade quickly. can you anticipate for your study in this early
■ Review the conceptual or theoretical frameworks phase of development?
commonly used within your discipline. Determin- REFERENCES
ing an appropriate framework can help you to gain Carnaby-Mann, G. D., & Crary, M. A. (2008). Adjunctive neuromuscular
a perspective on your study and to shape its design. electrical stimulation for treatment-refractory dysphagia. Annals of
Otology, Rhinology & Laryngology, 117(4), 279–287.
■ Do not be discouraged if your study topic and Chippendale, T., & Bear-Lehman, J. (2012). Effect of life review writing on
design change multiple times. Remember that re- depressive symptoms in older adults: A randomized controlled trial.
American Journal of Occupational Therapy, 66, 438–446. http://dx.doi.org/
search is a process and these features typically 10.5014/ajot.2012.004291
evolve over time as you delve deeper into the topic. Lelito, R. H., Palumbo, L. O., & Hanley, M. (2001). Psychometric evalua-
tion of a brief geriatric depression screen. Aging and Mental Health, 5,
387–393. http://doi.org/10.1080/13607860120080350
Rendon, A. A., Lohman, E. B., Thorpe, D., Johnson, E. G., Medina, E., &
Bradley, B. (2012). The effect of virtual reality gaming on dynamic balance
in older adults. Age and Aging, 41, 549–552. doi:10.1093/ageing/afs053
LEARNING ACTIVITIES Robey, R. R. (2004). A five-phase model for clinical-outcome research.
1. Consider the example in Box 5-1, then reflect Journal of Communication Disorders, 37, 401–411.
Trickey-Rokenbrod, D. (2011). Improving driving subskills and self-awareness
on your proposed topic. Could your topic be
in older drivers in an outpatient setting. Unpublished manuscript, Depart-
explored via quantitative, qualitative, or mixed ment of Occupational Therapy, Chatham University, Pittsburgh, PA.
methods designs? Draw up a simplified plan to
explore your topic with each of these research RESOURCES FOR MIXED METHODS RESEARCH
designs. DESIGNS
Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed meth-
2. Make a list of key terms for your study. Then ods approaches (4th ed.). Thousand Oaks, CA: SAGE Publications, Inc.
operationalize each term. Don’t forget terms as- Hesse-Biber, S. N. (2010). Mixed methods research: Merging theory with practice.
New York, NY: The Guilford Press.
sociated with defining your subjects, measuring

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
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Chapter 6

Quantitative Research
Methodology and Design
Success is a journey, not a destination.
—Arthur Ashe

categories of research designs discussed here include

LEARNING OUTCOMES experimental designs, quasi-experimental designs,
The information provided in this chapter will assist the
and nonexperimental designs.
reader to:
■ Identify features of quantitative research, includ-
ing manipulation, control, and randomization.
Features of Quantitative Research
■ Understand basic quantitative research designs. Before choosing a quantitative research design, it is im-
■ Explain how aspects of internal and external valid- portant to consider several features that can affect ex-
ity can impact outcomes of quantitative research. perimental rigor. These three concepts will be explored:
■ Describe how reliability can influence outcomes
1. Manipulation
of quantitative research.
2. Control
3. Randomization

Q
“ uantitative research is a formal, objective,
systematic process in which numerical data
are used to obtain information about the
world” (Burns & Grove, 2009, p. 22). Quantitative re-
Manipulation
Manipulation merely means doing something to one
or more variables in the study. A variable is anything
search designs are most often employed “to describe that can vary or change and therefore can be mea-
variables, examine relationships among variables, sured. For example, if the researcher offers a group of
and determine cause-and-effect interactions between patients with schizophrenia a daily program of self-
variables” (Burns & Grove, 2009, p. 22). In this chap- care activities to determine whether their appearance
ter, some of the major quantitative research designs can be improved, manipulation is provided in the
will be described and their advantages and disadvan- form of daily self-care activities. Generally, any treat-
tages discussed. Of course, there are many more de- ment or intervention offered to subjects in the hope
signs than those presented here, but beginning that they will show improvement can be called manip-
researchers should be able to find a design to fit ulation. Changing the environment or the timing of
their needs when starting the research process. Broad an intervention can also be considered manipulation.
45
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46 Section 2 ■ Research Methodologies and Designs

In other words, the researcher is manipulating one The researcher may be able to control some
or more variables in connection with the subjects. In variables such as:
the foregoing example, the variable of self-care is ■ Environmental influences (e.g., the amount of
being manipulated or given as treatment to deter- noise or the aesthetics of the surroundings)
mine whether it will have an effect on another ■ Change of healthcare practitioner providing the
variable, namely, the patient’s appearance. treatment (it might be important to the study
Dependent and Independent Variables that the same practitioner be used so that pa-
It is important to understand the difference between tients become accustomed to him or her, or it
variables in a quantitative study. The independent might be equally important that different practi-
variable is the variable that is being manipulated, tioners be used to eliminate the influence of cer-
which could affect the outcome (or dependent vari- tain practitioners’ styles)
able). Conversely, the dependent variable is typically
■ Certain events in the patients’ lives (such as
the variable being measured. In the previous example, obtaining a physician’s cooperation in maintain-
the independent variable (self-care) is manipulated ing patients’ medications during the period of
to determine the effect on the dependent variable the study)
(the patients’ appearance). The independent variable However, it is not possible to control all variables
is sometimes called the experimental or treatment that may affect the study results. Thus, it is important
variable. The dependent variable (appearance) deter- to have a control group of subjects who experience
mines the effectiveness of the manipulation or treat- the same day-to-day occurrences and influences as the
ment and is the outcome observed and measured at experimental group yet do not receive the study treat-
the beginning and end of the study. ment. By including a control group, the researcher is
Manipulation must be part of the methodology if attempting to ensure that any helpful or detrimental
the study is to qualify as a true experimental design. event influencing the amount of change in the de-
Thus, if the researcher does not actually manipulate pendent variable (the one being measured) will hap-
a variable pertaining to the subjects, a study cannot pen to both groups of subjects. At the end of the
be termed experimental. For example, a study in which study, when the dependent variable is measured for
subjects are asked to complete a questionnaire and both groups, if there is greater improvement in the
the researcher merely examines answers or variables experimental group, the researcher can say that this
after the fact is not experimental. was likely because of the manipulation or treatment.
In certain situations, it is not ethical to withhold
Control treatment from a group of patients in order for them
The second concept that needs defining in order to to serve as a control group. There are generally three
understand quantitative research designs is con- ways to deal with these circumstances. For example,
trol. Control refers to the researcher’s ability to a researcher might like to know if a new form of
control or eliminate interfering and irrelevant in- treatment is more effective for a certain condition
fluences in a study’s design. This will allow the re- than the traditional treatment for that condition.
searcher to say that the results are because of One option to test this question is to have the con-
manipulation of the variables and not because of trol group receive the traditional treatment and the
chance interferences of other variables. In the ear- experimental group receive the new treatment, hold-
lier example, if there were no control, it is possible ing all other conditions constant. This design satis-
that instead of the program of self-care skills, some fies the need for a control group as well as the ethical
other event in the patients’ lives (such as a volun- concern. Another option might involve collecting
teer taking the patients to the store to buy new data on the experimental group before initiation of
clothes) might have caused improvement in their the new treatment. By comparing data before and
appearance. after the new treatment, the experimental group
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Chapter 6 ■ Quantitative Research Methodology and Design 47

functions as its own control. A third option is to use the population. A sample is selected from the popu-
two distinct groups—an experimental and a control lation or the subpopulation (Box 6-1). A population
group, with the control group being offered the does not necessarily refer to people; it may also refer
experimental treatment following the initial phase to things such as records or events that are being
of the study. This allows the researcher to draw con- studied (Box 6-2).
clusions regarding the experimental treatment and For true random selection, every subject in the pop-
to satisfy ethical concerns by permitting both groups ulation of interest must have an equal opportunity of
to undergo the same treatment. The concept of being selected. Therefore, merely using patients
control embraces elements of the third concept to be who come through your door or client records that
discussed—that of randomization. happen to land on your desk would mean that not all
subjects had the same chance of inclusion in the
Randomization study, because all those who did not walk through
your door or whose records did not land on your desk
Systematic bias refers to inherent flaws in a study’s
had no chance of being selected. Instead, a complete
design that can influence or skew results. Random-
ization is used to reduce the risk of this bias creeping
into the study. In addition, randomization increases
BOX 6-1 ■ Example of Subject Selection
the study’s external validity, which is the chance that
the results found in the subjects can be generalized In Walach, Güthlin, and König’s 2003 study of
to others who are similar. It also increases the study’s the effects of massage therapy on chronic
internal validity, which is the chance that observed pain, the population of interest included all the
changes are because of the intervention or treatment patients with chronic pain, namely noninflam-
being provided and not because of other possible matory rheumatic conditions and headache,
causes. Randomization involves two components— although the subpopulation included all the
random selection and random assignment. patients with these symptoms residing in a
Random selection means that every subject in the locale in Germany. The sample for the study
population being studied has an equal chance of was selected from this subpopulation. Sub-
being selected for the study sample. Researchers care- jects were randomly assigned to the experi-
fully consider who they wish to study and then set cri- mental group, who received the massage
teria for the subjects. For example, inclusion criteria therapy treatments, or to the control group,
might consist of people diagnosed with chronic schiz- who received standard medical care for their
ophrenia who had multiple admissions to hospitals condition.
totaling at least 5 years and who have one or more
family members available for support. For the same
study, the researchers might determine exclusion cri-
teria as patients younger than 18 years of age, and BOX 6-2 ■ Example of Study of Records
those living more than 25 miles from the research or Events as Population
center. Once the inclusion and exclusion criteria are In studying the comprehensiveness of physical
determined, the researchers must choose a method to therapy documentation, Leerar et al. (2007)
select a group of individuals (sample) to be in the reviewed medical records in six private practice
study from among those who meet the criteria. clinics in Tacoma, Washington. Their subpop-
In research, the population of interest refers to ulation was comprised of all patient records
the entire group of people or items that meet the containing medical codes related to low back
subject inclusion criteria set by the researcher. The pain. From this subpopulation, 160 records
population consists of all such subjects, whereas the were randomly selected for review.
subpopulation is a researcher-defined subgroup of
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48 Section 2 ■ Research Methodologies and Designs

list of people or items in the population or subpopu- interest is studied. Thus, the results of your study can
lation of interest must be available to the researcher be more readily generalized to the entire population
and a random selection made from that list. In the of interest and are more useful to other healthcare
study by Walach et al. (2003) (see Box 6-1), they would practitioners who would like to use your treatment
have needed a complete list of all the patients in Ger- method with similar patients. Remember, if random
many who met the research criteria, namely all those selection has not been used, the results of a study may
with noninflammatory rheumatic pain. They then not be easily generalized to other people in the popu-
could have placed all the names in a hat and picked lation of interest.
out the required number for the study, or assigned a Random assignment, the second component of
number to each patient and used a random number randomization, means that those in the selected sam-
chart to select patients for the study sample. Either ple each have an equal chance of being assigned to
one is an acceptable method of random selection, but either the experimental group or the control group.
the latter is probably more practical. Although true A complete subject sample should be selected first,
random selection is the ideal, the ability to access and and then a similar process is used to assign subjects
randomly choose subjects from everyone that meets randomly to the two groups. Random assignment is
your subject inclusion criteria within an entire popu- done primarily to ensure that the candidates in each
lation is not usually realistic. group will be as alike (or as unalike) as possible; it also
A random number chart, which may be found in a ensures that the researcher will not be tempted to as-
statistics book, lists numbers that have been gener- sign a “good” candidate to the experimental group
ated by a computer in true random fashion. The chart because it looks as if he or she will show a lot of
may be read in any direction (up or down, side to side, improvement. This technique helps to minimize
diagonally), starting at any point, to produce a list of researcher bias, which can impact study results.
random numbers. This method is commonly used Random assignment will improve internal validity
when researchers mail questionnaires and have access and specifically help to ensure that the experimental
to a complete mailing list of potential subjects who treatment made a difference rather than something
meet their criteria—a population. It is simple enough else within the study design. It will also “even out”
to assign a number to each name, then to pick a series the effect on the study of such things as attrition
of numbers from the chart and to include the people (subjects dropping out of the study), developmental
with corresponding numbers in the study. For a list maturation (changes or improvements as a result
of names that has already been entered into a com- of natural aging or development), practice effects
puter file, many programs and online tools are avail- (changes because of new learning or repeated testing
able that will assist with random selection, saving the and training), or regression (patients getting sicker
researcher a great deal of time. Some examples in- over time).
clude Research Randomizer (Urbaniak & Plous, 2012), The point of randomization is to ensure that the
HotBits (Walker, 2006), or Microsoft Excel (Microsoft, sample is as representative of the population of inter-
2010). For more information on types of randomiza- est as possible and that the experimental and control
tion or other online programs, see Suresh’s (2011) groups are as similar to each other as possible. This
article, “An Overview of Randomization Techniques: enables the researcher to state more confidently that
An Unbiased Assessment of Outcome in Clinical the results are because of the treatment given rather
Research.” than to a difference in characteristics between the two
To further clarify, random selection ensures that groups. It also minimizes the chance that the sample
the sample is as much like the larger population from members were not typical of the population and
which it was drawn as possible, and will therefore im- improved because of some uncontrolled trait they
prove external validity—that is, that similar findings held in common. It is important to remember that
are likely if another portion of this population of some variations in samples are usually expected
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Chapter 6 ■ Quantitative Research Methodology and Design 49

and preferred, for eliminating all variation among a variety of other phenomena in the methodology, and
sample would greatly decrease external validity, or random selection and assignment of subjects to study
limit the ability to generalize results to groups with groups. These designs are prospective in nature, mean-
dissimilar attributes. For example, the results of a ing the plans for the study are laid out well in advance,
study examining the effects of an afterschool recre- and the subjects are followed moving forward in time,
ation program on Caucasian female kindergartners as opposed to retrospective studies where subjects or
with obesity in the rural Midwestern United States phenomena are examined backwards in time in relation
might not be easily generalized to older children, to an outcome that has already occurred. Experimental
males, those of other ethnicities, or those residing in designs are most commonly used to determine cause-
urban communities. Although the study may yield and-effect relationships, thus denoting a strong chance
beneficial information for this select group, applica- that the manipulation of the independent variable
tion beyond the original study is limited. caused a change in the dependent variable. This method
Randomization is not perfect. It is based on the laws allows the researcher to compare different types of
of probability; however, every once in a while the im- treatment and to determine which type is likely to be
probable will happen and a source of bias will appear the most effective.
in a study. For example, one group may end up being
composed of patients who are sicker or older than Basic Experimental Design
those in the other group. Also, methods must be used In a classic experimental design, the researcher delib-
correctly for random selection to be effective (Box 6-3). erately manipulates the independent variable in the
Keeping the concepts of manipulation, control, experimental group, but not in the control group, and
and randomization in mind, we can review three then looks for the results of those differences on the
categories of quantitative research designs: true ex- dependent variable. For example, with the rise in the
perimental designs, quasi-experimental designs, and aging population and the increased incidence of
nonexperimental designs. Alzheimer’s disease, a researcher might be interested
in studying the effects of a formal caregiver training
program on the stress level of caregivers of Alzheimer’s
Experimental Designs
patients. Caregivers can be randomly selected and
True experimental research designs involve manipula- assigned to one of two groups—an experimental group
tion of at least one independent variable, control of a that will be provided with formal education on how
to care for individuals with Alzheimer’s disease, and a
control group that will not receive this training. The
BOX 6-3 ■ Example of Poor Randomization dependent variable, caregiver stress level, is measured
A classic example of poor methodology oc- for both groups before and after treatment so that
curred in the 1969 selection of men who were comparisons can be made on the same group; com-
to be drafted into the army. A slip of paper parisons between groups can also be made by measur-
with the name and month of birth for each ing both “after” tests. The before and after tests are
man were put into an urn and drawn out, but called pretests and posttests.
the slips were not well mixed. The last slips A variation of the basic research design, a random-
put into the urn were of men whose birthdays ized controlled trial (RCT) is the most rigorous de-
fell in October, November, and December, sign, as it has high internal validity and is regarded as
and disproportionately more of these men’s the “gold standard” for clinical research (Portney &
names were drawn than others. This was a Watkins, 2009, p. 22). Internal validity can be further
case in which poor methodology had serious improved if the study is single- or double-blinded.
consequences. In a double-blinded RCT, the researchers and the
subjects are unaware of the hypothesis being tested
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50 Section 2 ■ Research Methodologies and Designs

or the assignment of subjects to experimental and If circumstances dictate, the random assignment
control groups. This lack of awareness prevents to groups can be performed after the pretest; how-
changes in subject performance because of their ever, the assignment should not be influenced by the
knowledge of treatment or the researcher’s expecta- results of the pretest. Following random assign-
tions. In a single-blinded RCT, only one group, ment, equivalency between the two groups may be
either the subjects or the researchers, are blinded to assumed; however, performing a pretest provides a
the treatment. Blindness can also be preserved by further check on equivalency. This double check is
having different individuals responsible for study particularly useful in dealing with small samples
design, implementation, data collection, and statis- (Portney & Watkins, 2009). Nevertheless, attrition
tical analysis (Portney & Watkins, 2009). (loss of participants), particularly that which differs
For ease of communication with other researchers between experimental and control groups, is a
and to permit the researcher to sketch out designs continuing concern.
quickly, a system of shorthand known as research
notation was developed by Campbell and Stanley Pretest–Posttest Design With Follow-Up
(1969). An O represents the observations or mea- If you want to determine whether or not the effect of
surements that occur at pretesting and posttesting; an intervention is long-lasting, the design may be fur-
an R represents random assignment; and an X rep- ther improved by adding a follow-up observation or
resents manipulation or treatment. Each study posttest (O2 and O4), as shown here:
group is written or represented on a separate line,
and time periods are aligned vertically. In research
notion, a design consisting of two randomly as- R O X O1 O2
signed groups, one with treatment and one without,
R O O3 O4
and both with pretesting and posttesting, would be
illustrated as follows:
This will enable you to see if any improvement fol-
R O X O lowing the treatment has been maintained over time.
R O O Box 6-4 illustrates the point with a follow-up occur-
ring 26 weeks after the posttest.
Using this design, the resulting data from the
pretests will enable the researcher to see whether Posttest-only Design
or not the two groups were truly similar to begin Sometimes, the results of the treatment may be influ-
with. In some circumstances, the pretest may be enced by the fact that a pretest has been administered.
necessary to assist with subject selection. For exam- For example, subjects may benefit from practicing a
ple, subject inclusion criteria might require partic- task used in the pretest, thus diminishing the effect
ipants to be able to remember and follow a short of the intervention. In this case, the pretest might be
sequence of directions. Pretesting might include a omitted as long as subjects have been randomly se-
brief cognitive screen to determine that subjects fit lected and assigned to groups. In other cases, the
the study’s inclusion criteria. At the conclusion of pretest may be excluded when administration is
the study, posttest scores can be compared to see deemed too time-consuming to support its use. A dis-
which group shows the greatest change in the de- advantage of this study design is that the researcher
pendent variable. Finally, the pretest and posttest has no way of confirming if the two study groups are
of each group can be compared to see how much equivalent before the intervention, which can impact
change occurred for the experimental versus the the ability to draw conclusions about the effective-
control group. ness of the intervention being provided (Thomas &
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Chapter 6 ■ Quantitative Research Methodology and Design 51

can eliminate this design flaw, but it requires many

BOX 6-4 ■ Example of a Pretest–Posttest subjects and a great deal of researcher time. It is
Design With Follow-Up constructed as follows:
A 2010 study compared the effectiveness of
therapeutic massage, thermotherapy (control Group 1 R O X O1
group), and a relaxing room therapy for indi-
Group 2 R O O2
viduals with generalized anxiety disorder. The
68 subjects were randomly assigned to the Group 3 R X O3
three groups and received the assigned Group 4 R O4
“treatment” for 10 sessions over a period of
12 weeks. An anxiety rating scale was admin-
istered pre-intervention, post-intervention There is random assignment to four groups—two
(12 weeks), and for follow-up at 26 weeks. experimental and two control groups:
All groups demonstrated improvements in ■ Group 1 receives the pretest, the experimental
anxiety level following the intervention, and treatment, and then the posttest.
there was no significant difference among the ■ Group 2 is given the pretest and the posttest, but
groups (Sherman et al., 2010). This design undergoes no treatment.
could be notated as follows: ■ Group 3 is not given a pretest but receives the
experimental treatment and the posttest.
R O X1 O O ■ Group 4 only receives the posttest.
R O X2 O O In comparing the posttest results, the researcher is
R O X3 O O able to test not only for differences between experi-
mental and control groups but for any interaction
between the pretest and experimental treatment by
comparing groups 1 and 3 (on O1 and O3) and groups
2 and 4 (on O2 and O4). An example of this study
Hersen, 2011). Using research notation, this design
design can be found in Box 6-5.
appears as follows:
Factorial Designs
The experimental designs mentioned so far are de-
R X O
signed to cope with one independent variable only;
R O however, researchers may be concerned with more
than one variable in the same study. Factorial
designs may be used to investigate two or more
Solomon Four-Group Design independent variables and their interaction with
In cases where the researcher is unsure whether or the dependent variable. These designs allow the re-
not the pretest has an effect, or knows that it has an searcher to use the same subjects to study the effects
effect but feels that it provides crucial information, of the independent variables on the dependent vari-
the Solomon four-group design can be employed. able as well as any joint effect or interaction effect.
Use of some pretests could impact outcomes by al- In factorial designs, each independent variable is
lowing the subjects to practice or learn skills being called a factor.
tested or by raising awareness of elements being For example, a study by two occupational thera-
investigated (Wludyka, 2012). The Solomon four- pists provides insight into how visual acuity and age
group design is a powerful research design that affect performance on cognitive assessments. Hunt
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52 Section 2 ■ Research Methodologies and Designs

BOX 6-5 ■ Example of Solomon Table 6-1 ■ Depiction of Hunt and Bassi’s
Four-Group Design 2010 Factorial Design Study
Garvin and Damson (2008) used the Visual Acuity Young Adult Older Adult
Solomon four-group design to determine the
20/30 Group 1 Group 4
effect of viewing ideal fitness images in the
media on physiological affect in male and 20/50 Group 2 Group 5
female college students. Subjects were ran- 20/100 Group 3 Group 6
domly assigned to one of two experimental
groups (who viewed fitness magazines) or
to one of two control groups (who viewed
If age were expanded to contain a third category,
National Geographic magazines). Only one
such as middle-aged adult, it would be a 3 X 3 design;
experimental group and one control group
this is shown in Table 6-2.
underwent pretesting, and all four groups
In a different variation, a third variable or factor,
completed posttesting. Results indicate that
such as gender, might be added to the original design,
the completion of the pretest did not impact
with two levels for the gender factor, making it a 3 X
overall study outcomes, but without use of
2 X 2 design as depicted in Table 6-3. Age and gender
this study design, researchers would have
are actually pseudo-independent variables because
been unable to confirm this.
they are not being manipulated by the researcher;
they are already occurring attributes of the subjects.
However, in factorial designs, pseudo-independent
variables are often treated in the same manner as true
and Bassi (2010) assessed 124 community-dwelling
independent variables.
adults, and divided them into six groups as follows:
As more variables are added, both the complexity of
1. Young adults tested with 20/30 or better visual the design and the number of subjects required in-
acuity (control group) creases. Specific statistical procedures are used to ana-
2. Young adults tested with 20/50 visual acuity lyze these designs, and usually the services of a
3. Young adults tested with 20/100 visual acuity statistician or a statistical software package are required.
4. Older adults tested with 20/30 or better visual
acuity (control group)
5. Older adults tested with 20/50 visual acuity Quasi-Experimental Designs
6. Older adults tested with 20/100 visual acuity Similar to true experimental designs, quasi-experimental
The two independent variables were the level of designs still contain an independent variable that is
visual acuity (20/30, which served as the control,
20/50, or 20/100) and the factor of age (young
adult, ages 19–30, versus older adults, 65 years
Table 6-2 ■ Chart Depicting 3 X 3
of age or older). Therefore, the study was concerned
Factorial Design
with the effects of these variables on the depen -
dent variable—performance on common cognitive Visual Young Middle Older
assessments. Acuity Adult Age Adult Adult
This study is charted in Table 6-1. There are three
20/30 Group 1 Group 4 Group 7
levels for the independent variable or factor of visual
acuity (20/30, 20/50, and 20/100), and two levels for 20/50 Group 2 Group 5 Group 8
the independent variable of age (young adult and 20/100 Group 3 Group 6 Group 9
older adult). Thus, this is called a 3 X 2 design.
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Chapter 6 ■ Quantitative Research Methodology and Design 53

Table 6-3 ■ Chart Depicting 3 X 2 X 2 Factorial Design

Young Adult Older Adult
Male Female Male Female

20/30 20/50 20/100 20/30 20/50 20/100 20/30 20/50 20/100 20/30 20/50 20/100

manipulated in order to determine the effect on a de- ization is lacking or a control group was not employed.
pendent variable; however, they typically lack a control Box 6-6 includes an example of a study without ran-
group or random selection and assignment of subjects, dom selection or a control group.
or both. The resulting designs are still very useful to
practitioners looking for validation of treatment meth- Quasi-Experimental Design Lacking Control
ods and techniques. When researchers want to study As noted previously, sometimes researchers use sub-
naturally occurring real world situations, or when there jects as their own control. There is no second group
are ethical concerns with use of a control group or of subjects who are without treatment; rather, the
withholding treatment from a particular group, quasi- subjects in the experimental group double as the con-
experimental designs are most appropriate. In some trol group. They receive the treatment, but they also
cases, time and financial constraints might also support experience a period of no treatment, which is consid-
use of a quasi-experimental design. Regardless, caution ered the control period. Sometimes data can be col-
should be used in generalizing study results if random- lected before the treatment, for a period of time equal

BOX 6-6 ■ Example of a Study Lacking Random Selection and a Control Group
In studying the effects of two treatment ap- Even though the two groups were found
proaches on plantar heel pain, Cleland et al. to be equivalent on pretesting, caution must
(2009) recruited patients from two outpatient or- be taken in generalizing results because sub-
thopedic clinics—one in New Hampshire, United jects were not randomly selected. Subjects
States, and one in New Zealand. Subjects were were recruited from only two clinics; there-
randomly assigned to one of the two groups, and fore, they may not represent the broader pop-
results of pretesting indicate that the groups were ulation of all individuals with plantar heel
analogous. If they had been found to be substan- pain. Outcomes indicate increased success
tially different at the pretest stage, the researchers with use of the manual physical therapy and
could have either abandoned the groups and exercise program versus the program of
started the study over or used statistical tech- modalities and exercise. Yet, one must con-
niques to take into account the differences. sider that without a control group (for exam-
In this study, one group received a series of ple, a group that received only the exercise
modalities and an exercise regimen, whereas the regimen), it is difficult to determine if it was
other group received manual physical therapy and the combination of these approaches that
an exercise regimen. The design looked like this: helped the patients or the manual therapy
and modalities alone.
R O X1 O
R O X2 O
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54 Section 2 ■ Research Methodologies and Designs

to the treatment period, and then later compared to

outcomes following the treatment. This can be re- BOX 6-7 ■ Example of Convenience
ferred to as a one-group pretest–posttest design. Sampling
For example, data on handwriting legibility for sec- In a study aimed at determining the effective-
ond graders might be collected during one semester, ness of discharge planning among pairs of
and then compared to data on handwriting legibility stroke survivors and their caregivers, the sub-
from this same group obtained during the next se- jects were recruited from four neurological
mester when students participate in a structured mul- wards in a hospital in Taiwan. Even though
tisensory handwriting curriculum. By comparing the sample was one of convenience, the re-
handwriting legibility in these two semesters, conclu- searchers took additional steps to decrease
sions can be drawn about the effectiveness of the bias. Two wards were randomly selected to
multisensory handwriting curriculum in comparison serve as the experimental groups, and two as
to the traditional handwriting program. the control groups. All four wards consisted
Quasi-Experimental Design Lacking of the same physical arrangement and num-
Randomization ber of beds, admitted patients with similar
diagnoses, and were staffed by the same neu-
In some situations, random selection or assignment
rologists, nurses, therapists, social workers,
of subjects may be unrealistic or unethical. Conven-
and doctors, thereby mitigating the effects of
ience sampling is the most popular type of sampling
staff behaviors and environmental conditions
because it is the easiest and least expensive of all sam-
(Shyu, Chen, Chen, Wang, & Shao, 2008).
pling techniques, and it is utilized when it is imprac-
tical to randomly sample the entire population of
interest. Major differences are likely to occur when
the two groups are convenience samples (i.e., groups other attributes considered important to the study.
that are already formed by some event preceding Rubin (2006) offers a plethora of foundational arti-
the research study). They may be groups of patients cles on matching in research designs, and explains the
in two different wards of the same hospital, two methodology of matching subjects. An example of
different nursing homes, or two day-care centers, matching is shown in Box 6-8.
for example. Box 6-7 illustrates the use of conven- Nonequivalent study groups are less likely to
ience samples. Additional sampling techniques will occur if the subjects have been randomly assigned,
be reviewed in Chapter 7. even though they were not randomly selected from
Some criticize the use of convenience samples, the population of interest. This obviously cannot be
maintaining that it is impossible to make reasonable achieved if convenience samples are taken from dif-
comparisons between such groups. Because subjects ferent locations, but can be achieved with a conven-
are chosen based upon availability, one cannot as- ience sample taken entirely from one facility. Random
sume that the sample will accurately represent the assignment may ensure that the two groups are sim-
population or subpopulation of interest. Yet, others ilar in characteristics, even though they may not be
suggest that using convenience samples provides a representative of the population.
practical solution to a very real problem and that
valuable information can still be gained as long as Cohort Designs
this bias is considered when interpreting and apply- Cohort designs involve specific groups, or cohorts,
ing results. The crucial question to ask is whether the of subjects that are followed over time. When using
two study groups truly come from the same popula- cohort designs, a control group is again used to as-
tion. The researcher may match subjects in the study sess the changes made in the experimental group,
groups so that there are commonalities in such items but this time the groups are not observed at the
as socioeconomic status, gender, age, diagnosis, or same time. The groups follow each other through a
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Chapter 6 ■ Quantitative Research Methodology and Design 55

BOX 6-8 ■ Example of Subject Matching BOX 6-9 ■ Example of How History Can
Impact a Study
Classen et al. (2011) used matched controls
in their study to determine what screening In studying the impact of depression on self-
tests could be used by driving rehabilitation care management in a group of hospitalized
specialists and neurologists to predict ac- depressed patients, a therapist reported that
tual driving performance in patients with the death of President John F. Kennedy, which
Parkinson’s disease. A convenience sample of occurred partway into the study, had a pro-
41 individuals with Parkinson’s disease was found impact on the patients (Clark, 1964).
age-matched with a group of 41 community- She surmised that this historically tragic event
dwelling adults. Matching the sample by age compounded the results of her study.
allowed the researchers to attribute differ-
ences in performance on the screening tests
to Parkinson’s symptoms rather than age The cohort design can be improved by employing
alone. This, in turn, led to conclusions about recurrent institutional cycles, using three different
which screening tools are most predictive of cohorts. The design is as follows:
actual driving performance.

Time 1 Time 2 Time 3

setting such as classes of students moving through X O1 O2 X O3 O4
a therapist training program or groups of trainees (Posttest) (Pretest) (Posttest) (Pretest)

entering a sheltered workshop for a training period.

One group is selected as the experimental group and
subjected to a unique experience, whereas another The first group receives the experimental treat-
group acts as the control group and experiences the ment followed by a posttest; the second group re-
usual events of the setting. The subjects in these ceives the traditional pretest, treatment, and posttest;
groups are obviously not randomly chosen, because and the third group receives only a pretest. The ideal
the groups are naturally occurring. Nonetheless, the pattern of results from this design would be a simi-
two groups may be considered somewhat similar in larity of responses on pre-tests O2 and O4 and on
that they both meet the setting’s admission require- posttests O1 and O3. The effect of the treatment
ments. The design may be depicted as follows, where would be evident by comparing scores on pretest O2
Time 1 and Time 2 represent two distinct differences and posttest O3.
in time:
Time-Series Designs
Time-series designs are used when the researcher
Time 1 Time 2 wishes to study the effects of some treatment or con-
O X O O O dition over time. These studies may also be referred
to as case series or longitudinal studies, and they can
involve multiple measurements (pre- and posttests)
There are internal validity problems with this de- before and after treatment. The amount of time
sign because of the difference in the time of the ob- from the study’s beginning to conclusion can range
servations. History (i.e., some sort of global event that from several weeks to decades. For example, Herman,
has an effect on all subjects in the sample) may play a Hopman, and Craig (2010) were interested in deter-
part in accounting for the differences in data from mining the effect of childhood body mass index
the posttests (Box 6-9). (BMI) and physical activity on adult health-related
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56 Section 2 ■ Research Methodologies and Designs

quality of life. Data obtained from a fitness survey ■ A learning effect (i.e., changes because of education,
in 1981 of 310 subjects ages 7 to 18 years was com- repeated exposure to testing, or other information)
pared to data obtained on follow-up assessments ■ An inherent characteristic in the subject such as a
22 years later. seasonal improvement
Time-series designs have no control group, and the There is no subsequent treatment period to use as
subjects in the experimental group act as their own a test for these possibilities.
control. In the single-group time-series design, sub- A third possible variation of the time-series design
jects are given a pretest, followed by experimental can control for some of these flaws:
treatment and a posttest. Then a period of time is al-
lowed to elapse, typically equivalent to the amount of
the experimental treatment time, and then another O O O O X O O O O
posttest follows. Periods of treatment and nontreat-
ment are alternated with tests. During the treatment The multiple pretests will give a more accurate pic-
periods, the subjects in the group comprise an exper- ture of how subjects score on the dependent variable
imental group, and during the nontreatment periods before the experimental treatment, will control for
they act as a control group. The design is notated as seasonal or cyclical changes in abilities, and will elim-
follows: inate the effect of history. An even more preferable
design would be:
O X O O X O O X O

O O O X O1 X O2 X O3 O4 O5
The group may be randomly selected to increase
the likelihood of its being representative of the pop-
Here, history is controlled for and the effects
ulation of interest. Of course, the issue of random
of experimental treatment can be viewed on
assignment to groups is a moot point because there
more than one occasion (at O1, O2, and O3), and the
is only one group. Overall, this design provides a high
permanence of the effect can be measured (O3
degree of internal validity, meaning that one can be
through O5). The disadvantages of this design are
fairly sure that any changes that occur in the depen-
that it is often impractical to wait long enough
dent variable at posttests are because of the experi-
to administer several pretests before treating the
mental treatment.
patient and that the entire study becomes lengthy
In a variation of the time-series design, a researcher
(Box 6-10).
may wish to assess the permanence of change in the
Despite the fact that these are quasi-experimental
dependent variable and may do so by administering
designs, they are effective and can be quite practical
several posttests after the intervention, thus:
for the clinical researcher. It is sometimes easier
to gain permission to recruit patients for quasi-
O X O1 O2 O3 O4 experimental studies than it is for experimental
studies; for example, it is difficult to deny treat-
ment to patients in control groups. Finally, the
However, this design does have a flaw, in that it is fact that these designs are carried out in clinical set-
difficult to know if improvement at the first posttest tings, with all the concomitant interferences and
(O1) was because of the intervention or because of lack of control inherent in such settings, makes
something else, such as: them more likely to be generalizable to other clini-
■ Some other event that occurred concurrently cal settings. It is, after all, in day-to-day clinical
■ Something special that occurred with the proce- practice that we wish to put the results of research
dure, instrument, or researcher into effect.
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Chapter 6 ■ Quantitative Research Methodology and Design 57

there is no manipulation of independent variables,

BOX 6-10 ■ Example of Time-Series Design and a cause-effect relationship cannot be established.
Curran, Sharpe, Flynn, and Button (2010) Instead, in correlational research, the researcher is
used a time-series design to study the atti- looking for a relationship between variables. Rather
tudes of undergraduate healthcare students in than hypothesizing, for instance, that being blind will
regard to interprofessional education and cause an individual to have heightened tactile sensi-
teamwork. Students from pharmacy, medical, tivity, one might conjecture that there is simply a re-
nursing, and social work programs partici- lationship between the variables “blindness” and
pated in a series of interprofessional learning “heightened tactile sensitivity.” Blindness has already
modules over a period of 3 years. Multiple as- occurred by the time the researcher is studying it,
sessments, designed to measure student atti- making this retrospective, nonexperimental research.
tudes and satisfaction about their experiences, The researcher tests a hypothesis, comparing two or
were administered as students progressed more variables by measuring differences and looking
through their education. Results of these as- for a relationship. The procedure for the correlational
sessments were then compared to determine research design is similar to that for experimental
if differences existed among professions or if designs; that is, reviewing the literature, formulating
attitudes changed as they progressed through research questions or hypotheses, defining and opera-
the program. tionalizing terms, selecting a sample from the popula-
tion of interest, and selecting data collection and
interpretation methods. However, in correlational re-
Nonexperimental Designs search, specific statistical tests, which look for an asso-
ciation between two variables, are used. This association
Nonexperimental designs are frequently used to de- is known as a correlation coefficient and yields a value
scribe or characterize phenomena, to examine relation- between –1 and +1, where 0 indicates no relationship
ships among variables, or to determine the reliability and the two extremes indicate a perfect negative (or in-
and validity of evaluations, tests, or equipment. They verse) relationship (indicated by –1) or a perfect positive
may also be referred to as preexperimental designs be- (or direct) relationship (indicated by +1) (Box 6-11).
cause they often serve as precursors to later experimen- Because this is nonexperimental research and,
tal or quasi-experimental studies. Nonexperimental therefore, is not subjected to the stringent rules of ex-
designs are commonly used in health care, where re- perimental research, similar results should be repli-
search often focuses on various forms of disability or cated in many studies before healthcare practitioners
illness, and the researchers only have access to subjects can claim relationships between variables concerning
after they have acquired the disability or illness. In their patients.
these cases, causal relationships cannot be assumed,
but insight into the condition and the response to Survey Research
treatments can be explored. These designs are also said “Survey research is a method of inquiry characterized
to be retrospective because the dependent variable by collecting data using structured questions to elicit
(disability or illness) has already occurred. The most self-reported information from a sample of people”
common nonexperimental designs are reviewed here. (Forsyth & Kviz, 2006).
Surveys are cross sectional in the sense that they
Correlational Research generally describe the group at one point in time, and
Many nonexperimental studies in health care fall into they are most commonly used to determine the preva-
the correlational category, and may serve as precur- lence or distribution of disease or disability, to evalu-
sors to later experimental studies. Correlational re- ate circumstances or needs of a population, or to
search is similar to experimental research in that a describe interrelationships (Kielhofner & Fossey,
hypothesis is being tested; however, it differs in that 2006). Information collected in survey research covers
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58 Section 2 ■ Research Methodologies and Designs

generalizing. Methods of sampling as well as design-

BOX 6-11 ■ Example of Correlational ing effective survey questions are critically important
Study Design in survey research and these topics are addressed in
A correlational study was conducted by greater detail in Chapter 7. Several other texts also
Tawashy, Eng, Lin, Tang, and Hung (2009) provide additional information on these topics
to see if there was a relationship between (Fowler, 2009; Groves et al., 2009; Salant & Dillman,
the physical activity level of individuals with 1994). Box 6-12 offers an example of survey research.
spinal cord injury and their levels of pain, fa- Quantitative Case Study Research
tigue, and depression. High intensity physical
In quantitative case study research, an individual,
activity was strongly correlated with less fa-
group, unit, community, institution, or event is stud-
tigue (r = –0.767) and pain (r = –0.612), and
ied in great depth over time—anywhere from a few
increased self-efficacy (r = 0.656). Moreover,
weeks to several years. Thus, it is a longitudinal study,
mild physical activity was correlated with
rather than a cross-sectional study like the survey de-
fewer symptoms of depression (r = –0.565)
sign discussed previously. Quantitative case studies
(p. 304). For negative r values, the two attrib-
are often referred to as single-subject, single-case,
utes were inversely proportional, whereas
multiple-case, case series (more than one case), or
for positive r values, the two attributes are
small-N studies in other publications. This design is
directly proportional.
used to examine unique cases or situations where the
subject or intervention in question is unusual, little
understood, or impractical to study under experimen-
a vast array of topics and may include items ranging tal conditions (Berg & Latin, 2008). The number of
from attitudes, values, opinions, and motives, to more variables is usually very large. Data is generally gath-
concrete information such as the respondents’ work ered by one researcher at various points throughout
situation, environment, living situation, and behaviors. the life of the case and may occur in a natural setting,
To qualify as research, the survey must be carefully
crafted to answer a well-defined set of questions that
have been grounded in a literature review and have BOX 6-12 ■ Example of Survey Research
significance and relevance. The manner of analysis In Fuller’s 2010 study, she wanted to investi-
and interpretation of the data also make this a re- gate the practice of speech therapists (type of
search design rather than solely a survey to elicit some treatment, trainings, interdisciplinary services,
facts about a particular group. The method of analy- locations of treatment) working in the United
sis needs to be chosen and applied judiciously; inter- Kingdom’s Sure Start program. Sure Start was
pretations and application to the population of a governmental program to provide multidis-
interest must be made with care. Information may be ciplinary services to children up to 5 years of
collected directly through a face-to-face interview or age from disadvantaged situations. She re-
telephone interview, or indirectly through the mail, cruited speech therapists by contacting all Sure
e-mail, or various web-based survey sites. Start program sites and inviting the speech
It is crucial that the relevant population be defined therapists employed there to complete her sur-
clearly and that its characteristics and limits are de- vey. Of 501 sites contacted, 113 speech ther-
scribed. Random sampling is most commonly used apists completed the survey, consisting of
to ensure that the conclusions of the survey can be both closed and open-ended questions, via
generalized to the larger population of interest. If e-mail. This yielded a response rate of 23%.
you are not confident that the sample is representa- Please refer to Fowler’s text (2009) for further
tive of the population, the resulting discussion will details on adequate response rates.
be invalid for the larger group about whom you are
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Chapter 6 ■ Quantitative Research Methodology and Design 59

such as the home, but more often in a clinical setting, survey, it is useful to bear in mind that “how” and “why”
such as a hospital. questions are best answered by case studies. For exam-
Case studies often fall into the category of ex- ple, Nwora and Gee (2009) asked, “How can sound-
ploratory studies, in which the goal is hypothesis based interventions be used to improve sensory
generation for further study under experimental con- processing and language skills in a child with pervasive
ditions. Information obtained can be generalized to developmental disorder?” Healthcare practitioners
theoretical propositions, rather than to populations in often ask how and why a particular adaptive aid or
the way that experimental results are. The researcher’s treatment procedure worked with a particular patient.
goal is to expand and generalize theories, such as how In the current example, the researchers wished to gen-
a phenomenon occurs, changes, or is sustained over erate ideas about the role of a therapeutic sound pro-
time, rather than to enumerate the frequency or preva- gram in improving sensory processing and language
lence of the phenomena. An abundance of case studies skills in children with pervasive developmental disor-
can be found in the rehabilitation and healthcare liter- ders, rather than just enumerating the times or the de-
ature, which provide accounts of treatment techniques gree to which the child was able to respond more
and procedures that have helped practitioners to be appropriately. Their hope was that other occupational
more effective in the direct care of clients. therapists would try this idea with similar patients, test-
When trying to decide whether to use a case study ing the hypotheses and elaborating on the theory. More
rather than another type of exploratory study such as a details about this example are included in Box 6-13.

BOX 6-13 ■ Example of Case Study Research

In a case report in Occupational Therapy Interna- revealed improvements in receptive and expres-
tional, Nwora and Gee (2009) recount the story sive language, attention, tolerance to touch
of John, a 5-year-old boy diagnosed with per- and sound, and the ability to regulate his be-
vasive developmental disorder–not otherwise haviors in classroom situations. A video of his
specified. He was currently receiving traditional in-classroom performance confirmed the re-
occupational therapy services because of de- sults of these administered assessments. Func-
creased attention, aggressiveness toward sib- tionally, he was able to participate in classroom
lings and peers, and decreased tolerance to games and songs, interact more effectively
touch and sound. John’s deficits were similar with his peers and siblings, and respond appro-
to those of other children diagnosed with vari- priately to directives and questions from his
ous autism spectrum disorders, and the re- teacher and his parents.
searchers were interested in how a therapeutic In the discussion, the authors argue that al-
sound program might impact these deficits. though John was not diagnosed with an audi-
Research dating back to the early 1950s sup- tory processing disorder, progress in this area
ports use of sound-based clinical interventions led to improvements in social and behavioral
with this population, but testing on current symptoms. They also suggest that because
therapeutic listening programs that involve use children with disorders on the autism spec-
of “psycho-acoustically modified music” in the trum each present with symptoms that vary in
client’s own home has been very limited. nature and severity, alternative treatments
During the intervention, John participated in should be explored to ensure the most success.
the therapeutic listening program two times Therefore, more research is needed to validate
per day, for 15 minutes each time, for a total the use of sound-based interventions with this
of 20 weeks. At the conclusion, posttesting population.
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60 Section 2 ■ Research Methodologies and Designs

Once you have determined that a case study design Multiple-case study designs are more appropriate
is most appropriate for your purposes, you will need when numerous similar cases are present, and when
to decide if you will use a single-case study or multiple- the aim is to substantiate theoretical constructs. In
case study. Single-case studies are often easier to this scenario, replicating the same experiment with
manage for researchers who have difficulty gathering multiple cases can increase the strength of the evi-
groups of homogeneous patients to form experimental dence generated. If you get very different findings
groups. Furthermore, group studies are usually con- among the cases, you need to rethink the original
cerned with comparing the average change between two theory for the study.
groups; however, researchers may not be as interested Moreover, multiple-case designs typically do not
in the average changes of a group as they are in changes involve critical, unusual, or revelatory cases (Yin,
in individuals. They are interested not only in the pa- 2009). If you chose the multiple-case study approach,
tient’s overall change by the end of the study, but also how many cases should you use? If there are not too
in the course of that clinical change over time. Single- many variables under study, use two or three cases; if
subject studies allow the researcher an opportunity for there are many variables, increase to five or six cases.
continuous assessment of a client’s progress at various It is also appropriate to use a pilot case study to ex-
points during treatment. The researcher can not only plore your choice of subject, data collection methods,
monitor changes throughout treatment, but can also and data analysis techniques before conducting a
alter the intervention based on the study data, should multiple-case study. Table 6-4 further differentiates
this be indicated. This is not usually possible with the reasons to select a single-case study versus a
group study designs. Data can be collected during multiple-case study.
the intervention period and compared with data In quantitative case study research, the investigator
collected when the intervention is not being provided is often designing and testing a specific treatment
(the process of using subjects as their own control that protocol, splint, or piece of adaptive equipment for
was described earlier). For these reasons, researchers a client with a particular disability. In the earlier
tend to find single-case studies manageable and desir- example (Box 6-13), the researchers were studying a
able in the clinical setting, whereas readers find them specific treatment—therapeutic listening (Nwora &
relevant to their own practice. Gee, 2009). In these types of studies, the researcher

Table 6-4 ■ Differences Between Single-Case and Multiple-Case Designs

Single-Case Designs Are Appropriate When: Multiple-Case Designs Are Appropriate When:
■ You can identify the critical case that illustrates all ■ Your aim is to build theory across cases, thus presenting
the theoretical propositions of the study. a stronger outcome.
■ One case is extreme or unique. ■ You have two or more cases available to you (thus, cases

■ You have a typical or representative case that can are not critical, unique, or revelatory)
capture information on common scenarios or ■ Single-case studies were previously completed on the

situations. topic, and replication can corroborate earlier findings.

■ A revelatory case is available that exposes a previously

inaccessible phenomenon.
■ A case is available over time, and you are interested in

looking at changes, transitions, and causation over

that period.
■ You have one case that will likely be used as a pilot

study for a future multiple-case study.

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Chapter 6 ■ Quantitative Research Methodology and Design 61

gathers baseline data on the client’s condition in Methodological Research

order to test whether the program or device has had For many years, healthcare practitioners have been
the desired effect. This is similar to the classic exper- interested in developing and fabricating their own
imental design in that a pretest, intervention, and adaptive aids, equipment, tests, and other instru-
posttest are conducted; however, the case study is car- ments for use in the evaluation and treatment of their
ried out with an individual rather than a group. patients. Methodological research can be used to test
Data for the quantitative case study are likely gath- and improve the validity and reliability of such mate-
ered in several ways: observing and counting such rials, and to develop, validate, and produce standard-
things as behaviors that are targeted for change, using ized testing measures. If the instruments used in
hardware to measure such things as joint flexion and clinical research are reliable and valid, the researcher
extension or muscle strength, or using a formal index can have more confidence in the results of the re-
to evaluate some portion of self-care activities or pain. search, and results can be compared across studies.
These data will provide the baseline information that The precise set of procedures used in standardizing
will be measured against data from later collection measures is described by Benson and Clark (1982) in
periods, usually conducted at various points through- their article, “A Guide for Instrument Development
out the study. Baseline data are often supplemented and Validation.” The stages include:
by documentary evidence such as information in
1. Deciding on the purpose of the measure and
patients’ charts, reports from case conferences, and
the population of concern (Why is the measure
previous assessments or progress reports. Although
needed? What group of individuals will it be used
providing the researcher with a rich source of data for
on? Considerations could include age, gender,
comparison, these data also “flesh out” a picture of
diagnoses, symptomatology, place of residence,
the subject for the reader. In the example of the ther-
vocational goals, or psychological attributes, to
apeutic listening program (Box 6-13), John’s medical
name a few.)
record was reviewed; several standardized assessments
2. Elucidating the content of the measure by using
were completed, and his in-class performance was
personal experience, review of relevant literature,
videotaped pre- and post-intervention, so that con-
and opinions of experts in the field
clusions could be drawn about the effect of the listen-
3. Organizing and compiling the content into a
ing program (Nwora & Gee, 2009).
logical and meaningful sequence
It may be appropriate to use statistical data analy-
4. Testing the resulting measure on a large sample
ses for a quantitative case study if you have sufficient
of the population of interest
data. For example, if you have collected data after
5. Subjecting the results to statistical tests for
various phases of treatment, and perhaps at several
reliability and validity
follow-up points after treatment has ended, this
6. Improving the design and content of the measure
could yield a dozen or more groups of data that could
based on the findings
be tallied and otherwise statistically manipulated in
7. Retesting the measure
order to show change over time. A pictorial presenta-
8. Repeating the last four steps several times until
tion, such as a graph, is often an informative way to
you are satisfied with the results
indicate changes that have occurred. See Chapter 12
9. Writing an accompanying manual outlining the
for details on visually displaying data.
research process used, the population for whom
Case studies are a useful and fascinating way for
the measure is intended, the results of the tests
practitioners and new researchers to learn the investi-
for reliability and validity, and exact procedures
gation process and to contribute to the body of research
for using the measure
in their profession. Most practitioners likely have at
least one client whose progress and style of learning As you can readily see from this list, the procedure
could benefit others, whereas the case study process it- to develop a standardized measure is quite labor inten-
self requires discipline and is thought-provoking. sive and rigorous. As a result, we often use self-made
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62 Section 2 ■ Research Methodologies and Designs

instruments in research studies without showing involves collecting data or opinions that can be used to
sufficient concern or caution in interpreting data pro- form a policy upon which to design a new program,
duced by these nonstandardized measures. In quanti- whereas summative research entails assessment of an
tative research designs, measures are usually selected existing program and its policies. In formative research,
as a way to objectively quantify some phenomenon, data is typically collected from potential users and
and to compare results before and after the study or providers of the proposed program, and then it is ana-
intervention, to determine the impact of the experi- lyzed to determine the appropriateness and feasibility of
mental intervention. In clinical settings, these mea- actually initiating the program.
sures are used to document patient progress, which is In summative research, the existing program goals
often required by regulatory agencies and insurance are examined and data is collected to determine
companies in order to continue treatment or to receive whether the goals are being met. Goals for all programs
payment for services rendered. The development, test- should be written in objective and measurable terms
ing, and refinement of sound standardized measures while keeping them aligned with the program’s mis-
are critical to producing quality research that can be sion, so that they can later be used to evaluate the pro-
generalized to broader populations. An example of gram’s effectiveness. Data can be gathered from many
methodological research appears in Box 6-14. sources including past and present consumers of a
program, providers of a program, written policies and
Evaluation Research procedures, client records, and the physical plant and
Evaluation research is designed to determine the need its equipment. Often large quantities of data need to
for new programs and to assess existing programs for be organized and applied to each of the program’s
possible quality improvement. Thus, the results of stated goals. The researcher then must make judg-
evaluation research will provide answers to the ques- ments as to whether or not the goals are being met.
tions “What should we do?” and “How well are we This type of research is often conducted by a program
doing?” This type of research can be referred to by a evaluator from outside the program, who is more likely
variety of other terms including audits, outcome analy- to be objective about the program’s good and bad points
sis, cost-benefit analysis, or impact analysis. Regardless of and is free of the burden of implementing recom-
the term that is used, the goals include assessing the mended changes. If evaluators knew that they would
potential for new programs, practices, or policies, or have to make the required changes at the end of an eval-
to determine the success of existing ones. uation, they might be biased in the type of changes being
Evaluation research involves two strategies—formative recommended. The negative side of having an outside
research and summative research. Formative research evaluator is that it takes time for the outsider to be ac-
cepted by program staff. Also, staff members have been
known to sabotage evaluations by not cooperating or by
BOX 6-14 ■ Example of Methodological
being dishonest with the outside evaluator. Box 6-15
Research
provides an example of evaluation research.
Lach, Ball, and Birge (2012) conducted
a methodological study to determine the Validity and Reliability of Quantitative
reliability and validity of The Nursing Home Research
Falls Self-efficacy Scale. They noted lower self-
efficacy in patients with decreased functional In order to prove the value of their studies, re-
mobility and cognition, as well as those with searchers need to address the credibility of their
increased fall risk and fear of falling. The study’s methodology and tools. In order to do so, the
study provides initial support for use of this principles of study validity and reliability need to be
scale, which could impact future research and understood. Validity is concerned with the accuracy
nursing home practices. of scientific findings, whereas reliability is concerned
with the replicability of scientific findings.
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Chapter 6 ■ Quantitative Research Methodology and Design 63

can be impacted by such events and internal va-

BOX 6-15 ■ Example of Evaluation lidity is compromised. Historical contamination
Research can be prevented by careful sampling and by con-
The authors of an article on community-based trolling subjects’ activities during the study.
programs for children and youth detail a 2. Maturation. Maturation refers to the subjects’
conceptual framework and practice consid- growth, development, or changes that occur natu-
erations used to develop and assess three rally over time, which may influence pretest and
separate community-based programs (O’Neil, posttest measurements. For example, it might be
Fragala-Pinkham, Ideishi, & Ideishi, 2012). difficult to determine if a year-long remedial writ-
The programs include an adapted ice skating ing program has resulted in improvement in a
program, an arts program, and a fitness pro- child’s handwriting, or if that improvement would
gram. The target population for each program, have occurred anyway with the passage of time.
as well as recruitment methods, program con- 3. Testing. If the same test is being used several times
tent, evaluation, and outcomes, are discussed. throughout the study, it is possible that subjects
Review of these critical aspects is necessary to will experience a practice effect and score higher
determine future implementation or modifica- simply because they have been able to practice the
tion of the existing programs. test. Additionally, if the test involves performing an
activity to demonstrate strength or endurance, it is
possible that performing the test itself will increase
the subjects’ skills and level of performance.
Validity 4. Instrumentation. The condition of the instru-
A study is valid only if researchers are truly addressing ments themselves may influence measurements.
the constructs they set out to study and measure. For example, an instrument may not be calibrated
Validity needs to be addressed from two points of accurately or it may be old, worn out, or in poor
view. First, internal validity—are researchers actually condition and not give accurate readings. Mailed
observing and measuring what they think they are surveys or attitude surveys may include cultural,
observing and measuring? And, second, external racial, intelligence, or language bias that would
validity—to what extent are the ideas generated or influence the results.
tested by the researchers applicable to other similar 5. Subject Selection. Subjects who volunteer for a
groups or situations? study are likely to be different from those who
are selected to participate. However, there is an
Internal Validity element of volunteerism for all subjects because
The effects of history (the events that have happened of the consent process. This can be controlled by
throughout the study), maturation of the subjects using more than one study group and by ran-
during the study, testing of the subjects, instrumen- domly assigning subjects to the groups.
tation used in the study, subject selection, and subject 6. Subject Attrition or Mortality. However well a
attrition (why and how many subjects were lost before study is designed, it is difficult to prevent subject
completion of the study) can all have an impact on attrition because of such things as illness, a geo-
the study’s internal validity. These situations will be graphic move, or death. Extra subjects should be
discussed in some detail. recruited into the study to account for these losses.
1. History. Historical contamination occurs when This is particularly important in a case study.
something happens to the subjects or the envi-
ronment that was not planned in the study de- External Validity
sign, such as a subject having an injury or losing External validity refers to the extent that research
interest in the study and not making an effort findings can be generalized and applied to “real-
during treatment sessions. Measurement scores world” situations and clinical cases. Researchers must
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64 Section 2 ■ Research Methodologies and Designs

balance the concepts of internal and external validity, as the independent variable and a single measure
as many of the controls that increase internal validity for the dependent variable have greater external
(rigorous methodology, highly controlled study envi- validity.
ronments, strict testing procedures, and randomiza- 5. Researcher Bias. Sometimes subjects react to the
tion of subjects) can compromise the relevancy and study in a certain way because of their relation-
application of research findings to real life clinical ship with the researcher, whether it is positive or
situations. Some of the most common threats to negative. Similarly, the researchers may uninten-
external validity are mentioned here. tionally alter their interactions with subjects,
1. Hawthorne Effect. If subjects perform better based upon their perceptions or feelings. These
on the study task simply because they are being are particularly important considerations if the
observed, and not necessarily because of the dependent variable has to do with interpersonal
treatment they are receiving, then subjects are relationships or emotion-laden topics.
said to exhibit the Hawthorne effect. This situa-
Reliability
tion is named after a series of experiments
that were completed with factory workers at A study is considered reliable if, when it is repeated,
the Hawthorne Works, an electric company in similar findings are produced. Dependability of pro-
Illinois, in the early 1900s. In these experiments, cedures is indicated whenever equivalent results are
worker productivity increased regardless of ma- obtained during repetitions of the same study. When-
nipulation of environmental and psychological ever close agreement occurs among several measures
variables; this increase was attributed to the of the same phenomenon, the reliability of the proce-
extra attention the workers received from the dure, instrument, or research will be high and con-
researchers (Franke & Kaul, 1978). sumers may have confidence in that portion of the
2. Replication. When researchers report on their study. In addition, reliability can refer to the extent
studies, they must describe their methods in to which an instrument agrees with itself, and four
sufficient detail that others may replicate the types of reliability pertaining to test instruments
studies. If you cannot be assured that the same will be described in Chapter 7: test-retest reliability,
methods have been followed in replicated studies, split-half reliability, intra-rater reliability, and inter-
then findings cannot be generalized confidently, rater reliability.
thereby threatening external validity. Some problems confounding the reliability of the
3. Generalizability. Generalizability refers to the study itself, rather than instruments used, need to be
extent that the results found in the study sample discussed. In the following cases, the study instru-
will also be found in the larger population from ment might be reliable but the study itself will not be
which the sample was drawn. Is the smaller sam- if these items are not considered.
ple being studied truly representative of those in 1. Subject Fatigue. This can be a problem when
the larger population? Randomly selecting the subjects are expected to perform physical or
sample from the population of interest is a sound mental tasks repeatedly, and are tired toward
way to increase the likelihood that results of the the end of the testing procedures. As a conse-
study can be applied to the larger population. quence, they do not perform to the best of their
4. Multiple Treatments. In a study in which abilities and results are affected. Physiological
subjects are given more than one treatment as abilities can change in response to diurnal or
the independent variable, the results cannot be circadian rhythms, which may result in different
generalized to other settings in which only one results at different times for the same person.
of those treatments is used. Effects of more than Scheduling testing and other performance
one treatment must be viewed as cumulative and tasks with adequate breaks can decrease subject
intermingled. Studies that use a single treatment fatigue.
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Chapter 6 ■ Quantitative Research Methodology and Design 65

2. Subject Motivation. Subjects are not always in- responses. Distractions such as noise or interrup-
terested in the study and may not perform at their tions are particularly intrusive on test results.
best because of lack of motivation or decreased Controlling the study environment so that sub-
mood. They may even dislike participating in the jects are tested under the same conditions each
study, which would certainly influence the effort time can minimize environmental influences.
they put forth in testing procedures. In this case, Once you have decided on the research method
test results will be varied and will not be reliable you will employ in your study, you will want to make
indicators of the subjects’ abilities. Recruiting an effort to control for as many of these threats to
subjects who have a vested interest in the study’s validity and reliability as possible. Comparing this list
purpose and results can combat this issue. of threats against your proposed study design can
3. Subject Learning. If there are repeated tests help you to identify potential issues early on. You
using the same instrument within the study, sub- likely will be unable to control for all threats to
jects are likely to achieve some learning. They validity and reliability, but being aware of these limi-
may perform better on later tests simply because tations is necessary when interpreting your results.
they have learned the material on the test rather
than because of an experimental intervention.
Considering use of a variety of assessment meth-
Chapter Summary
ods can decrease the impact of subject learning. Some design examples have been provided that may be
4. Subject Ability. Subjects’ ability to respond to employed in the three categories of quantitative re-
certain questions or tasks will vary according to search: experimental, quasi-experimental, and nonex-
their skill level or knowledge of the topic. Re- perimental. Naturally, there are many more types of
sponses may vary for the same subject, if he or quantitative research designs than have been men-
she chooses to create a response to appease the tioned here. In particular, there are many variations of
examiner or to make himself or herself look bet- the basic themes presented in the experimental and
ter. This might be especially true if a relationship quasi-experimental categories. Additionally, although
already exists between the subject and researcher quantitative and qualitative designs offer distinct fea-
or if a sensitive or embarrassing subject is being tures, advantages, and disadvantages, use of a mixed
investigated. Preserving a distinct researcher- methods design (multimethodology) may offer the best
subject relationship and handling sensitive topics of both worlds by allowing the researcher to address
appropriately can minimize this concern. multiple aspects simultaneously, holistically, and with
5. Tester Skill. If a tester does not administer the greater detail (Johnson, Onwuegbuzie, & Turner, 2007;
study instruments in exactly the same manner Teddlie & Tashakkori, 2008). Mixed methods designs
each time, responses for each subject may not be include both quantitative and qualitative measures, and
accurate. Training of those assigned to adminis- are appropriate when some phenomena can be quanti-
ter assessments can increase the reliability of fied and others warrant rich description. These designs
results, and is discussed further in Chapter 7. bear mentioning because they can be commonly found
6. Different Testers. People administering the test in healthcare literature; however, detailed explanations
differ in such things as their degree of enthusi- are beyond the scope of this text because mixed methods
asm, delivery of instructions, voice, personality, designs can be quite complex and are best undertaken
and ability to handle the situation. The same by experienced researchers. Careful reading of such texts
subject may score differently on the test depend- such as Portney and Watkins’ (2009) Foundations of Clin-
ing on who administers it. Again, adequate train- ical Research: Applications to Practice and Creswell’s (2008)
ing of test administrators can reduce this issue. Research Design: Qualitative, Quantitative, and Mixed Methods
7. Test Environment. Changes in the environ- Approaches will guide researchers toward the best design
ment from test to test can influence a subject’s for their particular sets of circumstances.
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66 Section 2 ■ Research Methodologies and Designs

SKILL-BUILDING TIPS 4. What ideas do you have for increasing your

study’s validity and reliability?
■ When choosing a study topic and design, be sure to
read a variety of existing studies on your topic. This
can help you formulate your question and choose REFERENCES
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and females. Journal of Health Psychology, 13(3), 433–437.
LEARNING ACTIVITIES
Groves, R. M., Fowler, F. J., Couper, M. P., Lepkowski, J. M., Singer, E., &
1. What advantages and disadvantages do quan- Tourangeau, R. (2009). Survey methodology (2nd ed.). Hoboken, NJ:
titative research designs offer? John Wiley & Sons, Inc.
Herman, K. M., Hopman, W. M., & Craig, C. L. (2010). Are youth BMI
2. Can you identify the independent and de- and physical activity associated with better or worse than expected
pendent variable(s) that you are interested in health-related quality of life in adulthood? The physical activity lon-
gitudinal study. Quality of Life Research, 19(3), 339–349. doi:10.1007/
studying? s11136-010-9586-8
3. Does your setting or situation lend itself more Hunt, L. A., & Bassi, C. J. (2010). Near-vision acuity levels and performance
on neuropsychological assessments used in occupational therapy.
to one type of design versus another? American Journal of Occupational Therapy, 64(1), 105–113.
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Chapter 6 ■ Quantitative Research Methodology and Design 67

Johnson, R. B., Onwuegbuzie, A. J., & Turner, L. A. (2007). Toward a def- massage for generalized anxiety disorder: A randomized controlled
inition of mixed methods research. Journal of Mixed Methods Research, trial. Depressionand Anxiety, 27, 441–450.
1(2), 112–133. Shyu, Y., Chen, M., Chen, S., Wang, H., & Shao, J. (2008). A family care-
Kielhofner, G., & Fossey, E. (2006). The range of research. In G. Kielhofner giver-oriented discharge planning program for older stroke patients
(Ed.), Research in occupational therapy: Methods of inquiry for enhancing and their family caregivers. Journal of Clinical Nursing, 17, 2497–2508.
practice (pp. 91–109). Philadelphia, PA: F.A. Davis. doi:10.1111/j.1365-2702.2008.02450.x
Lach, H. W., Ball, L. J., & Birge, S. J. (2012). The nursing home falls self- Suresh, K. P. (2011). An overview of randomization techniques: An unbi-
efficacy scale: Development and testing. Clinical Nursing Research, 21(1), ased assessment of outcome in clinical research. Journal of Human
79–91. doi:10.1177/1054773811426927 Reproductive Sciences, 4(1), 8–11.
Leerar, P., Boissonnault, W., Domholdt, E., & Roddey, T. (2007). Docu- Tawashy, A., Eng, J., Lin, K., Tang, P., & Hung, C. (2009). Physical activity
mentation of red flags by physical therapists for patients with low is related to lower levels of pain, fatigue and depression in individuals
back pain. The Journal of Manual & Manipulative Therapy, 15(1), 42–49. with spinal-cord injury: A correlational study. Spinal Cord, 47(4),
Microsoft. (2010). Microsoft Excel [computer software]. Redmond, WA: 301–306. doi:10.1038/sc.2008.120
Author. Teddlie, C., & Tashakkori, A. (Eds.). (2008). Foundations of mixed methods
Nwora, A. J., & Gee, B. M. (2009). A case study of a five-year-old child with research: Integrating quantitative and qualitative approaches in the social and
pervasive developmental disorder–not otherwise specified using behavioral sciences. Thousand Oaks, CA: SAGE Publications, Inc.
sound-based interventions. Occupational Therapy International, 16(1), Thomas, J., & Hersen, M. (2011). Understanding research in clinical and coun-
25–43. doi:10.1002/oti.263 seling psychology (2nd ed.). New York, NY: Routledge.
O’Neil, M. E., Fragala-Pinkham, M., Ideishi, R. I., & Ideishi, S. K. (2012). Urbaniak, G. C., & Plous, S. (2012). Research randomizer. Social Psychology
Community-based programs for children and youth: Our experiences Network. http://www.randomizer.org/
in design, implementation, & evaluation. Physical & Occupational Ther- Walach, H., Güthlin, C., & König, M. (2003). Efficacy of massage therapy
apy in Pediatrics, 32(2), 111–119. in chronic pain: A pragmatic randomized trial. Journal of Alternative &
Portney, L. G., & Watkins, M. P. (2009). Foundations of clinical research: Applica- Complementary Medicine, 9(6), 837–846.
tions to practice (3rd ed.). Upper Saddle River, NJ: Pearson Education, Inc. Walker, J. (2006). HotBits: Genuine random numbers, generated by radioactive
Rubin, D. B. (2006). Matched sampling for causal effects. New York, NY: decay. http://www.fourmilab.ch/hotbits/
Cambridge University Press. Wludyka, P. (2012). Study designs and their outcomes. In K. Macha
Salant, P., & Dillman, D. (1994). How to conduct your own survey: Leading & J. P. McDonough (Eds.), Epidemiology for advanced nursing practice
professionals give you techniques for getting the reliable results. New York: John (pp. 81–114). Sudbury, MA: Jones & Barlett Learning, LLC.
Wiley & Sons, Inc. Yin, R. K. (2009). Case study research: Design and methods (4th ed.). Thousand
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Bentley, S., . . . Cherkin, D. (2010). Effectiveness of therapeutic

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key word: Hissong.
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Chapter 7

Technical Aspects of
Quantitative Research
To reach a port, we must sail—Sail, not tie at
anchor—Sail, not drift.
—Franklin Roosevelt

LEARNING OUTCOMES Considerations in Quantitative Research

The information provided in this chapter will assist the To enable others to understand and apply your quan-
reader to: titative research, you will need to consider and iden-
■
tify the following: subject inclusion and exclusion
Establish proper inclusion and exclusion
criteria, recruitment and sampling methods, data col-
criteria for research subjects.
■
lection techniques, and data analysis. Each of these
Consider subject recruitment and select the
topics will be covered in greater depth here.
most appropriate sampling technique.
■ Choose a suitable method for data collection Subject Inclusion and Exclusion Criteria
from those reviewed (observation, interviews,
Subject inclusion and exclusion criteria are specific
surveys, record review, equipment use, assess-
conditions set forth by the researchers that must be
ments, or tests).
■
met for eligibility to participate in their study. The
Understand the complexities of survey construc-
population of interest refers to the entire group of
tion and where to locate additional resources to
individuals, events, documents, or records that meet
assist in this endeavor.
■
these criteria. Although the subjects in healthcare
Examine the validity and reliability of proposed
research are frequently individuals, they can also in-
testing instruments before electing their use.
■
clude records or events. (See Boxes 6-1 and 6-2 for
Comprehend differences between descriptive
examples.) In either case, those deemed eligible for
and inferential statistics used in data
participation in a study must meet a specific set
analysis.
■
of characteristics that have been established by the
Identify appropriate resources for statistical
researcher before initiation of the study.
analysis.
■
Subject inclusion criteria consist of characteris-
Report results and synthesize them with exist-
tics or traits that subjects must have to qualify for
ing literature to effectively draw conclusions.
participation in the study. For example, you might be

69
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70 Section 2 ■ Research Methodologies and Designs

interested in studying adults diagnosed with multiple hospital system; 200 of those individuals (a sample)
sclerosis in the United States who are 40 to 60 years would be selected to participate in a study. There are
old and who are employed full time. If so, demo- two basic sampling methods—nonprobability sampling
graphic data is collected before the study begins and probability sampling.
to ensure all participants meet these criteria. Subject
exclusion criteria take into account undesirable fea- Nonprobability Sampling
tures for participants. These could include subjects In nonprobability sampling, the subjects are not
residing more than 50 miles from the research center, selected randomly, but rather on the basis of some
those who only work one or more part-time jobs, or other phenomena such as location or convenient
those with impaired cognitive abilities that might in- access. This means that not all members of the pop-
fluence performance on study measures, for instance. ulation of interest have an equal chance of being se-
Inclusion and exclusion criteria are determined lected for the sample. Recall the earlier discussion in
based upon the literature review and goals for the Chapter 6 on convenience sampling, which involves
study, and they typically evolve as the assumptions the use of subjects simply because they are readily
and theoretical base of the study unfold. Therefore, available. Although convenience sampling is the least
these criteria are established well in advance of the expensive and easiest of the sampling techniques, it
study’s beginning. It is important to identify all ap- may decrease the generalizability of results. In health
plicable criteria, so that readers have a clear under- care, researchers frequently conduct their studies on
standing of the population being investigated. patients they already have on their caseloads or those
who are readily available in their facility. Using vol-
Subject Recruitment unteers is also a common convenience sampling tech-
Once the inclusion and exclusion criteria have been nique. Although use of convenience samples can pose
established, the researcher must decide where the sub- challenges, it is an effective way for novice researchers
jects will come from. This decision can be made only to get started in the research process. See Box 6-7 for
after consideration of the goals, geographic location, an example of convenience sampling. Other types of
funding, and other logistics of the study. Recruitment nonprobability sampling include quota sampling,
for studies in community-based settings such as fit- purposive sampling, and snowball sampling.
ness centers, day cares, and senior centers typically Quota sampling refers to the process of dividing the
rely on advertisements, directories, and mailings to population of interest into two or more subgroups based
solicit subjects. Clinical research that occurs in hos- upon some characteristic. The researcher then draws
pitals, rehabilitation clinics, or other medical centers adequate samples from each subgroup to represent the
often relies on recruitment of actual patients via word proportion of this characteristic occurring naturally in
of mouth by the practitioner or researcher. the population of interest. This technique ensures that
the characteristic in question is equally represented in the
Sampling population and the chosen sample. For example, a
After identification of the population of interest and researcher interested in studying ambulation in seniors
recruitment of subjects, the researcher must determine residing in a skilled nursing facility would likely want
the sampling method to be used. Sampling involves se- a greater number of female subjects than male subjects,
lection of a smaller subset of the population of interest because census information reveals a greater number of
to participate in the study. This technique is often em- females residing in these facilities. The researcher deter-
ployed when it is impractical to study the entire popu- mines the desired quota for each subgroup and selects
lation of interest because of time constraints, financial subjects until the quotas are reached.
concerns, or other logistics such as geographic location Purposive sampling, or judgment sampling, in-
or transportation issues. For example, a population volves hand selection of subjects based upon specific
of interest might consist of 713 individuals who un- attributes. Subjects might be selected based upon their
derwent rotator cuff repair surgery at one university diagnoses, motivational level, or perceived compliance,
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Chapter 7 ■ Technical Aspects of Quantitative Research 71

for example. The purpose of the research can dictate nth one for participation. You must consider the total
selection of a very specific sample, hence the name of number of subjects needed for your study (for exam-
this technique. Finally, snowballing sampling, also ple, 25) divided by the available subjects in your pop-
known as referral sampling or chain sampling, involves ulation (say 100). This means you need 25% of the
selection of a small number of subjects who meet study population for your sample. Selecting every fourth
criteria; these subjects then refer others who also meet subject in the random list of the 100-subject popula-
the same criteria. The process continues until a suffi- tion will accomplish your goal.
cient sample has been tested. This technique is useful Cluster sampling is useful when your population
to identify subjects who might otherwise be inaccessi- is spread out geographically. In this case, it is benefi-
ble to the researchers. Examples include subjects with cial to divide the population into smaller clusters,
a rare disease, those involved in illicit activity, or mem- which will then be randomly sampled. This is espe-
bers of distinct networks or social groups. cially useful if the researcher needs to be physically
present to conduct assessments or interventions with
Probability Sampling the subjects. Finally, multistage sampling involves a
Probability sampling is a method of sampling that combination of probability sampling methods. For
ensures all members of the population of interest have more details on the probability sampling techniques
an equal chance of being selected for the study sample. presented here or other types, because this discussion
Random sampling, also known as simple random is very basic, please see Portney and Watkins’ (2009)
sampling (described in Chapter 6), is one of the most Foundations of Clinical Research: Applications to Practice.
popular types of probability sampling. Random sam- In general, keep in mind that your sample should
pling involves compiling an exhaustive list of subjects represent the larger population of interest as closely
that meet the study’s inclusion criteria, and then ran- as possible.
domly selecting the study’s sample from this list. This
can be accomplished by placing all names in a hat and Sample Size
drawing names until an adequate number of subjects The question regarding sample size is not one that is
have been selected. In reality, most researchers find the easily answered. Just how many subjects will you need
use of a random numbers table (found in a statistical for your proposed study? Ideally, the sample should
text) or a statistical software package to randomly se- accurately represent the larger population of interest
lect subjects to be a more practical method. Random from which it was drawn, thereby allowing the re-
sampling increases the likelihood that the study re- searcher to generalize the results found in the sample
sults will be similar to results that would have been to the population. If the sample is too small, or was
found if the entire population had been studied. not randomly chosen or assigned, the sample may not
Other types of probability sampling include strati- be reflective of the larger population.
fied random sampling, systematic random sampling, Depending on the purpose of a study, it may not
and cluster sampling. Stratified random sampling in- be necessary to draw a sample; instead, all subjects
volves dividing the population into homogeneous sub- meeting the criteria can be included. For example,
groups, and then randomly sampling each subgroup. studies exploring the efficacy of practices and policies
This technique ensures that each subgroup is ade- within a specific health system or facility could use
quately represented in the sample. This type of sam- as subjects all individuals treated there. Although
pling is similar to the quota sampling discussed earlier these results may not be generalizable to other health
in that each technique involves dividing the population systems, this is not a disadvantage because the re-
based on a particular attribute. However, in stratified searchers are only looking to gain knowledge on the
random sampling the sample from each subgroup is practices in one facility or system.
drawn randomly, but in quota sampling they are not. In quantitative research, two concepts related to sta-
Systematic random sampling involves randomly tistical analysis also factor into determining the appro-
ordering all possible subjects and then selecting every priate sample size—the confidence interval and the
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72 Section 2 ■ Research Methodologies and Designs

confidence level. The confidence interval, or margin of Observation

error, represents a range of values that likely includes the This data collection technique may be used with any
scores or responses of the population. For example, if of the quantitative research designs and is commonly
the margin of error is 5, and 50% of a study sample re- used in conjunction with other techniques. Observa-
sponds favorably to a new treatment, the researchers can tions may be made of human subjects, videotape
have confidence that if they tested the entire population recordings of subjects or events, or nonhuman items
of interest, 45% to 55% would also respond favorably. such as pieces of equipment. In quantitative research,
The confidence level represents the certainty the re- the observation process is formalized in advance.
searchers have that the scores or responses of the popu- When observing the frequency or type of events oc-
lation would fall within this range. Confidence levels of curring in a quantitative study, a method for record-
95% or 99% are typically chosen, indicating that the re- ing observations needs to be carefully prepared and
searchers are either 95% or 99% confident that the scores the observers should be well trained. Rather than
or responses will fall within the margin of error. Once being asked to observe and record subjective items
you have determined the size of your population, the such as dependence or enjoyment, it is preferable for ob-
confidence interval, and the confidence level, a statistical servers to be given objective criteria believed to repre-
program, a web-based calculator, or a statistician can be sent those subjective items. For example, dependence
used to help you determine the appropriate sample size. may be represented by the number of times a subject
Although studies conducted with smaller samples asks for assistance, and enjoyment may be represented
may face criticism, using larger samples does not nec- by the number of smiles, laughs, or verbal statements
essarily translate into more accurate results. How the that would indicate happiness. Observers should be
subjects are recruited, sampled, and assigned to study provided with a protocol defining the items to be ob-
groups must also be considered. Smaller samples may served and a method for recording those items, such
be appropriate depending on the study’s goals, and they as noting any occurrence, frequency of occurrence, or
are often employed in pilot studies or by novice re- length of time between occurrences, on a previously
searchers. Sample size is often dictated by financial and designed form.
logistical circumstances, and as noted previously, con- Videotapes are useful for training purposes. The
venience samples are common in healthcare research. observer rates the tapes and the researcher checks the
ratings until he or she is satisfied that the observer is
Data Collection Techniques making correct and reliable ratings. This procedure
ensures intrarater reliability, or the degree to which
Sometimes the research method dictates data collec-
each rater or observer is consistent in his or her rat-
tion techniques, and at other times the researcher has
ings. If there is more than one observer or rater, the
a wide array of choices. To illuminate the choices,
researcher will probably want to confirm interrater
data collection techniques will be categorized and dis-
reliability, which means the raters are checked
cussed individually. It should be noted that some of
against one another, to ensure that the same results
these techniques may also be appropriate for use in
are obtained regardless of the rater. Objective mea-
qualitative research, and they will be discussed further
surements and observations are made until all raters
in Chapters 8 and 9. Techniques may be conveniently
score similarly and the researcher has confidence,
grouped as follows:
evidenced by statistics, that all raters will rate consis-
1. Observation tently well. Consistency between raters is critical to
2. Interview protecting the study’s internal validity.
3. Survey
4. Record Review Interview
5. Equipment Interviewing, either face-to-face or via telephone, or
6. Tests, Assessments, and Inventories through voice-over Internet programs, is one of the
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Chapter 7 ■ Technical Aspects of Quantitative Research 73

techniques used to gather data in survey research. In- by subjects, which may well be different from that
terviews conducted face-to-face or through videocon- used by the researcher. It is especially important to
ferencing methods are more intimate, allowing avoid abbreviations, medical terminology (i.e., use
the interviewer to physically see the interviewee. This stroke rather than cerebrovascular accident), and vaguely
direct interaction helps develop rapport and may be worded questions or those with biased wording or
important if sensitive issues are being explored. Ad- tone (Salant & Dillman, 1994).
ditionally, the interviewer has a chance to “read” the One of the problems with data obtained from in-
nonverbal cues given by the interviewee, which may terviews is that it is difficult to know if subjects are
indicate confusion or lack of understanding, so that telling the truth or trying to impress the interviewer
a question can be rephrased. Nonverbal information by saying what they think the interviewer wants to
may also be an important part of understanding the hear. They may also be embarrassed or ashamed to
full response to the question. tell the truth on sensitive issues. Experienced inter-
The disadvantage of true face-to-face interviews is viewers can gain skill in reading nonverbal cues to de-
the amount of effort required to set up the interview, termine the degree of truthfulness in answers. There
including contacting subjects, arranging mutually con- is a great deal to be learned about the construction of
venient times and locations, and traveling. Telephone individual questions and the interview as a whole.
interviewing eliminates these concerns, but the per- Because most of this information on question and
sonal contact and the chance to observe nonverbal cues interview construction also pertains to surveys, it
are lost. Also, it is easier for a subject to refuse an inter- will be discussed in the following section.
view on the telephone. Voice-over Internet programs
may provide the best of both worlds, but could present Surveys
technological challenges because both the interviewer There are multiple ways to distribute surveys, also
and interviewee must have adequate hardware and known as written questionnaires. They may be mailed
software and be able to operate both effectively. to respondents, e-mailed to respondents, conducted
In survey research, the interview format may be through online survey software such as Survey Mon-
structured or unstructured, sometimes referred to as key® (2012) or SuperSurvey® (Ipathia, 2011), hand
formal or informal. In structured interviews, the same delivered to respondents with instructions to mail
questions are always asked, and they are asked in the them back to the researcher, or completed by respon-
same order. Although this format may appear stilted dents in the presence of the researcher. If surveys are
and formal, the answers will be easier to compare from mailed or e-mailed or left for subjects to complete and
one subject to another and frequencies and percent- return on their own, there are special considerations.
ages can be compiled. In unstructured interviews, the First, the questions must be very clear and unambigu-
volume of material can be difficult to organize and an- ous because the researcher will not be present to clar-
alyze, and often it is not comparable from one subject ify concerns. This is of particular importance because
to the next. For this reason, structured interviews are if a question has been misinterpreted and answered
more common in quantitative research. They are also incorrectly, the whole questionnaire must be dis-
less difficult for the inexperienced interviewer or be- carded unless special statistical procedures are fol-
ginning researcher, because the data are easily tabu- lowed in analyzing results.
lated and analyzed, and interpretations are more likely Another concern regarding surveys is whether
to be accurate and meaningful. However, unstructured there will be sufficient responses to justify the study.
interviews are commonly used in pilot studies to clarify The response rate is defined as the number of
issues on the topic of interest, and for later develop- surveys returned divided by the total number in the
ment of a structured interview for the formal study. sample. Response rates can vary greatly depending
When writing questions, prime consideration upon the type of survey and method of distribution,
should be given to the language style and idiom used but Fowler (2009) cautions that response rates of less
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74 Section 2 ■ Research Methodologies and Designs

than 20% may render little accurate information For mailed surveys, provide a deadline for return-
about the larger population being investigated (p. 51). ing the survey—approximately 2 weeks after it has
Actual response rates for most studies fall between been received. Research shows that recipients rarely
30% to 60%, and response rates above 60% are con- return questionnaires after 2 weeks, and that about
sidered excellent by most researchers (Portney & 90% of responses for online surveys will be received
Watkins, 2009, p. 326). The Office of Management within the first 3 days of the e-mail invitation
and Budget (2006) of the U.S. federal government re- (Walonick, 2010). Unless returns are confidential,
quires a response rate of 95% for federally conducted keep a master list of those to whom you have mailed
research, as well as justification for lower response questionnaires and check off their returns. If you have
rates and plans to address nonresponse bias if this not heard from recipients in 2 weeks, send them a
target is not met. In another study, the researchers ex- reminder postcard, e-mail, or text.
amined 18 health science journals to explore publica- Always enclose a stamped, self-addressed envelope
tion requirements and reporting methods of response if the survey is to be mailed back. This will greatly
rates (Johnson & Owens, 2003). The researchers increase the response rate. Recipients will generally
found that none of the journals specified a minimum not make the required effort to find an envelope and
response rate and most did not outline standard your address on the cover letter (which has often been
procedures for reporting it. Thus, it is evident that destroyed), and may resent having to pay postage
controversy still exists as to what is an acceptable for your research project.
response rate. Surveys must be short enough to hold the respon-
Although the type of survey and method of distri- dents’ attention but long enough to obtain the
bution can affect your response rate, the rate can also required information. The cost to create and conduct
be negatively impacted when surveys are returned in- the survey is also a consideration (Fink, 2009). Re-
complete and subsequently have to be removed from search reveals that decreased response rates and qual-
the sample being analyzed. Conversely, response rates ity are likely if self-administered surveys take longer
are likely to be higher if the sample has some vested than 20 minutes (Cape, 2010). Other sources estimate
interest in the topic of study and therefore returns the the time respondents will devote to online surveys is
surveys promptly and completely. The American Asso- between 7–8 minutes, with respondents abandoning
ciation of Public Opinion Research (n.d.) provides addi- the survey or “satisficing” (speeding) through the
tional information on how to accurately calculate and survey if it takes longer (Chudoba, 2011). One good
report your response rate. rule of thumb is to view your survey as objectively as
It is also important to consider other techniques you can and to ask yourself if you would stick with it
for improving your response rate. The survey must be and answer all the questions if it was sent to you. In
attractive and pleasing so that recipients will not dis- most cases, it is also appropriate and worthwhile to
card it without reading the cover letter and initial in- pilot your survey before use in experimental research.
structions. The cover letter must be well-written to This will help to clarify any survey questions that may
catch the recipients’ attention, and to describe why be confusing to respondents, to increase accuracy of
recipients should be interested in the study and what information gained from the survey, and to deter-
benefits they can expect from participating (even if mine if the method of delivery and completion time
the sole benefit is that they will be assisting a student are appropriate for your goals.
to complete her or his thesis and will thereby be indi-
rectly helping to add one more person to the pool of Question Construction
working healthcare practitioners). Reviewing the When constructing questions for surveys and inter-
goals of the study and other details can capture their views, two types of questions—closed-ended and
interest and increase the likelihood that they will an- open-ended—may be used. Closed-ended questions
swer the questions. are those that require only a simple answer, usually
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Chapter 7 ■ Technical Aspects of Quantitative Research 75

“yes” or “no” or a check mark against a series of op- responses. There is a trade-off here, and the choice
tions, whereas open-ended questions are those that must be made by the researcher.
respondents can answer in as many words as they In closed-ended questions, response formats
please. Open-ended questions are most useful in deal- should be mutually exclusive and, when ratings are
ing with complicated information when slight differ- required, there should be a wide array of choices. In
ences of opinion are important to know. They also the “yes or no” answer, there are differing opinions
provide a good way to elaborate on a closed-ended about whether to include the “don’t know,” “unde-
question, such as: cided,” or the neutral option. Converse (1970, 1974)
first raised this concern, and authors since that time
have argued whether it was more beneficial to force
Do you teach clinical reasoning skills to your respondents into a positive or negative answer, or to
therapy students? Yes ______ No ______ give them the option to admit their lack of knowledge
If yes, please explain how and at what or inability to decide (Walonick, 2010). Face-to-face
point in the curriculum: interviews are advantageous as skilled interviewers
may be able to elicit clarifying information from in-
terviewees who at first choose one of these neutral re-
Open-ended questions may also be used as a way of sponses. Although mailed surveys do not allow
finding out which issue in a series of closed-ended additional probing, research on interactive web-based
questions is the most important or most relevant to surveys shows that use of additional prompts may
the respondent. For example, a series of specific ques- combat this problem (DeRouvray & Couper, 2002).
tions about specialty certification may be followed by The type of question, knowledge-based versus atti-
the question: “What is your opinion of specialty certi- tude-based, may also dictate the need to include a
fication?” This technique is useful in that it often neutral option.
makes respondents feel better after having been “boxed In addition to simple “yes or no” items, other ques-
in” for possible answers—they can now say what they tions rely on some sort of rating scale, the best known
want to say. You might not use the open-ended piece being the semantic differential and the Likert rating
of information in tabulating results, but it keeps the scales. The semantic differential, developed by
respondents interested and involved, and increases the Charles Osgood (Osgood, Suci, & Tannenbaum,
likelihood that they will complete the survey. 1957), is used as a measure of affective meaning. Re-
Open-ended questions are useful in allowing re- spondents are given a domain of concern and are
spondents to answer in any style and manner they asked to rate their affective responses about that do-
choose without giving them suggestions. This re- main on a list of bipolar scales. These are seven-point
duces the chance of their giving what they perceive as scales with opposing adjectives at the two extremes.
socially acceptable answers. Similarly, questions that Generally, three dimensions exist into which these ad-
may be viewed as sensitive or threatening are usually jective pairs can be categorized—the evaluative dimen-
best handled as open-ended questions and may be sion (good or bad), the potency dimension (strong
more honestly answered on an anonymous survey or weak), and the activity dimension (fast or slow).
than in a personal interview. Box 7-1 shows one use of the semantic differential.
Yet the fact is respondents are often more willing In the Likert scale (Likert, 1932), a statement is
to quickly complete a survey composed of closed- given to respondents to indicate the domain of con-
ended questions rather than writing several sentences cern, and the respondents are asked to indicate their
that they have to think about and compose for ques- level of agreement with that statement on a five-point
tions of the open-ended variety. However, the closed- or seven-point scale. The five-point scale is typically
ended responses may not satisfy the researcher who worded as follows: “Strongly agree, Agree, Neutral,
would prefer more detailed, qualitative, and personal Disagree, Strongly disagree.” The seven-point scale
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76 Section 2 ■ Research Methodologies and Designs

of behavior, or personality traits. A phrase is provided

BOX 7-1 ■ Example of Semantic Differential to indicate the domain of concern, and the respon-
Henry, Nelson, and Duncombe (1984) used dent is asked to complete the sentence. For example:
the semantic differential to elicit subjects’ re-
sponses on how they felt about themselves
following a choice or no choice situation in My opinion about placing adults with devel-
an activity group on three affective factors: opmental disabilities in group homes is:
evaluation, power, and activity. They used _____________________________________.
Osgood’s short-form semantic differential
where subjects were asked to assign a rating Multiple-choice items can also be used to elicit
on a 7-point scale for each of 12 scales. The opinions or attitudes from respondents. A statement
actual scale looked like this: is provided, sometimes in question form, and respon-
nice awful dents are asked to select from the list the item that
fast slow most reflects their opinion, attitude, or even a likely
quiet noisy action. For example, if researchers wanted to explore
sour sweet perceptions of common treatment interventions used
powerless powerful with stroke patients, the following question might be
young old included in their survey for healthcare professionals
bad good
working with this population:
weak strong
alive dead
deep shallow What is the best method for decreasing mus-
big little cle tone following stroke?
unhelpful helpful a) Application of moist heat
b) Gentle massage over the muscle belly
c) Daily range of motion exercises
d) Ultrasound
would add “Very strongly agree” and “Very strongly e) Application of a splint
disagree” at either end. For example, see the box at the
bottom of the page.
In other cases, respondents may be asked to fill in In rank-ordering items, a list of items is provided
the blank or to choose a relevant response from mul- and respondents are asked to place a number beside
tiple choices—either a rank-ordered or unordered list. each, indicating their order of importance. Some-
Incomplete sentences are sometimes used to find out times only the first two or three items of importance
such things as opinions, attitudes, knowledge, styles are asked for, and sometimes the whole list must be

Please circle the number that best represents your feelings:

Neither Agree
Strongly Nor Disagree Strongly
Agree Agree (Neutral) Disagree Disagree
Treatment at this clinic
5 4 3 2 1
is very client-focused.
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Chapter 7 ■ Technical Aspects of Quantitative Research 77

prioritized. It is important to remember that most things to consider in survey organization include the
people find it difficult to prioritize more than about visual layout, including font and spacing, transitions
10 items. Using the previous example, the question between sections, and adequate pretesting to ensure
would appear as follows: the information obtained is useful and that the sur-
vey is user-friendly and easily understood.
Suffice it to say, much reflection should be given
Please rank the following treatment interven- to the type of questions used and the method of
tions in order of effectiveness in decreasing presentation. Consideration of your population
muscle tone in stroke patients, starting with and the information you hope to gain is critical in
“1” for the treatment you believe to be most making these decisions. The reference list contains a
effective. variety of excellent texts that can assist you further in
Rank survey construction.
(1 through 5) Record Review
Application of moist heat __________ Review of written records is an appropriate data col-
lection method in several types of research, including
Gentle massage over the
experimental, ethnographic, retrospective or histori-
muscle belly __________
cal, and case study designs. Documents provide both
Daily range of motion exercises __________ historical and contextual dimensions to your obser-
Ultrasound __________ vations and interviews. They enrich what you see and
Application of a splint __________ hear by supporting, expanding, and challenging your
portrayals and perceptions.
Written documents may include patients’ medical
Survey organization records, minutes of meetings and case conferences,
The survey questions should be sequenced so that letters, speeches, articles, books, diaries, graffiti, notes,
they follow one another in a logical order. First, draw membership lists, newsletters, newspapers, and illus-
subjects in and gain their interest with broad, general trations. Artifacts may include physical materials
questions. Avoid sensitive questions until the respon- such as adaptive equipment, adapted clothing, pho-
dent is comfortable and, in the case of a face-to-face tographs, audio and video recordings, and films.
interview, until rapport has been established. It is a One way to obtain written materials is to ask subjects
good idea not to give too many questions that require to keep diaries, journals, or other kinds of records.
a simple “yes” or “no” or too many requiring a rating Collaboration with healthcare practitioners might be
at different levels (such as “Rate on a scale of 1 to 5”) necessary so that clinical notes simultaneously meet
in a sequence, because respondents lose interest and the needs of the healthcare facility and the research
concentration after a while and may answer without study. For example, if you are interested in patient sat-
giving the questions much thought. Break up these isfaction with healthcare services, you might be able
questions with others written in a different format. to play a role in the design of a patient satisfaction
Often researchers add a general open-ended ques- survey that would assist the healthcare facility as
tion at the end of a questionnaire, designed to give re- well as your study.
spondents an opportunity to add any information Traditionally, records used as research data are
they did not have a chance to include during the divided into primary and secondary sources. Primary
process. On mailed questionnaires, it is quite com- sources are firsthand accounts about the topic under
mon for respondents to write notes to the researcher review, such as autobiographies or eyewitness ac-
explaining things they think are unclear or adding counts, and secondary sources are accounts written
items they feel are relevant. The final general question about the topic by others that are not based on per-
gives respondents a legitimate place to do this. Other sonal experience, such as medical records (which are
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78 Section 2 ■ Research Methodologies and Designs

written by clinicians and not by the patients having

the experience). Researchers should try to verify BOX 7-2 ■ Use of Physical Equipment to
both the truth about the writing of the documents Operationalize Study Variables
(did this person actually write it?), as well as the In a study measuring posttreatment elbow
truth about the content of the documents (did this range of motion in patients with hemiplegia,
actually happen?). range of motion at the elbow can be opera-
Moreover, written materials may be used to corrob- tionally defined as the number of degrees reg-
orate researchers’ observations or what they find out istered on a goniometer placed on the joint
in interviews. Records can raise useful questions angle while in extension and in flexion.
about the study and shape new directions for obser-
vations and interviews. They can provide historical,
demographic, and sometimes personal information
that is unavailable from other sources. such as cable tensiometers, spirometers, electro-
In summarizing and interpreting the data gath- encephalographs, goniometers, dynamometers, pinch
ered, the researcher must use logical analysis and be meters, pedometers, heart rate monitors, digital
as objective as possible. In a retrospective study, where calipers, volumeters, scales, pulse oximeters, and
examination of records is often the only form of data ultrasound imaging, to name a few. When utilizing
gathering possible, the researcher usually cannot con- these types of devices, it is important to obtain infor-
firm that one event in the past caused another to mation from the manufacturer on specifications and
occur. In this case, the researcher must make assump- settings, and to ensure that the device is adequately
tions or draw inferences that assign causality. The calibrated and in good working order. Unfortunately,
more information that is uncovered about an event, many variables cannot be measured with hardware,
the more likely the cause of the event may be deter- and other means must be found to define and quan-
mined. Researchers must be careful to restrict inter- tify them. These other means are generally written
pretations about causes and generalizability of the tests and measures, which will be discussed in the
evidence gathered. Box 6-2 provides an example of use next section.
of medical records for data collection.
Tests, Assessments, and Inventories
Equipment Used in Research A great deal of research data used by health profes-
Many studies performed by healthcare professionals sionals is gathered via written tests, assessments, and
employ physical measures of such functions as joint inventories. A plethora of standardized assessments
range, muscle strength, or galvanic skin response. exist to measure variables including psychological fac-
Physical or mechanical instruments that provide a tors, functional performance of daily tasks, cognitive
valid and reliable measurement are usually more de- abilities, perceptual motor skills, child developmental
sirable in experimental research than the subjective stages, prevocational skills, vocational interests, per-
feedback given by subjects. However, before relying sonality factors, attitudes, and values, to name a few.
on a piece of equipment as a measuring instrument Some of the better-known tests have been gathered
in a research study, the researcher should make sure and critiqued in such bibliographic texts as Asher’s
that it is reliable and valid. The use of equipment for (2007) book on tests used in the practice of occupa-
measuring is also desirable in research because it pro- tional therapy, Fischer and Corcoran’s (2007) two-
vides a simple method for operationally defining volume set of clinical instruments and scales used by
and measuring dependent variables. Box 7-2 provides a variety of allied health professions, and Burlingame
an example. and Blaschko’s (2009) collection of assessments
In these days of sophisticated equipment, many for recreational therapy and related fields. Profes-
choices are available for objectively measuring depen- sional organizations representing each discipline
dent variables. Healthcare practitioners use instruments, often have resources that list applicable assessments
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Chapter 7 ■ Technical Aspects of Quantitative Research 79

to a particular practice area, summarize the purpose Four types of reliability pertaining to test instru-
of available tools, or provide links to research testing ments are important to understand:
the usefulness, reliability, and validity of assessments.
1. Test–retest reliability is concerned with the con-
One example is the American Physical Therapy Asso-
sistency of scores over time. More specifically, if
ciation’s (2005) List of Assessment Tools Used in Pediatric
subjects are measured regarding some character-
Physical Therapy. Other sources for tests are the cata-
istic now, and then re-measured on the same
logs from the major test publishers.
characteristic at a later point in time, the scores
If you find that there is no existing test to gather
should be similar, assuming that the conditions
exactly the type of information you are interested in,
and the characteristic being measured are stable.
you will probably need to design your own test. In
2. Split-half reliability concerns the extent to
order for your test to be valid and useful, you should
which different parts of an instrument measure
follow accepted test construction techniques. You are
the same thing. For instance, are two different
referred to Benson and Clark’s (1982) article “A Guide
items on a test for self-esteem both actually
for Instrument Development and Validation” for
measuring components of self-esteem? If not,
a step-by-step description of the procedure for test
the whole test may be suspect, and the compiled
construction.
score may not truly represent the subject’s self-
Validity and Reliability of Test Instruments esteem score. To assess this type of reliability, the
Tests, measures, and inventories can be standardized test is divided into two parts and subjects’ scores
or nonstandardized. Standardized tests have been on the two groups of items are compared. The
subjected to a process called normalizing, which es- two scores should be similar in order for the test
tablishes a level of validity and reliability in relation to to be considered reliable, and a high correlation
the “normal” population, whereas nonstandardized between sets of items indicates a higher degree
measures have not undergone such rigorous testing. of internal consistency (Kimberlin & Winterstein,
Validity 2008).
A valid test is one that measures what it claims to 3. Intrarater reliability is the degree to which each
measure; for example, an intelligence test truly mea- rater or observer is consistent in his or her rat-
sures a child’s intelligence rather than his or her ings. Multiple repetitions of the same test by
school performance, concentration, or motivation. one rater should yield consistently similar results,
Yet, “validity is not a property of the test itself. Instead, thus ensuring consistent administration and
validity is the extent to which the interpretations of testing procedures by that rater.
the results of a test are warranted” (Kimberlin & 4. Interrater reliability, or interobserver agreement,
Winterstein, 2008, p. 2278). In the health sciences, re- is the extent to which different raters or observers
searchers are often interested in studying abstract perceive the same person or characteristic simi-
concepts that cannot be directly measured. These larly. To obtain reliable study results, ratings
might include safety, feelings of self-efficacy, quality should be similar regardless of the rater. In other
of life, collaboration, or satisfaction, to name a few. words, if two different raters administer an as-
Thus, the ability to operationalize these terms is crit- sessment on the same study subject, the scores
ical in being able to provide an accurate system of should be relatively similar. Both intrarater and
measurement. interrater reliability can be increased by clearly
operationalizing all study variables and by con-
Reliability
ducting formalized training in administering
A test is reliable if the same results occur during re-
treatments and conducting assessments.
peated administrations over time. For example, a re-
liable intelligence test will give the same intelligence The manual that accompanies a standardized
quotient (IQ) score for the same individual time after test should include information about the process
time, all else being equal. by which norms were established, details of the
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80 Section 2 ■ Research Methodologies and Designs

population used as normative groups, and the actual After you have determined the best method(s) of
degree of validity and reliability achieved for the test. data collection, you should consider how you will
You should review this information to see if the test is analyze the data. In quantitative research, data result
rigorous enough for the purpose of your study. It is from variables that can be enumerated in some
important that you use the test only on the type of way so as to be tabulated and subjected to statistical
subjects described in the manual. The researcher must procedures.
learn the test administration procedures, and the test
should be given exactly in the manner described in the
Analyzing Quantitative Data
manual. The reliability and validity of a test can be en-
sured only if the test is administered to the prescribed This is the part that many people hate! Researchers
population, under the prescribed conditions, and in must decide what to do with the mass of numbers that
the prescribed manner. Once any of these conditions have been collected and what statistical tests to use.
are changed, the researchers cannot claim for their Some people have such a fear of this part of the re-
study the degree of reliability and validity listed in the search process that they never get beyond it. Although
manual. Table 7-1 includes a list of considerations in this fear or lack of knowledge is very real, it should not
selecting an existing assessment tool. be allowed to stand in the way of conducting mean-
ingful research. Those who are intimidated by data
analysis should seek assistance from a statistician.
Table 7-1 ■ Considerations for Selecting Consulting a Statistician
an Existing Assessment Tool
The question of when to seek statistical assistance dur-
■ Consider the construct you wish to measure. Your ing the research process is worthy of discussion. Gener-
literature review will help operationalize key concepts ally, a statistician should be consulted in the design stage
and determine possible assessment tools for use. of the project while the methodology and data collection
■ Review test items and the manual for any tool you
measures are being determined. Once researchers iden-
are considering to determine if it aligns with your
tify their topic of interest, a statistician can ensure selec-
study’s goals.
tion of the most appropriate study design for their
needs, and can make recommendations regarding sam-
■ What is the reliability and validity of the tool? Has it
ple size, blinding, randomization, structure and timing
been used on the population you intend to study?
of the therapeutic interventions, and coding of data
■ Can you locate other studies that attest to the tool’s (American Statistical Association (ASA), 2003).
reliability and validity? Although the researchers will decide on the actual
■ Will you need to purchase or request permission to use measures used and whether these measures will reli-
the tool, or is it in the public domain? ably collect the type of data they desire, the statisti-
■ Are there costs associated with obtaining the tool or cian understands how the data will be analyzed and
administering it? may have some advice concerning the format in
which the data are collected. For example, if you wish
■ What training procedures will be necessary to ensure
to compare two groups’ performances on pretests and
administration procedures follow the protocol in the
posttests in order to determine which group made the
manual?
most progress, the statistician may advise that data
■ Is the tool appropriate for your population? Consider from a certain measure are not in a format suitable
your subjects’ age, educational level, setting, and for such comparisons. An unclear response from sub-
motivation to participate in your study. Each of these jects such as, “I feel somewhat better,” does not lend
attributes could impact their ability to understand the itself to objective comparisons, either for that one
tool and provide worthwhile information. subject or among subjects. To further expand on this
(Kimberlin & Winterstein, 2008) point, the statistician will understand how data will
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Chapter 7 ■ Technical Aspects of Quantitative Research 81

be entered into statistical software, and can make rec- using one or two numbers, such as the mean and
ommendations of how to organize data for ease of standard deviation. They can be used to describe each
data entry. dependent variable, such as the percentage and mean
Additionally, researchers may unknowingly omit of each item physical therapists checked off on a list
some crucial piece of information concerning sub- of reasons for moving into supervisory positions and
jects from their questionnaire—for example, their their ages when they moved. Descriptive statistics can
ages. If they wish to group people by age for compar- also be used to give the variation or spread of scores
isons, this information will of course be important. within each group studied, such as the mean and
Although anyone has the ability to spot this type of range of scores for experimental and control groups
error, it sometimes takes an objective reader who is in a study on a new treatment technique for carpal
accustomed to studying data to notice it. tunnel syndrome.
Finally, a statistician can help to determine which Inferential statistics, on the other hand, allow re-
statistical tests will be best suited for data analysis searchers to make inferences about the population
and can advise on how many subjects are needed in from the sample findings. Sufficient subjects are
order to use the chosen tests. Researchers need this needed in the sample to be able to do this; in addition,
information early in the planning stages of a study random selection should be used. The types of statis-
so that they can recruit a sample of adequate size. tical tests used in inferential statistics include t tests,
Thus, seeking assistance from a statistician early F tests, and tests for r. These tests result in probability
in the research design process is helpful in ensuring statements that help one draw conclusions about dif-
that data will be collected in such a way that they can ferences or relationships between groups. For exam-
be manipulated effectively. ple, if a difference is found between the mean scores
Consulting a statistician has a price, but most peo- of two groups at the end of a study, the researcher
ple who have hired someone feel it is worth the cost. must decide whether a similar difference is likely to
You may be fortunate enough to be connected to a be found between the same mean scores in the whole
university or other facility that employs a statistician population from which the sample groups were
who is willing to help free of charge or for a nominal drawn. The t, F, and r tests allow the researcher to
fee. The American Statistical Association (http://www make this decision.
.amstat.org/index.cfm) or the International Statistics In- Both descriptive and inferential statistics are often
stitute (http://www.isi-web.org/) can provide additional used in the same research study. Descriptive statistical
information about hiring a statistician. methods are the same regardless of the type of data
Anything other than basic statistics is beyond the being used; however, inferential statistical methods
scope of this text. However, a simple explanation vary according to the type of data used.
of some of the processes involved in organizing and
manipulating data will hopefully enable the reader Types of Data
who has a fear of statistics to cope with the material Data are classified into four levels or scales of mea-
and know when to get help. surement: nominal, ordinal, interval, and ratio. Each
data type builds on the characteristics of those previ-
Descriptive versus Inferential Statistics
ously described.
Statistics are divided into two categories: descriptive
and inferential statistics. Descriptive statistics de- Nominal Data
scribe, organize, and summarize data. They include Nominal data are the numbers applied to nonnumer-
frequencies, percentages, descriptions of central ten- ical variables; for example, a group of people’s disabil-
dency (mean, median, mode), and descriptions of rel- ities could be coded as follows: right hemiplegia = 1,
ative position (range, standard deviation). left hemiplegia = 2, paraplegia = 3, and so on. Each cat-
These procedures allow for the description of all egory of data must be mutually exclusive, meaning that
the individual scores in a sample on one variable by no individual or variable can be assigned to more than
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82 Section 2 ■ Research Methodologies and Designs

one group. There is no ordered relationship between scales. Items are ordered on a continuum; however,
categories, meaning that one category cannot be con- there is no zero starting point. For example, temper-
sidered to come before or after another category. This atures can fall below zero or subjects can be asked to
type of data is sometimes referred to as discrete as op- rate the magnitude of a particular stimuli on a 1 to
posed to continuous. For discrete data there is no limit 10 scale, where the intervals are assumed to be equal.
to the number of categories that can be included,
whereas with continuous data there are an infinite Ratio Data
number of possible values along a continuum. Because Ratio data are numbers that are also continuous with
there is no numerical value assigned to categories of equal intervals between them. Additionally, ratio data
nominal data, they cannot be meaningfully added, sub- have a meaningful zero point. In other words, the zero
tracted, or multiplied, and so forth. One cannot calcu- point indicates a total absence of whatever ability or
late an average (mean) disability, for example. property is being measured. For instance, there can
Examples of categories might include male and fe- legitimately be zero range of motion or visual acuity.
male; inpatient, outpatient, and day treatment set- Other examples of ratio data include time, weight,
tings; and patients with schizophrenia, bipolar and income. Ratio data can be multiplied and divided
disease, or depression. A nominal scale may also be to reveal proportions. For example, if a goniometer is
used to code “yes or no” responses on a survey. used to measure elbow extension in a child with cere-
bral palsy, and the right elbow is measured at 160 de-
Ordinal Data grees of extension, whereas the left elbow is measured
Ordinal data are numbers that are still discrete but are at 80 degrees of extension, one could report that the
ordered; however, the intervals between the categories right elbow extends twice as much as the left.
are unknown and cannot be assumed to be equal. In As you can see, each data type builds on the char-
contrast to nominal data in which assignment of num- acteristics of those previously described. Nominal
bers to categories is arbitrary, numbers assigned to data are separated into categories; with ordinal data
groups of ordinal data signify a rank order or meaning- these categories can be rank-ordered; with interval
ful sequence. For instance, a review committee may data the values between categories are equal, but there
rank-order a series of program proposals and assign is no zero starting point; and finally with ratio data,
first, second, and third place, but the top-ranked pro- a real zero point exists. In healthcare research, ratio
posal may be considerably better than the ones ranked data are the most common type.
second and third, whereas the ones ranked fourth, fifth,
and sixth may be similar to each other in quality. These Parametric and Nonparametric Data
differences among intervals are not reflected in the nu- Interval and ratio data are known as parametric data,
merical assignment. Other examples would be ratings whereas nominal and ordinal data are nonparametric
on a Likert scale such as “Strongly agree,” “Agree,” data. It is important to make this distinction so that
“Neutral,” “Disagree,” “Strongly disagree,” or classifica- you will know what kind of statistics can be used to
tions for client ability such as “Dependent,” “Needs par- manipulate your data. Although most of the descrip-
tial assistance,” “Independent.” An ordinal data scale tive statistics can be used on both parametric and non-
indicates a greater or lesser degree of something, or it parametric data (the exception being that mean and
may reflect a “precedes” or “superior” concept. standard deviations cannot be used on nominal data),
different inferential statistics must be used on the two
Interval Data types of data. This is because of the properties of the
Interval data are also ordered in a logical sequence. data, such as the data being ordered or the intervals
However, this time the intervals between the numbers between numbers being equal. Some tests are not
are considered equal and represent actual amounts. powerful enough to cope with unordered, unequal
These are continuous data. Examples are intelligence data, whereas others are. Table 7-2 summarizes the
scores, degrees of temperature, and magnitude rating categories of data with their corresponding parametric
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Chapter 7 ■ Technical Aspects of Quantitative Research 83

Table 7-2 ■ Categories of Data With Corresponding Classifications and Statistical Tests
Appropriate Descriptive Appropriate Inferential
Category of Data Classification Statistics Statistics

Nominal Nonparametric ■ Frequencies ■ Pearson’s chi-square

(named categories; unordered) ■ Percentages ■ Fisher’s exact
■ Mode ■ Goodman & Kruskal’s tau b

Ordinal Nonparametric ■ Frequencies ■ Pearson’s chi-square

(ordered categories; unequal ■ Percentages ■ Spearman rho
intervals) ■ Mode ■ Wilcoxon rank sum

■ Median ■ Mann-Whitney

■ Kruskal-Wallis

■ Kendall’s tau

Interval Parametric ■ Frequencies ■ t test

(ordered data; equal intervals; ■ Percentages ■ Analysis of variance (ANOVA)
no zero starting point) ■ Mean ■ Analysis of covariance (ANCOVA)

■ Median

■ Mode

■ Range

■ Standard deviation

Ratio Parametric ■ Frequencies ■ t test

(equal intervals with zero point) ■ Percentages ■ Analysis of variance (ANOVA)
■ Mean ■ Pearson product moment

■ Median correlation
■ Mode

■ Range

■ Standard deviation

and nonparametric classifications and types of statis- Conversely, nonparametric statistics should be
tical tests. used when:
Parametric tests are appropriate when: 1. Random selection has not occurred, so that the
1. The sample is randomly selected, thereby helping sample is not considered representative of the
to ensure the sample is representative of the pop- population of interest and variables are probably
ulation of interest, and that the variables being not normally distributed.
measured fall within the normal distribution for 2. Variables have been measured in a manner that
that population. generates nominal or ordinal data.
2. Variables are measured in a manner that generates 3. The number of subjects in the sample is small.
interval or ratio data. Because nonparametric tests have less statistical
3. Random assignment or matching of study groups power, substantial differences must be found between
is completed, to ensure similarity between the sets of scores before those differences are considered
two groups. meaningful. Nonparametric statistics are frequently
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84 Section 2 ■ Research Methodologies and Designs

used in healthcare research because pathological (bimodal)—say if equal numbers of participants were
human conditions are being studied. The variables employed full-time and part-time. Each measure of
of illness or pathology are often not distributed central tendency has advantages and use is typically
normally in the target population. Also, it is often dictated by the type of data being analyzed. Salkind
difficult to locate many subjects with the requisite (2011) provides some additional guidelines:
pathology, so samples tend to be smaller. ■ Use the mode when you have nominal data—
namely data that are arranged in mutually
Descriptive Statistics
exclusive categories.
A great deal of quantitative data can be effectively ■ Use the median when your set of scores includes
analyzed using descriptive statistics. In fact, if a non- several outliers that will skew the mean.
experimental research design is used, almost all of ■ Use the mean when you have interval or ratio
the data can be appropriately analyzed descriptively data that do not include outliers (p. 30).
because of the lack of random selection or use of a
The reader also may wish to know the spread or
control group. It is difficult to make inferences from
variability of scores. These descriptive statistics, known
a sample to a population of interest (the purpose of
as measures of variation, include the range and stan-
inferential statistics) if random sampling and control
dard deviation. The range is the simplest and is cal-
criteria have not been met. The initial description and
culated by subtracting the lowest score in the set from
compilation of data can be achieved using descriptive
the highest score. In essence, a range will explain the
statistics—that is, providing the frequencies, percent-
section of the continuum in which the subjects
ages, and means for all the characteristics under study
scored, perhaps IQ scores from 90 to 120, resulting
so that the reader has a thorough understanding of
in a range of 30. The range could have practical im-
the subjects and variables. It is customary to present
plications as in the following scenario: You are asked
percentages alongside the frequencies, both in the
to conduct a therapeutic intervention on Monday for
text and in illustrative tables.
a class of 7-year-olds with a mean IQ of 100 whose
It is often useful to give the reader the group’s av-
scores ranged from 90 to 110; on Tuesday, you are
erage score—that is, their central tendency. The three
scheduled to conduct the same intervention with a
measures of central tendency are the mean, median,
group of 7-year-olds with a mean IQ of 100 whose
and mode. The mean is the most common average
scores ranged from 60 to 120. In the second group,
and is computed by adding all the scores and dividing
you might need more assistance or have to structure
the total by the number in the group. The median is
the session differently to meet the needs of children
the midpoint among all the scores. Each score must
with a wider array of cognitive abilities.
be listed in order from the highest to the lowest, or
Another way to describe variations is to use the
vice versa, to locate the score that falls in the center.
standard deviation, referred to as s or SD. The stan-
For example, a ranked order of IQ scores might be as
dard deviation indicates how the scores are grouped
follows: 150, 100, 98, 75, and 50. The median would
around the mean. If your standard deviation is small,
be 98 because that score falls in the middle. For lists
this is indicative of scores clustered close to the mean,
consisting of an even number of scores, it is protocol
whereas a larger standard deviation denotes a wider
to calculate the mean, or average, of the two middle-
spread in scores. The standard deviation is also im-
most scores. Finally, the mode is the most commonly
portant when you want to determine consistency of
occurring score or answer. For instance, in a study of
a particular variable; a standard deviation of zero sig-
employment status on quality of life, subjects might
nifies no variability.
be asked to indicate if they were employed full-time,
part-time, or if they were unemployed. If the majority
of respondents indicated they were employed Inferential Statistics
full-time, this category would be the mode. It is Inferential statistics are used to draw conclusions or
also possible for there to be more than one mode make inferences about the population of interest
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Chapter 7 ■ Technical Aspects of Quantitative Research 85

from a smaller chosen sample. They also help re- that this change occurred because of events in the re-
searchers to determine the probability of phenomena search study, and what is the probability that this
observed in the sample occurring in the larger popu- change would have occurred anyway, by chance? The
lation from which the sample was taken. If results are tests that are used to make this determination result
statistically significant, a researcher may decide that in a level of probability, and the researcher must decide
results can be generalized to the target population. whether or not this level is significant. In the social sci-
Inferential statistics can be divided into three groups: ences, the usual convention is that 5 out of 100 occur-
1. Those aimed at determining statistical significance rences of a phenomenon being caused by chance is a
2. Those aimed at determining the correlation or reasonable number to accept, and that any result bet-
association between two or more variables ter than that is statistically significant. This result
3. Those that compare two or more sets of scores to would imply that you are 95% certain that the im-
determine the extent to which they vary among provement in posttest scores was caused by the treat-
each other ment. This probability level (or confidence level) is
expressed as p “<” 0.05. Some scientific endeavors re-
Statistical Significance quire more stringent proof, and a standard of p “<”
In this group, the tests assist the researcher in decid- 0.01, or a 1 in 100 chance that the phenomenon oc-
ing whether the changes in the mean pretest and curred by chance, is set for those studies, otherwise
posttest scores of the experimental group are, in fact, known as a 99% success rate. Ultimately, it is up to the
a result of the experimental treatment rather than researchers to determine the acceptable significance
chance. They allow comparison of results from the level for their study. See Box 7-3 for an example of sta-
sample with that which was hypothesized as normally tistical significance in an experimental design.
occurring in the population of interest. The tests can The tests most commonly used to determine sig-
be used with a directional hypothesis or with a two- nificance levels are Pearson’s chi-square test on non-
sided hypothesis. We will use the classic experimental parametric (nominal and ordinal) data and the
research design as an example: student’s t test on parametric (interval and ratio) data.
The chi-square and t tests can be used to compare two
groups on only one variable at a time.
R O1 X O2 Pearson’s chi-square
R O3 O4 The Pearson’s chi-square test (X2) is used to analyze
categorical data (e.g., “How many subjects are men
and how many are women?” or “How many have right
Statistical difference tests are applied to the scores hemiplegia and how many have left hemiplegia?”).
from the pretest and posttest results of the experimen- Pearson’s chi-square test may be used when you wish
tal group (O1 and O2), and to the pretest and posttest to know if there are significant differences between
scores of the control group (O3 and O4), and finally to pretest and posttest scores for a given group, or if you
the posttest scores of the two groups (O2 and O4). The wish to know if two groups are similar when you in-
first result indicates the degree of change following tend to use one as an experimental group and one as
the experimental treatment; the second, changes fol- a control group. It can be used to compare groups on
lowing no treatment; and the third, the difference be- a single variable or on groups of variables, one at a
tween end conditions of the experimental and control time. This test is useful when the researcher is inter-
groups. If the difference between the scores on the ested in similarities between groups of subjects. If the
third test (between O2 and O4) were statistically sig- researcher can determine the numbers of characteris-
nificant, it would indicate that changes can be attrib- tics such as gender, age, or diagnosis, a chi-square
uted to the treatment rather than to chance. test on the subjects will test whether the sample
Significance testing is based on the laws of proba- matches the population. The calculated value for the
bility. It answers the questions: What is the probability chi-square formula is evaluated using standardized
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86 Section 2 ■ Research Methodologies and Designs

statistics were used to determine if dominant-side

BOX 7-3 ■ Example of Statistical paresis significantly affected improvements in quality
Significance in an and quantity of movement. P values (p = 0.551 for
Experimental Design quantity of use; p = 0.685 for movement quality) in-
Researchers in an outpatient physical therapy dicate no effect.
stroke center were interested in comparing the t Tests
effects of the Bobath approach to constraint- There are three different t tests, each of which is used
induced movement therapy on recovery of with a different research design, but all compare the
functional arm movements in stroke patients mean scores of two groups. The single sample t test
(Huseyinsinoglu, Ozdincler, & Krespi, 2012). compares the mean for a sample against a known
In their single-blinded randomized controlled population mean for a particular variable. This test is
trial, 22 patients were randomized into two rarely used because the mean score for a population
groups. One group received classic Bobath is rarely available. The paired samples (correlated)
treatment techniques, whereas the other t test is used when subjects are compared with them-
group received constraint-induced movement selves (i.e., they serve as their own control) or when
therapy. Chi-square tests and Mann-Whitney groups of individuals are compared after being
U-tests were completed initially and revealed matched on a particular characteristic. In this case,
no significant differences between the two the pretest and posttest scores are compared for the
groups at baseline. A variety of standardized first group and the two scores from the matched pairs
tests were employed in the study to measure are compared for the second group. In the indepen-
motor control, hand function, quality of dent samples t test, the pretest and posttest means
movement, and functional independence. Fol- are compared for the experimental and control
lowing the treatments, both groups demon- groups, and the two posttest scores are compared.
strated statistically significant improvements This is the most commonly used t test. If you have de-
in function, indicating that the improvements cided on a direction for your hypothesis, a one-tailed
could be attributed to the provided treat- t test should be used to determine the significance of
ments. When statistics were used to compare results. If a nondirectional hypothesis has been used,
the two groups post-intervention, results in- a two-tailed t test should be employed to determine
dicated that the constraint-induced move- the direction of the significance, if any. The t test is
ment group showed greater improvements in quite powerful and can be used on groups of subjects
movement quality (p = 0.01) and quantity of smaller than 30. Box 7-4 contains an example of a
use (p = 0.003). study employing t tests.
Wilcoxon rank tests
Wilcoxon rank tests can compare the degree and
direction of differences between two groups and
tables that list critical values. When the chi-square ex- are particularly useful for small sample sizes, usu-
ceeds the table value, the hypothesis is supported. In ally fewer than 30 subjects (Salkind, 2011). The
the case of Huseyinsinoglu et al.’s (2012) study of Wilcoxon signed rank test is used on nonparamet-
stroke patients, chi-square tests were used to compare ric data and is equivalent to the paired samples t test.
the study groups on the characteristics of age, gender, It is performed on paired scores and will determine
time since onset, educational level, lesion type, and the significance of the difference between either
location and extent of paresis. No significant differ- pretest and posttest scores for individuals or scores
ences were noted among the groups at baseline, al- on matched pairs of subjects. The Wilcoxon rank
though the constraint-induced movement group sum test is the equivalent to the independent sam-
contained slightly more individuals with paresis ples t test, but is used on nonparametric data. For
affecting their dominant side. During data analysis, this test, ranks are assigned to scores for all subjects
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Chapter 7 ■ Technical Aspects of Quantitative Research 87

Mann-Whitney test
BOX 7-4 ■ Example of Use of t Tests The Mann-Whitney test is another alternative to the
Leerar et al. (2007) used independent t tests t test for use on nonparametric data. It compares the
to determine if the quality of physical therapy means of two independent groups and is equivalent
documentation was impacted by four vari- to the independent samples t test. See Box 7-6 for an
ables: patient diagnosis, patient age, referral example.
source, and medical testing completed on the Tests for Correlation
patient. No significant differences were noted Correlational tests determine the relationship be-
on the t tests, leading to the conclusion tween variables or sets of scores. The two sets of scores
that therapists likely have a set approach to might be from one group of individuals or from two
documentation that they use regardless of different groups of individuals. Once it is seen that
specific patient characteristics. one score moves up or down, the intent is to find out
if the other score moves in a corresponding fashion.
The objective is to find out how closely the scores
in the study, and the ranks for all subjects in each covary; that is, whether they change together in a
group are summed. The test determines the degree particular pattern, in a positive or negative way. If
of difference between group total scores. An example both scores increase together, they are said to be pos-
of a study utilizing a Wilcoxon rank test is included itively correlated; for example, height and weight
in Box 7-5. scores for a group of subjects would probably increase
together. On the other hand, if scores for ages over
60 years and scores for muscle strength were com-
BOX 7-5 ■ Example of Use of Wilcoxon pared, age scores might increase whereas strength
Rank Test scores would likely decrease. These scores are said to
be negatively correlated. The two sets of scores that
Several occupational therapists were inter-
are being compared in correlation testing can be
ested in examining social participation in psy-
chiatric occupational therapy activity groups
(Donohue, Hanif, & Berns, 2011). Specifi-
BOX 7-6 ■ Example of Use of a
cally, they administered the Social Profile, a
Mann-Whitney Test
39-item assessment in which levels of social
participation are rated on a 6-point Likert In studying the effects of virtual reality gam-
scale, to participants before and after the in- ing on dynamic balance and strength in older
tervention. Their sample consisted of 31 psy- adults, Rendon et al. (2012) employed a
chiatric patients who participated in social Mann-Whitney U (P “<” 0.038) test to inves-
skills groups for 1 month. A Wilcoxon rank tigate differences between the control group
test was used in data analysis because the and virtual reality group at baseline and after
Likert scale ratings provided ordinal, non- the intervention. Outcome measures included
parametric data. This statistical test revealed the 8-foot Up and Go test, a balance confi-
posttest scores were significantly (p “<” dence scale, and the Geriatric Depression Scale.
0.0001) higher than pretest scores. Although These measures provided ordinal data (nu-
this fact supports use of occupational ther- merical scales used to rate fall risk, balance
apy groups to improve social participation in confidence, and feelings of depression);
psychiatric patients, the results have to be ap- therefore, a Mann-Whitney test was appro-
plied with caution because the sample was priate and results revealed significant im-
relatively small. provements in the intervention group.
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88 Section 2 ■ Research Methodologies and Designs

entered on a scattergram to show the degree of corre-

lation graphically. A scattergram is a graph on which BOX 7-7 ■ Example of Use of Pearson
two variables are plotted. For example, in the previous Product Moment Correlations
example, age can be plotted on the vertical axis and A correlational study was conducted by
strength can be plotted on the horizontal axis to Tawashy et al. (2009) to see if there was a re-
provide a visual representation of how scores are lationship between the physical activity level
distributed. of individuals with spinal cord injury and their
Tests for correlation yield a statistic called a corre- levels of pain, fatigue, and depression. Activity
lation coefficient, expressed as r. The r may range level (heavy, moderate, or mild) was mea-
from –1 (indicating a perfect negative relationship) to sured using the Physical Activity Recall Assess-
+1 (indicating a perfect positive relationship). A zero ment for individuals with spinal cord injury
indicates that there is no relationship between the (PARA-SCI). Pearson correlations revealed
two variables. Decimal factors are used to indicate r that heavy intensity physical activity was
scores (i.e., 0.87 or –0.66). As with the previous tests, strongly correlated with less fatigue (r = –0.767)
a level of significance can be computed for an r score. and pain (r = –0.612), and increased self-
A review of some of the most common correlational efficacy (r = 0.656). For negative r values, the
tests follows. two attributes are inversely proportional;
Pearson product moment correlation whereas, for positive r values, the two attrib-
The most common correlation test is the Pearson utes are directly proportional. To clarify, it is
product moment method, often called the Pearson r, likely that as physical activity increases, fatigue
which is used on parametric data. This test, which can and pain decrease and self-efficacy increases.
be used on group scores or individual scores, indicates The researchers also found that mild physical
only systematic disagreements between scores and activity was correlated with fewer symptoms of
does not show the odd or occasional disagreement. It depression (r = –0.565) (p. 304). Although it
is often used to estimate reliability between tests, as in might be easy to assume a cause-and-effect
a test-retest situation, or between two raters to indi- relationship, one must remember that corre-
cate interrater reliability. Box 7-7 includes a study that lations only define relationships and cannot
used Pearson correlations to determine the relation- prove causation.
ship between variables.
Spearman’s rank correlation coefficient
(Spearman rho)
The Spearman rho (denoted as ρ or rs ) is the equiv- children with movement disorders wanted to know
alent to the Pearson r. It is used in descriptive re- if changes in balance correlated with functional
search resulting in nonparametric data when items performance (Silkwood-Sherer, Killian, Long, &
have been ranked and the researcher wishes to com- Martin, 2012). They used a Spearman rho correla-
pare two sets of rankings to see if there is any type tion to determine that a statistical association exists
of relationship between them. Like the Pearson, it (rs = 0.700); however, there was no correlation be-
results in an rs value falling between –1 and +1. It is tween change in balance and change in function
important to remember that a relationship between (rs = 0.13) (p. 707).
two sets of scores does not indicate cause-and-effect. Simple regression analysis
The researcher can claim only that a positive or Regression analysis is a technique that can be used
negative relationship between the variables has after the correlation coefficient has been established.
been found, and no more. For example, researchers When a relationship is found between two variables,
studying the effects of hippotherapy, which employs one can attempt to predict future scores for the de-
the motor and sensory features of horseback riding pendent variable based on the scores on which the
into therapeutic sessions, on balance deficits in correlation coefficient was found.
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Chapter 7 ■ Technical Aspects of Quantitative Research 89

Comparison of More Than Two Variables the Bonferroni post hoc comparison illustrated that
The researcher often wishes to explore more than two the experimental group demonstrated better per-
variables in the same study. In this case, different formance after the intervention (immediately after
statistical tests are needed. and 1 week after) than the control group, thereby
Analysis of variance supporting the hypothesis that coordination training
Analysis of variance (ANOVA) is a statistical tech- can improve tennis skills.
nique that can compare the mean scores of three or Analysis of covariance
more groups in one study. If a study intends to answer A similar test is the analysis of covariance
multiple questions or is multi-factorial in nature, (ANCOVA), which controls for initial differences
using the ANOVA may be most appropriate. For ex- between groups. If pretest scores reveal that the de-
ample, in a study of the effect of coordination training pendent variable is substantially different for the
on tennis skills, the researchers randomized partici- groups because of extraneous variables such as age
pants into experimental and control groups (Zetou, or sex, an ANCOVA can take into account the extra-
Vernadakis, Tsetseli, Kampas, & Michalopoulou, neous variables by treating them as covariates and ex-
2012). The control group received traditional tennis tracting their effect from the data. If the groups are
skills practice, whereas the experimental group re- made more equitable to begin with, the final results
ceived 20 minutes of a tailored coordination program can be compared and judged more fairly. In Hunt
in addition to the traditional practice. Backhand and and Bassi’s (2010) factorial design study of the im-
forehand techniques were assessed via standardized pact of simulated near-visual acuity levels and age on
observations before the training, after 8 weeks of train- performance on cognitive assessments, they used an
ing, and then again 1 week after the training ended. ANCOVA to control statistically for differences
A one-way ANOVA was used to compare both the among the study groups including a range of actual
experimental and control groups at baseline; results visual acuities and pupil sizes. Without control
revealed no significant differences. A two-way repeated of these factors, the researchers might have drawn
measure ANOVA (2 study groups X 3 measures) different conclusions.
showed significant interaction between the study Kruskal-Wallis one-way analysis of variance
groups and backhand or forehand assessments at The Kruskal-Wallis test is equivalent to the one-way
three separate points in time. Thus, overall differences ANOVA and can be used on nonparametric data.
existed between the means of all the groups, but using Like other nonparametric tests, this test is based on
analysis of variance alone will not reveal where the rankings of scores on the dependent measure in
differences lie. which all subjects are put into one group during the
Specifically, the ANOVA yields an F ratio, which is ranking procedure and then put back into their orig-
evaluated using a standardized table to determine inal treatment groups for the remaining analysis. In
whether there is a significant difference between the Chiarello et al.’s (2010) study examining family
largest and smallest of the study group means. If you priorities for activity and participation for children
wish to see if there are significant differences between with cerebral palsy, the Kruskal-Wallis one-way
any of the other means, you must use another test, analysis was one of the statistics employed. Children
known as a post hoc comparison. A variety of these were grouped according to age (“less than” 6 years,
tests exist including Tukey’s honestly significant dif- 6–12 years, and 13–21 years), and were rated on gross
ference method, the Newman-Keuls test, the Scheffé motor skills. After family priorities were identified,
comparison, Duncan’s multiple range test, Fisher’s the researchers wanted to determine if different pri-
Least Significant Difference, and the Bonferroni t-test orities were found related to age and gross motor
(Portney & Watkins, 2009). Each test has different skills. Because both measurement data and nominal
features, but detailed discussion is beyond the scope (categorical) data are included, analysis of variance
of this text. For more information, consult your sta- could not be used because it is effective strictly with
tistical text or statistician. In the previous example, parametric data.
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90 Section 2 ■ Research Methodologies and Designs

Multiple regression analysis Only some of the many possible tests for manipu-
Regression analysis is a statistical technique used for lating data are reviewed here. A statistician will be
making predictions about the study (dependent) vari- familiar with other possibilities and will be able to
able by understanding the effects of two or more in- advise you on the appropriate statistical tests based
dependent variables on the study variable. In essence, on your specific research design.
how much do the independent variables correlate with
the dependent variable? Sometimes this procedure can Statistical Software
be used to imply causal relationships; in other in- All of the aforementioned tests can be computed by
stances, it may be used to simply explore relationships. hand, but this is a tedious and time-consuming
There are multiple types of regression analysis; the process and most people use a computer for statisti-
most common include simple regression (discussed cal processing. With the help of a statistician or a
in the previous section), which involves only one inde- computer assistant, researchers can enter the raw data
pendent (predictor) variable, and multiple regres- into a computer program. It is also possible for the
sion, which provides a methodology for determining relative novice to perform the statistical manipula-
how two or more independent variables can impact tions via use of a statistical software package. Some
the dependent (study) variable. It is possible to take of the most commonly used statistical software pack-
the procedure a step further by untangling the relative ages designed for the health and social sciences can
contributions of each of the independent variables. be found in Table 7-3.
One can then use stepwise regression to look at the
independent variables in various combinations to see Reporting Data and Drawing
which combination is most useful in predicting the Conclusions
occurrence of the study variable. See Box 7-8 for an ex-
ample of a study where regression analysis was used. In quantitative research, results should be reported
in objective terms with no interpretation. Researchers
should focus on providing a factual account of
what happened during the study and what was ac-
BOX 7-8 ■ Example of Use of Regression tually found. Results can be discussed in narrative
Analysis format or displayed in tables and figures, with fur-
The aim of a recent study in sports medicine ther details provided on the formal written report
was to determine if physical activity can pre- in Chapter 12.
vent age-related brain atrophy in the frontal For experimental, quasi-experimental, or correla-
and temporal lobes (Yuki et al., 2012). Specif- tional research, the study will yield quantitative data,
ically, the researchers wanted to find out and inferential statistics can be used to determine if
if there was any association between the there are meaningful differences or similarities between
independent variables (individual activity en- groups. The probability ratios provide that information
ergy expenditure, number of steps, and total and indicate if the hypotheses have been substantiated.
energy expenditure) and the dependent vari- At this point, each hypothesis should be reviewed and
able (brain atrophy). They used multiple logis- checked against the statistical results. For each hypoth-
tic regression to establish if any relationships esis, researchers should inform readers if the hypothesis
existed among these factors while controlling was substantiated, give the probability level, and report
for other factors including age, body mass the details of the findings. It is customary for results to
index, medical and educational histories, and be reported from the general to the specific. For exam-
alcohol and tobacco use. A predictive relation- ple, in their study on the effects of virtual reality gaming
ship was noted with physical activity and total on dynamic balance and strength in older adults, Ren-
energy expenditure foretelling brain atrophy. don et al. (2012) reported “the Mann-Whitney test was
used to determine significant differences (P “<” 0.05)
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Chapter 7 ■ Technical Aspects of Quantitative Research 91

It is up to the researcher to determine the most

Table 7-3 ■ Common Statistical Software effective method for presenting these results.
Packages In a nonexperimental study, data may have been
subjected to one or more coding procedures. The re-
Software Publisher Website
sults of the coding must be presented as clearly and
Stata StataCorp, LP www.stata.com simply as possible. In this type of presentation, it is
4905 Lakeway Drive the weight of the evidence that will determine if the
College Station, hypotheses have been substantiated—a judgment the
TX 77845-4512 researcher must make because it is not possible to
SAS or STAT SAS Institute, Inc. www.sas.com subject the evidence to statistical significance testing.
100 SAS Clearly delineating the coding methods so that they
Campus Drive can be replicated and objectively applied allows the
Cary, NC reader to have confidence in the study’s analysis.
27513-2414 In quantitative research, discussion of statistical re-
sults and drawing of conclusions typically follows data
SPSS IBM Corporation www.ibm.com analysis. Comparison of results to the literature review
1 New Orchard situates the current research within the context of pre-
Road viously conducted studies on the topic and allows the
Armonk, NY researcher to compare and contrast current results
10504-1722 with prior ones. Practical implications for the findings,
Minitab Minitab, Inc. www.mintab.com limitations of the study, and suggestions for future re-
Quality Plaza search are also considered. These sections provide the
1829 Pine Hall “take home message” of the research study, and readers
Road unfamiliar with or intimidated by statistical methods
State College, and analysis may skip to these sections in an effort to
PA 1680-3008 draw useful information from the study.
NCSS NCSS, LLC www.ncss.com
329 North Chapter Summary
1000 East
Choosing an appropriate quantitative study design is
Kaysville,
but one piece of the research puzzle. Decisions must
UT 54037
also be made regarding subject inclusion and exclu-
sion criteria, recruitment of subjects, sampling meth-
ods, data collection, and data analysis. Some choices
between groups at baseline and change in outcome will undoubtedly be made out of convenience or lo-
measures over time” (p. 551). Comparison of the statis- gistical concern, whereas others will be based directly
tical results with the chosen probability level reveals on a study’s goals and topic of investigation. Consid-
that the virtual reality group demonstrated signifi- ering all aspects well in advance of a study’s beginning
cantly improved balance (P = 0.038) and self-confidence and collaborating with others can be keys to success-
with balance (P = 0.038) when compared with the con- fully conducting quantitative research.
trol group (Rendon et al., 2012).
For survey, case study, or evaluation research, the
study will generate descriptive quantitative data. The
SKILL-BUILDING TIPS
data should be reported using frequencies, percent- ■ When contemplating features of your study’s
ages, ranges, and central tendencies, and can be dis- design, jot down your ideas and concerns. Discuss
cussed in narrative or presented in tables and figures. with your peers, advisors, or other professionals in
3916_Ch07_069-094 20/10/14 10:49 AM Page 92

92 Section 2 ■ Research Methodologies and Designs

your field for a period of several weeks. This process advisors, clients, statisticians, professors, adminis-
will help you to work out the bugs and ensure that trators, supervisors, and interdisciplinary team
you have a truly meaningful project that others will members, to name a few. Each one is likely to view
be able to understand. your project from a different perspective and will
■ Reflect on attrition (loss of subjects over time) when have different suggestions. Bear in mind that every-
you are determining sample size and study proce- one’s aim is to assist you to strengthen your project
dures. Keep in mind that if the demands on sub- and make it the best that it can be.
jects’ time and skills are high or if the study is ■ When drawing conclusions about your study, don’t
longitudinal in nature, the rate of attrition may be forget the difference between results that are clini-
higher. Keeping demands low and soliciting sub- cally significant, or meaningful in “real life,” versus
jects who have a vested interest in your topic those that are statistically significant. Statistical sig-
can boost retention, but may have implications for nificance is necessary to apply your results to the en-
application of results. tire population, but a positive outcome for only a few
■ Pilot your data collection tools. This will help subjects still carries importance in the clinical world.
you to identify any glitches and can increase the ■ Finally, a solid research plan, although tedious and
study’s usefulness by ensuring that you get the data time-consuming to develop, will allow you to effec-
you are aiming for. This may also help you to nar- tively investigate your topic. Don’t rush the process;
row your study’s scope if you find that the tool is take time to contemplate your decisions and reward
giving more information than what you are really yourself for small successes along the way. Getting
concerned with. there is half the fun!
■ If you are designing a survey, consider a course on
the topic or consult one or more of the texts in-
cluded in the reference list for this chapter. Use
language appropriate for your sample; avoid tech- LEARNING ACTIVITIES
nical jargon or vague terminology; check consis- 1. How will your project contribute to the body of
tency of items, and be prepared to pilot and revise knowledge in your chosen area?
it several times. The extra effort will be worth it 2. What environmental, financial, or other situa-
in the end, when you get the exact data you had tional factors will impact your study design and
hoped for. procedures?
■ Consider where you will store your study’s data. 3. Consider the sampling methods discussed in
Typically, approval by your school’s or facility’s this chapter. Which one seems most appropri-
Institutional Review Board (IRB) will be necessary ate for your topic and situation? Make a list
before beginning your project. One of the things of advantages and disadvantages of your
they will want to know is how you will keep the data proposed sampling method.
private and protect the subjects.
4. Who will support you in designing your
■ Seek assistance with your statistical analysis. The research project? Consider financial, social,
best way to do this is to consult your advisor or and physical supports as well as those who
a statistician in the design phase of the research. might advise you on content, procedures, and
Remember: You need not be an expert in statistics statistics.
to conduct meaningful research. Soliciting appro-
5. Ponder how you envision your project taking
priate help is half the battle!
shape—start to finish. Create a bulleted list of
■ Be prepared to deal with criticism—constructive your methodology. Review this list with others
criticism, that is! Throughout the research process, to help identify any gaps in your plan.
you will be working with a variety of people—peers,
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Chapter 7 ■ Technical Aspects of Quantitative Research 93

REFERENCES Huseyinsinoglu, B. E., Ozdincler, A. R., & Krespi, Y. (2012). Bobath con-
American Association of Public Opinion Research [AAPOR]. (n.d.). cept versus constraint-induced movement therapy to improve arm
Resources for researchers. Retrieved from http://www.aapor.org/For_ functional recovery in stroke patients: A randomized controlled trial.
Researchers/4683.htm Clinical Rehabilitation, 26(8), 705–715. doi: 10.1177/0269215511431903
American Physical Therapy Association [APTA]. (2005). List of assessment Ipathia, Inc. (2011). SuperSurvey [online computer software]. Longmont,
tools used in pediatric physical therapy. Alexandria, VA: APTA Section on CO: Author.
Pediatrics. Johnson, T. P., & Owens, L. (2003). Survey response rate reporting in the
American Statistical Association [ASA]. (2003). When you consult a professional literature. American Association for Public Opinion Research—
statistician. . . What to expect. Alexandria, VA: ASA Section on Statistical Section on Survey Research Methods, 127–133.
Consulting. Kimberlin, C. L., & Winterstein, A. G. (2008). Validity and reliability of
Asher, I. E. (2007). Occupational therapy assessment tools: An annotated index measurement instruments used in research. American Journal of Health-
(3rd ed.). Bethesda, MD: AOTA Press. System Pharmacy, 65, 2279–2284.
Benson, J., & Clark, F. (1982). A guide for instrument development and Leerar, P., Boissonnault, W., Domholdt, E., & Roddey, T. (2007). Docu-
validation. American Journal of Occupational Therapy, 36(12), 789–800. mentation of red flags by physical therapists for patients with low
Burlingame, J., & Blaschko, T. M. (2009). Assessment tools for recreational back pain. The Journal of Manual & Manipulative Therapy, 15(1), 42–49.
therapy and related fields (4th ed.). Enumclaw, WA: Idyll Arbor. Likert, R. (1932). A technique for the measurement of attitudes. Archives
Cape, P. (2010). Questionnaire length, fatigue effects and response quality revisited. of Psychology, 52, 140–145.
Beijing: Survey Sampling International. Office of Management and Budget [OMB]. (2006). Standards and guidelines
Chiarello, L. A., Palisano, R. J., Maggs, J. M., Orlin, M. N., Almasri, N., for statistical surveys. Washington, DC: Author.
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ipation of children and youth with cerebral palsy. Physical Therapy, ing. Urbana, IL: University of Illinois Press.
90(9), 1254–1264. Portney, L. G., & Watkins, M. P. (2009). Foundations of clinical research: Ap-
Chudoba, B. (2011, February 14). How much time are respondents willing plications to practice (3rd ed.). Upper Saddle River, NJ: Pearson Educa-
to spend on your survey? [Blog post]. Retrieved from http://blog tion, Inc.
.surveymonkey.com/blog/2011/02/14/survey_completion_times/ Rendon, A. A., Lohman, E. B., Thorpe, D., Johnson, E. G., Medina, E., &
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Comment. The status of nonattitudes. American Political Science Review, professionals give you techniques for getting the reliable results. New York: John
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Review, 20(1), 3–9. Silkwood-Sherer, D. J., Killian, C. B., Long, T. M., & Martin, K. S. (2012).
Donohue, M. V., Hanif, H., & Berns, L. W. (2011). An exploratory study Hippotherapy—An intervention to habilitate balance deficits in
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For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
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Chapter 8

Qualitative Research
Methodology and Design
And the end of all our exploring will be to arrive where we
started and know the place for the first time.
—T.S. Eliot

perspective is to ask if the topic has a story that needs

LEARNING OBJECTIVES to be investigated and shared with larger communities
The information provided in this chapter will assist the
of people. Furthermore, Rossman and Rallis (1998)
reader to:
point out the researcher must consistently be aware of
■ Identify the characteristics of qualitative the voice utilized in sharing the research with others.
research. This voice is appropriately described as the interaction
■ Explain the qualitative research process. between the researcher and participant(s).
■ Compare and contrast qualitative research More specifically, Kliening and Witt (2000) feel that
theoretical perspectives, as well as designs. qualitative methodologies should be directed toward
any research that is discovery-based. Patton (2002) sug-
gests that qualitative researchers consider the following
areas for inquiry: (1) individual experience(s); (2) mean-
Qualitative Research: Expectations, ings individuals place on their experiences; (3) individ-
Potential, and Opportunities uals studied within their environmental contexts; and
Qualitative researchers are especially concerned (4) a phenomenon for which standardized instruments
with how people develop meaning out of their lived ex- have not yet been developed. A moderate amount of
periences. Qualitative research is the study of people emphasis is placed on the participant being able to tell
and events in their natural contexts. Denzin and Lin- the story of his or her lived experience.
coln (2008) propose that a great majority of topics, if Although qualitative research used to be solely
not all of them, are appropriately suited for qualitative the domain of anthropology, history, and political
inquiry. The promise of the new frontier originates science, in recent years other traditionally “quantita-
from researchers asking ordinary questions about their tive” fields such as psychology, sociology, education,
current practice and everyday life. Crabtree and Miller healthcare administration, and public health policy
(1992) suggest the most efficient means of deciding if a are utilizing qualitative methodology to investigate
particular topic should be researched from a qualitative areas of strength and needs. In fact, it seems that
95
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96 Section 2 ■ Research Methodologies and Designs

many fields are “moving more toward phenomeno-

logical approaches and away from experimental ap- BOX 8-2 ■ Qualitative Research in
proaches, thus becoming less precise but more real” Physician Assistant for
(Yerxa, 2000, p. 201). As part of this movement, it the Nurse Practitioner
has become apparent that qualitative research meth- Tanyi, McKenzie, and Chapek (2009) con-
ods and designs are useful to health professionals. ducted a phenomenological qualitative study
In the 21st century there is a legitimate place in to investigate how primary care family prac-
healthcare research for qualitative methods and there titioners incorporate spirituality into their
are phenomena within health care that can usefully practices in spite of documented barriers.
be studied using naturalistic methods. In exploring The team utilized semi-structured interviews
client-related healthcare experiences with their clients and engaged 10 participants. Five major
and the process of therapeutic interaction, health- themes emerged from the interviews: (1) dis-
care practitioners’ understanding can be significantly cerning instances for overt spiritual assess-
increased by conducting research that employs a ment; (2) displaying a genuine and caring
naturalistic approach (Boxes 8-1, 8-2, and 8-3). attitude; (3) encouraging the use of existing
spiritual practices; (4) documenting spiritual
Constructs of Qualitative Research care for continuity care; and (5) managing
perceived barriers to spiritual care. The out-
Certain constructs cross boundaries among different come of the study provided health profes-
types of naturalistic designs. These are pervasive qual- sionals with insight to providing spiritual care
ities that are common to many qualitative research and options for future research.
studies.

BOX 8-1 ■ Qualitative Research in Athletic BOX 8-3 ■ Qualitative Research in Physical
Training Therapy
Pitney (2010) conducted a phenomenological Self, Driver, Stevens, and Warren (2013) were
qualitative study to address how work-related interested in determining physical activity
demands can challenge an athletic trainer’s knowledge, attitudes, intentions, and barriers
professional role commitment for an extended among individuals with traumatic brain injury
period of time while working in a secondary (TBI) undergoing outpatient rehabilitation.
school setting. The set criteria for participants The qualitative method used was a survey
included a minimum of 10 years of experience case inquiry. Seventeen participants engaged
and a self-identified professional commitment. in group interviews. The themes identified
The study included 17 participants. Data col- were (1) an inability to differentiate between
lection included interviews, peer debriefing, physical activity and physical therapy; (2) a
and member checks. Four themes came from limited knowledge of physical activity benefits
the inquiry: (1) professional responsibility, and the relationships to rehabilitation; and
(2) rewards, (3) respect, and (4) rejuvenation. (3) an interest in participating in a physical
The conclusion of the inquiry was stated as, “a activity-based health promotion program.
strong sense of professional responsibility Implications for practice and future research
to both students and the athletic training agendas for physical activity health promo-
discipline is a central feature of professional tion programming were discussed at length
commitment” (p. 198). as an outcome of the study.
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Chapter 8 ■ Qualitative Research Methodology and Design 97

Naturalistic Settings and indivisible into discrete variables, they regard their re-
Qualitative research can be described in general terms search task as coming to understand and interpret how the
as descriptive and naturalistic, with natural settings as various participants in a social setting construct the world
the sources of data. Qualitative researchers spend the around them. (p. 6)
bulk of their time in the field (at the site of the study), Qualitative data place emphasis on people’s lived
observing and talking to participants, and gathering experience and are thus well suited for identifying and
and analyzing data. They are greatly interested in locating the meanings people place on the events,
learning about the participants within the context of processes, and structures of their lives (Box 8-4). Their
the participants’ own world. Because understanding perceptions, assumptions, judgments, and supposi-
the culture is of overriding concern, participants are tions become clear and can be placed in context in the
observed and spoken with in their own environment social world around them.
while going about the usual business of daily life. Adopting the phenomenological viewpoint lends
Qualitative researchers are concerned with the process itself perfectly to any study in which practitioners are
as well as the outcome of their studies. What happens concerned with the patients’ perspectives on their
during the study’s data-gathering and analysis phase own life or environment, or their view of their own
is crucial to the outcomes that will guide the health- particular situation, such as their illness and how they
care professional’s future engagement in practice. will cope with it.

Local Groundedness Data as Thick Description

Local groundedness means that the study is embed- Geertz (1973) is credited with borrowing the phrase
ded in the participant’s local, everyday life. One of the “thick description” when he was discussing a defini-
strengths of qualitative research is that the focus on tion for “culture.” He stated that culture can be
naturally occurring, ordinary events in natural set- viewed as interwoven systems of symbols and, as such,
tings gives us a good handle on what “real life” is like is a context within which social events, behaviors, in-
for the participants in the study. This confidence in stitutions, or processes “can be intelligible—that is,
the data is assisted by local groundedness: the data thickly—described” (p. 14).
has been collected in proximity to the specific situa-
tion under study, rather than through the mail or the
telephone. The researcher’s emphasis is on a specific BOX 8-4 ■ The Phenomenological
case (person, place, event) embedded in its context. Perspective
Thus underlying, nonobvious issues and local influ-
ences can be taken into account. Anderson (2011) adopted a phenomenolog-
ical perspective throughout his investigation
Phenomenological Perspective into the addictive behavior that contributes
Although many approaches can be grouped under the to, or is a result of, substance abuse. His study
generic heading of “qualitative research,” the phe- shed light on the 10 participants, gaining in-
nomenological perspective is central to most qualita- sight into their lives from their own viewpoint
tive researchers’ outlook. The researcher has a based on a self-management and recovering
primary interest in gathering or knowing more about training program. The study’s main outcome
the meaning of the participants’ lived experience— was that an internal locus of control con-
from the participant’s point of view. Glesne and tributed significantly to their recovery and the
Peshkin (1992) define the phenomenological perspec- assumptions concerning substance abuse and
tive as follows: treatment for the participants were felt to be
relatable to other individuals experiencing the
. . . since qualitative researchers deal with multiple, so- same program of recovery.
cially constructed realities or “qualities” that are complex
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98 Section 2 ■ Research Methodologies and Designs

Qualitative data are rich and powerful with the poten- life situation. These situations are typically
tial for revealing complexity. These data provide “thick “normal” ones, reflecting the everyday life of
descriptions” that are vivid, are nested in a real context, individuals, groups, societies, and organizations.
and have a ring of truth that has a strong impact on the ■ The researcher’s role is to gain a holistic overview
reader. They are usually collected over a sustained period of the context under study: its logic, its arrange-
of time, making them powerful for studying process ments, its explicit and implicit rules. The re-
(including history). Rather than gaining a snapshot searcher adopts a learner role, learning from
view (such as that gained using the survey method), the the participants and their surroundings.
researcher gets an intensely detailed view at the mean- ■ The researcher attempts to capture the percep-
ing of lived experiences, as related to the everyday tions of local actors from a phenomenological
healthcare needs of an individual, group, or community. viewpoint, through a process of deep attentive-
ness, empathetic understanding, and suspending
Lived Experience preconceptions about the topics under discussion.
Because naturalistic data emphasize people’s lived expe- ■ Reading through the data, the main task is to ex-
rience, they are well suited for identifying the meanings plain the ways people in particular settings come
people place on the events, processes, and structures of to understand, account for, act on, and otherwise
their lives. As the data gathering and analysis proceed, manage their day-to-day situations.
participants’ perceptions, assumptions, judgments, and ■ Many interpretations of this material are possible,
suppositions become clear and can be placed in context but some are more compelling for theoretical rea-
in the social world around them. sons and because they meet the goals of the par-
ticular study.
Power of Qualitative Data ■ Questioning occurs simultaneously with collect-
A final feature of qualitative research is its power of data: ing information and making sense of it. One
it is the best strategy for exploring a new area and devel- process drives the other and results in the refor-
oping hypotheses; it has a strong potential for testing mulation and refinement of the problem and the
hypotheses; and it is useful when one needs to supple- structuring of smaller questions, which are then
ment, validate, explain, illuminate, or reinterpret quan- pursued in the field.
titative data gathered from the same setting (Creswell, ■ Relatively little standardized instrumentation
2007). The power of stories and narratives collected is used. The researcher is essentially the main
directly from participants or by embedding oneself in “instrument” in the study.
the daily lives of the individual, group, or community ■ Most analysis is done with words. The words
leads to rich and powerful insights, related to a health- can be assembled, clustered, and broken into
care issue or a change in public health policy that may segments. They can be organized to permit the
come from people who advocated for themselves. researcher to contrast, compare, analyze, and
search for patterns and themes.
Recurring Features of Qualitative
Research Qualitative Strategies
Although qualitative research may be conducted in As more health professionals have come to embrace
dozens of ways, there are some recurring features of naturalistic research, it is useful to see what can be
the methodology. A slightly modified version of a list learned from the strategies employed by other dis-
of such characteristics by Miles and Huberman ciplines. Some of these strategies are more useful
(1994) follows: than others for health care professionals. They are
■ Qualitative research is conducted through listed here to show some of the creative methods
intense and prolonged contact with a “field” or that investigators have used to study particular topics.
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Chapter 8 ■ Qualitative Research Methodology and Design 99

Health professionals can gain some ideas for their investigator does take part in the participants’
own needs by studying how others have tackled world to some degree in order to obtain
challenging study topics. more data.
■ Ethnography: Ethnographies are studies that ■ Interview Strategies: These strategies include in-
attempt to describe a culture or aspects of cul- vestigative journalism, biography, and oral his-
ture. The ethnographer’s goal is to share in the tory; the researcher interviews participants in
meanings that the cultural participants take for order to learn about their personal experience.
granted and then to depict the new understand- ■ Archival Strategies: Archival strategies include
ing for the reader (Creswell, 2007). literary criticism, historical research, retrospec-
■ Ethnography of Communication: This style of tive, content analysis, and philosophical research,
ethnography focuses on gaining an understand- in which documents and artifacts are used to
ing of the culture by studying all forms of com- gather data.
munication within the culture, including verbal, The following four major research designs are par-
nonverbal, and symbolic. Communication be- ticularly useful for the type of topics often studied by
tween the cultural participants is seen as the key healthcare professionals: ethnography, case methods,
to understanding the culture. phenomenology, and narrative inquiry. The ways to
■ Ethnomethodology: This term, coined by conduct these particular styles of research will be de-
Harold Garfinkel, refers to the subject matter scribed in greater detail later in this chapter. Mean-
researchers will investigate. That is, they will while, the following is a brief description of some of
study how individuals create and understand the features of these four designs.
their daily lives; how people see, explain, and de-
scribe the world in which they live. The subjects The Ethnographic Research Design
for ethnomethodologists are people in our own The attempt to describe culture or aspects of culture
society rather than members of primitive tribes. is called ethnography. Some anthropologists define cul-
Researchers in education have been heavily influ- ture as “the acquired knowledge people use to inter-
enced by Garfinkel’s approach. pret experience and generate behavior.” Thus, culture
■ Phenomenology: Researchers in phenomenology embraces what people do, what people know, and
are studying culture from the informant’s own things that people make and use (Creswall, 2007,
point of view, emphasizing the subjective aspects p. 10). Using this perspective, a researcher might think
of their behavior. They attempt to understand the about events in the following way: “Ethnography
meaning of events and interactions to ordinary peo- should account for the behavior of people by describ-
ple in particular situations, trying to gain entry into ing what it is that they know that enables them to be-
the conceptual world of their subjects in order to have appropriately given the dictates of common
understand how and what meaning they construct sense in their community” (McDermott, 1976, p. 159).
around events in their daily lives (Creswell, 2007). It has been said that ethnography succeeds if it teaches
■ Unobstrusive (Nonreactive) Research and readers how to behave appropriately in the cultural
Observer Studies: In these types of studies, the setting, whether it is among patients in a rehabilita-
investigator takes the role of an observer, making tion hospital, residents in a community residence,
an effort to be unobtrusive. The goal is to gather workers in a sheltered workshop, elderly patients in a
most of the data for the study solely through ob- day program, or psychiatric patients in a day treat-
servation, thus influencing the participants and ment facility (Box 8-5).
environment as little as possible; in this way, the The writing of ethnography can be seen as writing
investigator gathers “uncontaminated” data. thick, detailed descriptions, as described earlier.
■ Participant Observation: This research strat- When culture is examined from the perspective of
egy builds on the observer strategy, in that the thick description, the ethnographer is faced with
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100 Section 2 ■ Research Methodologies and Designs

the case, and have only recently begun treating groups

BOX 8-5 ■ Ethnographical Research of people as cases or units of study. This change in at-
Design titude brings health professionals more in line with
This study by sports and exercise physiologists the disciplines that developed ethnographic, phe-
provided insight into how mountain climbers nomenological styles of research and allows health re-
stay motivated and overcome the obstacles searchers to use these research approaches to the case
that are inherent in the activity when they per- method in the way they were intended (Box 8-6).
form on the mountain. This ethnographic The case method, then, can be used to study indi-
study explored the multidimensional experi- viduals or groups of individuals as a case series, such
ence of feel and motivation of a small group as a group of patients in a nursing home, a support
of Mount Everest climbers (N = 4) as they group for caregivers of people with Alzheimer’s dis-
scaled the mountain in order to shed light on ease, or a group of people at an Alcoholics Anonymous
factors that sustained their drive toward meeting. Case studies can also use one depository of
reaching their goals. The results indicated that documents or one particular event as a data source.
the climbers’ motivation was influenced by The Historical Research Design
the way they felt climbing once on the moun-
It is interesting to note that Bogdan and Biklen (1982)
tain. Differences and similarities between the
have listed historical organizational case studies as a
lived experiences of the climbers, and their
distinct type of historical study. These studies focus
ability to regulate how they felt through prepa-
on a particular organization over time and trace the
ration and how they responded to obstacles
organization’s development. Therapists can use this
in order to sustain their motivation, are dis-
type of design to study, for example, the American
cussed (Burke, Bush, & Doell, 2011).
Physical Therapy Association or American Massage
Therapy Association and the history of licensure,
treatment intervention, and practice standards. The
a complicated interpretation of a slice of life and an task may be to use the historical research methodol-
understanding of the community under study based ogy to trace how and for what reason the organization
on common sense. The ethnographer’s goals are to came into being, who was involved in starting the or-
share in the meanings that the participants take for ganization, what events and changes have happened
granted and then to depict their new recontextualized
understanding for outsiders.
BOX 8-6 ■ Case Study Research Design
The Case Method Research Design Henshaw, Polatajko, McEwen, Ryan, and
Case studies in the health sciences tend to draw from Baum (2011) conducted two in-depth case
other disciplines for their theoretical base and format. studies related to the usefulness of the Cog-
Anthropology, sociology, psychology, history, and busi- nitive Orientation to daily Occupational Per-
ness have cultivated the qualitative case method in the formance in stroke rehabilitation. The case
health care professions. As in other qualitative research studies describe in detail the process and out-
methods, case methods can be differentiated according come of the CO-OP. In both case studies,
to their purpose and end product. Some are descriptive, preliminary measures were administered
some interpretive, and still others evaluative. in three initial encounters, followed by 10
Other disciplines have traditionally taken a broad CO-OP sessions and immediate follow-up
view of the case method, readily viewing “the case” as testing. Field notes and a posttest interview
a naturally occurring group of people rather than as were conducted in an effort to capture the
an individual. Health professionals, on the other participants’ perspectives.
hand, have more commonly used a single patient as
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Chapter 8 ■ Qualitative Research Methodology and Design 101

over time, what it is like now, and how it came close of people?” (p. 104). From these foundational ques-
to being what professionals wanted it to be (Box 8-7). tions it was gleaned that in narrative analysis the focus
is on the texture of the story and the culture that shaped
The Narrative Analysis Inquiry Research it. In comparison, the foundational question in phe-
Design nomenology is focused on the meaning of the lived
Bochner (2001) notes, “Narrative analysis inquiry hon- experience (Box 8-8).
ors individuals’ stories as data that can stand on their
own as pure description of experience, worthy of nar-
Preparing for a Qualitative Research
rative documentary of experience or analyzed for con-
Study
nections between the psychological, sociological,
cultural, political, and dramatic dimensions of human To prepare for a qualitative study, the researchers
experiences” (p. 116). Patton (2002) presents the fol- must identify the problem they wish to study and
lowing as foundational questions of narrative analysis: generate research questions concerning the problem.
“1) What does this narrative or story reveal about the Review the literature to gain an understanding of the
person and world from which it came? and 2) How can depth and parameters of your problem, as well as
this narrative be interpreted so that it provides an un- other people’s views on the topic. (It should be noted
derstanding of and illuminates the life and culture that some qualitative researchers disagree with this,
that created it?” (p. 115). These foundational ques- believing that it is better to read after data collection
tions are in contrast to phenomenology where inter- to minimize their preconceived ideas.) You will need
views may take the form of stories; however, according
to Patton (2002), the foundational question is, “What
is the meaning, structure, and essence of the lived ex-
BOX 8-8 ■ Narrative Analysis Research
perience of this phenomenon for this person or group
Design
This narrative analysis inquiry addressed how
mothers with inflammatory arthritis experi-
BOX 8-7 ■ Historical Research Design
ence mothering occupations in the presence
DeLany (1999) utilized an oral history of arthritis and how this experience affects
method to discern “the learning paths of a participation and occupational identity. The
purposive sample of African American data collection included two interviews, par-
women who held positions of prominence ticipant observation, and document review.
within a predominantly female Caucasian al- Analysis focused on the stories of the moth-
lied health profession [occupational ther- ers and then there was a comparison of the
apy]. Specifically, it sought to understand the group’s stories to develop an overarching
processes by which these women learned and storyline. Storylines were presented as narra-
developed throughout their life span; the per- tives that describe the mothers’ experiences
sonal, family, and societal expectations and of identifying with the role of mother, partic-
support systems they experienced as well as ipation, fatigue, and the social context in
the opportunities and barriers they encoun- which mothering occurs. “Just because I can’t
tered during their life span; and the strategies do, doesn’t mean I’m not a mom” emerged
they employed to succeed in their educational as the main storyline. The main theme of
and career paths” (p. iii). The dissertation is the stories as a whole was that the mothers’
available in full-text at http://search.pro- doing and knowledge offset many of the
quest.com.ezaccess.libraries.psu.edu/docview negative effects of arthritis (Smith, Suto,
/304540347. Chalmers, & Backman, 2011).
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102 Section 2 ■ Research Methodologies and Designs

to formulate background material and decide on a theory is crucial in the definition of the problem and
theoretical base within which to design the study. in deciding how to tackle it.
Finally, you will choose a research design encompass- A typical model for naturalistic studies is based on
ing data collection and analysis techniques. Even the phenomenology. Because qualitative researchers are in-
format for the final write-up should be considered in terested in allowing the participant to take an in-depth
the early stages of the project. The early chapters of personal approach to being involved in the study, the
this book, therefore, are just as relevant to qualitative phenomenological model allows them to adopt the
research projects as to quantitative studies. view that all things are relevant only from the partici-
pant’s perspective (Box 8-9). Phenomenologically driven
studies are usually inductive; their results are generated
General Components of Qualitative
from the study data, and few explicit assumptions are
Research
made ahead of time about study informants or events.
All qualitative researchers tend to use similar principles, Creswell’s (2007) grounded theory method of analysis
techniques, and approaches. When using a qualitative is entirely based on such an approach.
approach, the investigator will interview relevant peo- Other theories used to guide naturalistic studies in-
ple, observe various interactions and events, examine clude cognitive theory, which assumes that we can de-
written documents, make decisions about the resulting scribe what people think by listening to what they say
information, and write a narrative for professional col- (using linguistically driven techniques), and cultural or
leagues. As stated earlier, before a naturalistic researcher personality theory, which encompasses psychoanalytic
begins to ask the first question in the field, a problem, theory. Some qualitative researchers adopt materialist
a theory or model, a research design, specific data col- theories and view the world according to observable
lection techniques, tools for analysis, and a specific behavior patterns related to class consciousness,
writing style will have been formulated. class conflict, social organization, and economic
Although researchers begin with planned research
designs, naturalistic work tends not to be orderly. The
researcher must be ready to follow where the data and
BOX 8-9 ■ Theoretical Perspective:
the informants lead, which means being open to
Phenomenological Perspective
serendipity, creativity, luck, and a lot of hard work. In
contrast to quantitative research, data collection and Peed’s (2010) study investigated the resilience
data analysis in qualitative research begin and con- from the perspective of individuals who have
tinue simultaneously. Data collection typically yields experienced it and utilized Giorgi’s descriptive
an enormous amount of data, and a preformulated phenomenological psychological method.
data analysis technique is needed to make sense Purposeful sampling was utilized to find indi-
of data. viduals who had experienced a traumatic
motor vehicle accident and had survived and
The Problem thrived through resilience. The individuals rep-
Qualitative research begins with a problem or issue resented different years of age and gender.
of interest that guides the entire project. It will dictate Open-ended guided interview questions were
the style of the research design, the data collection used, and the interview was audio recorded
techniques, and even the presentation of the findings. and transcribed for gathering data. Findings
from the data were consistent with prior re-
Theory search on components of resilience, specifi-
Similarly, no study, naturalistic or otherwise, can be cally spirituality, a sense of coherence, positive
conducted without an underlying theory or model. It adaptation and temperament, locus of control,
may be a formal anthropological or psychosocial the- and self-efficacy.
ory or a personal model about how things work, but
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Chapter 8 ■ Qualitative Research Methodology and Design 103

forces. Theories need not be elaborate sets of con- generated during the initial survey phase of field work.
structs, assumptions, propositions, or generalizations. Research questions are fluid in qualitative research and
Healthcare professionals engaging in qualitative re- they guide the flow of the inquiry. Some questions may
search may choose similar theories to those chosen for be dropped as irrelevant; some may be modified as
quantitative studies, which are often psychologically, additional data are gathered; and new questions may
sociologically, or medically oriented (Table 8-1). be added as the study proceeds. In qualitative research,
the final report may be written in the form of hypothe-
Research Questions ses with supporting material. In this case, researchers
Although the qualitative researcher will have devel- frequently request that others test their proposed hy-
oped some research questions during the research potheses further, under different conditions, or they
design phase, many more questions will typically be may do so themselves in later studies.

Table 8-1 ■ Variety in Qualitative Inquiry: Theoretical Traditions

Perspective Disciplinary Roots Central Questions

Ethnography Anthropology What is the culture of this group of people?

Autoethnography Literary Arts How does my own experience of this culture connect
with and offer insights about this culture, situation,
event, or way of life?

Reality Testing: Positivist Philosophy, social, sciences, What’s really going on in the real world? What can we
& Realist Approaches and evaluation establish with some degree of certainty? What are
plausible explanations for verifiable patterns? What’s
the truth insofar as we can get at it? How can we stay
a phenomenon so that our findings correspond, as
much as possible, to the real world?

Constructionism and Sociology How have the people in this setting constructed reality?
Constructivism What are their reported perceptions, “truths,”
explanations, beliefs, and worldview? What are the
consequences of their constructions for their behaviors
and for those with whom they interact?

Phenomenology Philosophy What is the meaning, structure, and essence of the lived
experience of this phenomenon for this person or
group of people?

Heuristic Inquiry Humanistic psychology What is my experience of this phenomenon and the
essential experience of others who also experience
this phenomenon intensely?

Ethnomethodology Sociology How do people make sense of their everyday activities so

as to behave in socially acceptable ways?

Symbolic Interaction Social psychology What common set of symbols and understandings has
emerged to give meaning to people’s interactions?

Continued
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104 Section 2 ■ Research Methodologies and Designs

Table 8-1 ■ Variety in Qualitative Inquiry: Theoretical Traditions—cont’d

Perspective Disciplinary Roots Central Questions

Semiotics Linguistics How do signs (words, symbols) carry and convey

meaning in particular contexts?

Hermeneutics Linguistics, philosophy, What are the conditions under which a human act took
literary criticism, theology place or a product was produced that makes it
possible to interpret its meanings?

Narratology and Social sciences (interpretive): What does this narrative or story reveal about the person
Narrative Analysis literary criticism, literary and world from which it came?
nonfiction How can this narrative be interpreted to understand and
illuminate the life and culture that it created?

Ecological Psychology Ecology, psychology How do individuals attempt to accomplish their goals
through specific behaviors in specific environments?

Systems Theory Interdisciplinary How and why does this system as a whole function as
it does?

Chaos Theory: Nonlinear Theoretical physics, natural What is the underlying order, if any, of disorderly
Dynamics sciences phenomenon?

Grounded Theory Social sciences, methodology What theory emerges from systematic comparative
analysis and is grounded in fieldwork so as to explain
what has been and is observed?

Orientational: Feminist Ideologies: Political, cultural, How is X perspective manifest in this phenomenon?
Inquiry, Critical Theory, and economic
Queer Theory, among
Others
From Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks: Sage.

Participant Selection Others may have useful information to add and will
Qualitative research can be characterized as an in- be seen as secondary informants.
quiry in which the researcher observes and questions There are several types of purposeful sampling in
participants in their own setting, to learn their per- qualitative research and they are chosen according to
spective on things—a naturalistic inquiry. Therefore, the researcher’s needs for a particular study. Some of
researchers will use purposeful sampling to choose the most popular types are:
participants who can offer the fullest and most rele- ■ Typical: A case is chosen because it is thought to
vant information about the topic under study. In pur- be like the majority (i.e., typical). For example, a
poseful sampling, you must establish the criteria or therapist might want to see how a typical person
conditions necessary to be included in the study, then with hemiplegia proceeds through a particular
purposefully choose a case or cases that match these rehabilitation program.
criteria. The participants who turn out to be the most ■ Extreme or Deviant: After the norm for a typical
reliable and informative become the key informants. case is established, the researcher might want to
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Chapter 8 ■ Qualitative Research Methodology and Design 105

explore extreme cases in order to make a compari- Some of the actual processes for collecting data in-
son; for example, a person with hemiplegia who clude observation, interviewing, filming, photogra-
does not complete the rehabilitation program phy, and record and artifact review.
or a person who completes the program in an
extremely short time. Data Analysis
■ Comprehensive: A situation in which all the Qualitative data analysis is the process of systemati-
cases in a sample can be examined; for example, cally organizing the field notes, interview transcripts,
all the people with hemiplegia completing reha- and other accumulated materials until you under-
bilitation programs with a particular treatment stand them in such a way as to address the research
regimen. questions and can present that understanding to
■ Unique-Case Selection: Selection is based on others. Several techniques can be used to analyze
unique or rare attributes; for example, a person qualitative data; the technique chosen depends on the
with double lower extremity amputations who goal of the study. For example, if you wish to generate
becomes an athlete. new theories about devalued people living in group
■ Reputational-Case Selection: A case is chosen situations, the grounded theory approach and its
on the recommendation of experienced experts, attendant techniques is suitable; if you wish to under-
based on its reputation; for example, a highly suc- stand what participants perceive to be the curative
cessful caregiver support program for persons factors in a helping group (Creswell, 2007), you can
caring for a spouse with Alzheimer’s disease. The appropriately use a priori or a posteriori coding.
program is recommended by an expert in care- Naturalistic researchers may even select specific tech-
giver support programs because of its excellent niques from different approaches for the same study,
reputation. using their experience to judge what will best serve
■ Comparable-Case Selection: Selecting cases on the project’s goals.
the same relevant characteristics over a period of
time in order to compare results for replication; Report Writing
for example, selecting one person with hemiplegia Naturalistic reports generally take the form of long
who successfully completes a rehabilitation pro- narratives, sometimes interspersed with pictorial pre-
gram for each month over a 6-month program. sentations. There are many formats to choose from.
■ Critical Case Selection: The one case that makes Again, what you plan to produce with the data will
the point dramatically; for example, a program suc- lead you to the appropriate choice. If you are writing
ceeding in a particularly difficult location, a suc- a thesis or dissertation, certain format and style con-
cessful program with especially low overhead costs, ventions will prevail. If you are producing an article
or a rehabilitation program showing an extremely or research report, there may be more flexibility. How-
high success rate with severely disabled clients. ever, as Wolcott (2009) points out, you will still need
a beginning, a middle, and an end.
Data Collection The beginning portion of the report should include
Often, the only data collection “instruments” used a general background to help readers understand the
during qualitative research are the investigators focus of your article’s design. The introduction often
themselves. Although some quantitative methods rely concludes with a description of the design of the rest
heavily on physical instruments such as paper and of the article. The description should include a discus-
pencil tests or goniometry, qualitative researchers sion of the research methods and techniques used,
generally collect data via observation, interviewing, the time and length of the study, the number of set-
and tape recording in the field. Because they are the tings and subjects, the nature of the data, where and
ones observing the events and asking the questions, how the documents were located, researcher-subject
they are considered the data collection “instrument.” relations, checks on data, and other information
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106 Section 2 ■ Research Methodologies and Designs

that might help the reader evaluate the soundness of story is then interpreted to understand and bring
your study. forth the life and culture that created it.
The middle of the article makes up the bulk of the
work. This is where you argue your thesis, present Research Design: Ethnography
your theme, and illuminate your topic. Everything in Strict ethnography, as opposed to simply applying
the core of the article should relate to the focus spec- ethnographic techniques and approaches, is the art
ified in the introduction. The material comes from and science of describing a group and its culture. The
the data analysis and can be organized around the description may be of the healthcare system in an-
patterns, themes, and relationships that arose from other country or of an inner-city clinic in urban Amer-
coding and categorizing the data. Use the most ica. Ethnography is characterized by the concept of
salient quotations you can find judiciously to illus- culture as the organizational or conceptual principle
trate the main points of the thesis. for interpreting data.
The end section should be written as a conclusion. The ethnographic research design originated in the
Often the focus is decisively restated, the arguments field of anthropology and has occasionally been bor-
reviewed, and the implications elaborated. For more rowed by health scientists to describe such settings as
pointers, read Harry F. Wolcott’s excellent booklet hospitals, special schools, sheltered workshops, and
Writing Up Qualitative Research (2009). group homes. There has been a growing interest in
healthcare research to find paradigms that relate to
Qualitative Research Designs the holistic nature of the client, environment, and
everyday living patterns.
It is difficult to differentiate types of qualitative re- Ethnographers, of course, have biases and precon-
search designs in the same clear-cut manner in which ceived ideas about the group under study, just as
quantitative designs can be specified and described. other researchers do. Controlled biases can focus and
Qualitative designs do not have strict boundaries; the limit the study, whereas uncontrolled biases can un-
same researcher may use one set of procedures in dermine the quality of the research. The first task of
one study and a different set in another, depending ethnographers is to make specific biases explicit to
on the study’s purpose. However, some qualitative de- themselves and, eventually, to the readers. Ethnogra-
signs have distinguishing characteristics and can be phers try to achieve an open mind before going into
discussed as discrete entities. For an ethnography or the field because they are vitally interested in under-
historical study, for example, researchers may begin standing and describing events and perspectives from
with different mindsets but may use the same data the study participants’ point of view, the emic per-
collection and data analysis techniques. spective. This is crucial to ethnography.
The designs we will consider are: The research design for ethnography will list
1. The ethnography research design, studying the each step of the study in sequence, guiding the in-
culture within a program, institution, or other vestigation toward an effective solution to the iden-
group setting. tified problem. Each step will build knowledge and
2. The case method research design, studying an understanding about the nature of the people or
individual person, program, or institution. organization under study. Fieldwork is the main
3. The historical research design, studying a past element of any ethnographic research design. The
event, a person or group of persons in the past, researcher will go out to the scene to meet the in-
or the development of a phenomenon such as a formants in their own setting, to observe events in
profession or an organization. context, and to view the environment itself. All
4. Narrative analysis inquiry as a research design in fieldwork is exploratory, aimed at finding out as
which a narrative or story is revealed about the much as possible about the site, as well as the par-
person and world from which they came. The ticipants and their lives.
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Chapter 8 ■ Qualitative Research Methodology and Design 107

Fieldwork analysis begin in earnest. A distinct line is rarely

The early stages of fieldwork are concerned with drawn between baseline data gathering and “real”
learning the basics about the culture. Let’s say the data collection; all of the information is usually used
culture under study is a particular rehabilitation in the data analysis. How long baseline data collection
department where an innovative, complex treatment takes varies enormously, depending on the investiga-
regimen has been introduced. The ethnographer is tor’s previous knowledge of the culture, the complex-
trying to determine the long-term effect on the staff, ity and size of the culture, and the complexity of the
the patients, and the overall functioning of the de- problem being studied.
partment, including its relationships with the rest of Similarly, the amount of time spent in overall field-
the facility and with other similar facilities. In the ini- work varies significantly, depending on the same fac-
tial fieldwork, the researcher focuses on learning tors. The data for some very simple studies may be
about the basic structure and function of the culture collected during 1 day per week for 6 weeks, for exam-
(the department, facility, and similar facilities); how ple, whereas a comprehensive study of a complex cul-
many people are involved and something about their ture may take 2 or 3 years full-time in the field. The
demographics; the relationships between all the peo- latter are typical anthropological studies of foreign
ple involved in the program; the language used by pa- cultures in distant lands, whereas the former are more
tients, staff, and administrators; and some historical typical of the recent ethnographic studies, sometimes
data about the department and previous treatments. called microethnographies, being undertaken by our
The first few sessions at a fieldwork site can be colleagues in therapeutic environments. Most ethno-
awkward and painful for a researcher. Bogdan and graphic studies probably fall on a time line some-
Biklen (1982) have some suggestions to make this an where between the two.
easier time: Ethnographers in the field do their best to be un-
obtrusive. They try to blend in with the routines and
■ Do not take what happens in the field personally.
appearance of the “natives,” be they members of a for-
What you are going through is a typical part of
eign culture or therapists in a rehabilitation facility.
the fieldwork process.
Although ethnographers attempt to minimize their
■ Set up your first visit so someone is there to intro-
effect on the setting, a stranger who is asking ques-
duce you. One of the people who gave you per-
tions and watching activities will always have some
mission [would be a good person to] do it. . . .
impact. Investigators need to keep a careful record of
■ Don’t try to accomplish too much the first few
their own behavior to assess its possible influence on
days. Ease yourself into the field. Have your first
informants and the ensuing data collection.
day be a short visit (an hour or less); use it as a time
The first problem in fieldwork is to gain access to
to get a general introduction and overview. . . .
the population under study. If it is impossible to get
■ Remain relatively passive. Show interest and en-
permission to enter the field, some researchers con-
thusiasm for what you are learning, but do not
duct covert or undercover research, collecting data
ask a lot of specific questions, especially in areas
without the subjects’ knowledge. This approach was
that may be controversial. . . .
used very successfully in a classic study of a mental
■ Be friendly. The first days in the field, subjects will
hospital in which the researchers had themselves
ask about why you are here. Repeat what you told
admitted as patients. This approach is not recom-
the people who gave you permission. . . but try to
mended for new ethnographers, however; you will be
use abbreviated explanations. Most suggestions on
more successful reaping the advantages of being free
how to behave in the field parallel the norms gov-
from the constraints of a regular participant, gaining
erning nonoffensive behavior in general. . . (p. 127).
access to a variety of informants, and, perhaps most
Once the ethnographer feels comfortable with importantly, not having to deceive others and risk the
baseline data on the culture, data collection and embarrassment of being caught.
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108 Section 2 ■ Research Methodologies and Designs

As to the degree to which you should participate because they offer insight into the culture will be se-
in the activities of the setting, you may choose from lected for observation; they are called key events. Some
a continuum ranging from one of a complete ob- examples might be dinnertime in a group home for
server role to one of an active participant observer mentally challenged adults or the weekly staff meeting
role. The complete observer does not participate in in a physical therapy department. Similarly, some doc-
any activities and looks at the scene as though uments, such as treatment plans or minutes of staff
through a one-way mirror. At the other end of the meetings, may be extremely fruitful and deserve more
continuum is the field-worker who is deeply involved time than other documents. Photographs can be used
in the site activities, with little discernible difference to take inventories of objects in a setting, and are also
between the observer and the informants. Most field- useful in reducing the need for descriptive field notes
workers settle on a role somewhere between these two of those objects. They might include such things as a
extremes. If you are observing a classroom or a treat- bulletin board, the writing on a blackboard, or the
ment setting, it is often inappropriate to take part in arrangement of furniture.
the teaching or treating. On the other hand, infor- Often the timing of the ethnographer’s visits af-
mants may ask you to act as an assistant; this may be fects the nature of the data collected. It is important
perfectly suitable and not distract you from your task during the initial fieldwork period to find out as
of observing. In the latter case, though, the students much as possible about routines, when certain events
or patients will view you in a certain way—as other happen, and who attends. Selecting when to observe
than solely an observer—and this must be accounted and interview, or time sampling, will depend on
for in the data analysis. the study’s purpose. If the goal is to gain a perspec-
tive on the overall functioning of a rehabilitation de-
Data-Gathering Techniques partment or of a group home, then the investigator
There are several ways to gather information during should sample widely from different times of the day,
ethnography fieldwork. The two most important week, and year. If, on the other hand, the goal is to
techniques are observation, together with the result- gain insight into the morning meeting on a psychi-
ing field notes, and interviews. Others include pho- atric ward, sampling should obviously occur during
tography and examination of written documents and the morning meeting, perhaps 5 days per week over a
artifacts. several-week period.
An important consideration is how to decide what Choices about sample selection are always made in
and when to observe, whom to interview, how many the context of the study, with an eye toward achieving
and which documents and artifacts to examine, and the goals for this particular study. The researcher
what to photograph. In ethnography, this is the ques- often steps back during the study and asks, “If I go in
tion of participant selection or internal sampling. If now, if I talk to this person, what will I miss? What
the focus of the study is narrow, you may be able to will I gain?” Ethnographers realize that choices are
talk to all the subjects in the setting, review all the being made throughout the study that will affect the
documents, or observe all the important events. If data collected and, therefore, the results of the analy-
you are unable to do this, it is important to sample sis. They simply use their best judgment in making
a range of people and materials, so that you have a those choices.
diversity of perspectives on the setting.
Some informants are more willing to talk, have a Leaving the Field
greater experience in the setting, or are especially in- During the first few days in the field, you will proba-
sightful about what goes on. These people become key bly feel awkward. As time progresses, you will become
informants and probably will be interviewed more fre- more comfortable and can do your job more easily.
quently and for longer periods than other partici- Eventually you will have accomplished your goal and
pants. Events and activities that are deemed important the time will come for you to leave the field. Leaving
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Chapter 8 ■ Qualitative Research Methodology and Design 109

can be quite difficult, as you likely will become inter- goal is to gain an understanding of that particular
ested in the setting and fond of the participants. It is client’s issues and circumstances, frequently concern-
not uncommon to feel as if you are deserting people ing the person’s disability and how it was overcome,
you have come to know well, especially if they are so that our colleagues can better treat other clients in
working under difficult conditions with a devalued similar circumstances. Data-gathering techniques for
population. You may also feel that you will miss a case method study are the ones that have been pre-
something important to the study once you stop vis- viously described, such as observation, interviewing,
iting the site. videotaping treatment sessions or the client’s achieve-
In any event, you must eventually tear yourself ments, and reviewing related artifacts such as assistive
away. As health care professionals, we can use our technology. Documentary evidence is likely to play
knowledge of the termination process to leave grace- an important part in a case study; it may consist of
fully, giving the informants due warning and easing patients’ charts, minutes of meetings, reports of case
out of the setting gradually. Frequently, ethnogra- presentations, patients’ assessments and progress
phers are asked to return to the setting at a later date reports, or even institution newsletters and adminis-
to report on the findings, and occasionally it is nec- trative memoranda.
essary to return to collect some missing data. Other- Denzin and Lincoln (2008) describe the design of
wise, researchers need to recognize when they have a case study as best represented by a funnel, the be-
reached the point of data saturation (when any new ginning of the study being the wide end, represented
data collected simply repeats data they already have) by researchers scouting around for possible sites or
and to say their good-byes. people they might wish to study and finding a few
possibilities. They make a wide search to increase
Research Design: The Case Study Method their chances of finding just the right case. Once they
In the healthcare setting, case studies are used when have found several possible sites, they collect some
we want to learn from individual clients, understand initial data, perhaps documents or an initial interview
certain issues and problems in our clinical practice, and observation. The researcher then studies the data,
and form professional and managerial policy. A case focusing in on the more promising aspects of the site.
is a unit of study. This unit is often an individual, but The researcher makes decisions about the study’s di-
may also refer to a situation, a family, a hospital ward, rection, which participants they might eventually in-
a nursing home, or any group setting. terview, which documents to access, and which events
Novice researchers are often advised to choose a to observe. The researchers may discard some initial
case study as their first research project because case ideas and formulate new ones as they go along, mod-
studies tend to be more “doable” than some other ifying the design and choosing procedures that will
types of qualitative research. Although case studies enable them to learn more about the topic. Eventu-
vary in complexity, it is possible to design one that is ally, they decide which individual or event will be
confined to one site or one person, that has a time studied; now they have developed a focus. The data
limit, and that has a limit on the sources of data (such collection narrows at this point to the particular topic
as the participant, records pertaining to the partici- under study—putting the researcher at the narrow
pant, and the participant’s therapist). This keeps col- end of the funnel.
lected data to a manageable amount so that analysis When conducting an ethnographic case study,
can be accomplished in a relatively short time. Also, the investigator must consider the following tasks:
the smaller volume of resulting material permits the (1) studying the case in its naturalistic setting;
study to be written up more easily than would a study (2) being concerned with meaning from the partici-
generating a large volume of data. pants’ point of view; (3) viewing the case from a
Perhaps most commonly, the single-client case longitudinal perspective; (4) using multi–data-
method design uses an ethnographic approach. The gathering techniques; (5) reviewing the data, both
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110 Section 2 ■ Research Methodologies and Designs

alone and with the participant(s), to explicate the ways historical studies have been recorded in occupational
by which these particular people understand, account and physical therapy literature. Loomis (1983) and Lit-
for, take action, and manage their day-to-day lives; terst (1988) have described the historical development
(6) decontextualizing the data according to the study’s of two schools of occupational therapy. Oral histories
goals; and finally, (7) analyzing and recontextualizing exploring the occupational and leisure history of
the data that is ready for presentation to colleagues. women leaders have been used to identify the qualities
Data are analyzed using the usual qualitative re- that contribute to women’s emergence as leaders
search analysis techniques. However, in a strictly case (AOTA, 1977–1980). Gutman (1978) has described the
study approach, analysis is more than an intensive, influence of the U.S. military and occupational ther-
holistic description of a person’s circumstances. apy reconstruction aides in World War I on the devel-
Rather, concern will be shown for the client’s cultural opment of occupational therapy. One therapist has
context. Wolcott (2009) has made a distinction be- proposed that the origins of graded activity in oc-
tween simply using ethnographic techniques to study cupational therapy lay in tuberculosis sanatoria of
a case and performing an ethnography. the late 1800s (Creighton, 1993). Another researcher
Sometimes the major data-gathering technique in posited that 19th-century practices of moral treat-
case studies is participant observation. If the focus of ment and phrenology contributed to a loss of caring
the study is an organization, the researcher must de- attitudes and actions in the treatment of mental ill-
cide which aspect of the organization to study. For ness (Peloquin, 1993). In physical therapy, Moffat
example, if the organization under study is a rehabil- (1994) has proposed the idea that therapists look to
itation hospital, the researcher may decide on a par- the evolution of their profession to decide whether
ticular place within the hospital (such as the ward for they can move on to achieve their professional dreams
people with quadriplegia); a specific group of people or whether their past will thwart those dreams.
within the organization (such as the people with Historical research uses prescribed techniques for
quadriplegia on that ward); or a specific activity or the collection, organization, and analysis of historical
event within the organization (such as the daily rou- data. These include critical investigation of past
tine of the people with quadriplegia on that ward). events, careful weighing of evidence regarding the
validity of sources, and interpretation and documen-
Research Design: Historical tation of the investigation (Kerlinger, 1979). The
The goal of the historical research design, or histori- historical researcher asks open-ended questions of in-
ography, is the same as those for many other quali- dividuals (or examines documents or artifacts) about
tative research designs (i.e., to present a holistic a past event; uses thorough prior knowledge of the
description and analysis of a specific phenomenon event to interpret the answers; and recontextualizes
whether it be event, person, or organization). Current and documents the event in an interwoven narrative,
behaviors or attitudes can often be better understood thus providing the reader with a new explanation
if the past is reviewed and examined in the light of from which current events can be understood.
current events. Thus, historical research is under- Thus, a historical study involves much more than
taken to test hypotheses or to answer questions about making a chronology of an event. To understand an
past events that may shed light on present behaviors event and apply one’s knowledge to present practice
or practices. means knowing the context of the event, the assump-
Schwartz and Colman (1988) presented the debate tions behind it, and perhaps the event’s impact on an
about whether individuals other than historians can institution or participants, both then and now. A
perform historical research in their own professions. good historiography, like any good research design,
They held that therapists can learn historiography and relies on asking well-formulated questions, identify-
are thus in a good position to examine the develop- ing reliable sources of information, verifying evidence,
ment of their own professions. A number of excellent and accurately interpreting data.
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Chapter 8 ■ Qualitative Research Methodology and Design 111

At the basis of the historical study lies a clearly lead you to others and you will soon find yourself
formulated, precisely worded research question clar- with a network of informants. Libraries, archival col-
ifying what information the researcher is seeking. His- lections, museums, government offices, and private
torical research questions tend to have several papers are all good sources of primary data (Schwartz
components, dividing the topic under study into its & Colman, 1988).
various parts. As with other research designs, care One of the first tasks of the historian is to deter-
should be taken not to have more questions than can mine which data in the primary sources are actually
comfortably be answered in one study and not to ask facts and which are opinions or distortions. Facts are
questions outside the scope of the particular study. seldom stated in their pure form; they are usually
The data for a historiography come from primary mingled with the opinions of the source. The histor-
sources and secondary sources. A primary source is ical researcher must also assess the veracity of the
an original account of an event, such as an eyewitness data, while selecting only data that are relevant to the
account, minutes of a meeting, a photograph, or research question.
a treatment plan and progress notes written by a Interpreting data is an exceedingly difficult process,
client’s therapist. A secondary source is a source of but doing it well is critical to the study’s success. The
information at least one step removed from the origi- researcher needs a sound understanding of the data,
nal source, for instance, a newspaper account (if the re- based on well-formulated inferences and logic, in
porter did not actually observe the event), a book by order to formulate a good analysis. Because historical
another historian, a clinical consult by a consultant researchers cannot go to firsthand informants for
who has not seen the client. A basic rule of historiog- verification of their analyses, as other qualitative re-
raphy is that data sources should be predominantly searchers can, the burden is on them to check their
primary sources, though an occasional secondary work for integrity and logic.
source may be used for back-up. Facts get biased and When documents are the only source of data, the
altered in the telling from one person to the next; the researcher cannot confirm that one event in the past
greater the distance from the original source, the caused another to occur. In this case, the investigator
more distorted the story. The historian lacks the ac- must make assumptions or draw inferences that as-
curacy and perspective of the eyewitness; even the ve- sign causality. The more information uncovered
racity of the primary source should be checked, as far about an event, the more likely the possible cause of
as that is possible. the event will become known. Investigators must be
At the core of historical research is hermeneutics, the careful to restrict interpretations about causes to the
study of historical texts, from the Greek hermeneutikos, evidence gathered. Of course, if the investigator is for-
meaning the clarification of what is unclear (Patton, tunate enough to have access to persons who were in-
2002). Often, written documents are the only source volved in the event being studied, then triangulation
of data available for historical research. If this is the can be used—checking one source of data against
case, it is particularly important that the investigator another for accuracy. Causality is a controversial sub-
conduct an initial search to be sure there are suffi- ject among historians; studies obviously cannot be
cient primary sources to support a worthwhile study. conducted under the controlled conditions of exper-
There are various ways of obtaining historical doc- imental research, and all variables are ex post facto.
uments. Reviewing a town’s newspapers or an insti- Most historical researchers confine themselves to de-
tution’s newsletters are easy ways to get started. scribing conditions surrounding events and exploring
However, you will probably get access to even more associations that suggest emerging patterns and
material by letting it be known, perhaps in your themes (Schwartz & Colman, 1988). Two further
association newsletter, that you are interested in old tasks of historians are generalization and argumen-
letters, scrapbooks, minutes of meetings, and so on. tation. What distinguishes a historian from a collec-
Once you have found the first source, that person will tor of historical facts is generalization—the ability to
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112 Section 2 ■ Research Methodologies and Designs

discern commonalities or patterns in the data and to answer is that it is not the stories but rather the in-
infer a general principle from them. This is achieved terpretation of the intact story offered by the partic-
through a similar process to that used by Glaser and ipant which is at the heart of narrative analysis
Strauss (1967) in their description of formulating (Leiblich, Tuval-Mashiach & Zilber, 1998; Patton,
grounded theory. Like the grounded theoretician’s 2002). It is about listening to and attempting to make
approach, the historian must make logical general- sense of individuals’ learned and lived experiences
izations that are based on sufficient data and do not through their personal stories. It relates to coming to
go beyond the scope and nature of the data. know that storytelling is at the core of an individual’s
Historical researchers will make inferences from being (Wilcock, 2002).
the data that will form the basis of an argument. It is the goal of narrative analysis inquiries to col-
Argumentation is their way of proceeding from an lect data that describes daily life (Clandinin & Con-
initial premise to an end argument (using inferences nelly, 2000). Denzin (1989) offers the following
along the way) in an orderly and rational manner. The description of a narrative:
argument represents the researcher’s understanding
A narrative is a story that tells a sequence of events that
of the data. It is expected that the historian will ap-
are significant for the narrator and his or her audience. A
proach the data with an open mind and let the facts
narrative as a story has a plot, a beginning, a middle and
shape the argument. The argumentation forms the
an end. It has an internal logic that makes sense to the nar-
major portion of the written report resulting from a
rator. A narrative relates events in a temporal, causal se-
historiography. Schwartz and Colman (1988) feel that
quence. Every narrative describes a sequence of events that
a final report should include an introduction, a state-
have happened. (p. 37)
ment of the problem, an identification of the assump-
tions and limitations of the research, a literature Within this and every narrative inquiry, the sys-
review, and a discussion of the findings (the argumen- tematic study of narratives (stories) informs the re-
tation). The report should take the form of a narrative searcher about the participants and the world they
and should describe and analyze the answers to the live in (Patton, 2002). Wilcock (2002) and Bloom
research question. (2002) suggest it is within the rich description of nar-
Recently, the volume of historical research in ratives where the participants truly come to know
healthcare professions, particularly in physical and about their being and experience their becoming.
occupational therapy, has increased. These profes- Narrative research allows participants to speak for
sions’ rich heritage offers many opportunities for themselves.
historical explorations. The more we probe our back- Narrative analysis is typically selected as the
ground, our roots, the more we will understand and methodology for a study because it allows for a con-
be able to put into context our present practice. centrated focus on and the telling of an individual’s
life within their cultural environment. Simply asking
Research Design: Narrative Analysis general questions and seeking general meaning can
Bochner (2001) notes, “Narrative analysis honors in- be problematic secondary to the complex and contex-
dividuals’ stories as data that can stand on their own tual nature of the texture of an individual’s life.
as pure description of experience, worthy of narrative As Bruner (1990) asserts, it is the forging of links be-
documentary of experience or analyzed for connec- tween the exceptional and the ordinary where the
tions between the psychological, sociological, cul- uniqueness of narrative inquiry blossoms. He states,
tural, political, and dramatic dimensions of human “When you encounter an exception to the ordinary,
experiences” (p. 116). Researchers may ask them- and ask somebody what is happening, the person you
selves, “How do stories you gather in a narrative ask will virtually always tell a story that contains rea-
analysis inquiry differ from the stories you gather in sons” (p. 49). Riessman (1993) expands on the same
a phenomenological or ethnography inquiry?” The notion by stating, “Respondents narrativize particular
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Chapter 8 ■ Qualitative Research Methodology and Design 113

experiences in their lives, often where there has been a ■ If you get stuck in the actual research process or
breach between the ideal and real, self and society” with writing up the outcomes, take a moment to
(p. 3). The motivation for conducting a narrative in- write down the obstacles in your path. Don’t sit
quiry is to actively put into text the tensions, solutions, with a “stopper” too long; instead, identify it so you
and creation of new ways for individuals to consider can move forward as quickly as possible.
personal stories of occurring in their everyday living.

Chapter Summary LEARNING ACTIVITIES

This chapter discussed the main principles in quali- 1. What research methodology do you think best
tative research and described some of the qualitative suits your qualitative study and why? List five
designs. If you are planning to engage in qualitative points of your preferred research methodology
research, now is the time to decide which design and that will assist you in designing and carrying
data collection and analysis techniques will best serve out your study.
your purpose. 2. Can you identify at least three resources that
will assist you in carrying out your study?
SKILL-BUILDING TIPS
3. What environmental factors are influencing
■ When you are completing a large project, such as a the route you are taking with your qualitative
research study, it is important to relax, pause, assess research endeavor?
where you are, make a plan for where you are going, 4. As you know qualitative research begins with
breathe, and move forward each day. Even if it is the researcher’s interests and perspectives. What
cleaning up your space or writing one page, don’t is bringing you or calling you to complete this
allow procrastination to come into your life. specific qualitative study?
■ When you feel like you can’t write one more page,
try to construct a diagram, write a poem, find a say- REFERENCES
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American Occupational Therapy Association.
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stimulates more thoughts and eases the flow of from persons in seasoned recovery. ProQuest Dissertations and Theses, n/a.
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accountid=13158
■ Embrace the chaos instead of being fearful of what
Bloom, L. R. (2002). Stories of one’s own: Non-unitary subjectivity in narra-
is yet to come. It is typical for there to be many tive representation. In S. B. Merriam & Associates, Qualitative research in
books and many pages of written work piled up in practice: Examples for discussion and analysis, (pp. 289–310). San Francisco:
Jossey-Bass.
your work space. Instead of being overcome by the Bochner, A. P. (2001). Narrative’s virtues. Qualitative Inquiry 7, 131–157.
flood of information, embrace the knowledge and Bogdan, R. C., & Biklen, S. K. (1982). Qualitative research for education:
skills that you are gaining. Breathe. Take the An introduction to theory and methods. Boston: Allyn & Bacon.
process one day at a time. Bruner, J. (1990). Acts of meaning. Cambridge: Harvard University Press.
Burke, S. M., Bush, N. D., & Doell, K. (2011). Exploring feel and
■ It is helpful to make up a daily task schedule to post motivation with recreational and elite Mount Everest climbers:
at your work space. For example, if you want to have An ethnographic study. International Journal of Sport and Exercise
Psychology, 8(4), 373.
all of your participant interviews completed by Clandinin, D. J., & Connelly, F. M. (2000). Narrative inquiry: Experience and
April 30, transcripts reviewed by May 30, so you can story in qualitative research. San Francisco: Jossey-Bass.
schedule a focus group with all participants by mid- Crabtree, B. F., & Miller, W. L. (1992). Doing qualitative research. Thousand
June, put that on a task schedule, print it on bright Oaks: Sage.
Creighton, C. (1993). Looking back: Graded activity: Legacy of the sana-
yellow paper, and post it on the bulletin board right torium. American Journal of Occupational Therapy, 47(8), 745–748.
in front of your desk.
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Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An
five traditions (2nd ed.). Thousand Oaks: Sage. expanded sourcebook (2nd ed.). Thousand Oaks, CA: Sage.
DeLany, J. V. (1999). African-American women in a predominantly Caucasian Moffat, M. (1994). Will the legacy of our past provide us with a legacy for
female profession: Learning paths to positions of prominence. The Pennsylva- the future? Physical Therapy, 73(11), 1063–1066.
nia State University. ProQuest Dissertations and Theses, 1-259. Retrieved Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.).
from http://search.proquest.com/docview/30454034 Thousand Oaks: Sage.
Denzin, N. K. (1989). Interpretive biography. Newbury Park: Sage. Peed, S. L. (2010). The lived experience of resilience for victims of traumatic
Denzin, N., & Lincoln, Y. (Eds.). (2008). Handbook of qualitative research vehicular accidents: A phenomenological study. ProQuest Disserta-
(3rd ed.). Thousand Oaks: Sage. tions and Theses, n/a. Retrieved from http://search.proquest.com/
Geertz, C. (1973). Thick description: Toward an interpretative theory of culture. docview/219925648?accountid=13158
New York: Basic Books. Peloquin, S. M. (1993). Looking back. Moral treatment: How caring
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strate- practice lost its rationale. American Journal of Occupational Therapy,
gies for qualitative research. New York: Aldine De Gruyter. 48(2), 167–173.
Glesne, C., & Peshkin, A. (1992). But is it ethical? Learning to do it right. Pitney, W. (2010). A qualitative examination of professional role commit-
In Becoming qualitative researchers: An introduction (pp. 109–125). White ment among athletic trainers working in the secondary school setting.
Plains, NY: Longman. Journal of Athletic Training, 45(2), 198–204.
Gutman, S. A. (1978). Looking back. Influence of the U.S. military and Riessman, C. K. (1993). Narrative analysis. Newbury Park: Sage.
occupational therapy reconstruction aides in World War I on the Rossman, G. B., & Rallis, S. F. (1998). Learning in the field: An introduction to
development of occupational therapy. American Journal of Occupational qualitative research. Thousand Oaks: Sage.
Therapy, 49(3). 256–262. Schwartz, K. B., & Colman, W. (1988). Looking back. Historical research
Henshaw, E., Polatajko, H., McEwen, S., Ryan, J. D., & Baum, C. M. (2011). methods in occupational therapy. American Journal of Occupational
Cognitive approach to improving participation after stroke: Two case Therapy, 42(4), 239–244.
studies. The American Journal of Occupational Therapy, 65(1), 55. Self, M., Driver, S., Stevens, L., & Warren, A. M. (2013). Physical activity
Kerlinger, F. N. (1979). Behavioral research. New York: Holt, Rinehart & experiences of individuals living with a traumatic brain injury: A
Winston. qualitative research exploration. Adapted Physical Activity Quarterly,
Kliening, G., & Witt, H. (2000). The qualitative heuristic approach: A 30(1), 20–39.
methodology for discovery in psychology and the social sciences. Redis- Smith, L. D. F., Suto, M., Chalmers, A., & Backman, C. L. (2011). Belief
covering the method of introspection as an example. Forum: Qualitative in doing and knowledge in being mothers with arthritis: Occupa-
Social Research. Retrieved from http://www.qualitative-research.net/fqs tion, participation and health. Occupational Therapy Journal of
Lieblich, A., Tuval-Mashiach, R., & Zilber, T. (1998). Narrative research: Research, 31(1), 40.
Reading, analysis and interpretation. Thousand Oaks: Sage. Tanyi, R., McKenzie, M., & Chapek, C. (2009). How family practice
Litterst, T. A. (1988). Boston School of Occupational Therapy. Unpublished physicians, nurse practitioners, and physician assistants incorporate
paper. spiritual care in practice. Journal of the American Academy of Nurse
Practitioners), 21(12), 690–697.
Loomis, B. (1983, April). Professional occupational therapy education in
Chicago, 1908–1920. Paper presented at the Written History Commit- Wilcock, A. (2002). Occupation for health volume: A journey from prescription
tee Symposium, American Occupational Therapy Association Annual Con- to self health. London: College of Occupational Therapists.
ference, Portland, OR. Wolcott, H. (2009). Writing up qualitative research (2nd ed.). Thousand Oaks:
McDermott, R. (1976). Kids make sense: An ethnographic account of the interac- Sage.
tional management of success and failure in one first grade classroom. Unpub- Yerxa, E. J. (2000). Occupational science: A renaissance of service to humankind
lished doctoral dissertation, Stanford University. through knowledge. Occupational Therapy International, 7, 87–95.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
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Chapter 9

Technical Aspects
of Qualitative Research
Much to-do about the details, just try to be kind to yourself
and remain focused.
—A. Hissong

of the study, glean the limitations of the study, and

LEARNING OBJECTIVES know if there are any overriding issues that are likely
The information provided in this chapter will assist the
to influence the outcomes or interpretation of the
reader to:
outcomes. Finally, readers should be able to find the
■ Understand the structure of a qualitative meanings of all terms used if they are not obvious.
research study. This information will enable readers to understand
■ Identify the need for assumptions, scope, limi- the qualitative researcher’s general intentions and to
tations, subject criteria, and selection of par- follow the researcher’s train of thought. The research
ticipants for a qualitative study. report should include sections on the study’s defini-
■ List and explain data collection techniques tion of terms, assumptions, limitations, subject crite-
in qualitative research. ria, and selection.
■ Understand the constructs of analyzing,
reporting, and drawing conclusions related Assumptions and Limitations
to qualitative research. The first step in establishing a study’s boundaries is
to think about your own assumptions regarding the
study and the premises upon which it is formulated.
Establishing Boundaries for Researchers customarily examine their assumptions
the Qualitative Research Study carefully and state them to the reader near the begin-
A qualitative research study needs to be given bound- ning of the study. Readers need not agree with your
aries and to be put into a suitable context for readers. assumptions but are able to follow the logic of your
Readers should be able to understand quickly where propositions and to understand why you approached
a study fits into the scheme of professional literature. the study as you did.
They should also be made aware of any of the au- Assumptions are underlying principles that the
thor’s assumptions about the underlying principles researcher believes or accepts but that are difficult to

115
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116 Section 2 ■ Research Methodologies and Designs

prove in any concrete way. In qualitative research, their nurturance or care of self with the environmen-
they are basic values or views about the world. They tal variables.
include such values as the notion that people are ba- Remember, only beliefs that are difficult to prove
sically good or that people want to function inde- concretely, beliefs that are untested or untestable hy-
pendently in their day-to-day activities. These ideas potheses, basic values, or views about the world
are very difficult to prove with the population at large should be included in the assumptions section.
or even with a small research group. Two kinds of as- Next, the research should identify the limitations
sumptions need to be examined: first, assumptions of the study. Continuing with the example of the
about the ideological principles upon which the study narrative inquiry conducted with mothers in a rural
is based, and second, assumptions that are made con- community, the researcher her identified the follow-
cerning the processes used in the study. People adhere ing limitations (Box 9-2).
to certain ingrained principles that will affect the way Now that the researcher has identified the defining
they approach situations and, therefore, the way they terms, assumptions, and limitations of the qualitative
design research studies. Making your assumptions study, it is important to precisely define the parame-
known in the early stages of describing a study is im- ters of participant criteria and selection of who will
portant so the readers know where you stand on is- engage in the inquiry.
sues related to the research and where they should
keep a critical eye on processes. Box 9-1 is an example Participant Criteria and Selection
of a researcher’s assumptions for a narrative inquiry At this point, a word about the participants in your
related to mothers living in a rural community and qualitative research project is in order. Although most

BOX 9-1 ■ Example of Assumptions of a Study

The following were the major assumptions ■ Individual understanding of, and the
that the researcher held as she entered into engagement in, meaningful occupation is
an inquiry from a feminist poststructuralist a positive aspect of personal health and
lens: well-being.
■ For research to be valid and useful in the ■ The primary researcher is always present in

everyday lives of individuals, those individu- the inquiry and the final product.
■ Attending to my feminist poststructuralist
als must actively participate and be actively
represented in all aspects of the research sense of being, I am going into this research
process. project thinking and feeling that the partici-
■ The feminist poststructuralist perspective of pants will want to speak for themselves in
constantly shifting identity (nonunitary self) the data collection and data analysis section
is an empowering notion for women living in of this dissertation.
■ The unique relationship that exists between
the 21st century.
■ The process of motherhood has not been re- researcher and coresearchers in a narrative
searched adequately in terms of the overall inquiry presents a unique set of ethical con-
positive and negative effects it has on the siderations that reflect the unique relation-
health and well-being of women. ship between researcher and coresearchers.
■ The feminist poststructuralist theory is a ■ An inquiry should challenge beliefs of truth

powerful and meaningful lens to view the that have held some women in bondage for
deconstruction of power and discourse generations—knowledge production outside
within women’s lives. of the box is empowering and emancipating.
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Chapter 9 ■ Technical Aspects of Qualitative Research 117

Primarily, the participant criteria of a qualitative

BOX 9-2 ■ Example of the Limitations study are determined from the researcher’s guiding
of a Study questions, which are informed by the literature re-
The following are the major limitations the view. Participant selection criteria are established
researcher identified as she entered into the gradually, as the assumptions and theoretical base of
inquiry: the study unfold. Additionally, in qualitative studies,
the criteria are dictated by the theory behind why a
■ I was a novice researcher; therefore, this
researcher feels the intervention being studied will be
was my first official attempt at conducting
helpful. For example, in a study that involves clients’
a narrative analysis inquiry.
compliance in the use of splints at their place of
■ This study was conducted within a small
employment might include such information as the
geographical area of the United States. It
subjects’ type of employment, how long they have
may or may not be pertinent or useful to
been absent from their jobs, and any previous treat-
other mothers of school-age children living
ment they received for carpal tunnel syndrome.
in different contextual environments.
Once the participant criteria are decided, the re-
■ A potential limitation was the loss of data
searchers use a qualitative study to actively and pur-
outside of the narrative structure; however,
posefully seek out individuals to engage in the research
I made every attempt to conduct a global
process with them. The researchers might, for example,
analysis of the entire transcript, as well as
set the criteria of the participants as adults in a specific
specifically focusing on intact stories.
rehabilitation system who have left hemiplegia, are be-
tween the ages of 45 to 65, who are dependent in dress-
ing, and have lived alone for more than 5 years to be
qualitative studies, particularly those investigating engaged in the research study. The goal is for the study
the efficacy of treatment, use individuals to supply to be useful in practice to as many similar individuals
the evidence, some studies may also rely on docu- or groups as possible. The study is not intended to be
ments, records, and verbal reports as evidence. Thus, replicated as is, but the parameters are clearly defined
data may be in the form of people’s thoughts, beliefs, if someone else wants to conduct a similar study with
actions, or written materials. It is important that your a different set of participants, in a different geograph-
readers know from which population the sample you ical area, or under a different theoretical frame of ref-
studied came and how they were selected. erence or theory. Continuing with the study example
Let’s examine purposeful sampling, which is a pri- in this chapter, in Box 9-3 you will see how the
mary identifier of qualitative research. Patton (2002) researcher defined parameters for participants.
states, “Qualitative inquiry typically focuses in depth Now that the assumptions, limitations, and partic-
on relatively small samples, even single cases (N = 1), ipant selection criteria have been established for the
selected purposefully” (p. 230). The participants for study, the researchers begin to think about the data
a qualitative study share a specific set of characteris- collection process.
tics or criteria that have been established by the re-
searcher. For example, for one study a researcher may
Data Collection Procedures
recruit 24 physician assistants working in the United
for Qualitative Research
States who are from 40 to 60 years old working in a
small private clinic to study the bias or philosophical In 2013, some skeptics still felt that qualitative re-
thoughts about flu immunizations. For another search, by its very nature, cannot be reliable, that is,
study, a researcher may recruit 24 physician assistants replicated to produce similar findings from study to
from a regional area in Texas to specifically study the study. Others find that validity, determining the ex-
outcomes of work-related injuries and intervention tent to which conclusions effectively represent sub-
within this specific part of Texas. jects’ reality, is difficult to assess in a qualitative study.
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118 Section 2 ■ Research Methodologies and Designs

Validity
BOX 9-3 ■ Example of the Participant
Many qualitative researchers feel that, contrary to the
Selection Criteria
criticisms raised, validity is the strength of a qualita-
Specifically, the selection of the participants tive study. This is especially true when one compares
in the rural mothers study was based on the qualitative research to experimental studies, surveys,
following criteria: and other quantitative designs. Typically, the quanti-
1. Have at least two school-aged children; tative researcher gathers data in an “unreal” setting,
2. Is over the age of 35; asking subjects to perform in a contrived manner
3. Currently lives in, or has lived for 80% of for a relatively short period of time. The qualitative
her life in, a rural, religiously conserva- researcher, in contrast, goes to the participants, ob-
tive, and patriarchal-driven community; serves them in their natural environment over a long
4. Work 20 or more hours outside of the period of time, and asks for their thoughts and opin-
home; ions. Frequently, questions and observations are
5. Identify self as the primary caretaker of guided by what the participants feel is important and
children and household management; relevant, and data analysis is shared with individuals
6. Identify that motherhood has had an to see if it “feels right” before the researcher comes to
impact on learning about or the engage- any conclusions. Thus, as one can see, the qualitative
ment in self-nurturance; study may be more likely to achieve validity than the
7. Identify that current or past religious af- quantitative study.
filiation has had an impact on learning Steps can be taken to further the likelihood of a valid
about and engaging in self-nurturance; study. Qualitative researchers must decide, first, how
8. Identify that living in a rural community much confidence to place in their own analysis, and
has had an impact on learning about or second, how to present their analysis so that readers
engagement in self-nurturance; can validate and verify the findings for themselves. It is
9. Identify that issues of patriarchy in their important to remember that, through a data analysis,
family and community has had an im- one presents only a perspective on the data, and not
pact on learning about or engagement the “truth.” There are several ways to go about the
in self-nurturance; task of validating and verifying that perspective. The
10. Identify that within the past year they six notions presented here are based on the work of
have attempted a routine, course, or Patton (2002) and Guba and Lincoln (2008).
program related to self-nurturance for Rival Explanations
their mind, body, or spirit. Once the analyst has identified and described pat-
terns, themes, and linkages from the data, it is impor-
tant to look for rival or competing themes and
Most qualitative researchers ignore such criticisms, linkages. This can occur inductively, by looking for
whereas others recognize that the credibility of their other ways to organize the data that might lead to
findings may be called into question and develop different findings; or it might be done logically, by
practices to address the criticism. thinking of other logical possibilities and seeing
The information in this chapter will now move if these possibilities can be supported by the data.
into the many reasons and ways qualitative research Failure to find strong supporting evidence for alter-
is a validated and valuable method of inquiry. Let’s native themes or linkages helps increase the analyst’s
begin by addressing validity and reliability, and then confidence in the original findings. There is un-
conclude by providing the reader with a perspective likely to be clear-cut support for the alternative
on analyzing, reporting, and drawing conclusions themes; rather, one must consider the weight of the
from qualitative research data. evidence and look for the best fit between the data
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Chapter 9 ■ Technical Aspects of Qualitative Research 119

and analysis. Alternative themes that were considered can be included in the final write-up as an indication
should be noted in the write-up, as this will lend cred- of the validity of the study findings.
ibility to the final findings.
Intellectual Rigor
Negative Cases The thread that runs through the previous sugges-
Once patterns have been described, our understand- tions for verifying and validating qualitative data
ing of those patterns can be increased by studying analysis is the investigator’s intellectual rigor. The
the instances and cases that do not fit within the effective investigator returns to the data over and over
patterns—the negative cases. For example, in a large again to confirm categories, patterns, themes, and
rehabilitation program in which the majority of the linkages, and to reexamine any interpretations to see
participants complete the program and return to if they really reflect the nature of the program or
work, the most important analysis may be an exami- activity being studied. As Patton (2002) notes, “Cre-
nation of the program dropouts. Readers may then ativity, intellectual rigor, perseverance, insight—these
decide for themselves the plausibility of the reasons are the intangibles that go beyond the routine appli-
why dropouts do not fit the usual patterns. cation of scientific procedures” (p. 339).
A great deal of rigor and detailed focus goes into
Triangulation qualitative research data collection. Furthermore, the
Triangulation is the process of using different data- data collected from a qualitative study is consistently
collection techniques to study the same program. Two guided by the theory and methodology that inform
kinds of triangulation contribute to validating and ver- the study at its onset.
ifying qualitative data analysis: (1) checking for consis-
tency of findings generated by different data collection Reliability
methods, such as a survey and an interview; and
Qualitative research reliability is more difficult to
(2) checking for consistency of different data sources
achieve than is validity. Generally speaking, reliability
using the same data collection method (e.g., obtaining
is concerned with replicability; it requires that a re-
verbal accounts of the same event from two people).
searcher using the same data collection and analysis
Triangulation tests the quality of information gained
techniques can obtain the same results as those of a
and may be useful in putting findings in perspective.
previous study. External reliability addresses the
Design Checks issue of whether two different researchers would
The validity of findings in qualitative research may be arrive at the same final themes and theories in the
compromised if there are flaws in the data-collection same study setting; internal reliability refers to the
techniques. Nontypical events or occasions may be ob- extent to which other researchers, given a set of pre-
served when the intent is to observe typical activities; viously generated codes and constructs, would match
problems may be caused by the people who were se- them with interview data and field notes in the same
lected for observations or interviews; and problems way the original researcher did.
may be caused by the time periods used for observa- Because qualitative research is concerned with
tions. It is important to acknowledge any such flaws naturalistic behavior (which is seldom repeated in
in the write-up and to limit conclusions to those situ- the same way) in a unique setting and occasion
ations, people, and time periods sampled in the study. (which will never be repeated because it is unique),
replication for the purpose of establishing reliability
Participant Reactions to the Analysis is a tall order. Problems with uniqueness and idiosyn-
Investigators can learn a great deal about the accu- crasy may lead to the claim that qualitative studies
racy, fairness, and validity of their data analysis by can never be replicated; however, there are ways
having the people in the study react to what has been in which researchers can acknowledge and address
described. The analysis is credible only if it “feels issues of reliability. The following notions are based
right” to the participants. The participants’ reactions on the work of LeCompte and Goetz (1982).
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120 Section 2 ■ Research Methodologies and Designs

External Reliability also be influenced by whether they are interviewed

Qualitative researchers can enhance external reliabil- alone or in a group. Thus, it is important to state the
ity by addressing five major problems: researcher sta- social setting in which the data are gathered.
tus position, informant choices, social situations and Analytic Constructs and Premises
conditions, analytic constructs and premises, and Even if a subsequent researcher were to reconstruct
data collection and analysis techniques. the relationships and duplicate the informants and
Researcher Status Position social contexts of a previous study, replication would
No qualitative researcher completely replicates the find- be impossible if the constructs, definitions, or units
ings of another because different researchers hold dif- of analysis of the former study were unclear. Analysts
ferent social roles within the studied group and begin writing up their research must make clear the under-
with different knowledge bases about the studied lying assumptions, theoretical base, choice of termi-
group. This problem can be eased by clearly identifying nology, and data collection and analysis techniques
in the study report the researcher’s role and status if a later researcher is to be able to replicate the study
within the group investigated and the degree to which successfully.
the researcher becomes involved with informants (i.e., Techniques for Data Collection and Analysis
where they fall on the spectrum between nonpartici- Replicability is impossible without precise identifica-
pant observers, with no personal relationships with in- tion and thorough description of the strategies and
formants, and participant observers who develop techniques used to collect data. It is tempting to use
friendships that provide access to special knowledge). shorthand descriptors because of the brevity that
Informant Choices journals often require in manuscripts. Unfortunately,
This concerns the problem of identifying the infor- shorthand descriptors are not yet universally accepted
mants who provide the data. Different informants rep- by qualitative researchers; consequently, their use can
resent different interest groups within the study group. lead to serious misunderstandings. More impor-
When researchers associate with one particular group, tantly, the strategies used for analyzing data are often
they may forfeit information from people in other poorly defined or not described at all. This is probably
groups, who may not be comfortable associating with because the analytic process used with qualitative
the first group. Additionally, people who gravitate to- data is often vague, personal, intuitive, and idiosyn-
ward researchers or are sought out by researchers to be cratic to the analyst. Researchers must specify their
informants may be atypical of the rest of the group. For data collection techniques and their analytic strate-
instance, they may be chosen because they are intro- gies to ensure reliability within the study.
spective and insightful about their own lives, a charac-
teristic that might not be found in other members of Internal Reliability
the group. Threats to reliability posed by informant bias Internal reliability in a qualitative study concerns
can be handled by careful description in the research re- whether, within a single study, multiple observers
port of those who provided the data. Such descriptions agree. It is particularly important when several qual-
should include personal characteristics relevant to the itative researchers plan to investigate the same prob-
research, as well as those that make the informants sim- lem at different sites, such as might be seen in an
ilar to or different from the rest of the group. ethnographic inquiry. The important matter within
Social Situations and Conditions internal reliability is that of interrater or interob-
The social context in which data are gathered may in- server reliability—the extent to which meanings held
fluence external reliability. Informants may not feel by multiple observers are sufficiently congruent that
free to reveal certain information in some social en- they describe phenomena in the same way and arrive
vironments. For instance, a patient interviewed may at the same conclusions about them. Agreement is
give one set of information while receiving treatment sought on the description or composition of events
in the hospital but other information when inter- rather than on the frequency of events. The following
viewed at home after discharge. The informants may five strategies are commonly used to reduce threats
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Chapter 9 ■ Technical Aspects of Qualitative Research 121

to internal reliability: low-inference descriptors, mul- Quite commonly, researchers ask for reactions and
tiple researchers, participant researchers, peer exami- feedback to their ongoing analyses from participants.
nation, and mechanically recorded data. Peer Examination
Low-Inference Descriptions Researchers may corroborate their findings with
Most guides to the construction of qualitative re- other researchers in three ways. First, they may inte-
searcher field notes distinguish between two types of grate descriptions and conclusions from other re-
field notes. Low-inference descriptions, phrased in searchers in their final report. Second, findings from
terms as concrete and precise as possible, include ver- studies conducted concurrently at multiple sites may
batim accounts of what people say as well as narra- be analyzed separately, and then compared. Similar
tives of behavior and activity. The second category findings across sites would support the reliability of
of notes may be any combination of high-inference observations. Third, the publication of study findings
interpretive comments and varies according to the indicates that the material is offered for peer review
analytic scheme chosen for the study. and a debate of the findings is encouraged.
Low-inference notes provide researchers with their Mechanically Recorded Data
basic observational data. Interpretive comments are Qualitative researchers use a variety of mechanical de-
then added, deleted, or modified, but the basic record vices to record data, such as audiotape and videotape
of who did what under which circumstances remains recorders and cameras. The idea is to record and preserve
unchanged. This basic material is analyzed and pre- as much of the data as possible, so that the veracity of
sented in excerpts to substantiate inferred categories the conclusions can be checked by other researchers.
of analysis. Studies rich in primary data, which pro- Now that you have a better understanding about
vide the reader with multiple examples from the field validity and reliability within a qualitative research
notes, are generally considered most credible. study, the chapter will move into the tasks of analyzing,
Multiple Researchers reporting, and drawing conclusions about the data.
The most effective guard against threats to internal re-
liability in qualitative research is the presence of multiple
Analyzing, Reporting, and Drawing
researchers. Ideally, investigations are conducted by a
Conclusions About Qualitative Data
team whose members discuss the meaning of what has
been observed until agreement is reached. The discus- Within the health-related fields, Law, Steinwender, and
sion period is regarded as training in interobserver agree- Leclaire (1998) offer the following criterion when re-
ment. However, most studies are conducted by a single searchers are considering qualitative research as the
researcher or pairs of researchers rather than larger method for their study. First, the beliefs and world-
teams or single researchers, because of funding con- views of the researchers must be taken into considera-
straints and because some qualitative research is often tion. Second, the researcher must ask themselves what
considered too time-consuming and labor-intensive for is the nature of the end result desired. They suggest a
lone researchers. Two researchers who achieve interob- qualitative study should be utilized when a researcher
server reliability are considered preferable to a sole re- is seeking meaning and understanding about individ-
searcher for achieving internal reliability. ual or group experiences. Third, they suggest that qual-
Participant Researchers itative research requires a depth of understanding and
Some researchers enlist the help of informants to con- description from participants. A moderate amount
firm that what the observer has seen and recorded is of emphasis is placed on the participants being able to
being viewed identically and consistently by both par- tell the story of their lived experience.
ticipants and the researcher. Sometimes participants Patton (2002) describes the first theme of quali-
serve as arbiters, reviewing the field notes to correct re- tative research as involving the following design
searcher misperceptions and misinterpretations. Other strategies—naturalistic inquiry; emergent design
researchers work in partnership with participants, keep- flexibility; and purposeful sampling. Within this
ing two sets of accounts of observations and comments. study, naturalistic inquiry addressed the context
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122 Section 2 ■ Research Methodologies and Designs

simply as it existed, whereas the emergent design as- proceed with your study. Take pictures of the environ-
sisted in the flexibility and adaptability of the re- ment, record what kind of day it was when you were
searcher. This allowed for the research to go outside gathering data, and indicate how you are feeling about
of the boundaries of judgment. the research process. The time taken to document,
The second theme involves data collection and document, and document will be invaluable.
fieldwork strategies—qualitative data; personal expe-
rience and engagement; empathy and mindfulness,
and dynamic systems. Qualitative data is defined as
observations, interviews, or documents that offer LEARNING ACTIVITIES
rich, detailed descriptions of the nature of an individ- 1. Once again, find three to four related and well-
ual’s perspectives of lived experience. Patton (2002) written theses or dissertations. Now, spend time
supports and encourages the researcher to become reading and reviewing your assumptions, limita-
embedded in the environmental context of the study. tions, theoretical constructs, and scope of study.
In other words, the researcher’s understanding of the Now spend some time fine-tuning your points.
lived experience is the starting point of the inquiry. 2. Considerations of your study:
The third theme involves analysis of research ■ Do you have access to appropriate partici-
strategies—unique case orientation; inductive analysis pants for your study?
and creative synthesis; balanced perspective; context ■ List the criteria for participants who would
sensitivity; and voice, perspective, and reflexivity. be appropriate.
As Patton (2002) notes, without acknowledging or ■ How many people will you be able to choose
knowing about the context of the inquiry, a qualita- from?
tive researcher has no eyes to see with or ears to hear ■ How will you gain their permission to be
the full meaning of a participant’s personal story. The participants?
final and most discussed component in qualitative
3. List three points related to the scope and mean-
inquiry is that the researcher must own and reflect
ingfulness of this study. Also, consider how
on his or her own voice and perspective, in relation to
your study will be limited in scope.
all aspects of the study. The researcher’s ability to be
reflexive addresses the credibility and authentic 4. List three reasons why this study will improve
nature of qualitative research. practice or the quality of daily living for your
participants.
SKILL-BUILDING TIPS 5. Identify potential audiences who may be inter-
■ Ifeverything appears as if it is going smoothly or ested in the outcomes of the study—other re-
coming too easily, go back and check what you have searchers, other practitioners, or policy makers.
done. Did you miss something? Is there more to the
qualitative narrative? REFERENCES
Guba, E. G., & Lincoln, Y. S. (2008). Paradigmatic controversies, contra-
■ Remember that your participants are living, breath- dictions and emerging confluences. In N. K. Denzin & Y. S. Lincoln
ing human beings. Sometimes they may have to (Eds.), The landscape of qualitative research (3rd ed., pp. 255–286). Thou-
sand Oaks, CA: Sage.
reschedule an appointment or show up an hour late. Law, M., Steinwender, S., & Leclaire, L. (1998). Occupation, health &
■ Buy yourself a special 5 x 7 notebook that you can well-being. Canadian Journal of Occupational Therapy, 65, 81–91.
LeCompte, M., & Goetz, J. (1982). Problems of reliability and validity
keep with you at all times. Keep notes of everything
in ethnographic research. Review of Educational Research, 52(1), 31–60.
you do during the research process. You may even find Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.).
yourself waking up at 3 a.m. with a thought of how to Thousand Oaks: Sage.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
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Section 3

Evidence-Based
Practice
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Chapter 10

Understanding the
Triad of Evidence-Based
Practice: Evidence;
Practitioner Skills and Knowledge;
and Client Goals, Values, and
Circumstances
As we work to create light for others, we naturally light
our own way.
—Mary Anne Radmacher

LEARNING OUTCOMES ■ Classify research by its level of evidence.

The information provided in this chapter will assist the ■ Critically appraise individual research studies.
reader to: ■ Synthesize multiple research studies to make
recommendations for practice.
■ Define evidence-based practice. ■ Examine plausible clinical scenarios for
■ Understand the three components of evidence- application of evidence-based practice.
based practice—namely, evidence (research), ■ Identify additional resources for evidence-
practitioner skills and knowledge, and client based practice.
goals, values, and circumstances.
■ Differentiate evidence-based practice from
ground-level research. What Is Evidence-Based Practice?
■ Explore motives for evidence-based practice
The first step in becoming an effective evidence-based
and consider challenges to engaging in it.
■
practitioner is gaining a clear understanding of the
Learn and apply five key steps for conducting
term. The most popular definition of evidence-based
an evidence-based practice project.
■
practice originated with the pioneer of evidence-based
Distinguish critically appraised papers (CAPs)
medicine, David Sackett. In his foundational article,
from critically appraised topics (CATs).
evidence-based practice is described as “the conscientious,

125
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126 Section 3 ■ Evidence-Based Practice

explicit, and judicious use of current best evidence in

making decisions about the care of individual patients”
(Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996,
p. 71). Although this definition emphasized the impor- Best evidence
tance of using research in the clinical decision-making
process, it failed to acknowledge the significance of the
practitioner’s knowledge and skills and the patient’s Practitioner
expertise
goals, values, and circumstances. Thus, the definition
was recently revised by Straus, Glasziou, Richardson,
and Haynes (2011), who now identify evidence-based
practice as “the integration of best research evidence
with our clinical expertise and our patient’s unique val- Client goals,
values, &
ues and circumstances” (p. 1). Best evidence refers to the circumstances
current applicable research available on the efficacy of
treatments for particular diagnoses or conditions. This
research could include quantitative, qualitative, or
mixed methods designs. Although research purporting
the value of a particular treatment technique is impor-
tant, this information cannot be used in isolation.
The knowledge, skills, and past experiences of the prac-
titioner are critical to appropriately apply results
of the research. In addition, consideration of each
client’s goals, values, strengths, weaknesses, and con-
texts is essential. A client’s context can encompass his
or her cultural background, personal demographics, Evidence-Based Practice
virtual communication, stage of life, and physical and Figure 10-1 Evidence-Based Practice
social environments (AOTA, 2008). The integration
of these three components—best evidence; practi- decision. Involving the client in the decision-making
tioner skills and knowledge; and client’s goals, values, process emphasizes the collaborative relationship
and circumstances—comprise evidence-based practice between practitioner and client (Gray, 1997).
and is illustrated in Figure 10-1.
Evidence-based practice involves the practitioner Client-Centeredness
searching and appraising available evidence on the The term client-centered was first coined by Carl
treatment being considered or the condition a client Rogers, in regard to the provision of psychotherapy,
presents with. For example, the practitioner might be and is still gaining attention in all aspects of health
considering the use of electrical stimulation to treat care today. He used the label client to accentuate the
a client’s low back pain, or he or she may be searching even relationship between the therapist and the
the literature to determine the best treatment(s) for patient. The approach should be nonjudgmental and
low back pain because of a specific diagnosis, say lum- indirect with the goal “not so much to solve particu-
bar stenosis. Once the available evidence has been gar- lar problems or relieve specific symptoms as to free
nered and evaluated, the practitioner needs to draw clients of the sense that they are under the influence
on past experiences, knowledge, and skills in treat- of malevolent forces beyond their control” (Miller,
ment of this condition to determine the research’s ap- 2006, p. 1). Being client-centered allows the client to
plicability to the current practice situation. At this become an active member of the clinical team by
point, the practitioner must consult with the client voicing concerns, preferences, and expectations in re-
in order to make the most effective and appropriate gard to the proposed treatment. After consideration
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 127

of the client’s views, the practitioner may then need New information is being produced daily, and
to use his or her clinical expertise to alter or adapt treatments that were formerly accepted are now
the interventions to best support the client. being questioned or dispelled.
■ Practitioners have an ethical responsibility to
Evidence-Based Practice Versus Research ensure that they keep up-to-date on clinical prac-
As the concept of evidence-based practice has grown, tices. Past practice experiences, clinical judgment,
students and practitioners alike have made the mis- or knowledge gained from initial schooling can-
take of confusing it with ground-level research. In not solely drive practice decisions.
ground-level research, the aim is to generate new ■ Clients, families, policy makers, and third-party
information on a particular condition, treatment, payors are demanding proof of efficacy for our
or phenomenon through testing some hypothesis. treatments. Without evidence to support treat-
Researchers are attempting to describe lived experi- ments, needed services may no longer be available
ences, assert connections among study concepts, or in facilities, included in legislation, or reimbursed
suggest cause-and-effect relationships. Evidence-based by payment plans.
practice differs in that already existing literature is
reviewed, appraised, and then applied to practice sit-
uations. Instead of generating new knowledge, the
Challenges to Evidence-Based Practice
aim of evidence-based practice is to apply existing Now that we have established the importance of
knowledge in a systematic way. One cannot assume evidence-based practice, we must acknowledge the chal-
that just because research is published or dissemi- lenges that need to be negotiated in order to effectively
nated, it is of sound quality and appropriate for the become an evidence-based practitioner. Barriers can be
current practice scenario. Therefore, critically apprais- found at both the individual and organizational levels.
ing the evidence before integrating the findings with At the individual level, perhaps the largest barrier to
existing skills and knowledge and the client’s goals conducting evidence-based practice, as noted in multi-
and values is critical to the process. ple sources among the allied health professions, is the
lack of time to retrieve, appraise, and apply best evi-
Why Is Evidence-Based Practice Needed?
dence to individual clients (Bennett et al., 2003;
The interweaving of these three elements—best evi- Dubouloz, Egan, Vallerand, & von Zweck, 1999; Ilott,
dence, practitioner expertise, and client goals, values, 2003; Jette et al., 2003). Similarly, many practitioners
and circumstances—culminates in effective evidence- lack the skills and confidence required to successfully
based practice. When any one of these elements is search databases, to read and understand research arti-
omitted from the picture, the result might be an inef- cles, and to interpret and apply the results (Dubouloz
fective treatment, decreased quality of care, or an inter- et al., 1999; Fruth et al., 2010; Ilott, 2003; Schreiber,
vention devoid of client-centeredness. Evidence-based Stern, Marchetti, & Provident, 2008). Another concern
practice is needed for the following reasons: is that not all research designs are readily applicable to
■ Clients deserve effective clinical interventions and real-life situations; perhaps a particular intervention
high quality of care. was shown to be successful but only under strictly con-
■ Gaps often exist between evidence and practice. trolled conditions that cannot be replicated in the clinic
Evidence-based practice can help to bridge this gap. or practice situation at hand (Jette et al., 2003; Salbach,
■ Ethical dilemmas exist when treatments are used Guilcher, Jaglal, & Davis, 2009).
that were shown to be ineffective. Barriers at the organizational level include lack of
■ Many practitioners are faced with increased caseloads support for research activities. Not all employers pro-
or productivity standards. Use of evidence-based vide access to appropriate resources including member-
practice can increase effectiveness and efficiency. ships in professional organizations, libraries, and online
■ Today, medical advances and changes in technol- journals, as well as reimbursement or time allotted for
ogy occur at a much faster rate than in the past. evidence-based continuing education (Houser, 2008;
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128 Section 3 ■ Evidence-Based Practice

McCluskey, 2003b). The work culture might also place (Salbach et al., 2009), and rewarding engagement in
greater emphasis on organizational goals, financial evidence-based practice via promotion or other means
gains, and productivity standards, and practitioners of recognition. Policy makers also need to balance
may lack the authority to make decisions about some their focus between cost-containment and quality of
practice changes (Houser, 2008). Although these chal- care. Creating local and national systems that support
lenges pose threats to evidence-based initiatives, they research and its real-life application can benefit prac-
are not insurmountable. Ilott (2003) proposes that suc- titioners and clients alike. In addition, a plethora of
cess is likely when individual practitioners, employers, databases containing preappraised evidence, collec-
and policy makers collaborate. Investment of all parties tions of evidence on specific topics, and systematic re-
in the process can lead to more competent practition- views have begun to emerge, all aimed at making the
ers, satisfied clients, and better clinical outcomes. application of research less time-consuming and eas-
Employers can support practitioners by providing ier on the practitioner. Some examples are included
access to evidence-based resources, encouraging such in Table 10-1. Most professional organizations are
activities in performance standards and appraisals also creating subsections, committees, and resource

Table 10-1 ■ Evidence-Based Practice Resources

Database Website Description

Cochrane Collaboration www.cochrane.org International network whose aim is to collect

and disseminate systematic reviews

The Campbell Collaboration www.campbellcollaboration.org Nonprofit organization whose reviewers conduct

and publish systematic reviews in social,
behavioral, and educational arenas

National Guideline www.guideline.gov U.S. Department of Health and Human Services

Clearinghouse public database of abstracts and evidence-
based clinical practice guidelines

PEDro Physiotherapy www.pedro.org Free database of randomized trials, systematic

Evidence Database reviews, and practice guidelines for physiotherapy

Clinical Evidence www.clinicalevidence.com Collection of systematic reviews on common

clinical interventions

OT Seeker www.otseeker.com Database of abstracts of systematic reviews

and randomized controlled trials relevant to
occupational therapy

Evidence-Based Medicine www.ebm.bmj.com Journal that publishes, reviews, summarizes, and

assesses applicability of international research

UpToDate www.uptodate.com Evidence-based clinical decision support system

available on the Web and mobile devices

Bandolier www.medicine.ox.ac.uk/bandolier/ Print and Internet journal focused on

evidence-based care

Evidence-Based On-Call www.eboncall.org/ Database of critically appraised topics

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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 129

pages on their websites to assist their members in will need to ponder each of these points in order
evidence-based practice efforts. Similarly to help to develop a meaningful evidence-based practice
bridge the divide between research and practice, re- question.
searchers have been encouraged to express their find- Strengths and weaknesses are generally considered
ings in more user-friendly language to support as internal aspects of the setting or situation. Reflecting
practitioners in applying the results to real-life situa- on the strengths of your clients, clinic, and organization
tions (Bennett et al., 2003; Jette et al., 2003). will be an important part of the process. Consider fi-
nancial, physical, and emotional supports. Even if you
have sound evidence to back up your plan, without the
Steps in Conducting an Evidence-Based
necessary supports in your setting, your project may
Practice Project
fizzle. Considering the challenges (weaknesses) in your
Regardless of the scale and scope of the project, setting will help you to identify ways of circumventing
most evidence-based practice projects consist of five these real issues. Envisioning problems ahead of time
basic steps: and devising a backup plan can greatly increase project
1. Identifying a need and an evidence-based practice success. Finally, the opportunities and threats present
question in the external environment have to be contemplated.
2. Searching the evidence In health care, this might include information about
3. Appraising and synthesizing the evidence the current healthcare climate, the state of reimburse-
4. Applying the evidence ment for services, and the existing or proposed legisla-
5. Evaluating the project tion. Each of these can present opportunities or threats,
depending on the time and situation.
Identifying a Need and an Evidence-Based Rationale for the Project
Practice Question Critically examining your practice situation and ana-
The evidence-based practice process begins by con- lyzing your clients’ needs can provide a solid rationale
sidering your practice setting and identifying an for the project. Being able to justify your ideas will be
evidence-based practice question. What are your important for getting buy in from other stakeholders,
areas of interest? Do you see any unmet needs? Is including clients, team members, and administration.
there anything that could be done better? Consider Your rationale should be supported with references
who your clients are, what you are doing currently from multiple sources. Box 10-1 includes an excerpt
to serve them, and if you have proof of efficacy for from an evidence-based practice project aimed at
these interventions. Your idea might stem from a training formal caregivers of clients with dementia.
clinical problem with a particular client or group of The practitioner has built the case for the project by
clients, or be driven by some larger need within your including multiple statistics on the incidence and im-
department, facility, or institution. pact of dementia, thereby supporting the need to ad-
equately train caregivers to handle these issues.
Needs Assessments
In clinical settings, practitioners conduct needs as- The Evidence-Based Practice Question
sessments before program development. A needs In this first phase of the project, you are essentially
assessment is a systematic process used to clearly “setting the stage” for your idea. Supporting your
explain problems or existing voids and to lay out points with observations, statistics, and a detailed de-
steps that will be followed for quality improvement. scription of your population and the problem are part
One of the most common types of needs assessments of this foundational step. Defining key terms and the
is a SWOT analysis. SWOT stands for strengths, weak- issues your project will address are precursors to iden-
nesses, opportunities, and threats. Each of these tifying your evidence-based practice question. The
concepts is considered with regard to the facility, evidence-based practice question (PICO question)
department, organization, or group of clients. You will define the population (P), the intervention (I),
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130 Section 3 ■ Evidence-Based Practice

BOX 10-1 ■ Example of Rationale for an EBP Project

It is believed that by 2013, 34 million people in dementia in their lifetime, the impact of this dis-
the world will have dementia (Gitlin & Corcoran, ease as a public health concern is significant.
2005). While there are unique features in dif- The Alzheimer’s Association report for 2008
ferent types of dementia such as Alzheimer’s, stated that 9.9 million US family members,
for the purpose of this project the term demen- friends and neighbors provided informal or un-
tia will be used to reflect the general course and paid care to people with dementia (Schaber &
progression of this group of diseases. Approxi- Lieberman, 2010). The value of the services
mately 4.3 million people are believed to have these caregivers provide is estimated at close
dementia in the United States with this number to $200 million per year with the total cost in
growing daily (Gitlin & Corcoran, 2005). This is productivity exceeding $11 billion annually
a staggering statistic alone but when combined (Gitlin & Corcoran, 2005). These statistics are
with the reality that there is no known cure for just a glimpse into the devastating, unpre-
dementia and that one in four people can ex- dictable and grueling consequences of this rap-
pect to be a caregiver for a family member with idly growing disease (Bickmore, 2011, pp. 5–6).

the comparison intervention (C, if applicable), and the solidify your question, or to show you where you
expected outcome (O). A well-constructed question might need to refine it. Sharing your ideas with your
will effectively guide the literature search and subse- peers, coworkers, mentors, or supervisors can help you
quent evidence-based project. determine if the question is specific enough, makes
In theory, formulating just one question seems like sense, and is applicable to the current practice situa-
a relatively simple task; however, it might take a few tion. Your initial question may continue to evolve as
weeks to narrow your focus and adequately define you go through the evidence-based process. Also re-
each element in the question. Sufficiently narrowing member that at this point, you need not be concerned
your population and intervention of focus will allow with what you will actually do in your project or
you to locate literature that specifically relates to your intervention—you should only be concerned with for-
situation at hand. Conversely, narrowing the topic too mulating a workable question. Figure 10-2 includes
much could yield very limited results from your liter- several examples of evidence-based practice questions.
ature search. Conducting a preliminary search of the In developing a new program or conducting an
literature in your area of interest can help you to evidence-based practice project, a formal report of

Does the use of touch screen Does massage therapy (I) Is diathermy (I) more effective
technology (I) increase attention decrease pain and anxiety (O) than ultrasound (C) to decrease
(O) in 6-year-olds with autism in patients who underwent upper extremity joint pain (O) in
spectrum disorder (P)? cardiac surgery (P)? college athletes (P)?

What is the average length of

stay (O) of patients with total hip Does formal interprofessional
replacement (P) who started education (I) improve
rehab the same day as surgery collaboration (O) among
(I) versus those who started healthcare practitioners in a
later (C)? hospital setting (P)?

Figure 10-2 Examples of Evidence-Based Practice (PICO) Questions

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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 131

the previous information is often prepared. The in- area of interest. Use broad search criteria and see
formation is typically arranged into chapters; more what results you get. Then narrow the search terms
details about writing the report will be provided in to see how the results change. Do you find that some
Chapter 12. See Box 10-2 for a suggested formalized databases and sites have more information in your
chapter outline for an evidence-based practice project. area of interest? It is a good idea to explore as many
resources and databases as you can, just to get a feel
Searching the Evidence for what is available. It will be time well spent, because
After you have formulated an evidence-based practice locating the literature can be very time-consuming if
question, it is time to begin the somewhat-daunting you do not know how to approach it.
task of searching the literature. Initially it is effective Once you are comfortable with your school’s or in-
to spend some time exploring the literature in your stitution’s online library and the other databases

BOX 10-2 ■ Evidence-Based Practice Project Outline

Abstract Chapter 4 Implementation and Results
Chapter 1 Introduction and Overview Section 4.1 Description of the Participants
of the Topic of Interest Section 4.2 Modifications to the Evidence-
Section 1.1 Description of Project Setting Based Plan
Section 1.2 The Need and Rationale for the Section 4.3 Description of Implementation
Project Subsections will be individualized to
Section 1.3 Identification of Supports and your project. Subsections may be or-
Barriers in the Setting ganized according to project phases,
Section 1.4 The Evidence-Based Practice individual sessions, or individual
Question participants, for example.
Section 4.4 Quantitative Outcomes (if
Chapter 2 Literature Review applicable)
Section 2.1 Methodology of the Literature Section 4.5 Qualitative Outcomes (if applicable)
Search
Section 2.2 Synthesis of the CAT Portfolio (See Chapter 5 Evaluation, Discussion, and
Appendix A: Individual CAP Outlines) Conclusions
Subsections will include: Section 5.1 Evaluation of the Project and
■ Description of the Portfolio
Correlation with Literature
■ Additional subsections will be in-
Section 5.2 Limitations
dividualized to your project and Section 5.3 Recommendations for Practice,
will be organized around common Policy, and Education
themes in the literature References
Chapter 3 Methodology Appendix A: Individual CAP Outlines
■ You will likely have additional
Section 3.1 Frameworks or Models of Prac-
tice Guiding the Project appendices that include items
Section 3.2 (Proposed) Activities of the such as tools used in the project,
Evidence-Based Project lengthy tables and graphs, and
Section 3.3 Assumptions so on.
Section 3.4 Approach to Client-Centeredness
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132 Section 3 ■ Evidence-Based Practice

that you have at your disposal, the formal literature Tracking Your Literature Search
search can begin. In addition to the evidence-based During your literature search, it will be important
resources already identified, some of the most pop- to keep track of the databases that you searched, the
ular databases for the allied health professions in- search terms used, your rationale for your search cri-
clude Medline, OVID, PubMed, CINHAL, Academic terion, and any additional search techniques em-
Search Premier, ERIC, and SAGE Publications. Some ployed. For example, one method commonly used is
of the databases include online tutorials to assist scanning the reference list of an article you identi-
with the literature search. One example is PubMed fied as appropriate in your initial database search,
(http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/ to determine if any articles in the reference list
index.html); although it is designed to help you nav- should be pursued. This technique has been referred
igate their database specifically, it also provides in- to as snowballing (Greenhalgh & Peacock, 2005,
formation basic to a literature search anywhere. p. 1064) or citation tracking (Taylor, 2008, p. 150). An
To begin, consider the search terms you might use, important part of evidence-based practice is being
which databases will be helpful, and the time period able to replicate the literature search. You may need
of the evidence you are seeking. If you are looking to go back and revisit something you saw previously,
for evidence on treatment interventions, limiting and your search techniques should be included in
your search to articles published within the last 5 to your formal report. It will be much easier to organize
10 years will likely yield the most appropriate results. this information from the beginning rather than try-
However, you may want to go back further in time if ing to recall it later. Detailed information about the
you are looking for information on the origin of a search methodology, key search terms used, and in-
particular treatment or for a more foundational in- clusion and exclusion criteria for the articles is usu-
tervention that has been shown to stand the test of ally included in the formalized report (see Box 10-2).
time. Additional search terms could be reflective of Table 10-2 is an example of a research log which you
the specific intervention that you are interested in, can use to track your literature search; a full version
the client population, diagnosis or condition, or the of the form is available on the DavisPlus website
outcome that you hope to achieve. Use of a combina- (http://davisplus.fadavis.com, keyword: Hissong).
tion of search terms is typical, and most databases The methodology of the literature search for a project
allow you to limit results based upon a variety of on professional leadership might look similar to the
criteria, including those discussed here. example appearing in Box 10-3.

Table 10-2 ■ Research Log

Date and Time of Search Database or Location Searched Key Words Used Results
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 133

articles that you located. Understanding and applying

BOX 10-3 ■ Methodology of the Literature research to practice is necessary to be on the cutting
Search edge of today’s practice. Ultimately, it is up to you to
Fifteen articles published between 2002 and evaluate the rigor and applicability of each study.
2012 were critically reviewed for this project. CAPs and CATs
Search terms used included leadership develop- Critically Appraised Papers (CAPs) or Critically
ment, leadership confidence, mentoring, leadership Appraised Resources (CARs) are short analyses of
recruitment, leadership skills, and commitment. individual studies, whereas Critically Appraised
Databases searched included: MEDLINE, Topics (CATs) are summaries of multiple studies on
CINAHL, PubMed, ERIC, and GoogleScholar. a single topic or practice concern. CATs are similar to
Search terms were used individually and in systematic reviews in that they include synthesis of
combination, and the reference lists from pre- numerous studies, but they are generally less rigor-
viously located articles were hand-searched ous, more concise, and more limited in focus, with
for any additional studies, in order to ensure the emphasis on practical application of research. Sys-
an exhaustive search. The following inclusion tematic reviews are usually undertaken by researchers,
criteria were also applied to the searches. whereas CATs are typically conducted by clinical prac-
First, research was primarily limited to the titioners. In practice, CAPs are completed on individ-
previous 10 years, so as to provide the most ual studies and compiled for the CAT portfolio. A
recent literature. Second, only research stud- variety of templates exist for completion of the indi-
ies published in English were included. vidual CAPs; one example is shown in Table 10-3.
After reading an individual study, you will highlight
the purpose, the setting, the participants or sample
used, the study design or methodology, the level of
How Many Articles Are Needed?
evidence, the main outcomes and findings, any limi-
The number of articles you need to locate on your
tations, and how and why the article was deemed
topic will largely depend on your goals and the qual-
applicable to the question at hand. An explanation
ity of evidence found. A few articles may be enough if
of each area is included within the template in
they are deemed of sound quality, include one or
Table 10-3. It is a good idea to number each CAP,
more systematic reviews, or will be applied to only a
as this number can be used to quickly identify indi-
small client group. More studies might be indicated
vidual sources when you begin to make notes and
if the studies conducted were less rigorous, if you
synthesize the articles.
wish to develop a completely new program at your
site, or if you want to apply the research across a Levels of Evidence
larger population. Conducting a thorough search of During appraisal, it will be necessary for you to assign
the literature will ensure that you gain a clear picture each article to the appropriate level of evidence. A
of the intervention in question and the outcomes you number of scales exist for the purpose of classifying
can expect with its use. You will know that your liter- research studies (Greenhalgh, 1997; Howick, 2009;
ature search was exhaustive when your continued Law & MacDermid, 2008), and it matters not which
search attempts do not yield any new results when scale you use as long as you identify it for the reader.
compared with what you located previously. One of the most common is the scale from the Centre
for Evidence Based Medicine (Howick, 2009). For our
Appraising and Synthesizing the Evidence purposes, a simplified version adapted from a num-
Following the literature search, you will appraise and ber of scales is included in Figure 10-3.
synthesize the articles that fit your criterion. Under- On this scale, the levels correspond to the relative
standing scientific inquiry and research methods is im- strength of the research study—with a level I study
portant in determining the value and relevancy of the possessing the greatest strength or rigor and a level V
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134 Section 3 ■ Evidence-Based Practice

Table 10-3 ■ Critically Appraised Paper Template

CRITICALLY APPRAISED PAPER # ______

List PICO Question Here
Put APA Formatted Citation Here

Purpose of the Study Briefly state the purpose of the study. How does the study apply to your discipline
or your PICO question?

Setting Examples: inpatient rehab unit, SNF, public school system, drug and alcohol clinic,
health club, community senior housing complexes, and so on.

Participants or Sample Include any information that is available regarding number of participants,
diagnoses, how participants were recruited, if the sample was random,
convenience, purposive, and any other pertinent demographics.

Study Design and Methodology What type of research design was used? Examples: Systematic review, RCT, cohort,
single case design, ethnography, grounded theory, and so on. Briefly describe the
methodology (in other words, what did the researchers do?).

Level of Evidence I, II, III, IV, V or Qualitative Study (see Figure 10-3 and the corresponding text for
an explanation of levels of evidence).

Outcomes and Main Findings Clearly state the results. Were the results statistically significant or clinically
significant? Were the outcome measures valid and reliable?

Intervention Highlighted In a short phrase, what intervention was highlighted? (This does not mean the
Through the Research results have to be positive.) Examples: Use of a multisensory environment to
decrease symptoms of pain, use of aromatherapy to increase appetite, use of
therapeutic exercise to decrease contractures, and so on.

Limitations List any limitations in the study that you need to consider in evaluating the results.

This Study Was Identified ■ Include bullet points here to identify why you included this study or article.
as the “Best” Evidence ■ Write in your own words why it is important; what are the implications for your
and Selected for the Portfolio project or intervention?
for the Following Reasons: ■ Keep in mind that you can glean valuable information from ALL studies regardless

of whether or not the results are positive. For example, say you are looking at fall
prevention and you believe that use of appropriate footwear can decrease the
risk of falls. Then you locate a study that reports this is not true. It would still be
important to include this study—remember that “best” evidence combines the
research with your skills and knowledge and the needs of your client or population.
You also have to consider how applicable this study is to what you are proposing.
*The information in the column to the right in the table has been provided for explanation purposes. You should delete this information and use this template for each resource.

study possessing the least. Each study’s level is dic- others cannot be studied under such strict condi-
tated by the research design, including whether or not tions. For example, if you are looking for research on
the study groups were randomized and if a control a rare neurological disorder, you are likely to find case
group was used. Keep in mind that certain topics lend studies or accounts from experts who have treated
themselves more easily to rigorous study, whereas clients with this condition. However, practitioners
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 135

High quality RCTs or Systematic

Reviews (SR) of these studies,
meta-analysis
Level I

Small-scale RCTs, non-randomized

studies with a control group such as
Level II cohort studies, case-control,
pretest-posttest designs, or SRs of
these studies

Non-randomized studies without a

control group such as pretest-posttest
Level III
designs, time series or longitudinal
studies, and cross-sectional studies

Descriptive studies including single

Level IV subject designs, case studies,
normative studies, and survey studies

Expert opinion, literature reviews,

Level V laboratory research (research not
performed on human subjects)

Figure 10-3 Levels of Evidence

interested in more commonly occurring diagnoses or Synthesizing involves integrating the findings from
treatments might expect to find larger scale studies all the individual studies you appraised to determine
in a multitude of settings. So, although a level I study your course of action. This can be one of the most
boasts greater rigor and confidence of results, not all labor intensive parts of the process, but well worth
practice areas can be studied under these conditions. the effort to gain a clear picture of the phenomenon
Considering each study’s design is vitally important in question. Did any common themes emerge among
in determining the validity and reliability of the find- the studies? Did you find some studies that sup-
ings. You must ask yourself if the researchers actually ported the treatment you are considering and others
observed and measured the constructs they intended that did not? It will not be enough to just restate the
to. In other words, does the study have internal valid- evidence; you will need to comprehensively integrate
ity? The quality of the design and instruments used, the findings from all the studies in your portfolio.
the integrity of the procedures, and the inter-rater re- Spend some time thinking about your literature re-
liability can all impact validity. Similarly, you must view and start to conceptualize some of the sections
contemplate the transferability, or external validity, of or themes in your mind. Themes are central concepts
the study’s findings. Was the study conducted in such or findings occurring in more than one study. If mul-
a way that allows application to other groups, namely, tiple studies have the same or similar findings, this
those in your current practice setting? Finally, are the adds strength to the conclusions and increases the
results statistically or clinically significant? What im- likelihood that results can be generalized to similar
pact will this have on your practice? situations and populations with the same outcome.
Using a notebook with one page devoted to each
Synthesizing Results From Multiple Studies theme is a good way to organize the process initially.
Once you have appraised each article individually, As you identify each theme, record it on a separate
it is time to synthesize the findings from all of your page in the notebook; then, review each individual
articles and make recommendations for practice. CAP and add notes, quotations, and statistics from it
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136 Section 3 ■ Evidence-Based Practice

to the corresponding themes in your notebook. You identified when more than one study yields the same
may also perform this same procedure by creating or similar findings.
separate electronic files for each theme, if you prefer. In other cases, a simpler, more-concise format can
be utilized for the CAT. Several templates and tools
Completing a CAT exist online including CATmaker (CEMB, 2009),
The CAT can take several forms depending on the na- Clinical Appraisal Skills Programme (CASP UK,
ture of the project and setting. In narrative form, the in- 2012), and CAT Template (McCluskey, 2003a). An
formation from the literature review and corresponding additional template has been included in Table 10-4.
synthesis and conclusions are typically included An explanation of each area is included within the
in Chapter 2 of the formalized report (see Box 10-2). template in the online materials.
A description of the CAT portfolio and a discussion In any case, determining the “bottom line” or an-
of the common themes and findings should be in- swering the evidence-based practice question based
cluded. The description of the portfolio is usually upon the available evidence is the goal. Although you
a straightforward review of the number of articles, can complete this process alone or with a group of
study designs, time frame of the studies, where the your peers or colleagues, previously completed CAPs
studies took place, and the general themes. Box 10-4 and CATs are often made available through a variety
contains an example of a portfolio description for of organizations and websites. Checking the resources
the previously discussed professional leadership proj- contained in Table 10-1, and some additional ones in
ect. Following these paragraphs, one would expect a Table 10-5, could save you valuable time if someone
detailed description of the various themes, with mul- already reviewed the research in your area of interest.
tiple citations from the referenced articles to support In many cases, these recommendations are for-
each point, as well as a summary of the recommenda- mally published as clinical practice guidelines. Con-
tions for practice. Remember that themes can only be ditions for publication typically include collaboration
by multiple individuals to critically appraise the liter-
ature and set forth practice recommendations. Expert
consensus may also be used when the involved parties
BOX 10-4 ■ Description of the CAT
have extensive experience or advanced training in the
Portfolio
subject area. The popularity of clinical practice guide-
The final portfolio contains 15 research arti- lines has grown as a result of their proven ability to
cles from both national and international enhance clinical practice, contain costs, and improve
journals. Study designs include three ran- patient outcomes.
domized controlled trials, two longitudinal
studies, eight experimental pre- and posttest Applying the Evidence
designs, one case study, and one mixed meth- Novak (2010), as adapted and cited by Glegg and
ods design. All studies relate directly to com- Barrie (2012), proposed a framework for applying re-
ponents of the evidence-based practice search to clinical practice. They use the metaphor of
question and will be used to draft new prac- a traffic light to explain the process. Less rigorous lev-
tice guidelines for mentoring new managers els of evidence or evidence proven to be ineffective or
in health care. to cause harm is given a red light—meaning the rec-
Five of the articles specifically describe ommendation is to abstain from using the treatment
characteristics of effective leaders with com- in question. Application with caution (yellow light)
monalities noted between articles. The other might be recommended for treatments with limited
10 articles address the process of mentoring evidence, inconclusive evidence, or no evidence, or
new leaders. These themes will be discussed if the studied population differs from your clients.
in detail. Clinical judgment is essential, so one must consider
the clinical situation, practitioner’s skills, and client’s
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 137

Table 10-4 ■ Critically Appraised Topic Template

Evidence-Based Practice Question

Include the PICO question. Be as specific as possible with each element of the question in order to sufficiently narrow
your search.

Clinical Scenario
Briefly describe the clinical situation or problem that motivated this investigation of the literature. What is your rationale
for pursuing this topic?

Databases Searched
Include all databases or websites searched.

Search Methodology and Terms

PICO Question Categories Search Terms Used

Population Include applicable search terms for each category.

Intervention

Comparison

Outcomes

Inclusion Criteria for Articles

Include any inclusion criteria. Examples might include particular study designs, full text articles, articles published only
in English, studies conducted with specific diagnoses or ages, or those occurring in a particular setting.

Exclusion Criteria for Articles

Include any exclusion criteria. Examples might include studies occurring more than 10 years ago; less rigorous research
designs, such as qualitative or Level V studies; or literature reviews.

Review Process
Discuss specifically how the process of the review was conducted. Include the following:
■ How was the question developed?

■ How were search criteria determined and databases selected?

■ How were the inclusion and exclusion criteria applied? For example, the abstracts of articles returned in the initial

search might have been scanned to determine if each study met the basic criteria and should be explored further.
■ How were individual analyses completed on each study? In essence, how did you complete the individual CAPs?

■ What did you do to ensure quality control in the process? For example, did a mentor or expert in this content area

review your analyses or did you use some other method of peer review?

Search Results by Level of Evidence

Level of Evidence Study Design Number of Articles Included
I High-quality RCTs or Systematic Reviews (SR) of these Include number of articles in
studies, or Meta-analyses each category

II Small-scale RCTs, non-randomized studies with a

control group such as cohort studies, case-control,
pretest-posttest designs, or SRs of these studies

Continued
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138 Section 3 ■ Evidence-Based Practice

Table 10-4 ■ Critically Appraised Topic Template—cont’d

Level of Evidence Study Design Number of Articles Included

III Nonrandomized studies without a control group

such as pretest–posttest designs, time-series or
longitudinal studies, and cross-sectional studies

IV Descriptive studies including single subject designs,

case studies, normative studies, and survey studies

V Expert opinion, literature reviews, laboratory research

(research not performed on human subjects)

Qualitative Studies Examples include phenomenology, ethnography, and

grounded theory

TOTAL ARTICLES REVIEWED:

Main Findings

Level I Use bullet points to list main findings for the studies under each level.

Level II

Level III

Level IV

Level V

Qualitative studies

Limitations

Level I Use bullet points to list limitations for the studies under each level.

Level II

Level III

Level IV

Level V

Qualitative Studies

BOTTOM LINE AND RECOMMENDATIONS:

Use this space to summarize your findings as they relate to clinical practice. Provide a clear and concise answer to your
evidence-based practice question. Clearly state your recommendations.
Do you recommend:
1. Using the intervention (proven effectiveness)
2. Using the intervention with caution (conflicting evidence, no evidence, or insufficient evidence)
3. Not using the intervention (proven ineffective or the potential for harm) (Glegg & Barrie, 2012)
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 139

Table 10-4 ■ Critically Appraised Topic Template—cont’d

REFERENCES
■ Include appraised articles here in bold.

■ Include any other sources used to make your appraisal (not in bold).

Name of Appraiser(s): Date Completed:

Table 10-5 ■ Sites Disseminating Completed CAPs and CATs

OT CATS: Occupational Therapy http://www.otcats.com/intro.html

Critically Appraised Topics

NSW Speech Pathology http://www.ciap.health.nsw.gov.au/specialties/ebp_sp_path/caps.html

Evidence-Based Practice

Journal of the American Academy http://www.jaapa.com/critically-appraised-topic/section/699/

of Physician Assistants

Evidence-Based Neurology CATS http://www.cnsuwo.ca/ebn/cats/

Evidence in Motion http://www.evidenceinmotion.com/

American Thoracic Society http://www.thoracic.org/clinical/critical-care/evidence-based-critical-care/

literature-reviews/index.php

Essential Evidence Plus http://www.essentialevidenceplus.com/

Joanna Briggs Institute http://www.joannabriggs.edu.au/Home

values in making these decisions. Finally, treatments the effect of sensory integration techniques with
substantiated with strong clinical evidence and stud- 3- to 5-year-olds is unlikely to be applicable to
ies conducted with similar populations and in similar geriatric clients in a nursing facility.
situations to the current practice scenario would 2. What special skills, knowledge, and past experi-
be given a green light—meaning the treatment is ences do you bring to the project?
recommended. 3. How does the proposed project fit within your
After you have appraised the individual studies and discipline’s scope of practice?
synthesized all articles in the portfolio, considering 4. What theoretical or conceptual frameworks
the following questions will help you to move forward will be used to guide the design of your project?
with your project: Some models, such as a behavioral approach, a
1. Are the settings in which the studies were con- biomechanical model, or a model of change, can
ducted similar to your current practice situation? be applied across disciplines. In other cases, indi-
Are the populations used in the studies similar to vidual disciplines have developed unique models
your client or client group? Context is extremely of practice to inform and guide their decision-
relevant. For example, a great level I study on making. Some examples of these include the
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140 Section 3 ■ Evidence-Based Practice

psychobiological adaptation model for physical details as possible. Imagine someone other than your-
therapists and the Model of Human Occupation self being responsible for carrying out the steps of
for occupational therapists. your plan. Ensuring that your procedure is replicable
5. What are the values, goals, strengths, weaknesses, will add credibility to your outcomes. In addition, be
and circumstances of your clients? sure to include references to other sources that sup-
Reflecting on your answers to these questions as port the various steps of your plan. Including cita-
well as the evidence leads to designing your evidence- tions for activities within your intervention, or for
based practice project. Unfortunately, there is no certain forms or assessments used, allows others to
clear-cut way of integrating the evidence, your skills easily see the connection between your project and
and knowledge, and the values and circumstances of the existing body of evidence.
your clients. This is where experience and sound clin- Discussing any forms, assessments, or tools that
ical reasoning skills are important. In some cases, the you will use during the project is an essential step. De-
evidence in favor of a particular treatment might be termining early on whether you choose to use a com-
present and appropriate for your client, but you may mercially available tool or one that you have designed
lack the necessary certifications or skills to imple- yourself, such as a survey, will ensure that you can ob-
ment the treatment. Likewise, a proposed treatment, tain appropriate information about your project after
albeit substantiated by research and within your com- its completion. Being able to evaluate the success of
fort zone to implement, might not mesh with your your project is critical in making recommendations
client’s goals or circumstances. for future practice. Finally, consider who will be par-
ticipating in your project. Are there specific inclusion
Designing the Evidence-Based Project Plan
and exclusion criteria or will everyone in your clinic
Most successful projects begin with a well-thought-
or setting be invited to participate? Revisiting the
out and detailed plan. In the early stages, creating a
goals for your project and the supporting evidence
bulleted list of the proposed steps of your project can
can assist you in making these decisions.
assist you to break it down into more manageable
Other elements worthy of consideration include
phases. Considering each phase individually allows
assumptions, limitations, and your approach to
you to adequately prepare and to navigate around
client-centeredness. In designing your project, as-
expected and unexpected barriers. Sharing your list
sumptions are things that you assumed to be true or
with your peers, coworkers, or mentors can also sup-
assimilated from a variety of sources, but which are
port you in identifying gaps in your plan. Some items
difficult to prove. For example, you may have as-
warranting contemplation are:
sumed that the clients in your clinic want to increase
■ Do you need to secure permission from anyone to their independence or quality of life. Although you
conduct the project? may not have definitive proof of this, you may have
■ Do you need to recruit participants? How and presumed this in designing your project.
when will you do that? Limitations are weaknesses in your project plan.
■ Do you have to arrange for use of physical spaces Because you are not conducting ground-level re-
or equipment? search, there is no need to be overly concerned if
■ Do you need permission to use documents, as- you have a small number of participants or the pres-
sessments, or other tools? ence of some bias. Some limitations that you might
■ Do you need to purchase supplies, make copies, discuss include the lack of appropriate assessments
or organize schedules or other program content, to evaluate the phenomenon in question; limited
such as lessons, presentation slides, or handouts? timing of the intervention possibly related to the
In the preliminary phase, you will likely be con- logistics of your setting, or assessment of more qual-
cerned with setting up the logistics of your project. itative characteristics that can be subjective or diffi-
Your plan should be descriptive and include as many cult to isolate.
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 141

Lastly, you should consider how your intervention the project and the evidence that supports it will as-
will be client-centered. Because this is a key element in sist you in gaining support from coworkers, admin-
evidence-based practice, reflect on who your clients istrators, and third-party payors (if the services are
are; how you will establish relationships with them; reimbursable). The description of the participants, a
and how you will adapt, alter, or modify your program discussion of deviations from the original project
to support each client to the best of your abilities. plan, and a formal report of the outcomes of the
Some interventions are inherently client-centered, evidence-based practice project are customarily in-
whereas others might have to be tweaked to ensure cluded in Chapter 4 (see Box 10-2).
this criterion is met. In today’s healthcare climate, a
cookie cutter approach, where each client receives the Evaluating the Project
same treatments under the same conditions, is no As healthcare students and practitioners, the process
longer acceptable. Your ability to tailor your program of reassessment or evaluation throughout the client
to fit each client’s goals, values, and circumstances will encounter is common practice. This allows us to see
impact success and client satisfaction. In a formalized if our interventions have been successful, determine
report, the project plan as well as discussions of guid- if there have been changes in the client’s status, and
ing frameworks or conceptual models, assumptions, make decisions about the course of treatment moving
limitations, and the approach to client-centeredness forward. The evaluation of your evidence-based prac-
are included in Chapter 3 (see Box 10-2). tice project works in much the same way. Closely ex-
amining the outcomes of your project allows you to
Project Implementation draw conclusions about the treatment in question
In the implementation phase, you should follow your and to decide if you will continue to use it with this
established procedures and document any deviations population.
in the plan. Keeping accurate and detailed records is In evaluating your project, you will need to con-
imperative in all aspects of health care today, and your sider your results within the context of the existing
evidence-based practice project is no exception. Ad- evidence. Do your findings agree or disagree with
ministering assessments per standardized procedures what was reported in the literature? Why or why not?
and objectively evaluating client performance allows One caveat about evidence-based practice is that even
you to draw accurate conclusions. Just like research, though something happened in your project that is
evidence-based practice projects can yield quantitative dissimilar to the literature, it does not mean some-
data, qualitative data, or both, depending on the na- thing is wrong. Perhaps your client’s values and cir-
ture of the project and the treatment being imple- cumstances differ slightly from those in the articles
mented. Data collection may include use of standard you appraised. Maybe you used different tools to
documentation in your setting and the use of new measure your outcomes, or you adapted the interven-
tools identified or designed following your literature tion based upon your past experiences. Discussing
search. Observations of clients, surveys, and focus these differences facilitates the comparison between
groups are also appropriate ways to gather data for what occurred in your setting and the existing litera-
an evidence-based practice project. ture. Referring to sources from your CAT Portfolio
In most cases, healthcare practitioners are imple- further strengthens the connection between research
menting evidence-based practice plans within their and practice.
current practice settings and under their discipline’s Visual displays of outcomes may also be useful in
current scope of practice. It is important to remem- explaining and evaluating your project. Similar to
ber that research is not being conducted, but rather the research examples given in Chapter 12, tables
existing research is being appraised and applied to the of data or figures, including pie charts, bar graphs,
current practice situation with the goal of improving line graphs, flowcharts, or other drawings, can be
client outcomes. Clearly articulating your goals for used to compare before and after data and to draw
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142 Section 3 ■ Evidence-Based Practice

conclusions. If you used an assessment tool employed decisions with unique or complex case scenarios;
in existing studies, a visual aide could be used to plot justifying the need for staff, equipment, or services;
your results next to the results of the prior studies. and mentoring, fostering teamwork, and motivating
Taking the time to adequately evaluate the outcomes patients and clinicians.
of your project leads to recommendations for future
practice, policy, and education. Program and Protocol Development
One of the most common uses of evidence-based
Making Recommendations for Practice, Policy, practice is to develop new programs or protocols. The
and Education following example will help to illustrate this point.
A worthwhile evidence-based practice project culmi- A group of physical and occupational therapists
nates with recommendations for the future. The rec- work together in a 120-bed skilled nursing facility in
ommendations could be for clinical practice in your a rural community. The average age of their patients
setting or across settings; for policy impacting access is 70 years old, and they frequently treat clients with
and payment for services; or for continuing education primary or secondary cardiac diagnoses. The facility
for existing practitioners, entry-level education for has recently implemented a specialized cardiac pro-
new practitioners, or education of other parties. If gram aimed at more effectively managing all chronic
your project was successful, how will you expand upon cardiac conditions, specifically congestive heart fail-
it or get the word out so others in similar situations ure, and decreasing the incidence of readmission to
can benefit from this information? Consider present- the hospital for this condition. The facility protocol
ing your project within your facility or at a state or na- is primarily limited to actions taken by nurses and the
tional conference; you may also seek publication in a physicians; these include things like dietary restric-
discipline-specific magazine or journal or with one of tions, daily weights, and changes in medications for
the groups that disseminate evidence-based practice residents on the program. The facility is looking to
guidelines. See Tables 10-1 and 10-5 for some ideas to increase marketing efforts for this patient group and
get you started. If you plan to continue the project, re- the administrator has asked the rehab director if the
flect on the outcomes to determine if it is necessary to rehabilitation department might be involved.
alter or tweak the methodology for future success. Fi- Before this time, clients with cardiac diagnoses have
nally, if the project was ineffective, contemplate how been evaluated for rehab services using standard eval-
this information can be put to good use. Even if the uations and procedures. Cardiac precautions, includ-
outcomes were not what you had hoped for, caution- ing limited use of weights and reaching over the head
ing others who might be considering this approach, during therapeutic activities, as well as education on
or discussing the issues at hand and how to circum- energy conservation techniques have been instituted.
vent them the next time, will be valuable. Evaluation Historically, therapists have also monitored blood
of the project and recommendations for the future pressures and oxygen saturation as necessary during
should be incorporated into Chapter 5 of the formal treatment of these clients; however, no standard reha-
report (see Box 10-2). bilitation procedures exist for this client group.
In response to the administrator’s request, the
Stories of Evidence-Based Practice
rehab director conducts a preliminary search of the
Now that you know the steps in conducting evidence- literature through the American Physical Therapy As-
based practice, we will discuss some examples of how sociation’s website (because she is a member) and
evidence-based practice can be integrated into clinical through Google Scholar using a combination of the
scenarios in real life. Ideally, evidence-based practice following search terms: “cardiac rehabilitation,” “car-
should be at the foundation of the clinical decision- diac protocols,” “congestive heart failure,” and “rehab
making process regardless of the setting. Educators, protocols.” This quick search uncovers a plethora of
practitioners, and students alike can use evidence- information on patient education, evaluation and
based practice for program development; guiding treatment protocols, assessments, and exercise and
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 143

ambulation programs. At this point, the manager re- also included to help guide therapists during the
alizes that the team could be doing much more for rehab process. Patient education includes informa-
this patient group and solicits the help of three other tion on the use of adaptive equipment, energy conser-
staff members to assist in this endeavor. Each staff vation and work simplification techniques, stress
member has goals on his or her performance review management, and precautions, to name a few. The ad-
for program development so this task fits nicely into ministrator and medical director approve use of the
the plan. new program, and all rehab staff are provided with
Each member of the task group then volunteers education before its formal implementation.
to conduct a detailed search on a specific area. This new program serves two purposes. First, it
Breaking the information down into subcategories provides the staff with an evidence-based program
not only makes the task more manageable, but al- that can be easily implemented. The instructions are
lows each clinician to select an area of interest. The detailed and clear; references are included to support
rehab director takes on the task of searching the lit- the procedures and activities. Second, it demonstrates
erature for evaluation and assessment procedures, the facility’s and the rehab team’s commitment to
whereas the other three staff members volunteer to providing quality patient care for this population,
delve deep into patient education, exercise and am- which may aid in marketing efforts as well as obtain-
bulation programs, and patient activities, respec- ing continued coverage from third-party payors for
tively. They agree to look at literature limited to the this service.
last 5 years since the goal is to create a rehabilitation The need for a new program may arise out of
protocol for patients with congestive heart failure a quality improvement initiative, as in this example,
based upon the most current evidence. or it may be necessitated by regulatory changes or
The group is given 3 weeks to search the literature citations on an agency, state, or national survey. Re-
before they meet again. At that time, the group is gardless of the motivation, evidence-based practice
charged with appraising the literature to determine if undertaken for this purpose is likely to require some
the information located is of sound quality and rele- extra time, effort, and research skills. Collaborating
vance to the clients at hand. The group uses a concise with others, as illustrated here, can disperse the work-
template similar to the one in Table 10-3 to assess the load, reinforce the need for teamwork among facili-
quality and applicability of the studies located. Those ties and departments, and increase team morale by
articles that pass the test are set aside for the next allowing everyone to have a voice in changes that
meeting, at which time the group analyzes them for will impact their practice.
common themes. Locating multiple articles that sup-
port a particular assessment, or exercise protocol, for Guidance for Unique Clinical Scenarios
example, will add strength to the findings and to the Although evidence-based practice can be used on a
subsequent program. large scale to impact whole programs affecting large
Next, the group uses the identified themes, as well groups of clients, it is also an effective tool for making
as their personal skills and experiences, and the per- clinical decisions about very unique or complex indi-
ceived values and circumstances of clients typically vidual cases. The following example is used to clarify
encountered in their setting to create a rehabilitation this point.
protocol for clients with chronic congestive heart A 33-year-old female, diagnosed with Isaac’s syn-
failure. The information is organized into a resource drome by her physician, independently seeks out a
binder with tabs for procedures for the therapists, massage therapist for possible pain management for
patient handouts, and exercise and ambulation pro- her condition. At the initial consultation, the massage
tocols. Information for therapists includes how and therapist is hesitant to initiate any type of massage
when to monitor blood pressure, oxygen saturation, as he is unfamiliar with this diagnosis and the ac-
and perceived client exertion during evaluation and companying symptoms, contraindications, and treat-
treatment. Protocols for exercise and ambulation are ments. He gathers some baseline data, performs a
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144 Section 3 ■ Evidence-Based Practice

basic assessment with the client, and tentatively specifically to research and disseminate information
schedules her to return in a few days. Because evidence- on them. Knowing that you could be faced with a
based practice should actively involve the client in the unique scenario in clinical practice can be intimidat-
decision-making process, he shares his concerns with ing, but knowing how to use evidence-based practice
her and explains that he would like to look specifi- to guide your decision-making can foster confidence
cally at the research on this diagnosis to determine and lifelong learning. Also be aware that in researching
what techniques might be most effective for her. rare conditions, or very specific medical complexities,
Later that day, the therapist conducts an initial In- you may be unlikely to find large numbers of or very
ternet search on Isaac’s syndrome. During this search, rigorous studies. Case studies, qualitative studies, or
he finds that Isaac’s syndrome is a rare neuromuscu- mixed methods designs with small sample sizes will
lar disorder characterized by continual muscle con- be more common. In these cases, you have to examine
tractions resulting in severe muscle cramps, joint the research that is available and integrate it with your
stiffness, and pain (NINDS, 2011). His search leads skills and knowledge, as well as the client’s goals and
him to the U.S. Department of Health and Human circumstances, to determine your course of action.
Services website on genetic and rare diseases, which Moreover, use of evidence-based practice can help to
includes information on clinical trials conducted incorporate client preferences. In the prior example,
with individuals diagnosed with this condition (U.S. remember that the client independently consulted the
Department of Health and Human Services, n.d.). massage therapist for services, and therefore had a
Current research includes studies of the etiology of vested interest in collaborating to determine the best
this condition as well as effective treatment options. treatment.
Because the condition is rare, he is unable to locate
any studies that specifically examine the use of mas- Justifying the Need for Staff, Equipment,
sage for pain management with Isaac’s syndrome; or Services
however, preliminary findings suggest that range of Evidence-based practice can be an invaluable means
motion and isometric exercise can be effective in man- of justifying the need for additional staff, equipment,
aging the symptoms. He also finds several single case or services. Additional staff and equipment might
examples of individuals with Isaac’s syndrome attest- be needed to meet the changing needs of your clinic
ing to the benefits of deep tissue massage to decrease or practice, or you might be asked to justify the
pain. This information coincides with his prior knowl- treatments that you provide to administrators, super-
edge of other conditions involving muscle spasticity. visors, or third-party payors. Without adequate sup-
Although research has not yet been conducted to port, clients may be denied beneficial services, or you
specifically examine the use of massage with Isaac’s may lack adequate staff and equipment to complete
syndrome, this search has allowed the therapist to your job. The following example reveals how evidence-
gain a full understanding of the condition and the based practice can be used in this endeavor.
current research. Armed with this information, he is A local high school places an advertisement for an
now prepared for the collaborative discussion with athletic trainer to replace the current one who is re-
his client when she returns. Using his skills and tiring after 40 years of service to the district. Although
knowledge, as well as the recently discovered evidence the former athletic trainer seemed to meet the needs
on this rare condition, the massage therapist collab- of the student athletes, the school board is looking to
orates with the client at the next visit to determine hire a recent graduate who has more cutting-edge
the best course of action. knowledge in the field. After several rounds of inter-
With advances in technology and medical science, views, a new trainer is hired and begins employment.
new conditions or complex cases are identified more Although the school board is excited about the inno-
frequently than in the past. As the previous example vative skills the new hire will bring to the table, they
illustrates, several organizations have been established have not planned nor budgeted for new equipment.
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 145

After accepting the position, it does not take the may have greater success in appealing each case if you
new trainer long to realize that the equipment in the can provide research that shows the success of the
training center is far outdated, posing potential safety modalities or procedures you are requesting. In addi-
risks. She knows the board may not respond favorably tion, providing support for what you do is not limited
to her requests so soon after beginning employment. to insurance providers. Clients, families, and policy
To combat the problem, she solicits some help from makers may also demand proof of efficacy for your
the National Athletic Trainers’ Association to locate treatments. Although using evidence-based practice
research on the most cost-effective and clinically ben- can ensure best practice for your clients, it can also
eficial equipment (NATA, 2012). Her search reveals promote modification of current practice to increase
that a variety of budget-friendly equipment, includ- efficiency and cost-effectiveness.
ing therapy balls, medicine balls, and resistive bands,
have been shown to be just as effective as more costly Mentoring, Teamwork, and Motivation
weight-lifting machines. In addition, much of the lit- Whether you are a nurse, therapist, laboratory tech-
erature substantiates her prior belief that the current nician, or athletic trainer, you have a professional and
free weights and outdated equipment pose serious ethical responsibility to provide your clients with the
risks to the athletes with continued use. best treatment possible. In many settings, teamwork
As a result, she selects the most rigorous and cur- lies at the foundation of the process. Research sup-
rent studies on appropriate equipment for athletic ports a multidisciplinary approach to care, where
training, assessing each for sound quality and proce- individual team members approach the client from
dures. She makes copies for the athletic director and their area of clinical expertise, but also meet and
prepares a concise two-page report pointing out the coordinate the care with other professionals for max-
main findings from the studies as well as a list of po- imum client satisfaction and benefit (DiGioia, Green-
tential risks if new equipment cannot be obtained. house, & Levison, 2007; Gabel, Hilton, & Nathanson,
She schedules a meeting with the athletic director and 1997; Murray et al., 2009; Tomita et al., 2009). Evidence
presents her findings. In cases like this, the evidence can provide support for your clinical decisions and
often speaks louder than any words. Although the assist other team members to understand your ap-
district needs to be mindful of its spending, the board proach. Likewise, when other professionals can justify
found it difficult to deny the request when the stu- their actions with sound evidence, you will gain a
dents’ safety was clearly on the line. clearer understanding of their perspective. Often
In this scenario, the trainer used evidence-based what you do will be impacted by the care provided by
practice by integrating her knowledge of anatomy and other professionals; ultimately, evidence can be used
physiology, injury prevention, and conditioning, as to collaborate with clients and families when the need
well as the goals of her students with current research arises to make tough clinical decisions.
to justify the need for some updated equipment. Sim- Similarly, evidence-based practice can be used in
ilarly, this same procedure can be used to justify addi- mentoring relationships. Although you may clearly
tional staff in a hospital rehab clinic, a clinical be the team’s expert for one aspect of the client’s care,
laboratory, or an academic setting. Although you may using evidence to support and teach others about
know firsthand the additional needs, looking to the your practice will add to your credibility. Whether you
literature can provide more objective support. are mentoring a student, a new staff, or a team mem-
Evidence-based practice can also be used to vali- ber from another clinical discipline, evidence-based
date use of specific assessment and treatment tech- practice can strengthen the collaborative relationship
niques in clinical practice. In some cases, third-party and ensure that you are doing what is truly best for
payors are denying coverage for various procedures your client. Practitioners can often fall into the trap
deemed medically unnecessary or unlikely to result in of “doing what they have always done.” Integrating
significant changes in condition or function. You evidence with your clinical skills and knowledge as
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146 Section 3 ■ Evidence-Based Practice

well as the goals and values of your clients can ensure Furthermore, you may need new supplies and space
best practice. to get your program started and using the evidence
When evidence-based practice is used in teaching can provide justification to administration. Irrevoca-
and mentoring relationships, the therapeutic rela- bly, using evidence-based practice can ignite your
tionship between client and practitioner is strength- passion for your profession and impact the clients
ened, and the cohesion among practitioners is that you serve.
increased. This sense of teamwork serves to improve
client outcomes and team morale. Subsequently, en- SKILL-BUILDING TIPS
hanced satisfaction and motivation leads to contin- ■ Use a small journal or an application on your phone
ued use of evidence-based practice in the decision- or other mobile device to organize your thoughts
making process. This cyclic relationship is illustrated and jot down ideas for your evidence-based practice
in Figure 10-4. project. You will find that you will spend a lot of
time thinking about the evidence-based practice
Chapter Summary project in the preliminary stages and never know
when a great idea will hit!
Clearly the benefits to evidence-based practice out-
■ Change is often difficult to accept. Despite your
weigh the time and effort that it takes. Although the
drive to make positive changes through use of
examples provided here are very distinct, you may find
evidence-based practice, know that not everyone
overlap of the reasons for using evidence-based prac-
will be on board. Recognizing and learning how to
tice. For example, you may be charged with developing
work around the barriers is an important part of
a new program in your setting. During the process,
the process.
you might mentor a student and a fellow staff mem-
ber with limited knowledge of appraising research. ■ Ifyou have difficulty locating literature on your
This effort could serve as a quality improvement subject, broaden your search terms. Likewise, if
initiative for your facility, as well as a way to foster your search is returning too many articles, consider
teamwork and motivation among staff and clients. narrowing your search terms by focusing on a more
specific treatment, population, or setting. Also, do
not forget to search the literature in other countries
and disciplines.
Use of evidence
■ As you search the literature, do not be afraid to
to guide
decision making reach out to the authors of individual studies if
you have questions. Most times, the authors con-
tact information or e-mail is included in the article,
and many are more than willing to assist others
interested in their area of study.
Satisfaction & Mentoring
motivation of others ■ In appraising the articles, do not let the statistics in-
timidate you. Consulting a basic statistical text
such as Salkind’s (2011) Statistics for People Who
(Think They) Hate Statistics or seeking assistance from
your supervisor or faculty mentor can help you
Reinforcement make sense of the numbers.
of teamwork
■ Remember that all research is flawed. With evidence-
based practice, your goal is to tease out the
Figure 10-4 Use of Evidence-Based Practice for strengths and weaknesses of each study to deter-
Mentoring, Teamwork, and Motivation mine if the findings can be applied to your current
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Chapter 10 ■ Understanding the Triad of Evidence-Based Practice 147

Bickmore, T. (2011). The power of occupation: Living life with dementia—A train-
practice situation. Drawing on your skills and ing program for formal caregivers. Unpublished manuscript, Department
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Gibson, L. (2003). Perceptions of evidence-based practice: A survey
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CASP UK. (2012). Clinical appraisal skills programme: Making sense of evidence.
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DiGioia, A. M., Greenhouse, P. K., & Levison, T. J. (2007). Patient and
sider your other obligations and responsibilities.
family-centered collaborative care: An orthopaedic model. Clinical
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Dubouloz, C. J., Egan, M., Vallerand, J., & von Zweck, C. (1999). Occupa-
will increase your chances of success, and there is tional therapists’ perceptions of evidence-based practice. American
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Gabel, M., Hilton, N. E., & Nathanson, S. D. (1997). Multidisciplinary
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R. D., . . . Volk, D. (2003). Evidence-based practice: Beliefs, attitudes,
4. Ponder your own evidence-based practice story.
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McCluskey, A. (2003a). CAT template. Retrieved from http://www
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key word: Hissong.
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Section 4

Common
Tasks Along
the Journey
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Chapter 11

Before Implementing
Your Plan: Important
Steps and Considerations
From a certain point onward there is no longer any turning
back. That is the point that must be reached.
—Franz Kafka

process you are engaging in will determine whether

LEARNING OUTCOMES or not you need to complete the human participants
The information provided in this chapter will assist the
or Institutional Review Board (IRB) process. This
reader to:
chapter will also inform the researcher about the
■ Understand the Institutional Review Board process, benefits, and limitations of conducting a
(IRB) process. pilot study. From this point on, the chapter will refer to re-
■ Acknowledge the many facets of healthcare search, but the same policies and procedures may need to be
ethics and professional behavior. followed for an evidence-based practice inquiry.
■ Identify if inquiry should include a pilot study
or survey.
Human Participants Committee
Procedures
Important Preparations Before you implement your research study, you must
You are now almost ready to engage in the inquiry submit a proposal describing your study to the human
and evidence-based practice process. Just two more participants committee, the group responsible for safe-
items need to be dealt with before you begin. First, guarding the rights of the individuals or groups you will
you must gain permission from the relevant human be studying. (These committees may be known by other
participants committee(s). Second, you must double- names, such as Institutional Review Board or research pro-
check to make sure that you have everything needed tocol review committee.) If you are a student, you will ad-
to complete the inquiry process. For example, make dress the committee within your university; if you are a
sure that all components (i.e., required equipment, ac- healthcare practitioner, you will approach the commit-
cess to meeting rooms, or permission to utilize an tee within or connected to your facility. Students plan-
evaluation tool) are granted before you begin your ning to conduct research with patients frequently need
project. Before going further, it is important to note consent from the human participants committees of
that the level or type of evidence-based practice both the university and the treating facility.
151
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152 Section 4 ■ Common Tasks Along the Journey

The purpose of the human participants committee sections will explain the scientific logic of the
is to ensure that individuals who are participating in a study to the committee.
research study are protected and that ethical research Study Is Worthwhile: This issue can be addressed by
standards are employed. This concern for the welfare a summary of the sections you prepared on the
of human participants in medical research studies was purpose and significance of the study, following
organized into a worldwide system in 1964, at the 18th Chapter 4.
World Medical Assembly in Helsinki, Finland. At that Sound Methodology and Safe Procedures: These items
meeting, the Declaration of Helsinki was adopted by the are addressed by the material in Chapters 5 to 9
assembly and has since provided the guiding principles containing the research design and the techniques
for human subject research. for collecting and analyzing data. The committee
Before conducting research, you must present a will decide whether the method is appropriate to
proposal to the appropriate human participants com- the study and whether it will achieve the purpose
mittee(s) outlining the purpose, hypotheses, back- of the study.
ground, definitions of terms, and methodology of the
Research Skill: Your qualifications for conducting the
study. The proposal should also describe procedures
research may be substantiated by submission of a
you will use to ensure the safety, confidentiality,
resume or by your presence before the committee
rights, and so on, of the participants. When commit-
to present your credentials.
tee members are satisfied that their requirements have
been met, they will give you permission to proceed Informed Consent: Participants must understand
with the research study. The committee will review the the nature of the project, what procedures will
proposal to see if it meets the following criteria: be used, and how the outcomes will be utilized
(Box 11-1). Therefore, you must explain the study
■ The scientific logic on which the study is
in lay terms. In survey research, participants give
constructed is sound.
their tacit consent to participate if they return
■ The study is worthwhile.
the survey. In experimental, quasi-experimental,
■ The proposed methodology is sound.
and qualitative studies, participants give their
■ Procedures are safe.
consent in writing and must be offered a copy
■ The researcher has the skills to perform the study.
of the signed informed consent form. Samples
■ There is provision for informed consent or
of informed consent forms are given in Appen-
agreement by participants.
dices F and G. If you feel that a subject is unable
■ The benefits of participating in the study outweigh
to give informed consent by virtue of cognitive
the risks.
or physical incapacity or age, you must obtain
■ Participants may withdraw their consent to
the legal guardian’s consent. If the participants
participate at any time.
are children, you must obtain the consent of
■ Participants’ confidentiality will be protected.
the parents or guardians. If the nature of the re-
■ Necessary treatment will not be withheld.
search dictates that you cannot tell participants
The researcher should always check the IRB’s re- the purpose of the study, because the knowledge
quirements; however, the previous list displays the may affect their participation in the study, that
most common components of any IRB application. At failure to disclose needs to be clearly explained
this time, let’s review the listed points in more detail: in the informed consent.
Sound Scientific Logic: This issue will be addressed Benefits Outweigh Risks: In the informed consent
by the material you present to the committee on form, any risks or benefits that may result from
the background, literature review, and scope of participating in the study must be explained to par-
the study. These sections of the proposal have ticipants (see Appendices F and G, and Box 11-1).
already been prepared from the work you did in The committee will expect that the benefits will
Chapters 3, 4, and 5, and a summary of these outweigh the risks. You should point out possible
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Chapter 11 ■ Before Implementing Your Plan: Important Steps and Considerations 153

participants can terminate participation in

BOX 11-1 ■ Outline of an Informed the study at any point without fear of reprisal
Consent (see Appendix F and G).
Title: Confidentiality: If there will be any audiotape or
Principal Researcher: videotape recording of participants’ behavior or
Advisor: interviews, such as samples of participants’ writ-
1. Purpose: ing or art work, the document must state how the
2. Procedures: information from these recordings and actual
3. Discomforts and Risks: tapes will be used and what will happen to them
4. Benefits: at the conclusion of the study (see Box 11-1). It is
5. Duration or Time commitment: typical to offer participants, or their guardians an
6. Statement of Confidentiality: opportunity to view the materials if they wish.
7. Right to Ask Questions: Participants must be assured that materials will
8. Compensation: be kept in a secure place during the study and told
9. Voluntary Participation: who will have access to them. If the results of the
study are to be published, participants need to
You must be 18 years of age or older to
know that their anonymity is guaranteed. Sepa-
consent to participate in this study. If you
rate written permission must be gained if photo-
consent to participate in this study and to the
graphs are to be used in the published material.
terms above, please sign your name and indi-
Survey respondents also need to be assured that
cate the date below. You will be given a copy
their anonymity will be guarded. This is usually
of this form to keep for your records.
accomplished by having them return the surveys
________________ ______________
anonymously. Survey respondents are not asked
Participant Signature Date
to sign a consent form, because responding to the
I, the undersigned, verify that the above in-
survey is considered as consent to participate. If
formed consent procedure has been followed.
participants are to be paid for their participation
________________ ______________
in the study, payment should be based on work
Researcher Signature Date
and time considerations rather than as compensa-
tion for any risk involved or as inducement to
side effects of the study and discuss precautions poor participants to participate.
you will take to prevent harm to participants. You Acknowledgement That Treatment Will Not Be
should also explain the place and length of time for Withheld: If experimental and control groups
the study sessions. will be included in the study, participants
Withdrawal of Consent: The informed consent form might not be told to which group they are as-
should include a statement indicating that there signed. If the study is conducted to test a new
will be no reprisal, regardless of the subject’s will- procedure with the experimental group, the
ingness to participate (see Box 11-1). Occasion- control groups may receive either the standard
ally, clients may fear that their treatment may be treatment or no treatment. Some facilities don’t
compromised in some way if they refuse to par- allow participants to be in control groups that
ticipate in a study; they may feel they will not do not receive treatment, which is understand-
receive the same quality of care as the study par- able, as these individuals are usually in the
ticipants. This problem especially arises if the facility for the express purpose of being treated.
therapist implementing the study is also the This expectation will dictate the activity of the
clients’ treating therapist. It must also be made control group, and researchers must abide by
clear in the written informed consent form that the facility’s regulations.
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154 Section 4 ■ Common Tasks Along the Journey

readily through the national association or registry.

Healthcare Research Ethics
Researchers must show integrity and be guided by
Healthcare researchers are expected to behave ethi- ethical principles that include respecting the rights of
cally in all areas of their practice. It is the researcher’s participants, abiding by the research design, and re-
responsibility to know the rules of conduct. Profes- porting results accurately and truthfully.
sional associations have a code of ethics: a public It is particularly important to guard zealously the
statement of the values and principles expected of rights of participants who are in institutional environ-
practitioners in that profession. Some of these ethical ments, such as persons with developmental disabilities,
principles pertain to healthcare practitioner research persons with behavioral health issues, and persons who
behavior, as reviewed in Box 11-2 for occupational are imprisoned. Individuals in these settings are par-
therapy practitioners. Each healthcare profession has ticularly vulnerable and are not usually in a position to
published ethical standards that can be obtained serve as their own advocates; therefore, researchers

BOX 11-2 ■ Example of Ethics in Research

The following excerpt from the 2010 Occupa- B. Make every effort to ensure continuity of
tional Therapy Code of Ethics pertains to services or options for transition to appro-
research behavior (AOTA, 2010). priate services to avoid abandoning the
NONMALEFICENCE service recipient if the current provider is
Principle 2. Occupational therapy personnel unavailable because of medical or other
shall intentionally refrain from actions that absence or loss of employment.
cause harm. C. Avoid relationships that exploit the recipient
Nonmaleficence imparts an obligation to refrain of services, students, research participants,
from harming others (Beauchamp & Childress, or employees physically, emotionally, psy-
2009, as cited in AOTA, 2010). The principle of chologically, financially, socially, or in any
nonmaleficence is grounded in the practitioner’s other manner that conflicts or interferes
responsibility to refrain from causing harm, in- with professional judgment and objectivity.
flecting injury, or wronging others. Although D. Avoid engaging in any sexual relationship
beneficence requires action to incur benefit, non- or activity; whether consensual or noncon-
maleficence requires nonaction to avoid harm sensual, with any recipient of service, in-
(Beauchamp & Childress, 2009). Nonmalefi- cluding family or significant other, student,
cence also includes an obligation to not impose research participant, or employee, whereas
risks of harm even if the potential risk is without a relationship exists as an occupational
malicious or harmful intent. This principle often therapy practitioner, educator, researcher,
is examined under the context of due care. If the supervisor, or employer.
standard of due care outweighs the benefit of E. Recognize and take appropriate action to
treatment, then refraining from treatment provi- remedy personal problems and limitations
sion would be ethically indicated. (Beauchamp & that might cause harm to recipients of
Childress, 2009) service, colleagues, students, research
participants, or others.
Occupational Therapy Personnel Shall F. Avoid any undue influences, such as
A. Avoid inflicting harm or injury to recipients alcohol or drugs that may compromise
of occupational therapy services, students, the provision of occupational therapy
research participants, or employees. services, education, or research.
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Chapter 11 ■ Before Implementing Your Plan: Important Steps and Considerations 155

BOX 11-2 ■ Example of Ethics in Research—cont’d

G. Avoid situations in which a practitioner, occupational therapy assistant to further
educator, researcher, or employer is un- one’s own physical, emotional, financial,
able to maintain clear professional bound- political, or business interests at the ex-
aries or objectivity to ensure the safety and pense of the best interests of recipients of
well-being of recipients of service, students, services, students, research participants,
research participants, and employees. employees, or colleagues.
H. Maintain awareness of and adherence K. Avoid participating in bartering for services
to the Code and Ethics Standards when because of the potential for exploitation and
participating in volunteer roles. conflict of interest unless there are clearly no
I. Avoid compromising client rights or well- contraindications or bartering is a culturally
being based on arbitrary administrative appropriate custom.
directives by exercising professional L. Determine the proportion of risk to bene-
judgment and critical analysis. fit for participants in research before im-
J. Avoid exploiting any relationship estab- plementing a study.
lished as an occupational therapist or

must be especially careful not to take advantage of highest integrity must be maintained in reporting on
them and know the boundaries of the research agenda. all phases of the study, exactly as they occurred in the
There is often an ombudsman or client advocate in moment of the inquiry.
these types of facilities, and researchers would do well Just a few more words are needed about ethical
to include such persons in the consent process. conduct in qualitative research. Qualitative re-
Another ethical consideration is that researchers searchers must remember the ethical issues raised
must abide by the research design as it was presented when they first became closely involved in the events
and approved by the human participants committee. or situations under study, confidentiality of data
Unexpected issues may arise that cause researchers that may be extremely personal, anonymity of par-
to redesign their study. If this is the case, the revised ticipants who may provide idiosyncratic and identi-
design must be submitted to the committee to en- fiable data, readers’ ability to distinguish between
sure that it still meets requirements. If any of the data and the researchers’ interpretations, possible
changes affects the informed consent form signed by long-term effects of in-depth interviewing about
the participants, they must also be informed and a personal issues, and knowledge gained from partic-
new informed consent form signed. ipants’ unself-conscious acts during participant
Finally, there are definite ethical standards involv- observation.
ing the reporting of research results. Sometimes, some
findings support the hypotheses or research ques-
The Pilot Study: A Helpful Measure
tions, whereas others do not. All findings must be re-
of a Researcher’s Readiness
ported. In a quantitative study, if findings are not at
the identified level for statistical significance, they The pilot study is a preliminary trial of the study, or
must be presented as found. In a qualitative study, it a mini-study, that may be performed before the final
is important to report exactly what the participant study. The pilot study has been suggested as a way to
said or identify themes that accurately relay what the check on the feasibility of various components of
participants meant when answering a question or the project, including the researcher’s readiness to
making a point. It can’t be stressed enough that the carry out the inquiry. The following paragraphs will
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156 Section 4 ■ Common Tasks Along the Journey

examine what a pilot study should include, how it is composed is very important. A pilot study will tell
done, and what can be learned from it. the researcher if respondents understand the questions,
Most of the steps in the final study should be in- if the questions elicit the information desired, and
cluded in the pilot study, but on a smaller scale. The whether the survey is too long or too short. Respon-
number of participants will be considerably smaller dents should know that they are answering a pilot study
than in the final study, but they should be selected instrument and that they will be asked if they have any
from the target population, so that results are likely suggestions for improvements in the questions and
to be representative of those of the final study. The the cover letter and how long it took them to complete
process will be the same as the one proposed for the the survey.
final study, including the analysis of the data gener- Performing a pilot study can be difficult in experi-
ated from the pilot group. As a result, the pilot study mental research because the researcher may have access
provides an evaluation of the proposed process and to only a few participants who meet the selection cri-
may be used to remove flaws. teria. Consequently, if participants are engaged in a
A pilot study may reveal fundamental problems in pilot study; there may not be a sufficient number of
the logic that leads to the study’s conclusions, in which participants for the final study. In behavioral research,
case a major revision of the research questions may be participants often cannot participate twice (once in the
in order. Lesser flaws may require only simple changes pilot study and again in the final study) because the
in the measuring instrument or subject selection crite- effects intervention provided in the pilot study might
ria to make the project satisfactory. Some modifications influence the results of the final study. Sometimes this
of the original proposal are almost always necessary, so can be overcome by using a pilot sample of suitable
pilot studies invariably improve the design and data of participants from another facility or by using a slightly
the final project. Therefore, it is worthwhile to take the different population. This solution is often preferable
time and effort to perform a pilot study. to eliminating the pilot study altogether.
The items that may be tested in a pilot study in- Sometimes experimental and quasi-experimental re-
clude methods and scientific logic. Those concerning search studies are performed on very small samples
scientific logic might include: with no pilot studies, simply because of constraints on
■ Has the problem under study been too broadly or time, money, or access to participants. The downside
too narrowly defined? to not conducting a pilot study is that the results of
■ Are the variables suitable? such inquiries are often published with a list of limita-
■ Will the resulting data address the purpose of tions and disclaimers. In this situation it is preferable
the study? to regard the project as a pilot study, and then pursue
a second study, amending philosophy and procedures
Those concerning methodological issues might
to address the limitations of the pilot study. The results
include:
of the second study would then be more valid and
■ Are the survey questions clearly stated? meaningful (Boxes 11-3 and 11-4).
■ Will the investigative methods generate informa- In methodological research, the pilot study is built
tion suitable for answering the research question? into the research process at the stage when the newly
■ Are appropriate participants available? developed measure is tested on a sample, changes are
■ Are the variables discrete and can they be measured made, and the revised measure is tested again. The
meaningfully? process may occur several times before the researcher
■ Is the measuring instrument accurate and feels satisfied with the results. This test and retest
practical? procedure serves the same purpose as a pilot study
Typically, certain items in each type of research and may be considered as such.
design can be best evaluated by a pilot study. For exam- In the summative component of evaluation research,
ple, in survey research, the way in which questions are the survey instruments used to garner data about the
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Chapter 11 ■ Before Implementing Your Plan: Important Steps and Considerations 157

Similarly, ethnographic research is similar to histor-

BOX 11-3 ■ Example 1 of Pilot Study ical research in this respect. One culture or program is
Case study research is often conducted as a under study, and data can be collected and analyzed in
pilot study, in the sense that the individual case many ways until the process is considered satisfactory.
is used to generate hypotheses that will later Sometimes an event within the culture or program will
be tested experimentally on a large sample of occur only once (such as an unusual ceremony or a
similar participants. However, if the researcher patient trying a rare treatment); in that case, the re-
does not intend the case study to be a pilot for searcher must be ready with the best method to cap-
a larger study, portions of the case may be ture that event exactly when it occurs. This may require
piloted ahead of time. Portions that may be preparation by testing certain techniques ahead of
pretested include the use of the equipment, time; in other words, running a pilot study, perhaps in
the validity of the measuring instrument, or the a simulated situation. It is almost always methodology,
usefulness of the data-gathering technique. rather than scientific logic or philosophical issues, that
needs testing in this type of once-only research. In fact,
in ethnographic research, proposing and rejecting
philosophical issues in the data analysis is one of the
BOX 11-4 ■ Example 2 of Pilot Study main ways of interpreting data.
Finally, another important purpose of perform-
In discussing the design of qualitative research, ing a pilot study is that it gives the researcher a
Marshall and Rossman (2011) state that: . . . chance to practice conducting research. Like most
use of a pilot study can lend credence to the things, research becomes easier and improves in
researcher’s claim that he can conduct such a quality with practice. A pilot study gives the novice
study. He can illustrate his ability to manage researcher a good opportunity to gain skill while
qualitative research by describing initial obser- achieving the all-important goal of improving the
vations or interviews. . . . A description of ini- research design.
tial observations demonstrates not only the
ability to manage this research, but also the
strength of the approach for revealing enticing Implementing the Project
research questions. Inclusion of a description Practical issues must now be arranged. Depending
of a pilot study or initial observations can on the type of research, these may be as varied as
strengthen the proposal. scheduling times and places to meet with participants,
arranging access to rooms and equipment, training
raters or data gatherers, copying and mailing surveys,
program under study may appropriately be subjected locating suitable client records for review, or arranging
to a pilot study. This ensures that the questions will to videotape a group procedure.
elicit needed data and be understood by respondents. You are finally ready to carry out your research
In regard to qualitative research, an historical study project. As you can see, it takes an enormous amount
does not lend itself to the use of a pilot study because of work to prepare for the treatment or action com-
it involves only one event or chain of events being ponent of a research study. Yet often this is the only
studied. If the method of data collection proves un- component that people equate with the term research.
satisfactory, no harm has been done to the historical
event and other methods may be explored. Generally,
Chapter Summary
it is considered part of the study method to try dif-
ferent forms of data collection and data analysis until First, this chapter provides the reader with insights to
satisfactory methods are found. the Institutional Review Board (IRB) process, which
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158 Section 4 ■ Common Tasks Along the Journey

takes a considerable amount of planning and time to

complete in addition to the inquiry or project. The LEARNING ACTIVITIES
reader is then reminded of the exacting policies, pro- 1. Find out which human participants committee
cedures, and professional behaviors that must be em- is responsible for the participants you intend
ployed and followed when engaging in an inquiry. to study. Request a copy of that committee’s
Lastly, readers are provided with insights to determine requirements to review sooner than later.
whether their particular inquiry should engage in a 2. Practice writing up an informed consent state-
pilot study or a survey. ment for your participants. (To assist with this
review, see the examples of informed consent
SKILL-BUILDING TIPS forms in Appendices F and G). Remember to:
■ Include the purpose of the study
■ Researchers often underestimate the length of time
■ Include the place and the amount of time the
needed to gain permission from a human partici-
pants committee. This process can take anywhere study will require of participants
■ Include a description of the procedure to
from 1 to 6 months, depending on the frequency
of committee meetings and whether all materials be used
■ State that participation is voluntary
have been submitted correctly and completely. If
■ State that participation can be withdrawn
the protocol needs to be revised, it may take even
longer. You should probably submit the proposal at any time without fear of reprisal
■ List the risks and benefits of the study
to the committee just after the research protocol is
■ Cite any costs that may be involved
written. This will allow sufficient time for notifi-
■ Describe how confidentiality will be protected
cation by the committee before the start of data
■ Give the name of someone who will be avail-
collection.
able to answer questions about the research
■ Itis important to determine the exact require- ■ State that a copy of this statement will be
ments of the committee to which you are apply-
offered to participants
ing. All of the committees have detailed written ■ Provide a space for the subject’s signature, a
instructions and most will have an electronic
witness’s signature, and, if needed, a parent
packet of instructions.
or guardian signature
■ When describing a study to potential participants ■ Provide a space for the date of the signatures
in order to obtain informed consent, it is some-
3. The committee will want to know details
times difficult to know if the explanation has
about the researchers involved in the study.
been fully understood. If there is any doubt about
List your qualifications as head of the re-
the participant’s comprehension, it is a good idea
search team, and state why you are qualified
for the person who knows the individual best to
to carry out the proposed research project. If
be present to assess how much is understood and
you have an advisor or mentors assisting you
perhaps to reword the explanation so that it is
with the study, you will also need to list their
meaningful to the client. Some human partici-
credentials.
pants committees require that a member of the
committee be present on such an occasion, 4. Decide whether your study lends itself to a pilot
whereas others have a human rights officer, an study. Will methodological issues, scientific
ombudsman, or an advocate who will serve this logic issues, or both need to be piloted? List the
purpose. parts you think could be improved by a pilot
study and say why.
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Chapter 11 ■ Before Implementing Your Plan: Important Steps and Considerations 159

Methodological issues: ■ Variables

Scientific logic issues: ■ Procedures for treatment (if quantitative
Is it feasible and wise to utilize participants for research)
the pilot study sample? ■ Data collection techniques (if quantitative

If so, how will you select them? research)

If not, where can you find pilot study participants? ■ Data analysis methods (if quantitative research)

■ Procedures for data collection and analysis

5. Write a protocol for a pilot study. It will re-
semble the protocol you wrote earlier and (if qualitative research)
should contain the following:
■ Subject criteria REFERENCES
Commission on Standards and Ethics, AOTA. (2010). Occupational ther-
■ Subject selection method apy code of ethics. American Journal of Occupational Therapy, 64, S4–S16.
■ Research questions or hypotheses Marshall, C., & Rossman, G. B. (2011). Designing qualitative research. New-
bury Park, CA: Sage Publications.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
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Chapter 12

The Art of Writing Up

the Research Study or
Evidence-Based Practice
Project
The difference between something good and something
great is attention to detail.
—Charles R. Swindoll

a research study is included in Box 12-1; the suggested

LEARNING OUTCOMES chapter outline for an evidence-based practice project
The information provided in this chapter will assist the
can be found in Box 10-2 (Chapter 10 of this text).
reader to:
There are many similarities between the two reports,
■ Understand the sections that are typically but some variations do exist related to the differing
included in a formalized report of a research goals of research and evidence-based practice. Whereas
study or evidence-based practice project. the purpose of the research report is to convey infor-
■ Determine the best way to present data and mation gained from scientific inquiry and procedures,
outcomes visually. the function of the evidence-based practice report is
■ Synthesize data with existing literature to to illustrate application of existing research and eval-
effectively report study findings and draw uate the outcomes to inform practice and future pro-
conclusions. gram development. Each chapter of the reports and
■ Explore styles of scientific writing and discover the suggested content will be reviewed.
tips for becoming a better writer.
Chapter 1: Introduction and Overview
■ Construct a formal report on a research study
of the Topic of Interest
or evidence-based practice project.
In both reports, Chapter 1 helps to “set the stage” for
the study or project. In the research report, Chapter
n conducting a research study or an evidence-based 1 serves to orient the reader to the topic investigated,

I practice project, a formal report of the back-

ground, methodology, outcomes, and analysis is
often prepared. This information is typically arranged
to outline the scope of the study, and to explicitly
review the research hypothesis or research question.
For the evidence-based practice report, Chapter 1
into chapters. A suggested formal chapter outline for commonly includes a detailed description of the
161
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162 Section 4 ■ Common Tasks Along the Journey

BOX 12-1 ■ Research Study Outline

Abstract Chapter 4 Implementation and Results
Chapter 1 Introduction and Overview Section 4.1 Description of the Subjects
of the Topic of Interest Section 4.2 Results (quantitative, qualitative,
Section 1.1 Background of the Topic or both, if applicable)
Section 1.2 Scope of the Study May include:
Section 1.3 Hypothesis and Research Question ■ Tables and figures to display

data, outcomes, and statistical

Chapter 2 Literature Review results
Section 2.1 Methodology of the Literature
Search Chapter 5 Evaluation, Discussion, and
Section 2.2 Synthesis of the CAT Portfolio Conclusions
(See Appendix A: Individual CAP Section 5.1 Implications of Findings and
Outlines) Correlation of Results With
Subsections will include: Existing Literature
■ Description of the Portfolio Section 5.2 Limitations
■ Additional subsections will be in- Section 5.3 Recommendations for Practice
dividualized to your project and or Future Research
will be organized around common
themes in the literature References
Appendix A: Individual CAP Outlines
Chapter 3 Methodology ■ You will likely have additional
Section 3.1 Frameworks or Models of Prac- appendices that include items
tice Guiding the Research such as tools used in the project,
Section 3.2 Subject Selection and Recruitment lengthy tables and graphs, and
Section 3.3 Research Design and Procedures so on.
Section 3.4 Assumptions

setting where the project took place, as well as an research. Without a detailed description of the set-
explanation of the problem and the rationale for ting, the reader is unable to place the existing research
addressing it. As noted previously, supporting these into the current context. Also, when evidence-based
points with other resources illustrates the need practice is used for new program development or
for the project, and a needs assessment or SWOT quality improvement, a strong rationale can aid in
analysis (see Chapter 10 of this text) can be helpful obtaining necessary funding or administrative ap-
during the planning phase of the project. Addition- proval for the project.
ally, a review of supports and threats inherent in the
Chapter 2: Literature Review
setting allows one to approach the project realisti-
cally, and ultimately devise a feasible evidence-based In both research and evidence-based practice proj-
practice question. ects, Chapter 2 contains the literature review. The
More details regarding the evidence-based practice group of research articles selected for the literature
setting are included because these projects, in con- review can be referred to collectively as the research
trast to ground-level research, are situated in real-life portfolio. In-depth descriptions about the search
practice scenarios and involve application of existing methodology, key search terms used, as well as
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Chapter 12 ■ The Art of Writing Up the Research Study or Evidence-Based Practice Project 163

inclusion and exclusion criteria for the articles se- Chapter 3: Methodology
lected, is usually included. Reporting on the databases
searched, search terms (and combinations of search Chapter 3 is very similar for the research study and
terms) used, and any other parameters set (such as the evidence-based practice project. It should include
limiting the search to articles published within the last the detailed methodology as well as discussions of
5 years) allows the search to be replicated if necessary guiding frameworks and conceptual models, assump-
and lets the reader know how exhaustive the search tions, and subject and participant information. In
was. Box 10-3 includes an example of what the search both cases, one should strive to sufficiently describe
methodology section might look like. the procedures so that they can be replicated. This
serves two purposes. First, it allows the reader to fully
Describing and Synthesizing the Literature understand and apply the results of the project; sec-
After the search methodology is sufficiently ex- ond, it permits modification of specific aspects of
plained, the task of describing and synthesizing the the procedures if shortcomings are noted.
research articles within the portfolio should be un- In describing the procedure, three elements need
dertaken. The description of the portfolio is usually to be included. First, it is important to review any
a straightforward review of the number of articles, frameworks or models of practice used to guide
study designs, time frame of the studies, where the or design the methodology. As noted in Chapter 5
studies took place, and the general topics. Box 10-4 of this text, conceptual frameworks, also known
contains an example of a portfolio description for a as models of practice, are theoretical explanations
professional leadership project. Following descrip- of functioning that can guide practitioners in client
tion of the portfolio, one would expect a compre- treatment or researchers in their approach to a
hensive narrative synthesis of all studies within the study. Discussing these guiding principles helps the
portfolio. This section is likely one of the most reader understand the perspective from which the
labor-intensive to write and will include multiple evidence-based practitioner or researcher approached
subsections individualized to the project being con- the project.
ducted. Subsections will be organized around com- Second, operational definitions of all key terms
mon themes within the literature, with multiple and concepts should be included within the method-
citations from the referenced articles to support ology. Recall from Chapter 5 of this text that opera-
each theme. Remember that themes can only be tionalizing involves strictly defining terms so that
identified when more than one study yields the same their meaning cannot be misinterpreted. It is accept-
or similar findings. able to use definitions from dictionaries, medical
In order to effectively synthesize studies in the textbooks, authorities on the topic, or to create your
portfolio, each one should be critically appraised, re- own. As long as sufficient detail is provided, misun-
gardless of whether research or evidence-based prac- derstanding of concepts or inconsistent measure-
tice is being conducted. When conducting research, ment of phenomena can be avoided.
existing literature on the topic needs to be appraised Third, assumptions made when designing the
in order to ascertain gaps in the research that the new methodology should be discussed. As noted in
study aims to fill. This task also helps to situate the Chapter 5 of this text, assumptions are underlying
current study within the context of past studies in principles that the researcher or evidence-based
the field. In evidence-based practice, evaluating the practitioner believes or accepts but that are difficult
scientific rigor and applicability of each study to the to prove in any concrete way. Assumptions can be
current practice situation allows the evidence-based made about the ideological principles upon which
practitioner to make decisions about if and how the project is based, or concerning the procedures
the research will be applied to practice. An individ- used in the project. Assumptions can be discussed
ual template to appraise each study is included in in narrative form, but are frequently enumerated in
Table 10-3 of this text. a bulleted list.
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164 Section 4 ■ Common Tasks Along the Journey

Subject or Participant Recruitment & Selection readers to gain a clear picture of the study sample or
Information about the subject or participant (client) participant group, so that later they may superimpose
recruitment and selection is also included in this the findings of the project on that picture. It is cus-
chapter. To clarify, the term subjects is often em- tomary to present descriptive statistics including
ployed when discussing research, whereas the terms frequencies, percentages, a range, and some sort of
participants or clients are used more commonly in the central tendency (such as the mean) for the data. This
evidence-based practice literature. For a research information will give readers solid information about
study, a list of subject inclusion and exclusion crite- what the subjects or participants looked like and how
ria, as well as descriptions of subject recruitment they performed during the project. The description
and sampling methods, should be included. For an can be in the narrative format or in the form of tables
evidence-based practice project, participant inclu- or figures. See Box 12-2 for an example.
sion and exclusion criteria are clarified as well as the
Reporting Results
approach to client-centeredness. Remember from
Chapter 10 of this text that evidence-based practice Research studies and evidence-based practice projects
involves the interweaving of three elements—evidence; can yield quantitative data, qualitative data, or both,
practitioner skills and knowledge; and client goals, depending on the topic, setting, and goals of the
values, and circumstances. Care should be taken to venture. Results are typically included in this chapter
delineate exactly how the methodology will be varied
to meet each client’s needs in an evidence-based
practice project. This section is omitted in a research BOX 12-2 ■ Example of Description
project, where the aim is to adhere to stricter proce- of Subjects
dures to generate new information.
In Chiarello et al.’s (2010) study on family
Chapter 4: Implementation and Results priorities for activity and participation of chil-
Whether you are conducting research or evidence- dren with cerebral palsy, they described the
based practice, Chapter 4 will be used to elaborate on subjects in a table as well as in the narrative
the course of the project as well as the results. For an that follows.
evidence-based practice project, thorough descrip- Table 1 provides demographic information
tions of the actual participants, modifications to the on the participants and their children. The
original project plan, and a synopsis of the implemen- participants were primarily mothers (80%)
tation are commonly provided. For a research project, and fathers (11%). Other participants included
it is usually not necessary to include lengthy discus- stepparents, foster parents, grandparents,
sions about these elements because little deviation in and guardians. All will be referred to as par-
stringent procedures occurs. The descriptions of the ents throughout the article. Parents had a
participants and project progression are typically mean age of 40.3 years (SD = 9.3), 50% had
more in depth for evidence-based practice projects, education beyond high school, and 61% were
because of the fact that procedures are commonly al- employed. The children and youth were 2 to
tered to accommodate real-life practice situations and 21 years of age, with a mean age of 11.0 years
participants’ needs. In any case, if modifications in (SD = 4.5); 56% were male, and 44% were fe-
procedures are necessary, they should be presented male. Table 1 provides demographic informa-
and discussed. tion of the children and youth grouped by
age: under 6 years, 6 to 12 years, and 13 to
Describing Subjects or Participants 21 years. Gross motor function varied across
The subjects or participants should be described Gross Motor Function Classification System
numerically for research or evidence-based practice (GMFCS) levels. (p. 1256)
projects. From this information, it will be possible for
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Chapter 12 ■ The Art of Writing Up the Research Study or Evidence-Based Practice Project 165

of the formal report (Chapter 4) and can be discussed that used to describe the sample or participant group;
in narrative format, or displayed in tables and figures. that is, using descriptive statistics such as frequencies,
In the results section of an article, only the facts of percentages, ranges, and central tendencies. Presenting
the study or project are presented, with no interpre- this data in narrative or visual form is appropriate.
tation. Authors must be careful not to include their In a nonexperimental study or a qualitative study,
own biases or conclusions in the results section. you may have subjected some data to one or more
Rather, they must keep to a factual account of what of the coding procedures. The results of the coding
actually happened and what was actually found. must be presented as clearly and simply as possible.
All the results must be mentioned in the results In this type of presentation, the weight of the
section of a report, not just the ones that substantiate evidence will determine if the hypotheses have been
the hypotheses or suit the researcher’s or practi- substantiated—a judgment the researcher must make
tioner’s needs. Even though interpretations and con- because it is not possible to subject the evidence to
clusions will be presented later in the article, readers statistical significance testing.
must be able to decide for themselves the efficacy of Descriptive statistics or qualitative thematic analy-
these conclusions by having all the data at hand. In a ses are most commonly used in evidence-based prac-
research report, it should be clearly stated which of tice. Because these projects tend to be rooted in
the hypotheses were or were not supported. In the real-life clinical situations, and participant groups are
case of inferential statistical results, the reader should smaller or restricted to one practice, clinic, or health
be told if the significance level established at the start system, inferential statistics are usually not appropri-
of the project was reached. ate. In addition, remember that the goal of evidence-
Experimental, quasi-experimental, or correlational based practice is to apply existing evidence to practice
research will yield quantitative data, and inferential and then evaluate the success of the outcomes. Al-
statistics may be used to determine if there are mean- though standardized measures can be used to gather
ingful differences or similarities between groups. The participant data, success of the intervention is not
probability ratios provide that information and indi- based on statistical outcomes, but rather clinical
cate if the hypotheses have been substantiated. Each ones. Tables and figures are commonly used to dis-
hypothesis should be reviewed and checked against play data in evidence-based practice projects as well.
the statistical results. For each hypothesis, readers
should be informed if it was substantiated and then Visual Displays of Data
provided with the probability level and details of the Displaying data pictorially allows readers to gain an
findings. It is customary for results to be reported immediate and overall concept of the results and lets
from the general to the specific. For example, in their them make sense of quantities of data at a glance. As
study on the effects of virtual reality gaming on dy- the old saying goes, “A picture is worth a thousand
namic balance and strength in older adults, Rendon words,” or in this case, a thousand numbers. Tables
et al. (2012) reported “the Mann-Whitney test was and figures can eliminate many complicated or bor-
used to determine significant differences (P < 0.05) ing narratives, but they should be used judiciously;
between groups at baseline and change in outcome too many can become confusing.
measures over time” (p. 551). Comparison of the sta- Data can be presented pictorially in one of two
tistical results with the chosen probability level re- ways—tables and figures. Tables are the most com-
veals that the virtual reality group demonstrated mon type of illustration, and can be used to present
significantly improved balance (P = 0.038) and self- simple lists of frequencies and percentages, or to con-
confidence with balance (P = 0.038) when compared solidate and present data, such as numbers of pounds
with the control group (Rendon et al., 2012). squeezed on a dynamometer. For example, if scores
Survey research, case studies, and evaluation re- are arranged in order from highest to lowest (rank
search may likely garner descriptive quantitative data. ordering), readers can easily gain an overview of
The data should be reported in a manner similar to the responses. They can see the range of scores—the
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166 Section 4 ■ Common Tasks Along the Journey

highest, lowest, and middle scores—and can compare

one person’s scores against the others. Table 12-1 ■ Degrees of Elbow Flexion
Tables are especially useful for condensing large Following Treatment (N = 50)
quantities of data so that the reader can under-
Degrees of Elbow Frequency of
stand the information more readily. Suppose a study
Flexion Occurrence
yielded 50 scores of degrees of elbow flexion for a
group of patients. Even presenting the 50 scores in 20–40 2
order of magnitude would be difficult for a reader to 41–60 4
digest and think about usefully. In this case, grouping
the scores, say into units of 20, would reduce the data 61–80 9
and allow the reader to grasp its implications more 81–100 10
efficiently (see Table 12-1). From this table it is pos-
101–120 12
sible to understand quickly the spread of scores. Most
patients had flexion in the midrange (60 degrees to 121-140 9
120 degrees), whereas few patients had flexion at the
141-160 3
greater and smaller angles. Even though some detail
is lost in this type of grouping, it is generally a useful 161-180 1
and efficient representation of data.
Tables are commonly used to illustrate the find-
ings from descriptive and inferential statistics. In practitioner should merely highlight important points.
this case, they can present detailed information more Tables 12-2 and 12-3 present data generated from
easily and in less space than would be required by descriptive statistics and inferential statistics.
narration. It is not necessary to repeat all the table Although tables are invaluable for concisely com-
data in the text. The researcher or evidence-based municating a large set of numbers, many people find

Table 12-2 ■ Distribution of Demographic Characteristics of Healthcare Administrators

and Clinicians (N = 385)
Administrators Clinicians
(N = 201) (N = 184) Total Group
Demographic
Characteristics Frequency Percentage Frequency Percentage Frequency Percentage

Age:
20–25 years 0 0 2 1 2 0.5

26–30 years 17 9 46 25 63 16

31–35 years 56 28 52 28 108 28

36–40 years 33 16 26 14 59 15

41–50 years 53 26 40 22 93 24

51+ years 42 21 18 10 60 16

College degree:
Associate 95 47 113 61 208 57
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Chapter 12 ■ The Art of Writing Up the Research Study or Evidence-Based Practice Project 167

Table 12-2 ■ Distribution of Demographic Characteristics of Healthcare Administrators

and Clinicians (N = 385)—cont’d
Administrators Clinicians
(N = 201) (N = 184) Total Group
Demographic
Characteristics Frequency Percentage Frequency Percentage Frequency Percentage

BA/BS 13 10 17 9 30 8

MA/MS 10 6 8 4 18 6

Certificate 21 11 4 2 25 7

Clinical doctorate 47 25 19 15 66 17

Research doctorate 4 2 0 0 4 1

Age when took first job:

20–25 years 178 89 156 85 334 87

26–30 years 14 7 17 8 28 7

31–35 years 4 2 5 3 9 2

36–40 years 2 1 5 3 7 2

41+ years 5 2 4 2 9 2

Specialty of practice:
Psychiatry 60 30 49 27 109 29

Pediatrics 31 15 59 32 90 24

Physical disabilities 95 47 63 35 158 41

Geriatrics 15 8 11 6 26 7

it difficult to get the “big picture” from a table. This Line graphs are used to show changes in a phenome-
is where we turn to figures. Figures are used to illus- non over time. Measurements of some attribute are plot-
trate visual images of items or events, changes in ted at multiple points during the study, and all points
numbers of items over time, or comparisons of are joined to form a continuous line on the graph. Line
multiple items. Figures can include bar graphs, line graphs can only present continuous data, and more
graphs, diagrams, flowcharts, pie charts, photo- than one line can be included on the same graph to re-
graphs, schematics, or drawings, to name a few. To veal trends among two or more groups. An example of
further clarify, tables are best for presenting data, a line graph can be found in Figure 12-1; student test
whereas figures are used to help the reader gain a scores were plotted for 2000 and 2012. Examination of
clearer understanding of the outcomes and to pro- the graph reveals that scores improved in 2012, possibly
pose relationships among key concepts in the study because of changes in curriculum design, for example.
or project. Consult Table 12-4 to determine the most Bar graphs are similar, except that they are formed
appropriate illustration for your goals. by drawing a vertical bar at each frequency gained
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168 Section 4 ■ Common Tasks Along the Journey

Table 12-3 ■ Differences Between Administrators and Clinicians on Demographic

Characteristics (N = 385)
Role by Characteristic Pearson Chi-Square Significance Level

Role by age 31.22 0.00*

Role by degree 31.22 0.00*

Role by age when decided to enter the field 2.68 0.75

Role by age at taking first job 2.24 0.69

Role by specialty practice 18.20 0.00*

Role by mother’s education 3.71 0.81

Role by father’s education 7.73 0.36

Role by mentor 6.22 0.10

*p < 0.001

Table 12-4 ■ Choosing the Most Effective Type of Illustration for a Given Goal
To Accomplish this: Choose one of these:

To present exact values, raw data, or data which do not fit into Table, list
any simple pattern

To summarize trends, show interactions between two or more Line graph

variables, relate data to constants, or emphasize an overall
pattern rather than specific measurements

To dramatize differences or draw comparisons Bar graph

To illustrate complex relationships, spatial configurations, Diagram

pathways, processes, or interactions

To show sequential processes Flowchart

To classify information Table, list, pictograph

To describe parts or electric circuits Schematic

To describe a process, organization, or model Pictograph, flowchart, block diagram

To compare and contrast Pictograph, pie chart, bar graph

To describe a change of state Line graph, bar graph

To describe proportions Pie chart, bar graph

To describe relationships Table, line graph, block diagram

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Chapter 12 ■ The Art of Writing Up the Research Study or Evidence-Based Practice Project 169

Table 12-4 ■ Choosing the Most Effective Type of Illustration for a Given Goal—cont’d
To Accomplish this: Choose one of these:

To describe causation Flowchart, pictograph

To describe an entire object Schematic, drawing, photograph

To show the vertical and horizontal hierarchy within an object, Flowchart, drawing tree, block diagram
idea, or organization
Matthews, J. & Matthews, R. (2008). Successful scientific writing: A step-by-step guide for the biological and medical sciences. (3rd ed.) United Kingdom: Cambridge
University Press. Reprinted with permission of Cambridge University Press.

Student Test Scores for 2000 and 2012 Comparison of Pre- and Post-Agitated
4.5 Behavior Scale Scores by Study Participant
30
4.0
3.5 25
Number of Students

3.0 20
2.5
15
2.0
10
1.5
1.0 5

0.5 0
Millie Ethel Gary
0.0
0 5 10 15 20 25 30 35
Test Scores Average of pre-ABS Average of post-ABS
Figure 12-2 Bar Graph Comparing Pre- and
2000 test scores 2012 test scores Postscores for Study Participants
Figure 12-1 Line Graph Comparing Test Scores for
Students at Two Different Points in Time
Percentage of Allied Health Professionals
Employed in a Rural Community Hospital
across the width of the score interval. This offers a
strong visual impact and is often effective for compar- Physical therapy
ing scores among all participants, or in comparing pre- 13 Occupational therapy
35
and postscores among individuals or the study groups. 15 Athletic training
See Figure 12-2 for an example of a bar graph. In this 5 Massage therapy
example, subjects were assessed using the Agitated 10 Speech therapy
22
Behavior Scale (Bognar, Corrigan, Bode, & Heinemann, Clinical laboratory science
2000), before and after sensory based treatments. Be- Figure 12-3 Pie Chart Depicting Breakdown of
cause higher numbers on the scale indicate the pres- Employees
ence of more behaviors, this graph reveals behaviors
dropped following the treatment sessions.
A pie chart is often used to depict a breakdown or phenomena. In designing these figures, the level of
of some quantity; for example, expenditures for a detail should match that required and understood by
program or types of employees in a facility, as shown the reader. The example in Figure 12-4 depicts the
in Figure 12-3. three phases of a proposed research project on the im-
Flowcharts, schematics, drawings, and design trees pact of online and group activities in promoting
are all ways of visually explaining processes, systems, healthy habits in obese adolescents. It clearly defines
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170 Section 4 ■ Common Tasks Along the Journey

Phase One Phase Two Phase Three

Recruitment Online education on stress Face-to-face group activities
Introduction to study purpose management, healthy habits to reinforce healthy habits
Informed consent
Initial Assessment Reassessment Final Assessment

Figure 12-4 Flowchart Depicting the Phases in a Proposed Research Study

the steps in each phase of the intervention and at similarities and differences are acknowledged. If you
what points in the process formal assessments of the note parallels between your literature review and your
subjects will take place. project’s results, this lends support to prior findings.
These are just a few of the possibilities for display- When dissimilar results are found, it is customary
ing data pictorially. For further ideas or descriptions to speculate plausible reasons for the departure.
of all types of figures, you may refer to Successful Recognizing confounding results and suggesting
Scientific Writing: A Step-by-Step Guide for the Biological plausible reasons for them allows readers to fully
and Medical Sciences (Matthews & Matthews, 2008). If understand what happened in your project. These
you use these visuals for presenting data, be sure findings will add to the body of knowledge on the
to label them correctly—tables are called “tables,” topic and provide implications for future studies.
whereas graphs, charts, drawings, photographs, and
so forth, are called “figures.” Include accurate and What If Results Do Not Support the Project
complete titles, column headings, axes labels, and leg- Question or Hypothesis?
ends, so that tables and figures can be understood on This brings us to the topic of what to do about projects
their own, without text. In addition, always refer to that generate limited data in support of the proposed
each table and figure within the body of the formal hypothesis or evidence-based practice question, or
report. Tell readers what to look for and be sure to those in which the hypotheses are not supported at all.
point out salient features. Should these projects be reported and published? It is
important that healthcare professionals be given access
Chapter 5: Evaluation, Discussion to the results of such projects for the following reasons:
and Conclusions
■ They may put to rest a popular myth that needs
Up until this point, the results should be presented to be dispelled.
in a straightforward manner, without further discus- ■ They may show that a particular methodology or
sion or interpretation. The discussion or conclusion research design is not a useful way to investigate
sections of the formal report are where the analysis of or approach a particular problem, thus saving
results and the comparison of them to the literature others from making the same mistake.
review take place. In addition, limitations of the proj- ■ Others may learn from the flaws and problems in
ect, implications of the findings, and recommenda- the project. The project can then be redesigned to
tions for the future are presented. achieve the original purpose.
In both research and evidence-based practice, this ■ Ethical dilemmas exist when treatments are used
last chapter is used by authors to evaluate the project that were shown to be ineffective. Reporting and
and draw conclusions about what the results actually publishing this information promotes evidence-
mean. Ideally, each new project should be contribut- based practice.
ing to a larger body of work, adding one more brick
to the wall of knowledge about that topic and per- Limitations
haps adding evidence that will tip the scales in one A review of the limitations of the project is also
direction or the other concerning theory about a customary. Acknowledging the shortcomings is re-
particular issue. The results are typically compared spectable and allows readers to view the results in light
with the results of other studies on the topic, and of these concerns. Limitations may be related to an
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Chapter 12 ■ The Art of Writing Up the Research Study or Evidence-Based Practice Project 171

unreliable data collection instrument, a small sample a snapshot of the entire project. Readers frequently re-
size or participant group, an unforeseen interference view the abstract to decide if the report warrants fur-
to the project, faulty assumptions by the researcher or ther inspection or is applicable to their purposes.
evidence-based practitioner, or any one of the forms Although the abstract is placed at the beginning of the
of bias discussed in prior chapters. Some limitations formal report, it is typically written last after all the
may be unavoidable; however, giving readers the infor- chapters have been completed. Abstracts are typically
mation will allow them to decide for themselves if 150 to 250 words in length, use clear and concise
the integrity of the project has been compromised. language, and effectively summarize content in the
chapters without the use of technical jargon.
Future Implications
Scientific Writing Styles
Finally, the practical and clinical implications of
the project, as well as suggestions for future practice, Now that we have addressed the content for each sec-
policy, education, or research, should be discussed. tion of the report, let us turn to the topic of writing
Specifically, you should review each of these questions: style. The style of writing is commonly dictated by the
setting and purpose of the report. In academic set-
■ How does the project contribute to the body of
tings, the accepted writing style is usually set forth by
knowledge on this topic?
the instructor, whereas many clinical settings may not
■ What are the clinical and practical implications
have specific requirements. For publication purposes,
of the project’s findings? For example, the results
the writing style is specified in the author guidelines
of your research study might not be statistically
for the particular work. (See Appendices M and N for
significant, but what does this mean in regard to
a sample of Author Guidelines for each of two publi-
clinical application of the information? Or per-
cations.) A variety of writing styles exist; Table 12-5
haps, results of your evidence-based practice proj-
includes some of the most popular style manuals
ect were overwhelmingly positive. What does this
applicable to the allied health professions.
mean for future clinical scenarios that are similar?
■ What are your suggestions for future work on this
topic? For research projects, you might include sug-
Table 12-5 ■ Style Manuals
gestions for improvements to the study’s design or
procedures as well as proposals for new research, if Writing Style Manual Reference
applicable. For evidence-based practice, you might
APA American Psychological Association.
incorporate ideas for program development, modi-
(2009). Publication manual of the
fication, or expansion, as well as changes to health-
American Psychological Association
care policies or educational opportunities.
(6th ed.) Washington, DC: Author.
Thinking critically about your outcomes and the
implications for the future can lead to a thought- MLA Modern Language Association.
provoking discussion. Although it is common for (2008). MLA style manual and guide
readers to skim the more technical sections of the pro- to scholarly publishing (3rd ed.).
ject’s report, such as the literature review or the statis- New York: Author.
tical analyses, the discussion is usually reviewed in its AMA American Medical Association.
entirety. This is where the summary of the results and (2007). AMA manual of style: A guide
the “take home message” are clearly delineated. for authors and editors (10th ed.).
New York: Oxford University Press.
The Abstract
The Chicago University of Chicago Press Staff.
The abstract is a comprehensive summary of the in- Manual (2010). The Chicago manual of style
formation contained throughout the project’s report of Style (16th ed.). Chicago, IL: Author.
(Chapters 1 through 5), with the purpose of providing
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172 Section 4 ■ Common Tasks Along the Journey

Each style manual outlines specific methods for Grammar and Organization
formatting headings, in-text citations, and reference The grammatical style and organization of the infor-
lists, as well as for organizing the various sections of mation sets the tone for the writing and ensures that
the report. The manuals also address plagiarism, it flows smoothly. Care should also be taken to en-
grammar, and syntax. Although there are many on- sure the level of writing is appropriate for the target
line resources available for each style, having a hard audience. Considering the following can assist with
copy of the appropriate style manual at your disposal these goals:
will prove invaluable. Reviewing the manual before
1. Organization: Present information in a logical
the start of writing allows you to become familiar
order, building on each point to develop the next
with the overall content so that you know where to
one. Beginning each paragraph with an effective
find the information when you need it. A well-worn,
topic sentence and then elaborating on those
highlighted manual with dog-eared pages is a sign of
points as you progress through the paragraph
a meticulous writer.
can increase understanding of the information
Becoming a Better Writer you are presenting.
2. Concise Language: Use clear and concise lan-
Although basic writing skills are necessary in the guage, choosing words precisely. Avoid inserting
allied health professions for documenting patient extra words that do not add to the content. In
progress, recording program outcomes, or taking scientific writing, more isn’t always better. Brevity
notes in education or meetings, many of us do not is a skill that requires diligent effort to achieve.
view ourselves as professional writers. However, with 3. Comprehension: Limit use of technical jargon,
the emphasis on research and evidence-based practice, acronyms, and abbreviations to aid in compre-
there is a push to disseminate information from these hension. Consider your audience and be sure the
types of projects to other healthcare professionals. writing is geared to that group. Using layman’s
Whether it is a formalized report that is submitted to terms and writing out most words allows your
your facility administrator or a doctoral thesis sub- work to be understood by a broader audience.
mitted to your professor, the ability to clearly and 4. Verb Tense: Writing in past tense is customary,
concisely articulate the main points of your project is because the project has already been completed.
essential. Assuredly, everyone has completed courses Although you may have written some sections in
in basic grammar and writing as part of earlier school- future or present tenses when the project was ini-
ing, and that training can be applied to the scientific tially being conceived, going back and revising
writing process. In addition, some other writing tips everything into past tense at the end places your
will be reviewed here. work in the appropriate context.
5. Grammatical Person: There is much debate re-
Use of an Outline garding use of first-person versus third-person
Basic outlines for a research study or evidence-based writing in scientific endeavors. For most aca-
practice project have been provided in Boxes 12-1 and demic programs and publications, the general
10-2, respectively. These outlines provide a good start- rule of thumb is to use first-person sparingly, or
ing point where additional details individualized to only when it is absolutely necessary. Third-person
your project can be inserted. Many writers prefer professional writing is generally preferred for
to begin with a detailed outline and progress to a formalized reports and research publications.
draft of the formal report generated directly from it, First-person writing may also be acceptable in
whereas others do better starting into the writing clinic-based settings or when recording outcomes
immediately. It is a matter of personal preference, but of evidence-based practice projects, as these situa-
either way, visualizing the writing plan, on paper or tions warrant more personal connections with
in your head, is essential to the process. participants and procedures are not as stringent.
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Chapter 12 ■ The Art of Writing Up the Research Study or Evidence-Based Practice Project 173

6. Grammatical Voice: Grammatical voice refers to after you have finished. Most programs also
the placement of the nouns and verbs in a sen- provide suggestions as to how to correct the
tence, and two types are active and passive voice. identified errors.
With active voice, the noun is performing the ac- 2. Readability Formulas: Readability formulas are
tion indicated by the verb, whereas with passive used to analyze the average sentence and word
voice the noun is being acted upon passively by length used in the document to determine the
the verb. See the following example: level of writing. Two of the most common tests
Active: The researcher conducted the study. are the Flesch Reading Ease Test and Flesch-
Passive: The study was conducted by the researcher. Kincaid Grade Level Test. The Flesch Reading
There are cases when passive voice may be appro- Ease Test rates reading ease on a 100-point scale
priate, but active voice is generally preferred be- (with a score of 90 to 100 easily understood by a
cause it is more direct and easier to understand. fifth grader, 60 to 70 easily understood by eighth
7. Use of Direct Quotations: Reserve use of direct or ninth graders, and a score of 0 to 30 understood
quotes for situations when you are unable to par- by college graduates) (Flesch, 1948; Kincaid, Fish-
aphrase the material effectively (i.e., when techni- burne, Rogers, & Chissom, 1975). Writing at the
cal phrases or terms are used that cannot be level of 60 to 70 is appropriate for most purposes;
stated another way or when the original authors however, for doctoral level projects or education,
stated the information in such a unique way that one might expect levels to be closer to 30. The
meaning would be lost with paraphrasing). Using Flesch-Kincaid Grade Level Test transfers the
too many direct quotes in one section or para- readability score into a U.S. school grade level. So
graph limits the flow of the writing and does not if the Flesch-Kincaid Grade Level score is 10.8, we
show that you understand the material and can would expect students in 10th to 11th grade to
effectively integrate it. A general rule of thumb is be able to understand it. These two tests are in-
to limit direct quoting to no more than one quote versely proportional, so as the readability score
per several pages of your own words. When using increases (meaning it gets easier to understand)
direct quotes, always be sure to follow the guide- the grade level score gets lower (meaning those in
lines set forth in the style manual for proper for- a lower grade can understand it). Although these
matting and citation. Remember that failure to are just one measure of the level of writing, these
cite appropriately can be considered plagiarism. tests provide a quick way for you to screen your
writing to see if it is at the appropriate level. Most
word processing programs will perform these
Use of Software Features
calculations automatically (Microsoft, 2010) or
Consider use of a variety of features contained within a number of calculators are available online
your word processing program to increase the quality (ReadabilityForumulas.com). For example, in
of your writing and to eliminate errors. These features Microsoft Word this option can be activated by
can include spelling and grammar checks, readability selecting “Word Options” under the Microsoft
formulas, a computerized thesaurus, document statis- Office Button, then clicking “Proofing” and then
tics, translators, and support for creating reference lists ensuring that the following options are checked:
and a table of contents automatically. Although it “Check grammar with spelling” and “Show read-
might take some extra time to figure out how to acti- ability statistics.” Results are shown once the
vate these features, the benefits will long outweigh the entire document has been checked.
initial effort. Each of these features is discussed here: 3. Thesaurus: Most word processing programs
1. Spelling and Grammar Checks: This feature have a built-in thesaurus that allows you to high-
can typically be activated to check the document light any word within a document to check for
as you write or to check the entire document alternative choices. This is especially useful when
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174 Section 4 ■ Common Tasks Along the Journey

you are struggling with a word choice or if you heading feature in the software program. Doing
seem to be using the same word repetitively. Using so permits the author to insert the entire table of
the thesaurus can add variety to your writing and contents after the formal report is written with
may even help you choose a stronger word than only a few key strokes.
what originally came to mind.
4. Document Statistics: Most programs are Chapter Summary
equipped with features to automatically calculate This chapter provides a starting point for writing up
statistics of your document including the num- your research study or evidence-based practice project,
ber of pages, words, characters, and lines. This and the suggested outlines can be tailored to meet the
can be useful if you are striving to meet the word needs of your setting or practice discipline. Paying
limits set forth in the author’s guidelines for a close attention to the required writing style, the gram-
particular publication or trying to be clear and mar and organization of your formal report, and the
concise in a particular passage (for example, try- software features available to you will all help to
ing to limit the abstract to 150 to 250 words). strengthen your writing and ensure that the details
Additionally, this feature can be used to verify of your project or study are accurately conveyed.
the length of directly quoted material for proper
citation. For instance, in APA style, direct quotes
SKILL-BUILDING TIPS
that are more than 40 words in length require
special formatting (APA, 2009). ■ Enlist the help of at least three proofreaders to re-
5. Translators: Translators can be used to convert view your writing. Select one person who is familiar
text in one language to another language. Al- with your topic and can proofread for actual con-
though opponents to these features argue that tent, one outside of your content area so that you
accuracy is somewhat limited, it is a viable option. will know if you are writing for a broader audience
It can be useful if your literature search turns up or if your content can be easily understood by
a quality piece of evidence in another language. those outside your field, and one that is skilled in
Using the translate feature in your program or grammar, writing, and formatting.
one of the many found online allows you to inte- ■ Avoid contractions in professional writing.
grate this useful information into your report. ■ Never end a paragraph with a direct quote. Being
6. Automatic Reference Lists and Table of Con- able to sum up the paragraph in your own words
tents: Creating each of these items manually is creates ownership of the material that you are
definitely an option, but utilizing the automated presenting.
features of your program can help to ease the
■ Steer clear of absolutes in your writing. Using
burden. Most programs allow you to create a
words such as always or never can create inaccuracies
database of references that you have used within
in your conclusions.
the body of the formal report. This is accom-
plished by first selecting the writing style, say ■ Congratulate yourself when you write something—

APA style, and then manually entering vital infor- a sentence or a paragraph can sometimes take an
mation, such as the authors, journal article, jour- entire day, whereas other days you will write many
nal title, volume, and page numbers for each pages.
reference used. Once references are added to the ■ Get in touch with your creative side, even if you
database, they can be inserted within parentheti- never thought of yourself as a writer. Spend some
cal citations, footnotes, or in the master reference time exploring your skills in this area. Participate
list as appropriate. The table of contents feature in a writing workshop or use a book such as Reeves’
works similarly. Headings are formatted accord- (2010) A Writer’s Book of Days, to get you started.
ing to the selected style guide via an automated This book is full of helpful tips about organizing
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Chapter 12 ■ The Art of Writing Up the Research Study or Evidence-Based Practice Project 175

your writing space, managing writer’s block, im- Chiarello, L. A., Palisano, R. J., Maggs, J. M., Orlin, M. N., Almasri, N.,
Kang, L., & Chang, H. (2010). Family priorities for activity and partic-
proving the quality of your writing, and creating ipation of children and youth with cerebral palsy. Physical Therapy,
meaningful and articulate passages. Without effec- 90(9), 1254–1264.
tive writing skills, scientific writing can be tedious Flesch, R. (1948). A new readability yardstick. Journal of Applied Psychology,
32, 221–233.
and boring. Perfecting the art of writing will allow
Kincaid, J. P., Fishburne, R. P., Rogers, R. L., & Chissom, B. S. (1975).
you to create a factual and inspiring account of Derivation of new readability formulas (automated readability index,
your research or evidence-based practice project. fog count, and Flesch Reading Ease formula) for navy enlisted person-
nel. Research Branch Report 8-75. Chief of Naval Technical Training:
Naval Air Station Memphis.
Matthews, J., & Matthews, R. (2008). Successful scientific writing: A step-
by-step guide for the biological and medical sciences (3rd ed.). United Kingdom:
Cambridge University Press.
LEARNING ACTIVITIES
Microsoft. (2010). Microsoft Excel [computer software]. Redmond, WA:
1. Before you start to write, consider your audi- Author.
ence and the goals of your writing. For exam- ReadabilityForumula.com. (n.d.). Welcome to readabilityforumulas.com.
Readability Formulas. Retrieved from http://www.readabilityformulas.com/
ple, do you need to write a report for formal
Reeves, J. (2010). A writer’s book of days: A spirited companion & lively muse for
academic coursework? Or will you be submit- the writing life (Revised ed.). Novato, CA: New World Library.
ting your report to an administrator or super- Rendon, A. A., Lohman, E. B., Thorpe, D., Johnson, E. G., Medina, E., &
visor? The goals and approach can be very Bradley, B. (2012). The effect of virtual reality gaming on dynamic bal-
ance in older adults. Age and Aging, 41, 549–552. doi:10.1093/ageing/
different. afs053
2. How would you rate your writing skills—below
average, average, above average? Be honest with ADDITIONAL WRITING RESOURCES
Day, R. A., & Sakaduski, N. (2011). Scientific English: A guide for scientists and
yourself; if you feel your writing is an area of other professionals (3rd ed.). Santa Barbara, CA: Greenwood.
weakness, brainstorm how you might improve Hofmann, A. H. (2009). Scientific writing and communication: Papers, proposals,
these skills or where you might seek out addi- and presentations. New York: Oxford University Press.
Katz, M. J. (2009). From research to manuscript: A guide to scientific writing
tional supports to assist in this endeavor.
(2nd ed.). New York: Springer Science + Business Media B.V.
3. Begin with the appropriate outline from Boxes LaRocque, P. (2003). The book on writing: The ultimate guide to writing well.
12-1 or 10-2 (depending on whether you are en- Portland, OR: Marion Street Press, LLC.
Lindsay, D. (2011). Scientific writing = Thinking in words. Australia: CSIRO
gaging in evidence-based practice or research). Publishing.
Insert additional subsections into the outline Matthews, J., & Matthews, R. (2008). Successful scientific writing: A step-by-
as applicable to your project. step guide for the biological and medical sciences (3rd ed.). United Kingdom:
Cambridge University Press.
Reeves, J. (2010). A writer’s book of days: A spirited companion & lively muse for
REFERENCES the writing life (Revised ed.). Novato, CA: New World Library.
American Psychological Association [APA]. (2009). Publication manual of
Strunk Jr., W., & White, E. B. (1999). The elements of style (4th ed.). Upper
the American Psychological Association (6th ed.). Washington, DC: Author.
Saddle River, NJ: Pearson.
Bognar, J., Corrigan, J., Bode, R., & Heinemann, A. (2000). Rating scale
Zinsser, W. (2006). On writing well, 30th anniversary edition: The classic guide
analysis of the agitated behavior scale. Journal of Head Trauma Rehabil-
to writing nonfiction (7th ed.). New York: HarperCollins.
itation, 15(1), 656–669.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
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Chapter 13

The Art of Presenting

the Research Study or
Evidence-Based Practice
Project
If you think in terms of a year, plant a seed; if in terms of ten
years, plant trees; if in terms of 100 years, teach the people.
—Confucius

your presentation—the content that you hope to

LEARNING OUTCOMES bestow upon your audience. With proper planning
The information provided in this chapter will assist the
and ingenuity, your knowledge is spread and the re-
reader to:
sult is a tree that flourishes, perhaps bearing fruit or
■ Understand the reasons for presenting a study providing shade on a hot summer day. As the tree
or project. grows, branches split and the trunk expands, just as
■ Evaluate how learning styles can impact new professional connections are made with the aim
presentation style. of advancing the knowledge of your specialty or dis-
■ Choose an appropriate presentation method cipline. And similar to a tree withstanding the harsh
from those reviewed (oral presentations, poster wind or weather, your presentation can leave a lasting
presentations, and cyber presentations). impression on your audience with ample care in
■ Create a meaningful PowerPoint or other design and delivery.
visual aides to support the presentation. Presenting your research or evidence-based practice
■ Identify additional resources for creating project is an effective way to disseminate details about
effective presentations. the project and its outcomes in academic settings,
clinical situations, and continuing education venues.
A variety of presentation methods can be used de-
resenting can be considered a form of art, as the pending on your goals for the presentation. In addi-

P skills required to successfully impart knowledge

on others requires diligence, creativity, and at-
tention to detail. The art of presenting is closely tied
tion, presentations can occur locally, nationally, and
even internationally. Reasons for presenting and sev-
eral presentation methods, including oral presenta-
to the art of teaching. Consider the metaphor of a tions, poster presentations, and cyber presentations,
tree, with the roots symbolizing the foundation of will be discussed.
177
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178 Section 4 ■ Common Tasks Along the Journey

Why Present? joint pain in geriatric clients, you would be unlikely

to reach potential clients themselves by presenting at
There are several reasons for presenting your re- a national conference or publishing in a professional
search study or evidence-based practice project. They journal. Although there are definite benefits to each
include: of these actions, they are not appropriate if your
■ To increase the ability for others to understand goal is to convey the information to geriatric clients.
your work In this case, a presentation at a local senior center,
■ To reach a variety of audiences, especially those hospital, or gym might be more fitting.
that may not be easily reached by other methods Third, presentations at continuing education venues
■ To network and collaborate with others in your allow you to share your knowledge with others in your
discipline or those that share an interest or passion discipline or those interested in your topic. This is an
in your topic area excellent way to network and collaborate with others,
■ To expand your professional skills and to advance the science of your discipline. The pro-
First, presentations are used to refine and translate fessional exchanges that often occur in continuing ed-
the information in your detailed project report so ucation workshops; state, national, and international
that it might be more easily understood by others. Al- conferences; or Web-based learning scenarios can lead
though many in your audience may have little interest to increased knowledge for you as well as your atten-
in reading a lengthy and detailed report or lack the dees. These professional connections can lead to other
skills or knowledge to understand it on their own, collaborative projects, publications, and friendships!
using a presentation tailored to the specific audience Finally, for some, presentations can be used to
is an effective way to transmit the information. Pre- hone public speaking skills or to accrue required con-
sentations are often used in academic settings as part tinuing education units for licensure or certification.
of formal coursework to ascertain a student’s ability Being able to clearly articulate details about your
to succinctly summarize his or her work. Conducting project and to field questions to a variety of audiences
a master’s or doctoral thesis can take months or even are worthy skills for many endeavors. Moreover, the
years, yet a successful presentation recaps the entire addition of multiple presentations to your resume
project in significantly less time. Clinical presenta- can emphasize your commitment to sharing your
tions can be used to distribute information about knowledge and expanding your professional skills.
projects whose results can impact practice. These
presentations might take the form of an inservice,
where treatment ideas are presented, discussed, and
What Is a Presentation?
rehearsed. In addition, clinical presentations can ad- The term presentation is used rather loosely, as the ses-
dress program development and outcomes, with the sion might take the form of a lecture, where the pre-
aim of gaining support from supervisors and admin- senter is dishing out information with little interaction
istrators for practice changes. from the audience. In another scenario, the presenta-
The second reason for presenting is to reach audi- tion might be very interactive, offering hands-on expe-
ences that may otherwise have been unavailable. Get- riences for the participants, or the opportunity to
ting the word out about your project can allow others engage in lively discussions or question-and-answer pe-
to use the information in practice (where applicable), riods. From a pedagogical standpoint, these examples
or to design future research studies or evidence-based focus on the “how” of presenting. Pedagogy is essen-
practice projects. Presenting your project is an effec- tially the art of teaching based upon scientific research
tive way to reach fellow researchers, students, policy and subsequent learning theories. With any presenta-
makers, administrators, or the general public, de- tion, it is fundamental to consider your audience be-
pending on the venue. For example, if you conducted fore determining the structure of the presentation.
a research project on the effectiveness of massage on Reflecting on the developmental stages, memory and
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Chapter 13 ■ The Art of Presenting the Research Study or Evidence-Based Practice Project 179

attention skills, learning styles, and cultural influences increases the likelihood that every attendee will walk
of your audience, as well as the goals of your presenta- away with valuable information.
tion, can assist you.
Oral Presentations
Learning Styles An oral presentation is typically a live presentation
A vast array of learning theories exist; they include to an audience that is physically present in the same
those rooted in classical conditioning, cognitive location as the presenter. Oral presentations can fol-
learning and information processing, developmental low a lecture format, but may also include demonstra-
maturation, neuroscience, and motivation (Shunk, tions of techniques or equipment, individual or group
2012). These theories attempt to explain how knowl- learning activities, role-playing, question-and-answer
edge is conveyed and how learning takes place from periods, interactive discussions or brainstorming, case
a variety of perspectives; they can be used to tailor studies, hands-on learning experiences, or any combi-
presentations of information for optimal learning nation of these strategies. Lectures are formal oral
experiences. Research supports the connection be- presentations in which there is little to no interaction
tween learning theories and how the information is between the presenter and the attendees. Lectures are
presented (University of Pennsylvania, 2009). Just as commonly used with larger audiences where increased
we all have different preferences for clothing, food, interaction is not practical, or when the goal is to
or vacation spots, each one of us has preferences for merely share technical or straightforward informa-
the way we take in and process new information. tion. Although this one-way communication may
One common model for classifying learning pref- limit comprehension of the material being presented,
erences is the VAK model. Learners are categorized by it is an efficient use of time and allows the presenter
one of three sensory systems—visual, auditory, or to get through the necessary information as planned.
kinesthetic—that predominates their ability to process Although lectures definitely have their place, using
and understand new information. Visual learners a variety of strategies within one presentation is pre-
tend to prefer the written word, charts, diagrams, or ferred in order to ensure optimum transfer of knowl-
videos, to name a few examples. Auditory learners re- edge from the presenter to the attendees. Presentations
spond best to verbal instructions or presentations, that employ more interactive methods such as demon-
and kinesthetic learners learn better when they are strations, discussions, or hands-on learning experi-
provided with hands-on tactile experiences for learn- ences tend to be less formal and audiences are often
ing. Even though all three systems are typically smaller in size and more engaged. Although these types
used, a learner may respond more favorably to one of presentations are generally preferred, they also have
method over another, or the method may vary based several disadvantages. They require more preparation
upon the information and topic being presented time; presenters need to be prepared to field questions,
(Fleming & Mills, 1992). Several free inventories are give additional clarification when needed, and keep the
available online (http://www.brainboxx.co.uk/a3_ presentation on track. With more interaction from
aspects/pages/vak_quest.htm; http://www.business- the audience, a discussion or activity can easily derail
balls.com/vaklearningstylestest.htm) or for purchase the presentation if the presenter is not skilled in mak-
in print (Walsh, Willard, & Whiting, 2011) to deter- ing adjustments or guiding the group appropriately.
mine your preferred learning style. The supplemental Gauging the time for a presentation with interactive
materials for this book also include additional links elements requires much more planning and practice.
and information on learning inventories. Understand-
ing your learning style can help you gain perspective Visual Support for Oral Presentations
on the styles of your audience. Infusing a variety of Oral presentations are often accompanied by handouts,
learning styles and techniques into your presentations overhead displays, or PowerPoint slides. Presenters need
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180 Section 4 ■ Common Tasks Along the Journey

to be mindful of the fact that these visual elements presentations, yet much controversy exists over the
should support or enhance the spoken word, but effectiveness of this method. Although the purpose
should not take the place of it. There is nothing worse of this software is to enhance the presentation, with-
than a presentation in which the presenter reads directly out effective slide construction, the presentation be-
from the handouts or slide presentation. Handouts comes boring and the intended message may not be
may be provided to the audience for ease of note taking, successfully conveyed to the audience. Constructing
or when the presenter wishes to reference detailed or PowerPoint slides is just one part of the preparation
complex elements that would be difficult to see on a for an oral presentation; the slides are for the audi-
slide or overhead presentation. Handouts are also an ef- ence and should supplement what the presenter has
fective method for sharing your references and contact to say. Many presenters make the mistake of trying
information, in the event that attendees wish to learn to include everything they want to say on the slides
more about the subject or have questions later on. (see Figure 13-1), but this only serves to create a pre-
An overhead projector can be used to display slides sentation devoid of spontaneity and interest. Present-
developed ahead of time or to create other visuals or lists ers should develop the slides with their audience in
of information on the spot as the presentation pro- mind, and then create a separate set of notes for
gresses. Flip charts, chalkboards, whiteboards, or themselves to be used as a guide during the actual pre-
Smart boards are other options for creating a dynamic sentation. See Figures 13-1 and 13-2 to compare two
presentation. These options allow presenters and atten- slides describing the increased incidence of Alzheimer’s
dees to generate lists, figures, and other clarifying visuals dementia and the need to consider alternative forms
during the presentation. These types of technology of behavior management. The first slide (Figure 13-1)
might be especially useful when additional examples are is constructed based upon the presenter’s needs and
needed to clarify a complex concept or process or when includes a significant amount of text. The second slide
group brainstorming or a discussion is planned as part (Figure 13-2) is simplified and only includes guiding
of the presentation. In each case, the presenter needs to points that the presenter will expand upon during the
adjust the presentation as it progresses in order to en- presentation. Figure 13-2 is the preferred layout.
sure comprehension of the subject matter by attendees.
Slide Construction
PowerPoint Presentations As seen in the previous two examples, content and
PowerPoint presentations are currently the most design are important considerations. In regard to
popular type of visual media used to supplement oral content, the prevailing thought is “Less is more.” The

Projected increase in elderly population thru 2050 (US Census

Bureau, 2008)
An estimated 10 million baby boomers expected to develop dementia
(Alzheimer’s Association, 2008)
Around 47% of nursing home residents have some form of dementia
(US Department of Health & Human Services, 2009)
Among the most common symptoms are mood & behavior changes
(agitation, lethargy, wandering, etc.)
Cost of managing behaviors is $183 billion per year, with increase to
$1.1 trillion projected by 2050 (Alzheimer’s Association, 2011)
Typical management includes restraints, medications, behavior
modification techniques
Lack of awareness of the role of the sensory system in dementia
patients Figure 13-1 PowerPoint Slide Tailored to
the Presenter With Too Much Text
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Chapter 13 ■ The Art of Presenting the Research Study or Evidence-Based Practice Project 181

presentation, it is often effective to ask yourself “So

what?” If you cannot come up with a strong reason
The Problem for including the information, then leave it out. Al-
though some details are important to you, they will
Rise in elderly population really have no bearing on the audience’s understand-
Increased incidence of dementia ing of the project. After you have decided on the slide
Behavioral symptoms of dementia content, the focus turns to slide design. Table 13-1 in-
Costs associated with behavior management
cludes some basic recommendations for designing
How behaviors are typically managed
your PowerPoint presentation.
Limited awareness of the sensory system’s role
Some proponents of PowerPoint presentations ad-
vocate for traditional slides with information
arranged in bulleted lists, whereas others suggest
more nontraditional layouts composed of less text,
Figure 13-2 PowerPoint Slide Tailored to the
more graphics or other visuals, and increased time de-
Audience With Guiding Points
voted to discussion of the content on each slide (Alley
& Neeley, 2005). Although PowerPoint software
presentation should not be a replication of your makes creating the actual slides very easy, presenters
formal project report; it should only summarize need to consider the design, structure, and delivery
the most important details and outcomes of the proj- of the presentation in order to be successful. Some
ect. Your time with the audience is limited, so it is crit- additional resources regarding creation of effective
ical to use the time efficiently. When considering PowerPoint presentations are included in the refer-
whether or not to include a particular detail in the ence list for this chapter.

Table 13-1 ■ Recommendations for PowerPoint Design

Organization ■ Use a consistent theme and font. Frequent changes can distract the audience.
■ Arrange slides in chronological order, beginning with a title slide and topic introduction,
and progressing through the various stages of your study or project.
■ Present only one topic or idea per slide.

Visual Appeal ■ Ensure the display is visually appealing and easy to read.
■ Dark text on a lighter background is generally preferred. Using very bright white or other

vivid colors can be harsh on the eyes.

Language ■ Know your audience; Avoid technical jargon and terminology as well as abbreviations unless
you are presenting to an audience that is sure to understand them.

Text ■ Use a minimum of 14 to 28 point font.

■ Headings should be at least 2 points larger than general content.
■ Avoid using all capitalized letters.

■ Reserve bold and italics for points that really need emphasis.

■ Use short phrases to summarize points, rather than whole sentences. General rule of thumb:

No more than six words per line; no more than six lines per slide.
■ Use graphics, photos, and figures in place of text when possible. If you include everything

you intend to say on the slides, there is no need for the presentation.

Continued
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182 Section 4 ■ Common Tasks Along the Journey

Table 13-1 ■ Recommendations for PowerPoint Design—cont’d

Tables ■ Simplify tables used in your project if you plan to include them in the presentation.
■ A table with too many numbers will be difficult to read.
■ If you need to use the table in its original form, distribute it in your handouts and skip

putting it into the PowerPoint.

Graphics and Figures ■ Include a title and label all components and axes.
■ Choose colors wisely so that attendees can easily discern differences in the components, or
understand the relationships or outcomes being illustrated.
■ Check the scale to eliminate distortion; the ratio of height to length is usually 1:2.

Pictures ■ Resolution should generally be set at 1024 pixels X 768 pixels for good quality when the
image is portrayed on a larger screen. Often, graphics will look adequate on your computer
screen, but will be very “grainy” when enlarged. Testing your presentation out on a larger
screen ahead of time or zooming in on your computer screen to 100% to view each image are
other ways to ensure the images are of adequate quality.

References ■ Always include citations for information, tables, and figures in your presentation, where
applicable. Include the author’s name and the year; using a smaller font for this information
is acceptable.
■ Include full references in your handout rather than in the PowerPoint itself.

Oral Presentation Etiquette arriving early to the presentation location will have
Presenters should be familiar with some basic eti- time to become acquainted with the moderator and
quette for conducting effective oral presentations. In to resolve any issues in a timely manner.
addition to dressing appropriately for the venue,
making good eye contact with attendees, and tailor- Practice
ing the presentation for the intended audience, pre- Presenters make many choices when creating an oral
senters should always arrive early to the presentation. presentation. Will you decide on a lecture format
Arriving early allows extra time to check technical or will you opt for a more interactive presentation?
components, such as PowerPoint presentations, sup- What will be the best way to get your message across
porting videos, microphones, and laser pointers, and and will you need to use additional visual supports to
to resolve glitches before the start of the presentation. enhance the spoken word? Regardless of the methods
This is also a good time to connect with the presen- that you choose, practicing your oral presentation
tation moderator, if one is provided. Many confer- ahead of time is very important. Practice allows you
ences use moderators, often volunteers, who are to become familiar with the content and flow of in-
present during the presentations with the responsi- formation and to gauge how much time it will take
bility of assisting with technology issues, monitoring to get through the material. You want to be familiar
the time, introducing and thanking the presenter, enough with the material so that you will not need to
facilitating question-and-answer sessions, and record- read from the slides or your notes; however, practicing
ing attendance for conference goers. Moderators too much can lead to delivering a memorized speech.
might also help to prepare the session room by ensur- A good oral presentation, if you have ever attended
ing the lighting, temperature, and seating arrange- one, includes some level of spontaneity, confidence,
ment are adequate for the presentations. A presenter and entertainment. Spontaneity allows you to make
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Chapter 13 ■ The Art of Presenting the Research Study or Evidence-Based Practice Project 183

adjustments in the presentation as you go by offering feedback from others before expanding the project or
additional examples or clarification when needed. seeking publication, and networking with others
Watching your audience will let you know if they are (Plunkett, n.d.). In contrast to oral presentations,
engaged (and if perhaps you should elaborate more on poster presentations allow you to connect with a large
a point they are interested in) or if they are bored (in number of attendees, from more diverse backgrounds
which case you may need to do something to gain their and interest areas, on an individual basis. They also
attention again). You should be confident in presenting provide an excellent opportunity for the first-time
your topic—after all, you know it better than anyone conference presenter, since the format is less formal
else! Practice can help to decrease nervousness, but and intimidating than an oral presentation.
some level of public speaking jitters is normal. Finally,
adding some element of entertainment to the presen- Poster Design
tation will help to sustain the audience’s attention. Al- Many of the techniques discussed previously in re-
though the focus should be on the main content of the gard to PowerPoint design are also applicable to
presentation, starting out with a personal story, inter- poster design. In fact, most professional posters are
active activity, or another attention-getting technique, created using just one PowerPoint slide, which is
as well as wrapping up in a creative way, can really en- scaled appropriately for the finished size of the
hance the presentation. Giving examples, telling stories, poster. A template (36” × 56”) is included in the sup-
or adding humor (when appropriate) increases the con- plemental materials of this book. A variety of other
nection between the presenter and the audience and templates are available online that you can customize
contributes to a greater understanding of the material. to suit your needs; the links are included here as well
As a final point, know that even if you practice and as in the supplemental materials.
effectively deliver your presentation, the information 1. http://www.posterpresentations.com/html/
your audience will remember afterwards is limited. free_poster_templates.html
Recall the Rule of Three, which Aristotle wrote about 2. http://www.makesigns.com/SCiPosters_
years ago. People are able to easily remember three Templates.aspx
things, and as the number of items increases beyond 3. http://office.microsoft.com/en-us/templates/
that, the ability to remember decreases. Consider medical-poster-TC010021411.aspx)
what three take-home messages you want the audi- Although using a single slide for poster construc-
ence to get from your presentation. Designing your tion is most common, another option is to create in-
presentation and supporting visuals around these dividual PowerPoint slides for each section of the
three points will increase your chances of success. poster (for example, methods, results, discussion,
and so on) which are then assembled on a larger
board for the presentation. The style and size of your
Poster Presentations
poster will likely be dictated by the conference you
Poster presentations involve creation of an eye- are presenting at, and checking the specifications
catching vertical display, which typically includes a ahead of time will avoid last minute revisions to the
combination of text and figures or graphics aimed at poster’s formatting or a stressful situation when you
portraying the results of research or evidence-based arrive at the conference.
practice. These presentations usually occur at profes- The poster is commonly organized into various sec-
sional conferences and meetings, where many posters tions that summarize different phases of your project.
are displayed together in one area for a set period of For research projects, sections might include the
time. It is also common for the author(s) of the poster introduction, methodology, results, limitations, and
to be physically present to discuss the project. implications of findings. For evidence-based practice
Poster presentations are an effective means of projects, sections may consist of setting or back-
getting the word out about your project, eliciting ground, literature review, project design, outcomes,
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184 Section 4 ■ Common Tasks Along the Journey

and significance of the project to the field or practice process not as trying to condense a paper but rather
area. Each section can be customized to suit the needs as expanding and enriching the abstract” (Matthews
of the author and the venue where the presentation & Matthews, 2008, p. 99).
will occur. A list of some of the common sections, as A superior poster includes a balance of text and
well as recommended content for these sections, is graphics, a visually-pleasing layout and color scheme,
included in Table 13-2. Section titles and content can and adequate information about the project, such
be adjusted for research or evidence-based practice that it could be understood, even if the author is not
presentations. present. Consolidating text and using photographs,
After selecting a template for poster construction tables, and figures in place of text, where possible,
and determining the sections and content that will be can add visual interest and attract more viewers.
included, attention must be given to the visual layout Moreover, a three-column format works best, and
and design. Remember that your poster should not the material should flow from top to bottom and
be a duplication of your entire project report, but left to right. The majority of attendees will be most
rather a striking visual representation of it. “Many interested in the results and application of the proj-
people find it helpful to view the poster-writing ect, so avoiding excess focus on the methodology,

Table 13-2 ■ Sections of a Poster

Section Recommended Content Includes:

Title Box ■ A shortened project title

■ Author(s) names with credentials and affiliation (school or place of employment)

Introduction, Setting, or ■ A description of the problem that was addressed in the project.
Background ■ Justification for the project. May include statistics or visuals that help to support the
need for the project.
■ A description of the setting or other background information that led to the project.

Literature Review ■ A recap of the existing research on the topic that was reviewed before the start of the
current project. It is common to review the number of studies, and to describe the
portfolio in terms of levels of evidence and common themes.

Methodology or Project ■ A summary of the steps of the project. Using bulleted lists or figures can be an effective
Design way to outline the various steps.

Results or Outcomes ■ The main findings of the project. Most often this is done visually, through the use of
tables, graphs, or other figures.

Discussion or Implication ■ Correlations and comparisons of the current project’s results with the literature review.
of Findings ■ Implications of the findings for future practice or research.

Limitations ■ A review of limitations believed to have a significant impact on practical implications of

the project.
■ Limitations may include those related to study design, instruments, or participants.

■ This section is typically omitted for evidence-based practice projects.

Significance of the Project ■ An explanation of the importance of the project for the profession or practice area
to the Field of Study or involved.
Practice Area
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Chapter 13 ■ The Art of Presenting the Research Study or Evidence-Based Practice Project 185

background, and literature review sections is ap- have the capability to print them, as do many online
propriate. Table 13-3 provides some additional sites. The advantage of online sites is that you can
recommendations for poster design, and Figure 13-3 upload your poster from home, and they can usually
includes an example of a professional poster. e-mail you a proof of the poster before they print it.
Posters can be printed on an array of paper with
Printing and Transporting the Poster varying quality and finishes, depending on personal
Because of their size, posters require use of a special- preference or the specifications of your institution or
ized printer. Many local print shops or office stores conference. Scoping out printing options in advance

Table 13-3 ■ Recommendations for Poster Design

Visual Appeal ■ Use a consistent theme and font.
■ Information should flow from top to bottom and left to right.

■ Do not use photographs as background. Instead, use photographs on the poster to illustrate

a point or to add visual interest.

■ Format section headings to draw attention to them and guide the attendees from one

section to the next in a logical progression. Use thin borders around each section heading
and a light-colored background to highlight the different sections and to emphasize which
items are grouped together.
■ Balance text and graphics. Placing all the graphics on one side of the poster will create visual

imbalance.
■ Strive for an organized, uncluttered representation of your work. White space can improve

flow and balance.

■ Limit text. Use short phrases to summarize points, rather than whole sentences. Use graphics,

photos, and figures in place of text when possible.

Text ■ Use a minimum of 28 to 36 point font for all content; 48 point font for section headings,
author(s) names, and affiliations; and 72 point font for the title.
■ Dark text on a lighter background is generally preferred. Using very bright white or other

vivid colors can be harsh on the eyes.

■ Content should be readable from 4 feet away.

■ Choose a simple font such as Times Roman or Arial, since more complex fonts are difficult

to read from a distance.

■ Avoid use of all capitalized letters.

■ Reserve bold and italics for points that really need emphasis.

■ Keep headings centered; Keep content text right justified.

Tables ■ Simplify tables used in your project if you plan to include them on the poster. A table with
too many numbers will be difficult to read.
■ Use a minimum of 28 point font for all tables.

Graphs and Figures ■ Include a title and label all components and axes.
■ Choose colors wisely so that attendees can easily discern differences in the components, or

understand the relationships or outcomes being illustrated.

■ Check the scale to eliminate distortion; the ratio of height to length is usually 1:2.

■ Use a minimum of 28 point font for all graphs.

Continued
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186 Section 4 ■ Common Tasks Along the Journey

Table 13-3 ■ Recommendations for Poster Design—cont’d

Pictures and Clip Art ■ Resolution should generally be set at 1024 pixels X 768 pixels for good quality when the
image is enlarged, but check with your poster printer. They can give you specifics related to
the size of your poster. Often, graphics will look adequate on your computer screen, but will
be very “grainy” when enlarged. Zooming in on your computer screen to 100% to view each
image is another way to test the quality of your images.
■ Be aware that images copied and pasted from the Internet are usually of poor quality when

enlarged.
■ Use photos you have taken yourself or ones in the public domain to avoid copyright

infringement.
■ Obtain informed consent if you plan to use photos of patients or subjects.

References ■ Always include references for information, tables, and figures on your poster, where applicable.
Include the author’s name and the year; using a smaller font for this information is acceptable.
■ Include full references on a handout for those that are interested.

Handouts ■ Craft a one-page handout on your project that you can offer to interested attendees. Some
ideas for the handout include:
1. A miniature reproduction of your poster on one side of the paper, and some important
references and additional information on the other side.
2. Using the abstract on one side of the handout, and references on the other side.
3. A handout with bullet points highlighting sections of your project. You may also want to
include a graph or chart depicting the results.
4. Regardless of what format you choose, be sure to include your name and contact
information.

will allow you to determine the best option for your Poster Etiquette
needs, and to ensure adequate turnaround time. As a final point, it is important to consider the eti-
There are a variety of ways to transport your poster quette required during poster presentations. Dressing
to the presentation site. Carrying cases range from professionally and wearing your name badge, arriving
more expensive options with shoulder straps to less on time to the presentation, and ensuring you have
expensive cardboard tubes. If you are traveling by air, an adequate number of handouts (or business cards)
you will need to check with the airline to determine will portray a positive image to those in attendance.
if you can take the poster with you as a carry-on item. Aside from creating the poster itself and the accom-
From experience, some airlines will permit this free of panying handouts, you should also be prepared to
charge, whereas others charge additional fees or insist field a variety of questions on your topic or project.
that posters be checked. If you must pay a fee, con- That being said, if you do not know the answer to a
sider coordinating poster transport with others in question, you should not feel compelled to make one
your area who are presenting posters at the same up. One of the purposes of presenting your poster is
venue. Multiple posters can be placed in one carrying to network with others interested or experienced in
case and presenters can share the expense. Other op- your topic, and it is quite possible that you will make
tions include shipping your poster to the hotel ahead valuable connections and learn something new in the
of time, or arranging to have it printed near the con- process. You should stay close to your poster during
ference site. the entire session and greet attendees professionally.
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Chapter 13 ■ The Art of Presenting the Research Study or Evidence-Based Practice Project 187

USE OF MULTISENSORY ENVIRONMENTS

TO DECREASE NEGATIVE BEHAVIORS IN DEMENTIA PATIENTS
Jennifer E. Lape, OTD, MOT, OTR/L
An Evidence-Based Occupational Therapy Intervention
Woody Pines Retirement Community, Beech Creek, PA

SETTING AND BACKGROUND LITERATURE REVIEW OUTCOMES

The Setting Reviewed 25 research articles, 2 systematic reviews, Qualitative Themes

Skilled nursing, assisted and a variety of other articles on the use of
living, and on-site adult Importance of
multisensory environments or Snoezelen therapy.
daycare. individualized sessions.
Serves adults 65 years What is Snoezelen? Snoezelen was found to: Timing of sessions.
and older. Approach developed in Decrease negative Causal factors of the
Medicare, Medicaid, and the Netherlands in the behaviors, pain, anxiety, behaviors.
private insurance 1970s. wandering, boredom, Relaxations of the mind,
accepted. Involves the use of a and lethargy. body, and soul.
multisensory Increase positive Increased alertness
The Facts environment. behaviors, attention, and engagement.
Projected increase in elderly population through 2030. The goal is to “stimulate concentration, Value of one-on-one
10 million baby boomers expected to develop the primary senses spontaneity, intelligible sessions.
dementia. without the need for speech, and recall. Carryover of effects.
46.4% of nursing home residents have a form of intellectual activity in an Be as effective or more
dementia. atmosphere of trust and effective than
One of the most common symptoms of dementia is relaxation. It is a failure alternative treatments.
mood and behavior changes. free approach insofar Comparison of Pre- & Post
Cost of managing behaviors is ~$148 billion/year. as there is no pressure Agitated Behavior Scale Score
Typical management: restraints, medications, and to achieve” (Burns, I., Averages by Resident The Agitated
behavior modification techniques. Cox, H., Plant H., 2000, 30 Behavior Scale
Lack of awareness of the role of the sensory system p. 120). 25 contains 14
in dementia patients. 20 behaviors that are
rated on a 4-pt.
15
Likert Scale as to
10 the degree of
DESIGN AND IMPLEMENTATION 5 presence.
PICO QUESTION 0 In 50/52 sessions,
Millie Ethel Gary a decrease in
Preliminary Work
Average of Average of behaviors was
Does the use of Snoezelen therapy/multisensory Created a Snoezelen room in a 9' x 9' unused room
pre-ABS post-ABS noted.
environments decrease negative behaviors in within the SNF.
dementia patients? Developed a sensory inventory to tailor experiences.
Designed a Snoezelen Session narrative
documentation form.
Reviewed Agitated Behavior Scale for documentation SUMMARY
SIGNIFICANCE of behaviors.
Conducted facility in-services on the intervention.
Collaborated with the Behavior Modification Use of Multisensory Environments
Supports the OT Practice Framework’s goal of Committee to identify candidates. Has a positive impact on resident behaviors as well
engagement. as the culture of the facility.
The Design & Intervention Changes how behaviors are perceived and managed.
Addresses sensory function in dementia patients.
Supports the OT Centennial Vision via use of a Multiple case-study design (3 participants) Emphasizes identification of causes of behaviors and
highly evidence-based & client-centered approach. Completed sensory inventories on participants. introduces a proactive approach to behavior
Addresses priorities of the Ad Hoc Group on Aging Conducted one-to-one sensory sessions: 30-45 management.
& Gerontology. minutes each, 3x/wk, for 6 weeks.
Completed the Snoezelen Session narrative These outcomes provide impetus for future research
documentation form and Agitated Behavior Scale and expansion of sensory interventions with the
for each session. geriatric population.

Figure 13-3 Example of Professional Poster

Give them time to view the poster on their own and and knowledge, and share valuable information
offer to answer any questions when they are finished. about your project.
Remember not to spend too much time with one at-
tendee if others are waiting; connecting with all inter-
Cyber Presentations
ested attendees is the goal and socializing with friends
or colleagues should be reserved for after-conference Here, the term cyber presentation will be used to
hours. With adequate attention to style, design, and refer to any Web-based presentation delivered syn-
content of the poster, and adherence to proper eti- chronously or asynchronously, in which the attendees
quette during the poster session, you can expect to are physically located in a different location or setting
make professional connections, advance your skills than the presenter. A synchronous presentation is
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188 Section 4 ■ Common Tasks Along the Journey

one in which the presenter and attendees are online technological glitches occur during the scheduled
at the same time, whereas in an asynchronous pre- presentation time. To combat this problem, presen-
sentation the presenter makes the presentation avail- tations could be made available online for viewing
able online and attendees can access it whenever it is asynchronously after the formal presentation, for at-
convenient for them. Cyber presentations offer the tendees who experienced technical problems during
following advantages: the actual presentation time. Synchronous presenta-
1. The ability to reach a larger and more diverse tions are most appropriate for complex topics, net-
audience. Attendance is no longer dictated by working, and collaboration.
geographic location, and the ability to connect
with individuals across the globe is possible. Presentation Tools/Platforms for Cyber
2. Increased access to the latest advances and Presentations
information in your field. Information can be The variety of tools and platforms for cyber presenta-
dispensed more efficiently and timely, which can tions is nearly endless. Creating a cyber presentation
impact research, medical advances, and practice. is very similar to creating an oral presentation; the pre-
3. Financial. Travel to conferences, especially senter must consider the audience, the amount and
national or international ones, could be cost- level of information to include, and how the material
prohibitive. The ability to attend or provide will be presented. This can include use of visual aides
presentations over the Internet can minimize to support the spoken or written word.
the financial impact for all involved. Web-based software similar to PowerPoint can be
4. Convenience. Presentations can be accessed employed to create dynamic visuals to emphasize the
nearly anywhere on Earth via computers, laptops, information being discussed. These presentations are
or mobile devices such as iPods or smartphones. often conducted synchronously but can be carried out
Asynchronous presentations offer an added con- asynchronously if the presenter narrates and records
venience for attendees as they can view the pre- the presentation. Embedded videos can help to clar-
sentation when it is most convenient for them. ify complex points or to demonstrate skills or proce-
Although cyber presentations offer clear advantages, dures. Presenters can use programs to create original
some disadvantages should also be considered. Partic- videos or they may utilize and cite ones created by oth-
ularly with asynchronous presentations, there is a lack ers. Voice-over-Internet protocols, which are used to
of personal interaction between the presenter and at- make calls over the Internet, are effective for synchro-
tendees and often little opportunity for attendees to ask nous meetings or conversations among small groups
questions. For this reason, asynchronous presentations of individuals. Video conferencing sites can be used
are better suited for straightforward material where few for collaborative meetings or educational webinars.
questions might be anticipated. The presenter can also These sites allow all attendees to gather virtually to
address this issue by providing his or her e-mail or a dis- view and hear presentations, and to converse verbally
cussion forum where questions can be posted and re- or via an instant messaging system. Podcasts, or short
sponded to. Asynchronous presentations tend to be digital media presentations typically published in a se-
highly focused on topic content with little emphasis on ries, can be created to disseminate information asyn-
collaboration or social support (Hrastinski, 2008). chronously. Screencasts are similar to podcasts, but
Synchronous presentations allow more collabora- use narration to accompany video of a computer
tion between attendees and the presenter; questions screen (where a screenshot is a picture of a computer
can be responded to immediately, and attendees are screen; a screencast is a video of what is actually hap-
usually more committed to the learning experience pening on the screen). Table 13-4 includes descrip-
(Hrastinski, 2008). However, since all attendees must tions of some of the most common tools for cyber
participate simultaneously, synchronous presenta- presentations. Many other options are available; the
tions can be less convenient or present challenges if intention here is to provide a brief overview.
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Chapter 13 ■ The Art of Presenting the Research Study or Evidence-Based Practice Project 189

Table 13-4 ■ Tools for Effective Cyber Presentations

Type of Tool Name Description

Web-based presentation SlideRocket (www.sliderocket.com) Enhanced Web app with advanced text, graphics,
software and media integration. Presentations can be
shared through social networking, and
statistics on viewers and their comments can
be collected.

Web-based presentation Prezi (http://prezi.com) Web-based presentation and storytelling

software software. Instead of slides, it uses a dynamic
canvas with zooming features.

Video sharing site YouTube (http://www.youtube.com/) Video sharing site that allows you to create,
edit, and store your own videos as well as
embed them into your dynamic presentation.

Voice-over-Internet protocol Skype (http://www.skype.com/en/) Software that employs VoIP (voice-over-Internet

protocol) to make calls over the Internet. Can
be used for conference calling, and callers can
see each other if a webcam is used.

Video conferencing GoToWebinar or GoToMeeting Video conferencing sites used to conduct

(http://www.gotomeeting.com/fec/) lectures, presentations, or meetings.

Podcast creation site PodBean (http://www.podbean.com/) Site for creating and sharing digital media
arranged in an episodic series (podcasts). May
include audio, video, and other related files.

Podcast creation site Buzzsprout (http://www.buzzsprout Site for creating podcasts. Can track statistics
.com/?source=gaw03&gclid= on your listeners.
CPDEgZHwtrYCFY9DMgodBi8A0Q)

Screencast creation site Screenr (http://www.screenr.com/) Site for creating screencasts. Can be shared
through social media.

Chapter Summary is the perfect way to hone your public speaking skills
and promote expansion of your topic as well as your
In summary, there are many elements to consider in own professional growth.
designing and delivering your presentation. Carefully
matching your presentation format with the learning
SKILL-BUILDING TIPS
styles and needs of your audience can ensure atten-
dees walk away with the information you intended. ■ Know that you will likely need to submit a proposal
With advances in technology, a variety of tools exist for your presentation to the conference committee
to increase understanding of your material and to or venue that you have chosen. Proposals are usually
add pizazz to your presentation. Beginning with an peer-reviewed and scored based upon the quality,
informal presentation to a small group of individuals relevance, and innovation of the topic. Top scoring
and progressing to more formal or larger scale ones proposals are accepted for presentation, and lower
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190 Section 4 ■ Common Tasks Along the Journey

scoring presentations are rejected. Each venue has your audience and establish a connection between
a limited number of spots available, so if you are you and the attendees.
not successful initially, do not be afraid to try again. ■ Remember that even experienced presenters get
Poster presentations and shorter presentations nervous, and some degree of public speaking jit-
(those 15 to 30 minutes in length) are a great way ters creates positive energy for an enthusiastic
for the novice presenter to get started. presentation. Breathe deeply, maintain your com-
■ Be sure to practice enough. Not practicing enough posure, and remember that you are an expert on
can lead to limited time to cover all the information your topic.
you had planned; as the presenter, you will appear ■ Begin your presentation by telling your audience
rushed toward the end or need to skip important what you will tell them (review the objectives for the
information to stay within the time limit. The op- presentation); then tell them (give the presenta-
posite can also occur; the presentation will end very tion); then end by reminding them what you just
early, creating an awkward feeling about what to do told them (recap and summarize the presentation).
with the excess time. Following these three steps, regardless of if the pre-
■ Know that slide and visual preparation is very dif- sentation is formal or informal, live or Web-based,
ferent from presentation preparation. Preparing can ensure your intended message is received.
your PowerPoint, poster or other visual aids is just
one part of the process. Actually rehearsing what
you will say and how you will say it is the key to a
smooth presentation.
■ Videotape yourself, practice in front of a mirror (for LEARNING ACTIVITIES
live presentations), or record your voice (for cyber 1. What are the three main points that you
presentations) to help you identify errors in speak- want your attendees to take away from your
ing, posture, and hand gestures. Another alternative presentation?
is to practice the presentation for a group of friends
2. How will the title or abstract of your presenta-
or colleagues ahead of time. Ask them to be brutally
tion impact attendees? Using a highly descrip-
honest with you regarding the quality of the pre-
tive, yet catchy title and succinct abstract can
sentation and be willing to accept the constructive
increase interest and attendance at your pre-
criticism.
sentation. Brainstorm some possible titles and
■ Do not spend too much time addressing technol- write a two to three sentence abstract, to share
ogy issues. However, be sure you are familiar with with others for feedback.
the technology that you will use during the presen-
3. Consider your presentation from the viewpoint
tation, if any. Practice ahead of time if you can, and
of your audience. What would you want to
do not spend more than 5 to 10 minutes trying to
know? What organizational method would
resolve the issue. Doing so will decrease your pre-
make the most sense? What techniques and
sentation time and it may be difficult to adjust the
visual aids would help you to understand the
plan you have practiced. In case of technical diffi-
more complex relationships or concepts?
culties, be sure you have a backup plan in mind.
4. Are you a visual, auditory, or kinesthetic
■ Be sure to allow time for questions and answers and
learner? Use one of the inventories mentioned
provide attendees with your contact information in
earlier in the chapter to identify your learning
case they have questions later.
style; then consider the style of your audience.
■ Use storytelling, case studies, or personal and real-life
What method of delivery will be most effective
examples to bring life and passion to your presenta- for your presentation and why?
tion. These elements often help gain the attention of
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Chapter 13 ■ The Art of Presenting the Research Study or Evidence-Based Practice Project 191

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Hrastinski, S. (2008). Asynchronous & synchronous e-learning. Educause
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Carter, M. (2013). Designing science presentations: A visual guide to figures,
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poster_presentation.pdf
Shunk, D. H. (2012). Learning theories: An educational perspective. Boston: ADDITIONAL RESOURCES FOR CREATING
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University of Pennsylvania. (2009, March 28). Visual learners convert Clay, C. (2012). Great webinars: Create interactive learning that is captivating,
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Science Daily. Retrieved from http://www.sciencedaily.com/releases/ Gendelman, J. (2010). Virtual presentations that work. New York, NY:
2009/03/090325091834.htm McGraw-Hill.
Walsh, B. E., Willard, R., & Whiting, A. (2011). VAK self-audit: Visual, audi- Handley, A., & Chapman, C. C. (2012). Content rules: How to create killer
tory, and kinesthetic communication and learning styles. British Columbia, blogs, podcasts, videos, ebooks, webinars (and more) that engage customers and
Canada: Walsh Seminars Publishing House. ignite your business (Revised ed.). Hoboken, NJ: John Wiley & Sons, Inc.
Turmel, W. (2011). 10 steps to successful virtual presentations. Alexandria, VA:
ADDITIONAL RESOURCES FOR CREATING ASTD Press.
POWERPOINT PRESENTATIONS
Altman, R. (2012). Why most PowerPoint presentations suck and how you can ADDITIONAL PRESENTATION RESOURCES
make them better (3rd ed.). Pleasanton, CA: Harvest Books. Kapterer, A. (2011). Presentation secrets. Hoboken, NJ: John Wiley &
Atkinson, C. (2011). Beyond bullet points: Using Microsoft® PowerPoint® to Sons, Inc.
create presentations that inform, motivate, and inspire (3rd ed.). Redmond, Reynolds, G. (2008). Presentation Zen: Simple ideas on presentation design and
WA: Microsoft Press. delivery. Berkeley, CA: New Riders.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
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3916_Ch14_193-202 20/10/14 10:28 AM Page 193

Chapter 14

The Art of Publishing

the Research Study or
Evidence-Based Practice
Project
Believe you can and you’re half way there.
—Theodore Roosevelt

material languishes in a drawer waiting to be writ-

LEARNING OUTCOMES ten. Until colleagues, consumers, policy makers, or
The information provided in this chapter will assist the
the general public are informed about the findings
reader to:
of the study or project, those findings are not useful.
■ Explore the reasons for publishing a study or Specific reasons to pursue publication may include:
project. ■ To share knowledge gained via research or
■ Determine publishing goals and consider how evidence-based practice efforts to allow informed
they impact publication style and approach. decision-making by professionals and consumers
■ Differentiate between peer-reviewed and ■ To allow fellow researchers or practitioners to
non–peer-reviewed publications. build on your work
■ Choose an appropriate target publication for ■ To enable others to avoid pitfalls noted in your
the identified publication goals. study or project in their future endeavors
■ Use the formatting guidelines discussed to ■ To network and collaborate with others in your
write an article for submission to the target discipline or those interested in your topic area
publication. ■ To expand your professional research and writing
■ Identify additional resources and tips for skills
composing a quality article. ■ To build your resume for future employment or
funding opportunities

Why Publish?
No research study or evidence-based practice project
Defining Publishing Goals
is complete until the results are shared. Unfortu- Once you have decided to pursue publication, it is
nately, this is often the point at which researchers important to consider the goals you hope to achieve
and practitioners lose momentum; as a result, the in this effort. For example, are you most interested
193
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194 Section 4 ■ Common Tasks Along the Journey

in sharing your results with fellow professionals who

could benefit from or build on your work? Might BOX 14-2 ■ Example Evidence-Based
your work be appropriate to share with the general Practice Project and
public who are consumers of your service? Or could Potential Publication
your work impact the decisions of policy makers or Opportunities
administrators, in which case it really needs to An evidence-based practice project was un-
be shared with them? Depending on the nature of dertaken by a school-based occupational
your study or project, you may find one or more of therapist. She was interested in exploring
these options to be fitting. There are usually multi- the research related to the use of sensory-
ple opportunities for publication within a single based activities to improve attention and
study or project. Boxes 14-1 and 14-2 show examples emotional regulation in 5-year-olds with
known sensory processing difficulties. She
appraised 25 research articles on the use
BOX 14-1 ■ Example Research Study
of sensory-based activities with similar
and Potential Publication
populations. Then she designed and imple-
Opportunities
mented a program based upon her findings
A research study was conducted by three phys- from the research; her prior knowledge and
ical therapy students and their faculty advisor to experiences with the use of sensory-based
explore the impact of a balance training pro- treatments; and consideration of the goals,
gram on the incidence of falls within one senior values, and circumstances of the 5-year-
retirement community. Seventy-six subjects were olds on her caseload. She collected data
randomized into one of two study groups: an throughout her treatments to compare in-
experimental group that participated in the bal- formation before and after implementation
ance training program three times per week for of this new program to determine if her out-
2 months and a control group that did not par- comes matched that of the literature that
ticipate in the balance training program in the she searched. Publication opportunities
initial phase of the study. Results indicate that might include:
the experimental group had significantly fewer ■ Publication in a discipline-specific journal
falls during the study compared with the control or magazine (may be peer-reviewed or non–
group. Publication opportunities might include: peer-reviewed, depending on the journal)
■ Publication in a professional peer-reviewed to share her experiences or the procedures
physical therapy journal to share the study’s she used in conducting the evidence-based
outcomes with others in the field who might project as well as the outcomes from the
want to expand on this research or apply project
the results to their practice ■ Writing an article for a parenting maga-

■ Writing an article for a discipline-specific zine on how to recognize signs of sensory-

magazine on the steps involved in setting processing difficulties, tips for managing
up a balance training program similar to behaviors, and where to locate additional
that used by the researchers resources if needed
■ Composing a piece for a senior citizens’ ■ Publication in an education journal or

newsletter on the risk factors for falls, magazine focusing on collaboration be-
how physical therapy can help, and how tween teachers and other professionals
to get more information or find a physical to address sensory processing difficulties
therapist in the area with children
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Chapter 14 ■ The Art of Publishing the Research Study or Evidence-Based Practice Project 195

of a research study and an evidence-based practice accessible to the public or others in your field is
project, respectively, with some potential publica- appropriate. Publishing allows you to contribute
tion avenues for each. to the body of knowledge within your discipline,
Although these examples are not exhaustive, they and the potential for personal and professional
illustrate the variety of opportunities that exist in any growth is great. Contemplating your personal and
given situation. The goals of publication can vary professional goals will ensure that your publica-
greatly and thus will impact the publication style tion decisions support them.
and approach. Some key elements to consider when
establishing your publication goals are:
Choosing a Publication
1. Who is your audience? Identifying your potential
audience can help you choose an appropriate After outlining your publishing goals, you must de-
publication, and will often dictate the approach cide the type of publication you want to pursue.
and style of writing. For example, if you hope to There are generally two options: peer-reviewed jour-
reach consumers of your service, publishing in a nals and non–peer-reviewed publications. Both are
discipline-specific peer-reviewed journal is unlikely explored in more detail here.
to accomplish this goal. Similarly, the style of writ-
ing and choice of language for an article geared Peer-Reviewed Journals
toward other professionals may not be easily un- Peer-reviewed journals (sometimes called scholarly
derstood by the general public. Some publications or refereed publications) are publications that con-
are discipline specific; others span multiple disci- tain articles authored by one or more experts in a par-
plines or practice groups. Still others are appropri- ticular field or topic area, which are reviewed by other
ate for specific groups of people, for example, those experts in the field or topic area to confirm each arti-
older than 65 years of age, or those caring for a cle’s quality before acceptance for publication. To
child with disabilities. Identifying your audience minimize biased reviews of the articles, the reviewers
can guide your publishing decisions. are usually unaware of who the authors of an article
2. What is your message? Considering the main are when they are reviewing it. In this way, the review-
points that you want to convey to your audience ers must assess the value and quality of the article it-
is a foundational step in publication. Publica- self without being influenced by the reputation of the
tions vary in their purpose. Some aim to dissemi- authors.
nate research, whereas others are geared toward The publication process for peer-reviewed journals
evidence-based practice. Moreover, publications is often very rigorous with multiple revisions required
appropriate for the general public tend to be less over long periods of time. The aim of most peer-
formal and not as scientific. Comparing your in- reviewed journals is to disseminate quality research
tended message with the goals of your target or evidence-based practice. Peer-reviewed journals are
publication can help you determine if the chosen not appropriate for informational-type articles or ar-
publication is a good fit. ticles geared toward the general public. Some features
3. What are your personal and professional of peer-reviewed articles include:
goals? Your personal and professional goals can ■ Evidence of completion of a research study or for-
impact your publication decisions. For example, if mal evidence-based practice project. Keep in mind
you are looking to connect with other researchers that some journals may only publish research, but
interested in your topic, then a more formal publi- others will consider high-quality evidence-based
cation in a peer-reviewed journal is a good choice. practice projects.
If your priority is to disseminate your study’s or ■ Approval by an Institutional Review Board (IRB)
project’s outcomes to consumers or practitioners to conduct the study or project. See Chapter 11
who might find it useful, a less formal publication for additional information on the IRB process.
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196 Section 4 ■ Common Tasks Along the Journey

■ Possible use of complex statistical methods, graphs, typically reviewed only by the editor(s) of the publica-
or tables to support outcomes. tion, who are not necessarily experts in the field or
■ Highly structured format, with required sections subject area. Non–peer-reviewed articles must be ap-
specified in the author guidelines. praised by the individual readers to determine the
■ Inclusion of multiple references from other scien- quality and applicability of the information contained
tific or professional journals to support the work. within it.
■ Use of complex professional language and terms The publication process for non–peer-reviewed
that may not be easily understood by those out- publications is less demanding than that of peer-
side the profession or unfamiliar with the topic. reviewed publications, although some revisions are
Peer-reviewed journals typically appear very plain, usually necessary. Non–peer-reviewed articles are
with black and white photos or illustrations and little usually less scientific, intended for general audi-
or no advertisements. Publication in these journals is ences, and aim to publicize information on a fo-
highly respected among academicians, who are often cused topic. Some features of non–peer-reviewed
required to publish for continued employment. Oth- articles include:
ers may seek publication in peer-reviewed journals to ■ Less structured organization, with sections
gain professional respect and recognition for future designed and arranged by the authors
employment or funding opportunities. ■ Provision of news or other general information to
Most peer-reviewed journals publish accepted arti- the public or other professionals
cles free of charge; nonetheless, pay-to-publish jour- ■ Possible use of anecdotal evidence, photographs,
nals, which require authors to subsidize publishing simplified charts and figures, or personal or pro-
fees, are increasing in number. There is no guarantee cedural narratives to illustrate the main points
of publication with pay-to-publish journals, and ar- of the article
ticles submitted still undergo rigorous review. Au- ■ Limited to no inclusion of references from other
thors submitting to pay-to-publish journals may have sources to support the work
to pay review costs as well as per-page charges if the ■ Use of layman’s terms that can be easily understood
article is accepted. by those outside the profession or unfamiliar with
Some examples of peer-reviewed journals include the topic
The Journal of the American Medical Association, The British
Journal of Occupational Therapy, The American Journal of Author Guidelines
Physical Medicine & Rehabilitation, and the Journal of Ath-
letic Training, to name a few. Most professional orga- Most publications include specific author guide-
nizations publish discipline-specific journals, and lines, available either in the print version of the
there are many multidisciplinary or subject-specific publication or online, that outline the specific re-
journals that you might consider. A list of some com- quirements for submitting your work. Author guide-
mon health-related journals is included in Appendix lines can include information about the writing style
I to get you started. used by the publication (for example, APA style); the
number of manuscript pages or words that are ac-
Non–Peer-Reviewed Publications ceptable; and any specific requirements regarding
Non–peer-reviewed publications include maga- photographs, drawings, figures, and so forth. Some
zines, books, pamphlets, or other works that publish publications have distinct guidelines for different
articles intended to provide more general information. types of articles, meaning that the requirements may
Authors are usually professionals with some advanced vary depending on whether you are submitting a
level of experience in the subject area; however, con- case study or an editorial. Submission requirements,
ducting research or evidence-based practice in the sub- including the need to provide additional items
ject area is usually not a requirement. In contrast to such as a cover letter, author biography, financial
peer-reviewed articles, non–peer-reviewed articles are disclosure forms, copyright forms, or any associated
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Chapter 14 ■ The Art of Publishing the Research Study or Evidence-Based Practice Project 197

publication or review fees, are also specified in the research study or project report will be ineffective.
author guidelines. Considering the content and organization of your
It is essential to strictly adhere to the guidelines set article separate from the formal report is an essential
forth by the chosen publication. Your work may be re- step in the publication process.
jected simply because of improper formatting or failure
to provide all the necessary forms and information, re- Peer-Reviewed Articles
gardless of the content or quality of your work. Addi- The format for research or evidence-based practice ar-
tional information on author guidelines, as well as some ticles in peer-reviewed journals is highly structured,
samples, can be found in Appendices L, M, and N. with required sections laid out in the author guide-
In addition, looking at past issues of a publication lines. A sample outline with sections typically included
you are considering can be an effective way to deter- in a peer-reviewed article is contained in Table 14-1.
mine if it is a good fit for your work. Key elements to In addition to the sections described in Table 14-1,
review and consider include: authors typically submit an abstract. The abstract is
■ What organization is responsible for publishing a comprehensive summary of the research study or
the journal? evidence-based practice project. Authors most often
■ Is the publication discipline-specific, multidisci- condense the main objective, methods, results, and
plinary, or geared toward the general public? conclusion of the project into 150 to 250 words.
■ What is the aim and purpose of the publication? Readers frequently review the abstract to decide if the
■ What topics are typically covered in the publication? article warrants further inspection or is applicable to
■ Does the publication include specific columns or their purposes. Although the abstract is placed at the
features, such as editorials, book reviews, personal beginning of the article, it is typically written last after
anecdotes, or other topic-based columns? the article is completed.
■ What is the review process for submissions (for Although most peer-reviewed articles follow a for-
example, editorial review or peer-reviewed, how mat similar to that included in Table 14-1, you may
many people will review the submission, and how need to modify this outline, depending on the nature
long will it take to hear if an article is accepted)? of your project. Articles based upon quantitative re-
■ What is the typical circulation of the publication? search should closely resemble this outline, whereas
This can help you clarify how many professionals those based upon qualitative research will require
or other individuals your work will reach. more narrative description.
Answering each of these questions and then com- Format for Qualitative Research Articles
paring this information with your publication goals Qualitative articles are often ethnographically based,
and specific study or project content will help you to meaning they are specialized commentaries about a
choose the most appropriate publication. narrowly defined project that has been conducted using
naturalistic methods. Qualitative articles are typically
Format of the Article of greater length because of the more subjective meth-
ods and the subsequent need for richer description of
The format and amount of detail for an article can
procedures and outcomes. Fetterman (1998) feels that
vary depending on the chosen publication, the in-
ethnographic writing is difficult, yet satisfying:
tended audience, and the topic being discussed. It is
important to note that the approach and content for From simple notes about small events . . . to efforts to de-
an article will differ significantly from the formal scribe an experience or explain a sudden insight, ethnographic
research or evidence-based practice report discussed writing requires an eye for detail, an ability to express that de-
in Chapter 12. Articles are considerably shorter in tail in its proper context, and the language skills to weave
length and often written for alternative audiences, de- small details and bits of meaning into a textured social fabric.
pending on the publication goals. For these reasons, The ethnographic writer must recreate the varied forms of so-
merely copying and pasting content from the original cial organization and interaction that months of observation
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198 Section 4 ■ Common Tasks Along the Journey

Table 14-1 ■ Sample Peer-Reviewed Article Outline

Suggested Research Article Sections What to Include in Each Section

Description of the Problem and ■ Clearly describe the major issue addressed in the study.
Background ■ Most of the background section will come from the literature review you
conducted.
■ Discuss the literature, but do not include an exhaustive historical review.

This is the section that will be most condensed, given the amount of
material you have amassed. Because of space constraints, most journals will
not accept more than a few paragraphs concerning the background.
■ State the purpose of the study and the hypotheses.

Method ■ Describe how the study was conducted in sufficient detail to allow other
■ Subjects or Participants researchers to replicate the study and readers to assess the appropriateness
■ Interventions or Procedures of your methods and the reliability and validity of the study. The method
■ Outcome Measures section may be divided into subsections covering subjects, procedures,
■ Data Collection outcome measures, data collection, and analysis.
■ Data Analysis ■ Subjects or Participants. Describe criteria used to determine the population

for the study, stating the literature that indicates that these criteria are
necessary or desirable. Then, describe the method of sample selection (i.e.,
random or nonrandom). If nonrandom selection was used, was convenience
sampling or some other technique used? The method of assigning subjects
to groups should be addressed, if relevant. State the number of subjects in
the study and how many were included in each group. If there was any
subject attrition during the study, this should also be mentioned.
■ Interventions or Procedures. If any intervention or treatment was provided,

this should be described in detail, including who provided the treatment,

where it was provided and under what conditions, and specifically how it
was provided.
■ Outcome Measures (Testing Instruments). Identify all measures used with

information on reliability and validity of the tools, if available. If you devised

the measure specifically for the study, this should be mentioned, and it may
be useful to include a copy of the instrument in the article.
■ Data Collection. Describe how the data were collected, including whether a

pretest and posttest were used, who administered the tests, whether the tests
were administered in a group or individually, the environmental conditions,
and how long the data collection took.
■ Data Analysis. Report on specific statistical methods or software used, if

applicable.

Results ■ Summarize the main findings (do not include interpretation of findings in
this section).
■ Use figures and tables, if necessary, to illustrate results.

■ When reporting the findings from inferential statistics such as t tests or chi-

squares, include information about the significance level and the degrees of
freedom. Style manuals give information on how to type statistical results.
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Chapter 14 ■ The Art of Publishing the Research Study or Evidence-Based Practice Project 199

Table 14-1 ■ Sample Peer-Reviewed Article Outline–cont’d

Suggested Research Article Sections What to Include in Each Section

Discussion ■ State whether the hypotheses were supported or the research question
■ Limitations was answered.
■ Implications of Findings ■ Discuss similarities and differences in the findings of your study and the

■ Future Research studies mentioned in the literature review.

■ Be sure to state findings that do not support your hypotheses and briefly

speculate on why they might have come about and what they might mean.
■ Limitations. Review limitations within the study’s procedures.

■ Implications. Explain implications of the study’s findings to practice.

■ Future Research. Review recommendations for future research or evidence-

based practice.

References ■ Include a full reference list (in the style specified in the author guidelines)
for any references used in the article.
■ Include only references used in the article. You should not include references

used in the study or project but not mentioned in the article.

and study have revealed. The manifold symbolism every cul- 1. Clearly identify the focus of your article.
ture displays and the adaptiveness of people to their environ- 2. Ensure that the aim of the chosen publication
ment must somehow come to life on the page. (p. 111) aligns with the focus of your article.
3. Follow the author guidelines for the chosen
The outline in Table 14-1 will still prove useful, but
publication explicitly.
qualitative articles typically have limited focus on strict
4. Use the reference style outlined in the author
procedures and statistical methods. More of the article
guidelines, and credit all sources appropriately.
will be devoted to descriptions of the participants and
5. Select a concise, descriptive title.
their experiences and specific data collection techniques
6. Include all required sections of the article, typically
such as participant observation, in-depth interviewing,
an abstract, introduction, body, and conclusion.
or document review. More detail is also included regard-
7. Use clearly designed and labeled figures and tables,
ing data analysis and discussion of identified themes
where appropriate, to support the written word.
than in quantitative research articles. Specific methods
(Refer to Chapter 12 for support in creating visual
of data analysis need to be explained, including how the
displays of data.)
data were obtained and if any checks were imposed to
8. Be prepared to receive constructive criticism and
confirm the findings. If sufficient detail is omitted, it
endure the rigors of multiple edits. The purpose
will be unclear if the findings come from your own
is only to make your work stronger (PHC RIS
knowledge of the culture, direct personal experiences of
et al., 2009).
the activities studied, other people’s theoretical frame-
works, or actual fieldwork and interviewing.
Non–Peer-Reviewed Articles
Tips for Peer-Reviewed Articles In contrast to the structured format for peer-
Whether the content is research or evidence-based reviewed articles, the format for non–peer-reviewed ar-
practice, composing and submitting a peer-reviewed ticles allows for greater flexibility and creativity. The
article can be challenging. Following these sugges- possibilities of how to organize and approach these
tions can assist you in getting your article accepted articles is nearly endless, and the decision will be based
for publication. largely on the chosen publication and audience.
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200 Section 4 ■ Common Tasks Along the Journey

Because many non–peer-reviewed publications are

designed for the general population, the approach BOX 14-3 ■ Outline for Non–Peer-Reviewed
taken is usually a less formal, more conversational one. Article on Fall Risk in a Senior
Layman’s terms and explanations are more appropri- Citizens’ Newsletter
ate, as are color photos, diagrams, and attention-
getting facts, stories, and titles. Although the purpose Introduction
is still to inform or share scientific information based ■ Attention-getting statistics on falls
upon research or evidence-based practice, the infor-
mation is tailored to a specific audience and organized What Are the Risk Factors for Falls?
as deemed appropriate by the author. ■ Intrinsic Factors: Decreased strength, vision,
From the sample study in Box 14-1, one of the pos- reflexes, cognitive changes, disease-related
sible publications included composing a piece for a changes (dementia, cardiovascular disorders,
senior citizens’ newsletter on the risk factors for falls, osteoporosis), fear of falling
how physical therapy can help, and how to get more ■ Extrinsic Factors: Environment, medica-
information or find a physical therapist in the area. tion, time of day, staff and caregivers
Box 14-3 includes a possible outline for this article, to
illustrate how the organization of a non–peer-reviewed Am I at Risk for Falls?
article contrasts with that of the peer-reviewed article ■ Plan to include a short 10-item self-
outline included in Table 14-1. This example reveals questionnaire that readers can use to
that the sections of the article are unique and are or- identify their risk for falls as minimal,
ganized in a logical manner. Goals of the article are to moderate, or maximum
grab the senior citizens’ attention about falls, provide
them with background information on fall risks What Physical Therapy Can Do If You Are
in layman’s terms, enable them to assess their fall risk at Risk for Falls
via a short questionnaire, and explain that help is ■ Environmental modifications
available for them if they need it. ■ Strengthening and coordination activities

■ Balance retraining

■ Set up a home program

Publication Procedures
Once you have selected an appropriate publication How to Get More Information
and written your article, you are ready to submit it. ■ Consult your MD
The author guidelines typically outline the submis- ■ How to find a physical therapist near you
sion procedure, with most publications requiring ■ How to learn more about falls
electronic submission now. Many publications re-
quire potential authors to sign a copyright form at-
testing that their work is not under consideration by article is accepted for review, this means that the arti-
any other publication. For this reason, you should cle passed the first evaluation and is being sent to mul-
submit your article to only one publication at a time. tiple experts on the topic who will review it and
If and when you find out that your article has been provide feedback on whether or not it should be
rejected by one publication, then and only then is it accepted for publication. Considerations include
acceptable to submit it elsewhere. whether the topic is relevant to the readership, if it has
Authors are notified if their articles are accepted been adequately covered, and if the study or project is
for review or publication; however, the length of of good quality. Once the expert reviews are complete,
time it takes to receive notification can vary greatly the editor will determine whether or not the article
depending on the publication. If a peer-reviewed is appropriate for publication. Non–peer-reviewed
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Chapter 14 ■ The Art of Publishing the Research Study or Evidence-Based Practice Project 201

articles are usually appraised by only the editor(s) of you can refer to it during the writing process to
the publication and then rejected, accepted with see if you are staying true to your purpose.
revisions, or accepted as submitted. 4. Poor writing. It is quite possible to have a quality
project, but to have your work rejected based upon
Revising the quality of the writing. Day (n.d.) advises au-
Often editors accept an article but require the author thors to avoid verbosity and jargon by writing
to make revisions. These requests should be viewed clearly and concisely and avoiding technical terms
positively because this means that the editor is inter- that could confuse readers. She also recommends
ested in the work and wants to help the author polish writing “to express—not impress,” meaning that
it and share it with others (Day, n.d.). Reviewers or ed- authors should avoid use of long impressive terms
itors may request revisions to clarify confusing points, (pp. 23–24). In addition, articles should always be
to simplify the information for better readability, or to reviewed for proper grammar and spelling before
more clearly align an article with the publication’s aims submission.
or current research. Nevertheless, it is important to re- 5. Failure to consider the audience. Remember to
spond promptly to an editor’s request for revisions and consider the intended audience and how you will
to make the necessary changes to the article. Do not be tailor the message to them. There is a clear differ-
surprised if your article goes back and forth between ence between writing and communicating; alter-
you and the editor a few times before it is acceptable. ing your writing style and approach will ensure
Above all, do not become so discouraged that you stop that the audience receives the message you in-
revising and resubmitting. If the editor considers the tended (Day, n.d.).
material suitable for publication, it is merely a matter Research articles might also be rejected based
of time before you have it in publishable form. upon flaws with the research design, data collection,
data analysis, or interpretation of results. Although
What If My Article Is Rejected?
you cannot erase these mistakes, you have several op-
If your article is rejected for publication, you will usu- tions. You might resubmit your article to a non–peer-
ally be given the reason for rejection. Some common reviewed publication, or alter the way you ap-
reasons that an article might be rejected are: proached the article. For example, instead of writing
1. Submission to the wrong publication. If the a traditional research article, you could focus on
topic and the purpose of your article do not mesh summarizing your literature review or highlighting
well with the aims of the chosen publication, your the topic via a case study. Both approaches may be
work could be rejected (Day, n.d.). beneficial to readers interested in your topic and still
2. Poor organization. As noted in the discussion of allow you to share what you have learned. Another
formatting earlier in this chapter, the article should option is to conduct another study, perhaps a pilot
flow logically with later points building on earlier or case series, controlling for the previously identi-
ones. Without good organization, readers will not fied flaws. The quality of the research upon which an
understand your work. article is based can definitely impact acceptance for
3. Lack of purpose or focus. Although you could publication.
discuss many aspects of your study or project, If your work is rejected, you should not be discour-
consider the chief message you want to convey. aged. Even experienced authors can experience rejec-
Ask yourself what your paper is about and why tion or be asked to make substantial revisions. It is a
this information is important. To gain focus, Day learning experience and part of the writing process. Re-
(n.d.) suggests trying to write in 20 words or less member that you have valuable information to share
the main objective for writing your article (p. 9). with others—it is just a matter of finding the right pub-
Although you likely will not include this in the lication, format, and approach to do so. With a little
actual work, the exercise can be clarifying and hard work, your publication goals are achievable.
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202 Section 4 ■ Common Tasks Along the Journey

Article Acceptance creative or catchy title might be more appropriate

Once your article has been accepted, it will be copy for a non–peer-reviewed article.
edited to clarify any uncertainties, to polish the writ- ■ Remember your goal is to communicate information,
ing and flow of the work, and to finalize the layout. not to write for self-recognition, although that may be
This process will likely involve multiple revisions a secondary gain. The most difficult part of the writing
and collaboration with the editor. Your editor may process is writing enough to be informative, but being
send you one or more proofs to review and can clear and concise, so as not to bore the reader.
let you know the anticipated publication date of ■ Consider use of photos, graphs, or charts to supple-
your article. Depending on your topic and the pub- ment or emphasize information in the text. Re-
lication, it could take a while for your article to ap- member to secure permission for photos if they
pear in print. During this time, it is perfectly include participants.
acceptable for you to list this publication on your ■ Remember to include your references in the style spec-
resume, noting that the publication is “in press.”
ified in the author guidelines (often APA style). Be sure
to include only those references that you used in the
Chapter Summary article, not all the references for your entire research
Focusing on your publication goals and reviewing the study or evidence-based practice project.
author guidelines for your chosen publication can guide ■ Pay close attention to page, spacing, and style re-
you to write a meaningful article on your topic. The op- quirements. Often your article can be rejected if you
portunities and benefits associated with publishing far did not adhere to these specifications.
outweigh the challenges along the way. In the end, you
should be proud of your accomplishment and the con-
tribution you made to your profession and area of study. LEARNING ACTIVITIES
1. Consider that there are likely multiple opportu-
SKILL-BUILDING TIPS
nities for publication within a single study or
■ Know your publications. Which publications are for project (as illustrated in Boxes 14-1 and 14-2).
a more generalized audience versus a more specific Brainstorm and make a list of at least five pub-
one? What are the acceptance rates for the publica- lication opportunities for your study or project.
tion you are considering? Review a copy of the pub- 2. What is the main objective of your article? Try
lication you are considering. What are the styles of writing this down in 20 words or less.
the articles within it?
3. What supplemental materials, such as tables,
■ How and where is the best place to disseminate your
figures, or photographs, could be used to sup-
information? Who is your intended audience? Is a port or enhance the text of your article?
discipline-specific publication appropriate, or
would another venue suit just as well or better?
■ Ponder some of the top reasons that papers are re- REFERENCES
jected: no clear focus identified; poor organization; Day, A. (n.d.). How to write publishable papers. Retrieved from http://
sigma.poligran.edu.co/politecnico/apoyo/Decisiones/curso/
and information is not current. howtowriteclean.pdf
■ Contemplate the title. This is often what “sells” Fetterman, D. M. (1998). Ethnography: Step by step (2nd ed.). Thousand
Oaks, CA: Sage Publications, Inc.
your paper initially. For peer-reviewed articles, you
PHC RIS, McIntyre, E., Nisbet, S., Magarey, A., Keane, M., & Roeger, L. (2009).
should consider something concise that clearly Fact sheet: Publishing in peer review journals: Criteria for success (2nd ed.).
articulates the focus of your article. Considering a Adelaide: Primary Health Care Research & Information Service.

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
3916_Ch15_203-208 20/10/14 10:29 AM Page 203

Chapter 15

Grant Funding: Insights

and Approaches
Often when you think you’re at the end of something,
you’re at the beginning of something else.
—Mr. Rogers
Oh, it’s delightful to have ambitions . . . and there never
seems to be any end to them—that’s the best of it! Just as
soon as you attain one ambition you see another one glitter-
ing higher up still. It does make life so interesting.
—Anne Shirley (L.M. Montgomery)

or evidence-based practice venture. Key factors when

LEARNING OUTCOMES searching for grants are identifying your skills and
The information provided in this chapter will assist the knowledge to carry out the inquiry, finding support-
reader to: ing evidence, enlisting people to help you with the
■ Gain knowledge in how to locate, write, and project, and maintaining persistence and persever-
obtain grant funding. ance. Grant writing involves a combination of the
■ Identify the pros and cons to developing and im- following:
plementing a program based on grant funding. ■ A well-thought-out and written work plan
■ Build skills in seeking out funding sources to ■ A collaborative and cooperative team
ascertain as much information as possible ■ An exhaustive search of your resources (in-house
before writing a grant. and out-of-house)
■ Acknowledge the need to celebrate and accept ■ A plan to network and check in with key support-
challenges during the grant-writing process. ers of the grant project (i.e., letters of support, ad-
ministrative assistant time, work-study student)
■ A keen knowledge and insight into the client’s needs
Charge to Engage in Grant Writing for the program or product you are proposing
Acquiring money is a helpful, and often mandatory, ■ A simple, yet inclusive mission statement as to
task to help with the processes involved in a research why you need money (Figure 15-1)

203
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204 Section 4 ■ Common Tasks Along the Journey

Charge to Engage in Grant Writing

Healthcare practitioners
may enhance their daily Practitioner
practice by embracing and knowledge
engaging in the challenge and skills
of grant writing.

This engagement will

positively impact Successful
practitioner, peers, Grant
environment, and clients.
Evidence Persistence
for the area and
of need perseverance

Figure 15-1 Charge to Engage in Grant

Writing

When going through the process of grant writing, grant, start small—but think big! You don’t want to get
a helpful saying to recall is, “It is amazing how much yourself into a position where you take people’s money,
you can accomplish when it doesn’t matter who gets but then can’t sustain the journey by fulfilling all the
the credit” (unknown source). proposal’s demands at the end of your project.
Every single grant is different, yet the application
process puts similar demands on your time and re- Grant Writer’s Skills and Knowledge
sources. The first priority is to recognize the mission
of your project’s targeted funding source. Determine If you are reading this, you are most likely planning
upfront if their mission and requirements align with to write or prepare a grant, so take three deep breaths
those of your project. Do not apply for a grant that is and be confident in your ability to properly write and
going to compromise the process or outcomes of submit a grant on time! There are a few things to con-
what you want to accomplish. sider in relation to your skills and knowledge when
When gathering information to support the com- you commence writing a grant:
ponents of the grant, start by utilizing what you have ■ Trust yourself!
already written in your thesis, dissertation, or evidence- ■ Remember who you are doing this for and
based practice plan. Start with your abstract and then why . . . the process can get lonely, so if you can
look at your literature review. You will find that many keep the original intent of securing funding at
of the answers to the questions asked in the grant ap- the forefront, it helps.
plication can be copied and pasted or simply tweaked ■ You will be constantly gaining new skills and
from the work you have already done. You will more knowledge as you move through the process.
than likely need information from multiple people or Although you will not know every step of the way
sources within the institution or community housing upfront and there will be bumps in the road, you
your project. Keep detailed notes of who is giving you must keep going. Every time you write a new grant
the information and where you are obtaining informa- or a renewal it is a new learning experience. The
tion to support the mission of the grant. This seems rules change constantly.
like a commonsense comment, but you will forget ■ Hence, be constant and consistent in keeping
points and people if you do not write things down. the pace. Although it is a time of learning, there
Networking is a must when you are writing a grant, is [always] a deadline for the grant to be submit-
particularly a large grant. It often takes a village to ted and it isn’t optional. Grant funders give no
write a grant. If this is your first attempt at writing a extensions.
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Chapter 15 ■ Grant Funding: Insights and Approaches 205

In addition to understanding your skills and knowl- are the grant’s primary investigator or coinvesti-
edge, it is also important to glean when you need to en- gator, you will want someone else to do the
list the help of others. Therefore, consider how your budget. It typically accounts for 25% of the
clients, students, and peers can help you write your score on the application.
grant. Ask them for answers—how do they feel, what do ■ Write a statement of how the grant will not only
they need or want, and how can they assist you in ac- assist the individuals directly involved in the
complishing the task of writing a grant to improve upon process, but the larger community as well.
a treatment intervention, modality, or piece of equip- ■ Consider and build in the outcome measures as
ment? Dovetail your everyday experiences in practice early on as possible, using criteria and actual
into the grant-writing process. Consider interventions process measures.
and programming that have been working or those ■ Seek out someone in your organization or circle
components that need modification. Now that we have who is proficient at quantitative statistics. Find
covered your skills and knowledge as a grant writer, the another who excels in qualitative stats–narratives,
next section will review some grant-writing basics. themes, and stories are quickly becoming of
interest to funding agencies.
Grant Writing 101 ■ If the grant source states, “Submit a four-page pre-
liminary proposal,” get on the Web and pull down
The following list features pieces that you should pull some samples to follow. The sources are endless!
together before you even start searching for a grant: You will find one to match your needs and style.
■ Find out if there is a key person in your organiza- ■ Get sleep while you can. Once the window for
tion who assists with grant writing. state and federal grants opens, you have 6 to
■ Subscribe to as many grant and foundation 8 weeks to upload all supporting materials to the
listservs and e-mail alerts as possible. site. Remember, most educational and business
■ If the grant you are looking at is offering a work- organizations have someone who will want to
shop to review the application process, sign up review the grant 2 weeks before it goes to the
and attend the workshop. grant source; therefore, back your deadline up by
■ Bookmark key grant websites and check them a minimum of 10 days. Unfortunately, when you are
often. in the thick of writing the grant there is no minimum
■ Remember that grant writing can become a time for sleep . . . especially if you are the primary
40+ hour per week occupation all unto itself! writer. Again, take care of yourself!
Take care of yourself! ■ Utilize focus groups to assist with brainstorming.
■ Write a background of the entities that will be in- Client groups, boards of directors, and water cooler
volved with the grant. Look to mission statements, mates are great people to pull into the process.
philosophies of education, and business plans. ■ Finally, stay calm throughout the process. We’ve
■ Find and secure a minimum of one partnership witnessed people melt down hard! Grants may be
entity. important to your organization; however, they are
■ Write down a brief description of the issue you not worth risking your health or relationships.
wish to address with grant funding.
■ Do a literature search on the issue you wish to
Enablers and Barriers
address with the scholarly and general public
domains. There are many ways to empower yourself and oth-
■ Write a one-page statement on why you are the ers when you are thinking about writing a grant or
most deserving entity to receive the foundation when engaged in the post-grant funding process.
or grant source’s money. First and foremost, facilitate and lead by example.
■ Find someone who is efficient at designing bud- We promise that if you keep a smile on your face and
gets, even if you think you are good at this. If you a light heart through the sometimes stifling process
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206 Section 4 ■ Common Tasks Along the Journey

of grant writing, others around you will be intrigued

and motivated to keep working. Be a trend setter BOX 15-1 ■ Ten Reasons Proposals
and start a weekly grant e-mail update on the Get Rejected
strengths and needs of the project. Start a grant- 1. Program activities are not based on best
writing mentor program. Seek out others who have practices.
been successful in your setting with securing grants 2. Proposals are unclear or missing required
and have lunch with them to pick their brains. In- information.
corporate grant writing into your professional de- 3. Need has not been adequately identified
velopment plan. Start a focus group with clients, in the proposal.
students, and peers to brainstorm what is needed in 4. Programs are not well thought out. Por-
your setting and make a top 10 list of possible proj- tions are inconsistent with one another.
ects and grant-funding sources. 5. Proposals are too ambitious for the
The common barriers that are typically associated amount of time and money requested
with grant writing are as follows: or proposals are not ambitious enough
■ No time is available to find or read grant applica- for the amount of time and money
tion requirements. requested.
■ No time is available to write up a proposal, as it 6. Budget is vague, inconsistent, or
takes an immense amount of time. unrealistic.
■ No time is available to carry out every component 7. Staff expertise is not conducive to
of the project that the funders may want included program activities.
in the project. 8. Program has a bad track record for
■ Limited support is given from administration or completing activities.
peers. 9. Proposals are submitted after the due
■ A change in practice can be difficult and some- date (a deadline is a deadline).
times the status quo just seems too safe to move 10. Proposal submitter has good ideas but
away from for some individuals, groups, or the proposal is written poorly.
communities. http://www.cippp.org/pubs/granttip.pdf
■ Some people on your team will not value securing
a grant. They just do not feel a grant-funded
program will add value to their or their clients’
experience (Box 15-1). ■ Become more confident in your everyday
In response to the enablers and barriers of grant practice
writing, just remember: Breathe, seriously, breathe! ■ Take ownership in your mission to engage in best
Muster up the unshakable confidence and move for- practice
ward in your skills and knowledge as a healthcare Given all of this insight, there is one final point
practitioner. By embracing the enablers and down- about grant making: Do exactly what the grant fund-
playing the barriers you will move forward in the ers tell you to do—exactly! Follow the directions of the
grant-writing process and succeed in the following: application exactly—do no more, no less! This is not
■ Gain new skills the time to be creative with fonts or graphics. It is
■ Recognize what you already know smart to have only a few writers; however, use many
■ Believe more in your knowledge and skills readers to proof the narrative with the application di-
■ Learn from the positives and negatives that you rections. Finally, have an expert do the budget. Seek
encounter out the best money manager within your organization
■ Elicit and gain support from your peers or group and have him or her set up the budget and
■ Assist in the skill and knowledge development recheck it three times before hitting the submit
of others button. Congratulations! You have engaged in the
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Chapter 15 ■ Grant Funding: Insights and Approaches 207

very meaningful process of grant writing. See Appendix ■ Embrace the ever-evolving organic arousal of your
O for an outline of a grant proposal. mind, body, and spirit in this process; we promise
it is a journey to cherish! A great deal of the grant-
writing process comes from within. . . you have to
Chapter Summary
keep your momentum going. One way to do so is
As you can see by the comments and suggestions in to allow the writing process to just wash over you!
this chapter, grant writing can be time-consuming It is a grand thing—embrace it!
and somewhat of a challenge; however, know that
thousands of people every year find it is worth their
time and effort. There are two overriding challenges
in the grant process. The first is finding a grant source LEARNING ACTIVITIES
that aligns with your mission and the needs of your 1. Identify at least five potential grant sources
practice. The second is allocating the time and re- that address the needs of your project.
sources to write and submit the grant. Most impor- 2. Write a draft of the components of a typical
tantly, throughout all phases of the grant-writing and grant proposal:
implementation process, stay organized and ask for ■ Statement of need or rationale
help when the tasks become too overwhelming. ■ Implementation strategies (i.e., goals, objec-

tives, activities, time line)

SKILL-BUILDING TIPS ■ Outcomes

■ Personnel
■ Remember to breathe—it is SO very important!
■ Evaluation
■ Congratulate yourself when you read or write ■ Budget
something. Some days a sentence or a paragraph
3. Do you need a one-time grant or is your pro-
can take a day to write, whereas other days you will
gram going to need ongoing funding?
write pages.
■ Keep a 5 x 7 notebook with you all the time or use
Consider and describe how you plan to sustain
the program once funding from your first grant
your phone to keep notes. As you dive deep into
is complete.
the grant-writing process, you will be amazed
where and when thoughts pop into your mind. If 4. Identify three people or institutions who can
need be, write thoughts down on napkins or old write a letter of support for your project. Write
receipts, or ask your waitress or waiter for a piece a draft of the support letter they can use as an
of paper. At all costs, don’t allow the thought to example.
get lost!
■ Itis essential to make a reading and writing space
GRANT AND FOUNDATION FUNDING
for yourself. Whatever you have to do, get your
RESOURCES
space organized! If you don’t have a file cabinet Grants.Gov
drawer to organize the mass amounts of literature http://www.grants.gov/
and information you will be collecting, buy a two- Grants.Net
www.grantsnet.org
drawer file cabinet or get yourself a three-pack of
*Pages and pages of grant opportunities*
cardboard file boxes.
National Collegiate Inventors and Innovators Alliance
■ When engaging in grant writing, you will generate http://www.nciia.org/grants.html
a lot of paper. Another option is scanning and keep- National Endowment for the Arts
ing files on your computer, as this will save a tree! http://www.nea.gov/grants/index.html
National Institutes of Health
■ Own the passion of writing and reading as an occu-
http://grants.nih.gov/grants/grant_basics.htm
pation; it will be your primary means of communi- National Science Foundation
cating what you are doing with the money. http://www.nsf.gov/about/glance.jsp
3916_Ch15_203-208 20/10/14 10:29 AM Page 208

208 Section 4 ■ Common Tasks Along the Journey

Population Research Institute U.S. Department of Health and Human Services

http://cairo.pop.psu.edu/allen/Agencies.cfm http://www.hhs.gov/grants/index.shtml
*This database is updated weekly by PRI staff and includes funding opportunity U.S. Department of Justice
announcements targeting researchers in population science and related fields. http://www.usdoj.gov/10grants/
For help on conducting your own funding search, please see the Population FOUNDATION OPPORTUNITIES
Research Institute Library’s Funding Resources Links.*
Foundation Center—One Stop Shop!
Sloan Grants
http://www.foundationcenter.org/
http://www.sloan.org/main.shtml
Top 100 Foundation Funders
Small Business Administration
http://foundationcenter.org/findfunders/topfunders/top100assets.html
http://www.sba.gov/services/financialassistance/grants/index.html
*Overwhelming amount of funding links*
U.S. Department of Agriculture
http://www.csrees.usda.gov/fo/funding.cfm

For additional materials, please visit http://davisplus.fadavis.com,

key word: Hissong.
3916_App A_209-220 20/10/14 10:13 AM Page 209

Appendix A

Example of Mixed
Quantitative–Qualitative
Study
The intent of providing you with the outline of this study is
for you to glean insight from the structure and description of
the inquiry.

The Effects of Massage Therapy on Pain Management in the Acute Care Setting
Background massage therapy were recorded using a 0–10
Pain management remains a critical issue for visual analog scale. Quantitative and qualita-
hospitals and is receiving the attention of hos- tive methods were used for analysis of this
pital accreditation organizations. The acute descriptive study.
care setting of the hospital provides an excel-
lent opportunity for the integration of massage Participants
therapy for pain management into the team- Hospital inpatients (n = 53) from medical, sur-
centered approach of patient care. gical, and obstetrics units participated in the
current research by each receiving one or more
Purpose and Setting massage therapy sessions averaging 30 minutes
This preliminary study evaluated the effect of the each. The number of sessions received depended
use of massage therapy on inpatient pain levels on the length of the hospital stay.
in the acute care setting. The study was con-
ducted at Flagstaff Medical Center in Flagstaff, Result
Arizona—a nonprofit community hospital serv- Before massage, the mean pain level recorded
ing a large rural area of northern Arizona. by the patients was 5.18 [standard deviation
(SD): 2.01]. After massage, the mean pain
Method level was 2.33 (SD: 2.10). The observed re-
A convenience sample was used to identify re- duction in pain was statistically significant:
search participants. Pain levels before and after paired samples t52 = 12.43, r = .67, d = 1.38,
Continued

209
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210 Appendix A ■ Example of Mixed Quantitative–Qualitative Study

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
p < .001. Qualitative data illustrated improve- hospital experience and found that “tension,
ment in all areas, with the most significant stress, pain, and anxiety were key challenges for
areas of impact reported being overall pain patients” (6). The integration of massage ther-
level, emotional well-being, relaxation, and apy into the team approach in patient care con-
ability to sleep. stitutes a move forward that recognizes pain as
the fifth vital sign after pulse, blood pressure,
Conclusions temperature, and respiratory rate (5). Although
This study shows that integration of massage each patient’s healing process is unique (7),
therapy into the acute care setting creates over- common themes of healing recognized in the
all positive results in the patient’s ability to deal present study underlie the significance of a ho-
with the challenging physical and psychological listic approach to patient care.
aspects of their health condition. The study Research has documented the use of
demonstrated not only significant reduction in massage therapy as an effective tool for pain
pain levels, but also the interrelatedness of management (8–10), with the added benefit of
pain, relaxation, sleep, emotions, recovery, and producing few adverse reactions (11–13).
finally, the healing process. When, with cardiac surgery patients, opioid
KEYWORDS: Massage therapy, acute care, medications are initially necessary, the contin-
hospital, pain management, research, inpa- ued use of large doses can delay the recovery
tients, patient care management, postoperative process and lead to prolonged hospitalization
pain, anxiety, reflexology, craniosacral, acu- (11). Patients with increased blood pressure
pressure, Swedish effleurage, pregnancy, can- because of stress may also benefit from mas-
cer, fibromyalgia, relaxation sage therapy (14,15). A study at the Mayo
Clinic, in which 58 cardiac surgery patients
Introduction postoperatively received 1–3 massage therapy
Pain management within the acute care setting sessions of 20 minutes each, created evidence
is a concern that is being carefully examined compelling enough for the Mayo Clinic to hire
not only by individual hospitals, but also by ac- a full-time massage therapist to be available on
creditation organizations across the United the inpatient unit (6).
States (1). Massage therapy is one of the com- Cardiac surgery patients often complain of
plementary and integrative medicine (CIM) back, shoulder, and neck pain from manipula-
therapies most often prescribed by physicians, tion of the body during the surgical procedure
and it is noted to be the most likely to be ben- and from physical manifestations of tension
eficial and the least likely to be harmful (2). and stress (11). When massage therapy is
Studies have examined the experience of hospi- incorporated as part of the postsurgical proto-
talized patients and found that high levels of col, fewer medications may be needed, provid-
stress and anxiety can increase pain (3,4) and ing an added advantage of fewer adverse side
slow a patient’s recovery by limiting “physical effects and acting as an effective adjunct or
functioning, including the ability to cough and alternative to pharmaceuticals (10).
breathe deeply, move, sleep, and perform self- The gate-control theory of pain postulates
care activities” (5). that massage may be effective in “closing the
The Mayo Clinic of Rochester, Minnesota, gate”—that is, inhibiting the transmission of
conducted a systematic evaluation of the patient noxious stimuli by stimulating large nerve fibers
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Appendix A ■ Example of Mixed Quantitative–Qualitative Study 211

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
that have been shown to alter pain perception randomized controlled trial of 605 veterans
(13). In the acute care setting, health care pro- undergoing major surgery at Department of
fessionals have a tendency to touch patients Veterans Affairs hospitals (5).
only when performing procedures, which can Lack of sleep in the hospital environment
be uncomfortable and even painful. As White is a well-known phenomenon and can delay a
wrote, “Touch is often the most neglected or as- patient’s recovery (4,9,17). Hospital-induced
saulted sense of the hospitalized patient” (16). sleep deprivation is generally remedied with
The relaxation response (RR) is the body’s medications (17). Critically ill and elderly
mechanism to decrease the level of psycho- patients are a vulnerable population and may
physiologic arousal produced by stress (17). benefit from non-pharmacologic methods to
Massage therapy can produce a RR that creates promote sleep (17). By studying the amount of
a calm state and enhances the ability to rest, REM and NREM sleep in 69 elderly men,
qualities that are so essential for healing to Richards found that sleep efficiency was 14.7%
occur (4). In addition, the RR elicits physiolog- higher in patients who received a 6-minute
ical changes, including lower blood pressure back massage than in a control group (17).
and heart rate, decreased oxygen consumption That study is comparable with another that
and muscle tension, and lower levels of cortisol followed 30 patients with fibromyalgia who
and noradrenaline (15). “The majority of stud- received 30 minutes of massage therapy
ies show that back massage induces a physio- twice weekly for 5 weeks. The patients experi-
logical or psychological relaxation response enced decreased depression, improved sleep
and that it is not injurious for critically ill (a greater number of sleep hours and fewer
patients with heart disease” (17). sleep movements) and decreased symptoms,
Stressors experienced by hospital patients in- including pain, fatigue, and stiffness (8). An-
clude excessive noise, lack of sleep, social isola- other study of 41 hospitalized oncology
tion, enforced immobility, and pain from patients illustrated that sleep quality, pain,
procedures. Anxiety and stress during cardiac symptom distress, and anxiety all improved
catheterization can lengthen the hospital stay when massage therapy was given during the
and increase the use of sedative medication be- hospital stay (19).
fore and during the procedure (3). Hamel’s re- Egnew concludes that healing may be de-
search using a randomized clinical trial design fined as “the personal experience of the tran-
with 46 participants demonstrated that a 20- scendence of suffering” (7), and therefore each
minute back massage successfully reduced individual will have a personal concept of what
blood pressure before cardiac catheterization “healing” means to them. Some aspects of
(3). Studies note that fear and anxiety are com- healing are subjective and intensely personal,
mon emotions felt by cardiac surgery patients with different meanings for each person (7).
(6), and as Moyer suggests, “There is much Integration of massage therapy may improve
agreement that how a person feels, emotionally, the healing environment for the patient, thus
is at least partly a function of that person’s bod- allowing the deeper aspects of psychological
ily state” (18). When patients have higher post- healing to occur along with physical healing.
operative mobility, they may also have fewer As authors, we felt that it was important
serious postoperative complications, as demon- to include both quantitative and qualitative in-
strated by Mitchinson and his colleagues in a vestigation. The value of including qualitative
Continued
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212 Appendix A ■ Example of Mixed Quantitative–Qualitative Study

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
research is reflected by Kania and her col-
leagues in an article that describes how the use Table A-1 ■ Demographic Data of
of the mixed methods approach “can provide Research Participants
highly valuable insights and a more complete Characteristic Value
understanding of the effectiveness of an inter-
vention” (20). Using the mixed methods ap- Participants (n) 65
proach, the present study tests the research Mean age (years) 45
hypothesis “Does the use of massage therapy
in an inpatient setting improve patient percep- Sex [% (women/men)] 87/13
tion of pain management?” Ethnicity (%)

Participants and Methods White 82

This preliminary study enrolled a convenience Native American 12

sample of 65 inpatients admitted between Oc- African American 2.3
tober 1, 2006, and March 31, 2007, at a non-
profit community hospital serving a large rural Hispanic 1
area in the southwestern region of the United Asian 1
States. Criteria for inclusion in the study were
a physician order for massage therapy, the pa- Hospital unit (%)
tient’s (or a family member’s) ability to com- Medical 42
plete and sign a consent form, and willingness
Surgical 31
on the part of the patient to give feedback on
the experience of hospital massage therapy and Obstetrics 26
to return the qualitative survey after hospital
discharge. Table A-1 presents demographic
data for the research participants. Participants were given the post-hospitalization
The plan for the current study was submitted survey at the end of their last session.
and approved by the hospital’s institutional re- Three licensed massage therapists employed
view board. Participation in the research proj- by the hospital provided the therapy sessions.
ect was voluntary. Informed consent, including The experience in massage therapy of the ther-
confidentiality and the right to withdraw from apists (all female) ranged from 2 years to more
the study at any time, was obtained, and forms than 20 years. Each had received additional
were completed before the initiation of any ses- training for working with hospitalized or med-
sion for the research project. Participants were ically frail patients, and all had worked in the
told that, whether they chose to partake or not acute care setting for 1 to 3 years.
to partake in the research, their regular treat- Massage interventions consisted of 15-minute
ment would continue unaffected. Standardiza- to 45-minute therapeutic massage sessions
tion was assured by having each of the massage given at the bedside. Because of the disruptive
therapists use the same scripted dialogue when nature of the hospital environment, the length
approaching potential subjects for the study. of the sessions varied based on each partici-
Visual analog scale (VAS) scores were obtained pant’s energy level and availability. Treatments
by the therapists before and after therapy. included gentle Swedish effleurage or petrissage,
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Appendix A ■ Example of Mixed Quantitative–Qualitative Study 213

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
acupressure, craniosacral therapy, or cross-fiber Qualitative data drawn from nursing com-
myotherapy with light-pressure effleurage and ments in a retrospective chart review and partic-
pressure points being the most commonly used ipant comments from the post-hospitalization
modalities. The treatment area on the body var- survey were analyzed using the grounded theory
ied according to participant need or concern, method to code and label categories. “Grounded
taking into consideration any contraindications, theory” can be described as a method of analysis
including but not limited to areas of acute injury that aims to develop middle-range theories
and surgical and intravenous sites. Head, neck, from qualitative data. The founders of grounded
shoulders, back, and feet were the areas most theory, Glaser and Strauss, not only intended
commonly chosen, with participants in either to conceptualize qualitative data, but also
supine or side-lying positions. Participants were planned to demonstrate relationships between
given a choice of unscented or lightly scented conceptual categories and to specify conditions
oils, and relaxing music was offered. within which theoretical relationships emerge
The survey used in this research project (21) (pp. 311–312). We used the grounded the-
(Patient Survey for Massage Therapy Research) ory method to group qualitative responses into
was adapted from a survey used by Motsinger several categories to guide the analysis. These
in her Capstone Project, titled Development of categories reflected responses by the participants
an Inpatient Massage Therapy Program in an and nurses regarding reactions to the massage
Allopathic Hospital.a The survey asked about therapy session or sessions the participant re-
length of hospital stay, number of massages re- ceived while hospitalized. The themes generated
ceived, and whether massage therapy had im- demonstrate an interrelationship between cate-
proved, had had no effect, or had worsened the gories and an overall theoretical sensitivity that
participant’s overall pain levels, emotional well- supports the overriding theme that “massage
being, ability to move, ability to participate in therapy promotes recovery.” Finally, all data were
therapies, relaxation, ability to sleep, and recov- triangulated to determine whether massage ther-
ery. Additionally, participants were asked if apy improves patient perception of pain manage-
they felt that massage therapy had had an ef- ment while in hospital.
fect on their need for pain medication, how
long the effects of the massage had lasted, and Results
whether they planned to continue using mas- Quantitative Data
sage therapy as part of their healing process. From the initial sample of 65 participants, 53
An open-ended inquiry at the end of the survey completed the research project. Pain levels re-
encouraged participants to comment freely ported by the participants using the VAS
about massage. ranged from 0–10. The mean score before mas-
Quantitative and qualitative methods were sage was 5.18 [standard deviation (SD): 2.01].
used for analysis of this descriptive study. De- The mean score after massage was 2.33 (SD:
mographic data, number of massage sessions, 2.10). A comparison of pain levels before and
before-and-after pain levels using the VAS after massage shows the individual responses
scale, survey data, and nursing comments were by massage session (Fig. A-1). The observed re-
analyzed. Inferential statistical analysis was duction in pain was statistically significant:
conducted using the paired t-test, with the sig- paired samples t52 = 12.43, r = .67, d = 1.38,
nificance level preset at p < .05. p < .001 (Table A-2).
Continued
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214 Appendix A ■ Example of Mixed Quantitative–Qualitative Study

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d

Table A-2 ■ Analysis of Pain Level Before 10

and After Massage Therapy
9
Variable Value

Mean pain score (±SD) 8

Before 5.18 (2.01)

7
After 2.33 (2.10)

Correlation .67 6
×2
Standard mean error 0.23
5 ×2

Pain
95% confidence limits (1.88, 2.78)a
×2
Significance (2-tailed) <.001a 4 ×2

Cohen’s d 1.38 ×3
3
a Statistically significant.
SD = standard deviation.
×2
2

×2 ×2
The data show that most participants in the 1
survey received 1 massage (50.8%). Another
40% received 2–3 massage sessions, and 0
6 participants (9.2%) received more than t(52) = 12.43, r = .67, d = 1.38, p < .001
3 massage sessions. Most sessions (83.9%)
Pretreatment Posttreatment
lasted 30 minutes, 14 sessions lasted 45 minutes
(14.9%), and 1 session lasted 15 minutes. Figure A-1 Pain level on a 1 – 10 visual analog scale
The effects of massage therapy were felt to before and after massage therapy in 65 inpatient
last 1–4 hours by 34 participants (53.1%), and research participants. Of the 65 charts reviewed,
4–8 hours, by 13 participants (20.3%). Accord- 53 charts contained complete data (before/after
ing to 9 participants (14.1%), the effects lasted pain levels) and are shown here.
8–24 hours, and according to 7 (10.9%), more
than 24 hours. One person felt no effect. The relaxation after massage, ability to sleep, contri-
response to the question “Do you plan to con- bution to faster recovery, and less need for pain
tinue using massage therapy in your healing medication after massage. Participants were
process?” was yes in an impressive 67.2% of par- asked if there was improvement, no change, or
ticipants. Another 14.1% responded no, and a worsening in the foregoing factors because of
18.8% didn’t know if they would continue with the massage. In all areas surveyed, a majority of
massage therapy after their hospitalization. participants reported an improvement, although
The survey reported participant perceptions some participants stated that they could not re-
concerning the effects of massage therapy member. Notably, no participant indicated a
on overall pain level, emotional well-being, abil- negative effect from massage therapy. The most
ity to move, ability to participate in therapies, significant areas of reported effect were overall
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Appendix A ■ Example of Mixed Quantitative–Qualitative Study 215

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
pain level, emotional well-being, relaxation, and
ability to sleep (Fig. A-2). Table A-3 ■ Qualitative Theme of Pain
Findings from the current preliminary study Management With Massage
parallel existing research showing that pain for Hospitalized Patients
levels significantly improved with a massage Hospital inpatient “After three days in the
intervention as an adjunct to conventional hospital I was suffering a
treatments (5,19). Other noteworthy observa- migraine, nausea, and
tions included improved relaxation, emotional a lot of body pain.
well-being, ability to sleep, and a reduction in After the massage my
the perception of use of pain medications. headache was lessened
and my body pain was
Qualitative Data
greatly reduced.”
Using the grounded theory method, “massage
therapy promotes recovery” was the main Nurse “Patient reports relaxation
theme identified. Within that theme, several and pain relief after
subthemes emerged, including pain manage- massage—slept for three
ment (Table A-3), ability to sleep, relaxation, hours”
emotional well-being, and healing. Each cate- Cancer patient in ICU “I looked forward to the
gory is represented with comments from nurses massages I received while
or participants or both. Of the 65 participants in ICU—each helped to
in the study, 45 (72.3%) returned surveys. At reduce the pain.”
the end of the survey, an open-ended question
ICU = intensive care unit.
encouraged participants to comment freely

100.0%

80.0%

60.0%

40.0%

20.0%

0.0%
Relaxation Emotional Overall Ability to Contribute Ability to Needed Ability to
after well-being pain level sleep to faster move less pain participate
massage recovery medications in therapies

Figure A-2 Patient survey results. Black bars = improved; white bars = no change; gray bar = cannot
remember.
Continued
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216 Appendix A ■ Example of Mixed Quantitative–Qualitative Study

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
about their experience of massage therapy. massage therapy. Nursing comments included
Qualitative responses were received from “Patient states his neck pain lessened with
33 participants. massage,” “Denies pain or needs . . . had mas-
In the medical charts of participants, 25 sage therapy this am, in no apparent distress,”
nursing comments relevant to the research and “Massage therapy ordered and given with
project were found. All comments were catego- good relief.”
rized into themes and subthemes. Interrelating
themes were also acknowledged. Sleep
Comments about ability to sleep were often as-
Pain Management sociated with pain relief. One patient noted that
Of the 33 qualitative responses from partici- “massage brought dramatic pain relief and abil-
pants, 16 were related directly to pain manage- ity to sleep and an overall sense of well-being in
ment. Participants mentioned improved pain a stressful environment.” Another commented
levels after surgery (n = 9), lessening of breast that “I fell asleep almost immediately after [the
engorgement after a cesarean section (n = 1), massage therapist] left.” Nursing observations
decreased body and headache pain and inten- confirmed what patients stated on the survey.
sity (n = 4), and decreased pain associated with Nursing comments included “Patient reports re-
cancer (n = 2). One cancer patient commented, laxation and pain relief after massage—slept for
“I looked forward to the massages I received three hours” and “Patient stated the massage
while in ICU—each helped to reduce the pain.” was a big help in decreasing his pain and allowed
Another patient commented, “After three days him to relax enough to get a good nap today.”
in the hospital I was suffering a migraine, nau-
sea, and a lot of body pain. After the massage Relaxation
my headache was lessened and my body pain Relaxation can play a significant role in a pa-
was greatly reduced.” While still hospitalized, tient’s healing and recovery process. More than
one patient noted that “I’ve never had anything half the participants surveyed mentioned relax-
take this pain away completely.” Still another ation in their qualitative responses (n = 17).
noted that “I’m very much supportive of Patients mentioned relaxation, relief from
massage therapy as a healing and pain relief muscle tension, and increased feelings of well-
procedure.” Not only was perception of pain being and calm. Overall nervous tension and
lowered, but also perception of the need for the stressful environment of the hospital were
pain medication. Significantly, more than half also mentioned. Remarks from patients relating
the participants (52.7%) felt that they needed to relaxation included “[massage therapy] was
less pain medication after receiving massage very helpful, soothing, comforting, and relax-
therapy. ing,” and “this was very helpful to me, in that
The responsibility of nurses for pain man- this is so pleasurable during an unpleasurable
agement plays a significant role in quality experience.” A quadriplegic patient who re-
health care. Managing pain is a team effort be- ceived massage therapy commented that “over-
tween physicians, nurses, and other health all well-being (emotional, physical, spiritual,
care providers. Of the 25 comments by nursing patience, decreased anxiety, and decreased pain
staff, 16 referred to decreased pain levels or and spasticity) was improved immeasurably by
decreased necessity for pain medications after massage therapy and subsequent relaxation.”
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Appendix A ■ Example of Mixed Quantitative–Qualitative Study 217

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
In 10 comments from the nursing staff, the Healing
benefits of relaxation for their patients were References to healing and subthemes of healing
mentioned. Nursing notes reflecting the bene- including spirituality, recovery, and therapeutic
fits included “Patient seemed calmer tonight,” benefits were found in responses from 10 par-
“Patient reports improved muscle relaxation ticipants. One participant noted that “I feel
post massage therapy,” and “Massage made massage is very important to helping patients
her relaxed, resting comfortably, no distress.” heal, in so many ways,” and another com-
mented that “[massage therapy] was a very
Emotional Well-Being healing experience emotionally and physically.”
The interrelatedness of themes becomes ap- Other participant comments included “Reduc-
parent in how patient and nursing comments tion of stress also was very helpful in recovery,”
alike reflect the connection between emo- “It was very therapeutic,” and “It is such a heal-
tional well-being and relaxation, pain relief, ing process and definitely relaxing.” No nursing
and ability to sleep. Participants mentioned comments on the theme of healing were found.
emotional well-being 8 times in connection
with decreased anxiety, state of mind, attitude Discussion
improvement, and human contact. One pa- The experience of hospitalization creates pain
tient commented “[massage therapy] was one and anxiety for many people, regardless of their
of the few times I could look forward to underlying medical condition. The goal of the
human contact without the potential for pain present study was to explore how massage
(as opposed to shots, IV’s . . .).” Another pa- therapy would affect a patient’s perception of
tient described her experience with massage pain in the acute care setting. Previous studies
therapy this way: “I was so relieved and grate- have established the benefits of massage ther-
ful. I was no longer crying and felt much bet- apy for patients suffering from particular ill-
ter. I was so grateful for the body and mind nesses—for example, cancer (19)—and cardiac
relief.” One of the participants in the research surgery or procedures (3,6,17). Other studies
project was in advanced stages of cancer. Al- have focused on patient experiences within par-
though she died, her husband returned the ticular hospital units including transplantation,
survey, commenting that his “wife appreciated neuroscience, and rehabilitation (4). By select-
the pain relief, and that ‘the massage brought ing research participants in units throughout
a smile to her face,’” also noting his own ap- the hospital, with a wide variety of diagnoses
preciation of the therapy. and reasons for hospitalization, our project
Although nursing comments focused mainly provides a unique picture of how massage ther-
on pain management and relaxation, 2 nursing apy may benefit any patient coping with the
notes articulated improved emotional well- pain and stress associated with hospitalization,
being. A nurse in the Women’s and Infant Cen- offering a strong argument that massage is an
ter noted that “patient has been teary about effective adjunct therapy for pain management.
infant in special care nursery, had a massage, The primary findings of this preliminary study
now coping a little better.” Another nurse com- show a strong correlation between reduction of
mented “Patient seemed calmer tonight, not pain levels after massage therapy and statisti-
agitated, or hostile.” cally significant differences in pain scores before
Continued
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218 Appendix A ■ Example of Mixed Quantitative–Qualitative Study

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
and after massage. The perception among par- Participation in our research study was
ticipants of improved pain levels and less need limited to adults whose medical circum-
for pain medication underscore the promise of stances allowed them to receive massage
massage therapy’s positive effect on pain man- therapy and to complete the study paper-
agement protocols. In addition, a majority of work. The study does not reflect the percep-
patients felt that massage therapy contributed tions of patients whose energy or pain levels
to increased relaxation, emotional well-being, precluded them from participation. Patients
ability to sleep, ability to move and to partici- whose level of pain did not allow for partici-
pate in other therapies, and faster recovery. For pation may have found less benefit from
most patients, the effects of the session lasted massage therapy, revealing the need for fully
1–4 hours, with some participants experiencing integrative services in which massage is
benefits for more than 24 hours. merely one component of a comprehensive
Reports of improved levels of relaxation pain management protocol.
after massage therapy were received from 98% Another limitation of the present study is
of the research study participants. The fact the lack of collection of physiological data, in-
that patients throughout the various hospital cluding heart rate, blood pressure, and oxygen
units, with a wide variety of pre-massage pain levels. The absence of data on the physiologi-
levels, experienced relaxation through massage cal indicators of pain and the RR means that
therapy indicates the true potential for mas- the study relied on participant perceptions
sage to support healing for hospitalized pa- without additional external measures to verify
tients. This finding was reiterated in comments participant responses to massage therapy.
from patients and nurses alike. By accessing a Pain is an inherently subjective experience that
patient’s ability to relax, massage therapy ad- includes physical and emotional elements.
dresses a variety of needs. Indeed, the RR may Within the hospital environment, health care
be the most profound mechanism through workers rely on patient perceptions for pain
which massage therapy helps the hospitalized management. The present study thus reflects
patient. current standards for assessing the effective-
In addition to relaxation, massage therapy ness of various interventions to address pain
also counters another fundamental aspect of in patients.
hospitalization, the sense of isolation experi- The current project, designed to gather pre-
enced by many patients. In the present research liminary data on the research hypothesis, did
study, participants reported an improvement not use a control group. The selection of addi-
in emotional well-being—an aspect of healing tional patients in units throughout the hospital,
that may speak to the need for human touch. combined with randomization to groups,
More and more hospitals are recognizing the would have required substantial additional
importance of touch for the hospitalized pa- resources. However, future studies on massage
tient (4,6). As the face of health care changes therapy in an acute care setting may benefit
in the coming years, it is a hopeful sign that from the addition of a control group. Such
safe, skillful touch is being recognized as a research may also help to identify specific types
mechanism of healing for patients in the acute of massage therapy that are most effective in
care setting. the acute care setting.
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Appendix A ■ Example of Mixed Quantitative–Qualitative Study 219

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
Conclusions 9. Hernandez-Reif M, Field T, Krasnegor J, Theakston H. Lower back
pain is reduced and range of motion increased after massage ther-
Evidence-based research continues to confirm apy. Int J Neurosci 2001; 106(3–4): 131–145.
the importance of human touch to balance 10. Melancon B, Miller LH. Massage therapy versus traditional therapy
for low back pain relief: implications for holistic nursing practice.
the high technology of today’s health care Holist Nurs Pract 2005; 19(3): 116–121.
practices. The further integration of CIM 11. Anderson PG, Cutshall SM. Massage therapy: a comfort intervention
therapies such as massage into the hospital for cardiac surgery patients. Clin Nurse Spec 2007; 21(3): 161–165.
offers the possibility to improve the experi- 12. Cassileth B, Trevisan C, Gubili J. Complementary therapies for can-
cer pain. Curr Pain Headache Rep 2007; 11(4): 265–269.
ence for patients who face physical, psycho- 13. Ferrell-Torry AT, Glick OJ. The use of therapeutic massage as a nurs-
logical, and social challenges in an unfamiliar ing intervention to modify anxiety and the perception of cancer pain.
environment. A large and growing body of Cancer Nurs 1993; 16(2): 93–101.
14. Aourell M, Skoog M, Carleson J. Effects of Swedish massage on
research, including the current project, justi- blood pressure. Complement Ther Clin Pract 2005; 11(4): 242–246.
fies the use of massage therapy for pain man- 15. Benson H. The Relaxation Response. New York, NY: William Morrow
agement in the acute care setting. Massage and Company; 1975: 99–110.
therapy can provide pain relief and relaxation, 16. White JA. Touching with intent: therapeutic massage. Holist Nurs
Prac 1988; 2(3): 63–67.
can support a patient’s emotional well-being 17. Richards KC. Effect of a back massage and relaxation intervention
and recovery, and can ultimately aid in the on sleep in critically ill patients. Am J Crit Care 1998; 7(4): 288–299.
healing process for hospitalized patients. 18. Moyer CA. Affective massage therapy. Int J Ther Massage Bodyw 2009;
1(2): 4.
REFERENCES 19. Smith MC, Kemp J, Hemphill L, Vojir CP. Outcomes of therapeutic
1. Pearson Education. American Academy of Pain Management massage for hospitalized cancer patients. J Nurs Scholarsh 2002;
accreditation helps pain organizations meet JCAHO standards. 34(3): 257–262.
Pearson Education, Bridging the Gap website. http://test.pearsonass- 20. Kania A, Porcino A, Vehoef MJ. Value of qualitative research in the
essments.com/bridginggap/fall2001-p1.htm. Published Fall 2001. study of massage therapy. Int J Ther Massage Bodyw 2008; 1(2): 6–10.
Updated n.d. Accessed July 12, 2007. 21. Charmaz K. Qualitative interviewing and grounded theory analysis.
2. Ezzo J. What can be learned from Cochrane systematic reviews of In: Holstein A, Gubrium JF, eds. Inside Interviewing: New Lenses, New
massage that can guide future research? J Altern Complement Med Concerns. Thousand Oaks, CA: Sage Publications; 2003: 311–330.
2007; 13(2): 291–295.
3. McCaffrey R, Taylor N. Effective anxiety treatment prior to diag- ACKNOWLEDGMENTS
nostic cardiac catheterization. Holist Nurs Pract 2005; 19(2): 70–73.
4. Smith MC, Stallings MA, Mariner S, Burrall M. Benefits of massage This research was conducted at Flagstaff Medical
therapy for hospitalized patients: a descriptive and qualitative eval- Center, Flagstaff, Arizona, from October 2006 to
uation. Altern Ther Health Med 1999; 5(4): 64–71.
March 2007.
5. Mitchinson AR, Kim HM, Rosenberg JM, Geisser M, Kirsh M,
Cikrit D, et al. Acute postoperative pain management using mas- The authors thank Alisha Witcomb, LMT, for
sage as an adjuvant therapy: a randomized trial. Arch Surg 2007; her contribution as one of the three massage ther-
142(12): 1158–1167.
apists involved in this study and as an integral col-
6. Cutshall SM, Fenske LL, Kelly RF, Phillips BR, Sundt TM, Bauer
BA. Creation of a healing enhancement program at an academic laborator in the data collection process. The
medical center. Complement Ther Clin Pract 2007; 13(4): 217–223. authors also express their gratitude to Lori Pearl-
7. Egnew TR. The meaning of healing: transcending suffering. Ann mutter, PT, MPH. Lori was inspirational and sup-
Family Med 2005; 3(3): 255–262.
8. Field T, Diego M, Cullen C, Hernandez-Reif M, Sunshine W, Dou-
portive throughout the process, as a co-investigator
glas S. Fibromyalgia pain and substance P decrease and sleep im- and a mentor.
proves after massage therapy. J Clin Rheumatol 2002; 8(2): 72–76.

Continued
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220 Appendix A ■ Example of Mixed Quantitative–Qualitative Study

The Effects of Massage Therapy on Pain Management in the Acute Care Setting—cont’d
CONFLICT OF INTEREST NOTIFICATION Adams, R., White, B., and Beckett, C. The Effects of
The authors declare that no conflicts of interest are Massage Therapy on Pain Management in the Acute
associated with this research project or publication Care Setting. International Journal of Therapeutic Massage
of findings. & Bodywork: Research, Education, & Practice, North
a Motsinger S. Unpublished report for the Capstone America, 3, Mar. 2010. Available at:http://www.
Project for DPT. Flagstaff, AZ: Northern Arizona ijtmb.org/index.php/ijtmb/article/view/54/101. Date
University; 2003. accessed: 26 Jul. 2013. Reprinted with permission.
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Appendix B

Example of Qualitative Study

The intent of providing you with Chapter 1 from a
qualitative study is for you to glean insight from the
structure and description of the entire inquiry.

Chapter 1 of Qualitative Study

Introduction Background of the Study
The shape of one’s knowing becomes the shape of My interest in facilitating a narrative inquiry
one’s doing, being and becoming. with mothers of school-age children living
—Author Unknown within a rural, religiously conservative, histori-
This chapter provides an overview of a narrative cally patriarchal-driven environment and their
inquiry that sought to glean a more informed subsequent journey to situate self-nurturance
and in-depth understanding from stories of within their daily living stems from my experi-
four working mothers of school-age children ence as a woman, a mother, and an occupa-
and how they pursued and engaged in self- tional therapist interested in women’s wellness
nurturance within a rural, religiously conserva- education within rural communities. Clandinin
tive, and historically patriarchal-driven context. and Connelly (2000) note, “Narrative inquiries
The chapter includes the background of the are always strongly autobiographical. Our re-
study, need for the study, a purpose statement, search interests come out of our own narratives
guiding research questions, an overview of the of experience and shape our narrative inquiry
theoretical framework undergirding the study, plotlines” (p. 121). As a woman living within
an overview of the research methodology, an this contextual environment I have consistently
identification of the study’s significance, and a received nonconstructive messages about how
delineation of the assumptions and limitations much time and effort I should put forth nur-
associated with the study. turing self. The majority of the messages I have

Continued

221
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222 Appendix B ■ Example of Qualitative Study

Chapter 1 of Qualitative Study—cont’d

received over the years questioned whether I well-being. In occupational therapy, meaningful
should, as a wife and mother, take time away occupation is defined as those experiences that
from my household, husband, and children to promote, enhance, or maintain an individual’s
facilitate and maintain my own personal health state of well-being (Christiansen, 1999). It has
and well-being. One of my closest and dearest been further defined by Pierce (2001) as being
friends, who happens to be a woman, has personally constructed within perceived tempo-
posed this thought to me numerous times ral, spatial, and sociocultural conditions. Wilcock
throughout the years, “Is it really appropriate (1998) describes engagement in meaningful oc-
for you to take time away from your children cupation as, “[T]he synthesis of doing, being
and husband to have a facial or sign up for a and becoming” (p. 249). Consequently, in the
painting class—what if the boys need you and field of adult education, Parker Palmer’s
you aren’t available because you are doing (2000) perspective of coming to know self
something for yourself—what if all mothers enough to allow one’s life to speak of its needs
spent time taking care of themselves—who is is closely related to Wilcock’s interpretations of
going to cook, clean, and help the children with doing, being, and becoming (Hasselkus, 2002).
their home-work?” A religiously conservative During the past decade as a mother, woman,
man within the community, who has always and an occupational therapist, I have heard
been slightly irritated with my independent na- other mothers wanting to engage in self-
ture, once told me “Your place is in the home– nurturance; however, because of both time
you don’t need time for yourself—your children constraints and sociocultural influences that
and husband always come first!” These and told them their needs are less important than
similar messages from my sociocultural envi- husband and children, they had left the mean-
ronment have facilitated my confused narrative ingful occupation of self-nurturance unex-
about the worthiness of my identity as it relates plored, untouched, and unattained. Nurturing
to a mother who nurtures self. As an occupa- self and taking care of one’s emotional, physi-
tional therapist I have struggled for nearly a cal, intellectual, and spiritual needs is impor-
decade to conceptualize and move forward tant to women’s overall development; thus, the
with an educational program focused on facil- conceptualization of this study was that self-
itating mothers’ engagement in nurturing self nurturance and women’s development of self
within this sociocultural environment. must be dealt with simultaneously. It would be
At this juncture, it is important to explain impossible to address nurturing self without
what self-nurturance means to this inquiry, the parallel notion of women’s formation of
which is focused on in-depth narratives. For the self. Therefore, the focus of this inquiry was to
purpose of this study, self-nurturance refers to deconstruct mothers’ lived stories around nur-
the invaluable and precious time required to turing self within their contextual environment
refuel a mother’s mind, body, and spirit—those and how their identities shifted over time as
moments of time that mothers capture to they attempted to or successfully engaged in
take walks, engage in gourmet cooking classes, self-nurturance.
write in journals, or join a book club. Addition- As will be discussed later, key assumptions
ally, as a function of this study, self-nurturance of the study were grounded in the feminist
is defined as a meaningful occupation that sup- poststructuralist notions of constantly shifting
ports and enhances mothers’ overall health and identity and non-unitary self. The notion of
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Appendix B ■ Example of Qualitative Study 223

Chapter 1 of Qualitative Study—cont’d

non-unitary self is defined by Clark (1999) as these women did not feel they have the right to
a self that is consistently challenged by society engage in self-nurturance. Throughout my
and split between an experience and the inter- years of living within this sociocultural context,
pretation of the experience. What one thinks I had noted nurturance of self was not generally
and feels about one’s self is not totally in that highly regarded; therefore, it was rarely thought
individual’s control; rather, it is largely shaped of or even talked about as a facilitator of
by ideas and experiences within many different women’s health and well-being.
contexts in light of gender, race, class, religion, Again, I must note that I had heard mothers
geographical location, and so on. The conjec- tell stories over and over again about not en-
ture is that as an individual’s knowing and un- gaging in self-nurturance which revealed the
derstanding of how these factors influence his basic fact of these women having limited
or her constantly shifting identity, a conscious amounts of time and energy; however, this fact
raising is developed; hence, individuals have an appeared to be compounded by an overwhelm-
enhanced understanding and management ing feeling of guilt and responsibility to make
over their doing, being, and becoming. those around them content and comfortable
This narrative analysis served as a means of above and before nurturing self. These moth-
focusing on the mothers’ ownership and invest- ers shared an unspoken truth with me—they
ment in self-nurturance as a positive determi- knew they were neglecting and sacrificing
nant of their health and well-being. I was self-nurturance; however, they had been unable
hopeful that by the conclusion of this study, the to resolve key barriers in their path toward this
mothers had a deeper understanding of their important component of mothers’ personal
constantly shifting identities and the impact health and well-being.
discourse and power had within their environ- As a researcher, I wanted to further explore
ment on their learning, knowledge, and partic- mothers’ stories of negotiating self-nurturance,
ipation in self-nurturance. In addition, I was in relation to their culturally defined roles and
certain this narrative study would assist me responsibilities as mothers with school-age chil-
in understanding how to more efficiently and dren. By engaging in this narrative inquiry, it was
effectively organize wellness education for hoped that both the researcher and participants
mothers within this specific cultural context. would construct an expanded understanding of
women’s identity and, more importantly, their
Need for the Study: Situating the Problem role in nurturing self. My agenda was to find
In light of insights from my personal life and four mothers willing to participate in the study
professional practice, it was my impression that and then glean insight from their stories. I then
there was a preponderance of women, more planned to narrate their stories in an effort to
specifically mothers with school-age children afford them the opportunity to reflect upon
living within this environment, who did not their constantly shifting identities within their
consider or engage in self-nurturance primarily cultural surroundings and determine how this
for three reasons. First, they had a limited impacts their balance of self-nurturance, health,
awareness of its value in relationship to their and well-being. As Tisdell states (2001):
overall health and well-being. Second, they It is the unpacking of the story around issues
found the contextual and sociocultural barriers of positionality, and the critical reflection, both
of engagement too great to overcome. Third, on the story and on the story’s unpacking that
Continued
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224 Appendix B ■ Example of Qualitative Study

Chapter 1 of Qualitative Study—cont’d

helps us understand our constantly shifting There is a substantial amount of literature
identity around systems of power, privilege and that consistently heralds women as being nur-
oppression that inform our lives. It raises our turers of others; however, none of the litera-
consciousness, it changes our behavior, it does ture addresses why mothers consistently do
indeed, move us to action. (p. 283) not find the time, the privilege, or learning
By affording these mothers the opportunity experiences aimed at nurturing self (Bateson,
to share their stories around the cultural para- 1990; Chodorow, 1978; Duffy, 1991; Esdalie
digms of motherhood, rural living, conservative & Olsen, 2004; Gilligan, 1987; Ruddick,
religious beliefs and value systems, and patri- 1989). In addition, literature from the field of
archy, I suspected that they would better un- psychology implies that women have been so-
derstand the state of their constantly shifting cially constructed to take care of others, which
identities and how this negatively or positively consequently informs the basis of their identity
impacted their ability to nurture self. of self (Duffy, 1992; Gilligan, 1987; Kegan,
Within the field of women’s studies, Carol 1994; Miller, 1986, 1990; Rogers, 1961).
Ryff (1985) has argued that research needs to Throughout my review of the literature on
focus on combinations of identity, experience, women’s construction of self and nurturance
and development as they specifically address of self, it became increasingly evident that the
lived experience. While conceptualizing the voices and experiences of mothers nurturing
study, I felt that many mothers were unable self, no matter what sociocultural environment
to validate and put worth on the learning they they are living in, are absent.
incurred while engaging in meaningful occupa- Several research and conceptual pieces
tions that were focused on self. As an occupa- focused on women consistently advocate for
tional therapist, I conceived this lack of inquiries that will offer a greater under-
importance and negotiation of self to other’s standing of women’s learning and knowing
needs on a consistent basis was having a nega- (Bateson, 1996; Collins, 1990; Hayes & Flan-
tive impact on mother’s health and well-being. nery, 2000; Hooks, 1994). From a narrative
Studies have been completed about women’s inquiry perspective Clandinin and Connelly
inability to care for self; however, these studies (2000) state, “We need to continually ask
are fueled by issues such as eating disorders, questions about the way narrative inquiry
posttraumatic stress disorder, and older illuminates the social and theoretical contexts
women’s life experiences of well-being (Morris, in which we position our inquiries” (p. 124).
2000; Rashotte, 1997; Sherwood, 2000). Re- By engaging in narrative analysis inquiry
cently, Nemcek (2003) reviewed 19 research guided by the theoretical perspectives of fem-
studies conducted within the past 8 years specif- inist poststructuralism and non-unitary self,
ically related to self-nurturance. The research whereby women’s voices and stories were
topics focused on eating disorder studies, ways heard firsthand, I hoped to contribute to the
of living (i.e., surviving grief and living with HIV acknowledgement that this type of inquiry is
or AIDS), and well adults (i.e., employees and important enough to put time, faith, and ef-
college students). The research methodology fort into as a woman, mother, and researcher.
for these studies included phenomenology, I feel this contribution has constructed new
grounded theory, concept analysis, descriptive, knowledge that will inform the way women
and quasi-experimental inquiries. teach, learn, and engage in self-nurturance.
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Chapter 1 of Qualitative Study—cont’d

Purpose of the Study in this study. Specific questions that I was con-
The purpose of this narrative analysis study cerned with were as follows:
was to glean insight from and illuminate 1. How do these women explain their identity
personal stories of four working mothers as a mother living within a rural, religiously
of school-age children living in a defined cul- conservative, and historically patriarchal-
tural context and to explore how the cultural driven environment?
realities impacted their engagement in self- 2. What positive or negative messages have
nurturance. The study took place in a rural these mothers received within their con-
northeastern community, which was defined textual environment about engaging in
by the following characteristics: Ninety-five self-nurturance?
percent White or Caucasian, with 51% of the 3. How have these mothers renegotiated
population being female. Seventy-two percent aspects of their identity over time in
of the households are two parent households, order to nurture self within their cultural
with 64% of these households having both environment?
parents in the labor force. Seventy-six percent 4. What aspects of self-nurturance are these
of the business industry within the community women still struggling with at this point
is owned and operated by men. Of the 20 in time, secondary to perspectives and
religious faiths in the community, the largest notions of the cultural environment?
percentage is identified as conservative 5. How has past and present engagement of
Christian (i.e., Bible Brethren, Pentecostal, self-nurturance been simple or complex
and Mennonite). in relation to gender within this cultural
The narrative inquiry was completed in an environment?
effort to gain a greater understanding of 6. How has past and present engagement of
the complexities and multiplicities that influ- self-nurturance been simple or complex
ence four mothers’ lived experiences of self- in light of living in a rural environment of
nurturance. With the previously described con- conservative religious beliefs or values and
text, as DuPlessis (1985) states, “Women need patriarchal-driven systems?
to make the conflicts that emerge from their
marginalized status and their rebellions againstOverview of Theoretical Framework
After considering many theoretical perspectives
marginalization central to their stories” (p. 67).
It was the purpose of this narrative inquiry to and insights gleaned from everyday experience,
provide an opportunity where four mothers’ the theoretical perspective of feminist post-
gendered perspectives and subjectivities, structuralism and the notion of non-unitary self
within their specific sociocultural context, arewere most appropriate as the guiding frame-
created into narratives as they related to self-work for this study. Feminist poststructuralism
nurturance (Bloom, 1998). considers the positionality of women within so-
ciety and offers a lens to address the intersec-
Guiding Research Questions tions of gender, rural living, and conservative
The goal of this narrative analysis inquiry was religious beliefs of the women who will be en-
to concentrate on the sociocultural contextual gaged in this narrative inquiry. Weedon (1997)
issues that influenced engagement in self- broadly describes the relationships among the
nurturance for the mothers who participated different aspects of positionality as discourse,
Continued
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226 Appendix B ■ Example of Qualitative Study

Chapter 1 of Qualitative Study—cont’d

knowledge, and power, with positionality being lens guiding these mothers’ narratives related
the intersections of social structures such as to self-nurturance, it was anticipated that cul-
race, class, sexual orientation, geographical lo- tural norms would be challenged and their par-
cation, and so on (Tisdell, 2000). Furthermore, ticipation in nurturing self would be facilitated
St. Peirre and Pillow (1998) state, “the repre- by the insights gained in relation to the decon-
sentation of positionality is always in crisis, struction and construction of their constantly
knowledge is constitutive of power, and agency shifting identity among the intersections of
is the constitutive effect, and not the originator, gender, rural living, conservative religious
of situated practices and histories” (p. 5). The beliefs or value systems, and patriarchy.
mothers engaged in this study were and still are
deeply embedded and situated within a socio- Significance of the Study
cultural context that for the most part does not Specifically, this narrative inquiry sought to tell
understand or promote the discourse and ac- the stories of four mothers who kindly gave of
tive engagement of mothers nurturing self. their time, among already overwhelming sched-
For this reason, the premises of non-unitary ules, during a 5-month period as a means to
self were an integral part of the study. Actually, open up dialogue in relation to their personal
it is difficult to understand the notions of fem- health and well-being. To this end, the four
inist poststructuralism without considering the mothers who participated in this study pre-
notions of non-unitary self. Non-unitary self is sented narrative accounts of nurturing self
defined by Robinson (1999) as, “the active and around the cultural realities of motherhood,
continual process of production of self within rural living, conservative religious beliefs and
historical, social, and cultural boundaries . . . non- values, and patriarchy.
unitary subjectivity is an ongoing process of This study is significant to rural community
production and transformation [and] . . . a health and well-being research in that it consid-
doing rather than being” (p. 11). Non-unitary ered women’s learning outside of academic
subjectivity is a compatible venue for narrative structures utilizing deconstructed narratives.
inquiry because the participant usually feels Stories from women about their lives and learn-
more open to exploring multiple layers of self. ing continue to be voices that need to be con-
The experience most often opens up the self- sidered within the field of adult education
reflective nature of the participant (Bloom, (Hayes & Flannery, 2000). Consequently, at the
1998). Furthermore, it is extremely constructive recent Mid-Atlantic Women’s Studies Associa-
to combine social appraisal with the theoretical tions Annual Conference, Mary Catherine Bate-
perspectives of non-unitary self. This approach son (2004) noted the need for adult educators
encourages the clarification of the cultural to actively pursue inquiries focusing on
norms, power issues, and dominant ideologies women’s lived experiences and stories in rural
that individuals must navigate and negotiate communities.
throughout their daily lives (Bloom, 2002). In Furthermore, there continues to be a need
this light, the notion of non-unitary self just for the employment of feminist methodologies
made sense from my perspective as a woman, focusing on the diverse frameworks of women’s
mother, and researcher. learning within the field of adult education
By utilizing feminist poststructuralism and (Bloom, 1998; Brooks, 2000; Clark, 2001).
the notion of non-unitary self as the theoretical The significance of this study utilizing the
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Appendix B ■ Example of Qualitative Study 227

Chapter 1 of Qualitative Study—cont’d

feminist poststructuralist philosophy was that engaged in the meaningful occupation of
it facilitated a collective group of women to nurturing self.
question the circumstances of various oppres-
sive forces alongside their routines of health Overview of Research Design
and well-being. This philosophical standpoint and Methodology
appeared to give these mothers more of an Narrative analysis or narratology was utilized
opportunity to question what had been facili- as the methodology for this inquiry in an at-
tating or squelching their collective health tempt to understand the mothers’ process of
and well-being. A narrative study of mother’s nurturing self and how this plays out in their
nurturance of self guided by feminist poststruc- everyday lives. The narratives focused around
turalist philosophy afforded the opportunity to the cultural realities of motherhood, rural com-
dive deep into the societal norms and thoughts munity living, religious values or belief systems,
about how the four mothers did or did not nur- and patriarchy, and it was guided by feminist
ture self on a daily basis. It moved them to poststructualism and the notion of non-unitary
question, challenge, and critique society’s min- self. As Bloom (1998) states, “Personal narra-
imalist notion of women’s health and well- tives provide primary data through which we
being (World Health Organization, 2002). can explore ways that different dominant ide-
Lastly, this study is significant for occupa- ologies and power relations are maintained and
tional therapy theory and practice. Yerxa reproduced, or subverted in the discourses of
(1998) purports that occupational therapists the respondent’s narratives” (p. 145).
must develop a better understanding of how to Reissman (1993) describes narrative analysis
assist individuals in learning how to promote as the investigation of a story, in order to dis-
their own status of health and well-being. cern how individuals telling the story make
She states, “Occupational therapists need to sense of their actions and the surrounding
learn much, much more about how human be- contexts of the story. Mishler (1995) feels
ings develop adaptive skills, rules, and habits there are many methods of approaching, defin-
that enable competence . . . such knowledge of ing, and studying narrative analysis. He feels
‘coaching’ could benefit all persons who need the researcher should be clear in the design and
to develop skills in order to survive, contribute, methodological premises under which they will
and achieve satisfaction in their daily life occu- conduct their study. Denzin (1989) provides in-
pations . . . ” (p. 418). In addition, it is gleaned sight to the notion of narratives in the following
from a wide range of literature on women’s statement:
learning that women who have a greater under- A narrative is a story that tells a sequence of
standing of their own learning and knowing can events that are significant for the narrator and
more effectively and efficiently promote the his or her audience. A narrative as a story has
positive aspects of self (Belenky et al., 1986; a plot, a beginning, a middle and an end. It
Goldberger et al., 1996; Hayes & Flannery, has an internal logic that makes sense to the
2000; Hooks, 1994). The outcome of this narrator. A narrative relates events in a tempo-
study provides occupational therapists with a ral, causal sequence. Every narrative describes
greater understanding of how mothers, who a sequence of events that have happened.
were up against socioculturally prescribed is- (p. 37)
sues of power and discourse, successfully
Continued
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228 Appendix B ■ Example of Qualitative Study

Chapter 1 of Qualitative Study—cont’d

As noted earlier, this narrative analysis in- conservative, and historically patriarchal-driven
quiry was informed by feminist poststructural- environment nurture self, while at the same
ism. Bloom (1998) contends there are three time deconstructing the foundations on which
core objectives that theoretically structure a their daily living is constructed and experienced
feminist poststructuralist approach to narra- (Bloom, 1998). Within this inquiry, four moth-
tive research: (a) the study focuses on individ- ers elaborated and offered extensive accounts
ual life stories of women as the primary source of nurturing self as related to the realities of
of data; (b) narratives of self as a location from their sociocultural context. It involved my care-
which the researcher can generate social cri- ful interpretation as I completed an in-depth
tique and advocacy is necessary; and (c) de- analysis of and reflected upon the experiences
construction of self as a humanist conception, that these women recalled in relation to their
allowing for non-unitary conceptions of self by personal stories of health and well-being
women, is a primary goal for narrative inquiry. (Grbich, 1999; Rice & Ezzy, 1999).
The challenge for me, as stated by Polking- The data collection consisted of two semi-
horne (1995), was to, “Construct a display of structured interviews, participant journaling, a
the complex, interwoven character of human creative synthesis project, and a dinner gather-
experience as it unfolds through time” (p. 18). ing after all other data collection. The first in-
As a researcher, I planned to focus on Bloom’s terview utilized a semistructured interview
charge that poststructuralist feminist researchers guide and the second interview was led by
engaged in narrative analysis inquiries must, questions gleaned by the reading of the first
“Embrace the idea that an understanding of interview and journal. Both interviews were
non-unitary subjectivity in women’s lives is crit- audiotaped and transcribed. The women
ical” (p. 3). The concept of non-unitary self kept a self-nurturance journal for 3 months
was critical to this study because it was utilized focusing on the cultural components of moth-
as the grounding by which these mothers ex- erhood, conservative religious beliefs and val-
plore the multifaceted, multilayered, complex- ues, patriarchal-driven implicit and explicit
ity and fragmentation of self within this dynamics, and rural community living. In addi-
specific sociocultural context and how this tion to completing two interviews and journals,
notion of self impacts their past, present, and each woman completed a creative synthesis
future nurturance of self. project focusing around the following themes:
Bloom (1998) further suggests that any nar- (a) How does it feel when you are not engaged
rative that utilizes the notion of non-unitary self in self-nurturance? (b) What are the obstacles
as a theoretical lens is a solid grounding for to self-nurturance? and (c) How do you feel
studies that wish to get to the heart of women’s when you are engaged in self-nurturance? The
stories. Narratives are indispensable resources creative synthesis projects were completed after
for occupational therapists because they are in- the second interview and were to be brought to
dividual interpretations and perspectives of the dinner gathering where the women met one
their engagement in meaningful occupation another. Following the completion of their
(Wicks & Whiteford, 2003). To this end, it was creative synthesis projects, three of the four
the goal of this narrative study to gain a deeper women attended the dinner gathering to dis-
understanding of how working mothers with cuss their overall participation in the project
school-age children living in a rural, religiously and to share their creative synthesis projects
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Appendix B ■ Example of Qualitative Study 229

Chapter 1 of Qualitative Study—cont’d

with one another. The interview transcripts, individuals must actively participate and
journal entries, creative synthesis projects, and be actively represented in all aspects of the
the dinner gathering provided the data for research process.
which the findings of this study were based and 2. The feminist poststructuralist perspective
are explained in more detail in Chapter 3. of constantly shifting identity (non-unitary
Consequently, feminist poststructuralism de- self) is an empowering notion for women
mands that researchers be more responsive and living in the 21st century.
attentive to women’s everyday life contexts 3. The process of motherhood has not been
(Bloom, 1998). I discerned it was my responsi- researched adequately in terms of the over-
bility as a researcher to listen to the lives of all positive and negative effects it has on
women in relation to their needs and strengths the health and well-being of women.
of nurturing self as a unique dovetailing into 4. The feminist poststructuralist theory is a
their personal health and well-being. Through- powerful and meaningful lens to view the
out the study I felt comfort in Bloom’s (2002) deconstruction of power and discourse
sentiment, “For feminist researchers, the need within women’s lives.
to know is based on a need to understand the 5. Individual understanding of, and the engage-
forces that shape women’s lives and a need to ment in, meaningful occupation is a positive
discover ways for women to transform and have aspect of personal health and well-being.
authority over their own lives” (p. 147). The re- 6. The primary researcher is always present in
search environment provided the lens of feminist the inquiry and the final product.
poststructuralism to initiate and enlighten these 7. Attending to my feminist poststructuralist
four mothers’ understanding of the oppressive sense of being, I am entering into this re-
and sometimes overpowering sociocultural real- search project thinking and feeling that
ities of their lives. As Hooks (1989) notes, the participants will want to speak for
women need to learn to resist sexism in the themselves in the data collection and data
home—”That special place in which there should analysis section of this dissertation.
be care for others . . . the need for transforma- 8. The unique relationship that exists between
tion of the self, of relationships, so that [women] researcher and coresearchers in a narrative
might be better able to act in a revolutionary inquiry present a unique set of ethical con-
manner, challenging and resisting domination, siderations that reflect the unique relation-
transforming the world outside the self” (p. 22). ship between researcher and coresearchers.
The central objective of this narrative inquiry was 9. An inquiry should challenge beliefs of truth
to offer these mothers an opportunity to deepen that have held some women in bondage for
their understanding of their self-nurturance rou- generations–knowledge production outside
tines within their sociocultural environment. of the box is empowering and emancipating.

Assumptions Limitations
The following were the major assumptions that The following are the major limitations that I
I held as I entered into this inquiry from a fem- felt were relevant as I entered into this inquiry:
inist poststructuralist lens: 1. I was a novice researcher; therefore, this was
1. For research to be valid and useful in my first attempt at conducting a narrative
the everyday lives of individuals, those analysis inquiry.
Continued
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230 Appendix B ■ Example of Qualitative Study

Chapter 1 of Qualitative Study—cont’d

2. This study was conducted within a small this inquiry will serve as a facilitator for health-
geographical area with the characteristics care practitioners to consider how they may
of being religiously conservative, patriar- incorporate concepts of women’s learning and
chal-driven, and in a rural defined area of knowing into their daily practice.
the United States. It may or may not be
pertinent or useful to other mothers of Definition of Terms
school-age children living in different In order for the reader to understand, with
contextual environments. more clarity, I have defined the following terms
3. A potential limitation was the loss of data that will be frequently utilized throughout this
outside of the narrative structure; however, dissertation.
I made every attempt to conduct a global
analysis of the entire transcript, as well as Constantly shifting identity—based on the ongo-
specifically focusing on intact stories. ing development of women’s understanding
of their positionality (see definition below),
Summary which encumbers their historical, political,
To date, insights from feminist perspectives and cultural lives.
have not been addressed adequately within the Feminist poststructuralism—notions of decon-
field of occupational therapy and occupational struction and reconstruction of power,
science. This may be why the occupational ther- discourse, and knowledge as related to
apy profession continues to struggle with find- the everyday lives of women.
ing its place in providing preventative and Health and well-being—includes elements of
holistic education for women; more specifically, choice, meaning, balance, satisfaction,
mothers of school-age children. Most impor- opportunity, and self-actualization
tantly, the outcome of this research is for the (Wilcock, 1998).
women involved in the study and for those lives Meaningful occupation—meaningful work, play,
that are touched by the extensions of this re- or daily living tasks in the stream of time
search. I hold the overwhelming belief that a and in the contexts of one’s physical and
large majority of working mothers of school-age social world (Kielhofner, 2002). Wilcock
children living in rural environments are in emi- (1998) describes engagement in meaning-
nent need of a starting point of conversation for ful occupation as, “the synthesis of doing,
learning more about their constantly shifting being and becoming” (p. 249).
identity and how this relates to their construc-
tive engagement in self-nurturance as a facilita- Non-unitary self—active and continual process
tor of their everyday health and well-being. of production of self within historical, social,
This narrative analysis inquiry situated from and cultural boundaries . . . non-unitary
a feminist poststructuralist lens will assist subjectivity is an ongoing process of produc-
healthcare practitioners in understanding more tion and transformation [and] . . . a doing
about research outside of formal academic and rather than being” (Robinson, 1999, p. 11).
work structures. Specifically, it will assist them Occupation—activities, tasks, and roles for the
in understanding the unique wellness education purpose of productive pursuit, maintaining
needs of the mothers in rural communities. In oneself in the environment, and for purposes
addition, on a broader scale, I am hopeful that of relaxation, entertainment, creativity, and
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Appendix B ■ Example of Qualitative Study 231

Chapter 1 of Qualitative Study—cont’d

celebration; activities in which individuals Synopsis of Research Inquiry
are engaged to support their roles and The following is a picture in preview of the re-
needs (Christiansen & Baum, 1997, p. 60). maining chapters of the qualitative research
[A]ctivities . . . of everyday life, named, inquiry. Chapter 2 includes a review of the lit-
organized, and given value and meaning by erature, both research and conceptual, deemed
individuals and a culture. Occupation is relevant to this study. Chapter 3 of the study
everything people do to occupy themselves, provides a detailed explanation of, and the
including looking after themselves (self-care) rationale for, the methodology utilized to con-
. . . enjoying life (leisure) . . . and contribut- duct the inquiry. Chapters 4 to 7 is the presen-
ing to the social and economic fabric of their tation of narratives in motion for each mother
communities (productivity) (Law, Polatajko, who participated in the study. Chapter 8 will
Baptiste, & Townsend, 1997, p. 32). present the intersecting narratives in motion, which
Positionality—An understanding of “particular is collective theme interpretation of the narra-
structures” such as racism, sexism, or euro- tives in motion. Chapter 9 offers an in-depth
centrism. A form of theorizing with first analysis of the findings, which represents the
knowing where you are positioned. Locat- insights gleaned from this narrative inquiry and
ing the self in relation to others within recommendations for future research.
social structures (Maher & Thompson
Tetreault, 1994, p. 202).
Self-nurturance—the acts of engaging in
meaningful occupations which promote,
enhance, or maintain one’s state of health
and well-being (Nemeck, 2003).
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Appendix C

Example of Evidence-Based
Practice Project
An example of the first chapter from an evidence-based prac-
tice project is provided for you to gain insight into the purpose
as well as the process of engaging in evidence-based practice.

Introduction A brief statistical description of the population and

geographical location serves to set the scene for this
This chapter describes the geographical location and intervention. The rural community, nestled in the
the practice setting in which the evidence-based prac- foothills of the Laurel Highlands in southwestern
tice project was conducted. It provides background Pennsylvania, boasts a population of just over 11,000,
information related to managing problematic nega- with approximately 17% of the population over the
tive behaviors in patients with dementia within the age of 65 according to the 2000 U.S. Census. The bor-
skilled nursing facility and the rationale for consid- ough itself has a population of 4,728, with the re-
ering use of a multisensory environment as a viable mainder of the population residing in primarily
solution. Potential opportunities and threats to im- single-family dwellings within its more rural town-
plementation of the project as well as its impact on ship. The U.S. Census Bureau projects a significant
the field of occupational therapy are also discussed. increase in the population of those 65 and older from
the year 2000 to 2030. Statistical projections for the
Description of Evidence-Based Practice Setting
state of Pennsylvania suggest an increase from 4% to
Woody Pines, located in a rural community in south- 50.6% in the elderly population during this period
western Pennsylvania, is a geriatric care center that in- (U.S. Census Bureau, 2007).
cludes a 109-bed skilled nursing facility, a 70-bed
assisted living facility, and an on-site adult day care. Background Supporting the Evidence-Based
The rustic log home, built in the early 1900s, origi- Practice Intervention
nally served as a private family home, but was pur- Dementia is the significant loss of intellectual abili-
chased in 1988 by a management services company ties, such as memory capacity, which is severe enough
and renovated to function as it does today. The facil- to interfere with social or occupational functioning
ity offers pharmacy, medical supply, hospice care, and (MedicineNet). The Alzheimer’s Association (2007)
rehabilitation services primarily to adults over the age reports Alzheimer’s disease is the primary form of
of 65 years. dementia, affecting over 5 million Americans. It is the

233
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234 Appendix C ■ Example of Evidence-Based Practice Project

seventh-leading cause of death and limits cognitive related to dementia, and implementation of sensory-
and behavioral abilities, thereby affecting one’s ability based treatments in an attempt to curtail unwanted
to engage in meaningful work, self-care, leisure, and behaviors and increase engagement in meaningful
social activities. In the skilled nursing facility, these occupations.
residents often exhibit inappropriate behaviors
including “severe mood swings, verbal or physical Rationale for Evidence-Based
aggression, combativeness, repetition of words and Practice Intervention
wandering” (Alzheimer’s Association, 2007). Staff
Caregivers, staff, and families of patients with de-
often become frustrated and respond by raising their
mentia often find the behavioral changes that
voices, trying to reason with the residents, requesting
accompany the disease most challenging to manage.
medication changes from the doctor, and physically
Damage to the brain cells as a result of disease pro-
restraining the residents; however, many of these
gression can cause agitation, aggression, anxiety, and
responses only stand to exacerbate the symptoms of
sleep disorders. Other explanations for the onset of
dementia.
these behaviors include medication side effects, other
The complex interaction of the senses of audition,
medical conditions or diagnoses, and environmental
vision, taste, smell, movement, touch, and body posi-
factors. Environmental factors can loom high on the
tion is necessary for an individual to interpret infor-
list of causes for nursing home residents because of
mation in his or her environment and make
the inability to manage the transition to a new living
appropriate behavioral responses to the stimuli
situation, changes in routine, absence of familiar sur-
(Kremer, Hildeman, Lape, & Miller, 1998). The inte-
roundings and individuals, and perceived fears
gration of all of these sensations promotes adaptive
(Alzheimer’s Association, 2005).
behaviors (Fisher, Murry, & Bundy, 1991). In addi-
Yet another plausible explanation for negative be-
tion, the importance of sensory function is high-
haviors is occupational deprivation, which is a lack of
lighted in the Occupational Therapy Practice
involvement in required or meaningful occupations,
Framework under the client factors area. Vision, hear-
because of factors that are uncontrollable by the in-
ing, vestibular function, taste, smell, proprioception,
dividual (Whiteford, 2000). This concept can be seen
touch, pain, temperature, and pressure are all areas to
in the typical nursing home resident, but two other
consider when viewing the dementia resident holisti-
occupational terms are also discussed in the literature
cally (AOTA, 2008). In the skilled nursing facility,
that accurately describe the occupational dilemmas
where the regulations of Medicare and third-party
of residents with dementia. The first is occupational
payers often reign, little attention is given to this vital
dysfunction, which is explained as a consequence of un-
area. Review of a typical occupational therapy evalu-
resolved deprivation related to a lack of adequate oc-
ation includes a short section on vision, hearing, and
cupational capacities (Whiteford, 2000). The second
touch sensation, but does a poor job of investigating
is occupational alienation, which describes situations
other areas of sensory processing, despite the fact that
where occupations may be available, but they may not
it can significantly impact moods, behaviors, and the
be meaningful. Townsend and Wilcock (2004) note
ability to participate in meaningful occupations.
that this concept is associated with “prolonged expe-
The intent of this evidence-based occupational
riences of disconnectedness, isolation, emptiness, lack
therapy program is to explore current literature on
of a sense of identity, a limited or confined expression
the use of Snoezelen or multisensory environments
of spirit, or a sense of meaninglessness” (p. 80).
to manage negative behaviors in clients with demen-
tia who reside within a skilled nursing facility. The A visit to a typical skilled nursing facility could allow one
project requires creation of a multisensory environ- to view the following:
ment within the skilled nursing facility, identifica- Several residents are seated in various wheelchairs
tion of residents exhibiting negative behaviors and recliner chairs around the nurses’ station. One balding
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Appendix C ■ Example of Evidence-Based Practice Project 235

gentleman smiles gently at passersby and repeatedly asks, dementia in a skilled nursing facility, time is irrele-
“Where can I get the bus to Chicago?” Another emaciated vant. Often the days run into the nights. There are no
woman with needle-straight gray hair beckons with one out- discernible differences between weekends and week-
stretched finger, “Come here” over and over to anyone that days. Often there are few meaningful events to look
glances in her direction. A small-featured woman clutches forward to. A familiar yet inappropriate response
a baby doll and cries uncontrollably, so much so that the to this situation is sleep. Whiteford (2000) reports
words she utters are not discernible. Another African- the same response in inmates who are occupationally
American man stands repeatedly from his wheelchair and deprived.
the alarm sounds its familiar tune, while the nurses nearby Focusing on increasing awareness of sensory pro-
repeat, “Sit down; Sit down.” cessing in relation to function in dementia residents
Some residents are found in the dining room par- within the skilled nursing facility could provide a
ticipating in bingo or beauty spot, whereas others sel- more holistic approach to therapy and nursing care,
dom leave the confines of their rooms. Some help to decrease physical and chemical restraints, and
residents are able to bathe and dress themselves, increase the staffs’ understanding of dementia and
whereas others have nurse aides who complete the effective interventions to create a positive and mean-
chore because of sheer convenience or increased ingful experience for residents and caregivers alike. A
speed. A lack of appropriate socialization skills seems concentration on occupations and the environment
to prevail because of worsening symptoms of demen- is most appropriate with dementia residents, who
tia and increased frustrations by family members and often exhibit symptoms that cannot be changed, but
staff. You can see it in the furrowed brow of a tired rather need to be managed.
spouse unable to make the connection with a loved Patricia Wilbarger lays claim to the term sensory
one, or in the hurried pace of a nurse’s aide who ap- diet, which involves a usually unconscious modifica-
parently has too much to do in too little time. Televi- tion of sensory activities throughout the day to calm,
sions blare in various rooms and lounges, but no one alert, and organize behaviors (Occupational Therapy
really appears to be watching. Many residents are put Innovations, 2008). With disease, illness, or injury, as
to bed when the staff feels that it is time. Many are in the case of the dementia residents, this ability may
not given the choice of clothing or when they will get be missing or ineffective. The Snoezelen approach,
up or get washed. They are told what to eat and when which originated in the Netherlands in the 1970s, is
to eat. The facility has an assortment of activities one approach to coping with poor sensory modula-
scheduled daily, but at times the schedule seems to tion. The term comes from the combining of the
lack variation. Some activities are appropriate for Dutch words sniffing and dozing. The goal of this ap-
either sex, but many are geared more toward the proach is to provide environments and sensory expe-
women, who make up the majority of the residents riences “that stimulate the primary senses without
residing there. the need for intellectual activity in an atmosphere of
The philosophy is quality of care, but closer exam- trust and relaxation. It is a failure free approach inso-
ination reveals a facility full of elderly people, most far as there is no pressure to achieve” (Burns, Cox, &
with some form of dementia, who are no longer able Plant, 2000, p. 120). Much of the literature available
to make decisions about their care or to participate presents Snoezelen as more of a philosophy of care
in meaningful occupations. These frustrations be- that infiltrates all aspects of care with the elderly,
come apparent in the cries, aggressive behaviors, rather than a single therapy modality (Achterberg,
wanderings, and lethargy of the residents. 2004; Burns et al., 2000). Application of this philoso-
In a study by Christianson, he comments on the phy can range from whole rooms devoted to the
“positive relationship between time spent engaging sensory experience to mobile carts or bags with more
in meaningful occupation and perceived wellbeing” portable items that can be used in other areas of
(Whiteford, 2000, p. 203). For the resident with the building including the residents’ rooms (Ball &
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236 Appendix C ■ Example of Evidence-Based Practice Project

Haight, 2005). Moreover, this approach comprises deemed necessary to provide any needed equipment
many of the tenets of occupational therapy laid out in and to allow work time to educate and train nursing
The Occupational Therapy Practice Framework: Domain and and rehab staff. Strong organizational and clinical
Process (AOTA, 2008). Snoezelen “requires a resident- skills of the project coordinator and fellow rehab staff
oriented attitude, knowledge and skills, allowing care- facilitated development of a structured presentation
givers to incorporate personal circumstances such as to justify the need for the project as well as the ex-
lifestyle, preferences, desires, and cultural diversity to pected outcomes. Describing the marketing and cus-
achieve or maintain a state of well-being” (van Weert, tomer service advantages to the facility were used to
van Dulmen, Spreeuwenberg, Ribbe, & Bensing, 2005, gain approval for purchase of the necessary supplies.
pp. 24-25). The overwhelming reason that this project
might be beneficial to the skilled nursing facility Barriers
setting is to “overcome the expectation on confused Initially, the most common foreseeable threats to this
people to function in ‘our world’ and instead under- project were lack of financial support and time con-
stand the meaning of their world” (Burns et al., 2000, straints. It was believed that the greater the financial
p. 120). support given, the more expansive the project could
become. Ultimately, this evidence-based project was
Identification of Support and Barriers conceptualized with many possibilities, perhaps being
in the Setting viewed in phases, with each phase providing the sup-
Support port for further expansion into the subsequent phases.
As with any good project, the support of numerous The entire project was designed to be undertaken with
individuals was required to bring this evidence-based little financial support initially, if necessary.
intervention to fruition. As the manager of the rehab With the current climate of health care, staff reten-
department, the project coordinator had a great deal tion and productivity are highly scrutinized factors
of flexibility with how things operated on a day-to- that threatened this project. Use of creative schedul-
day basis and the program initiatives implemented, ing and teamwork were essential to allow ample time
so getting “buy in” from the rehab staff was not an to educate and train facility staff. During education,
issue. Facility administration was usually receptive to the information was presented in innovative and
proposals from the rehab department, provided that fun ways so as to excite the staff about the program’s
solid justification for the service was provided and the possibilities and help them recognize the benefits to
therapy staff was willing and motivated to allocate using the equipment and techniques.
time for accomplishment of the initiative. The sup-
port from administration was believed to be critical Significance of the Evidence-Based Project
because this project had the potential to affect the The Occupational Therapy Practice Framework: Domain
entire philosophy of care within the facility. and Process highlights the overarching goal of the field
In regards to physical space, a small unused room— of occupational therapy as “supporting health and
formerly an office—existed within the therapy depart- participation in life through engagement in occupa-
ment, which was to be transformed into a multisensory tion” (AOTA, 2008, p. 626). Use of multisensory en-
environment. Use of this space enabled initiation of the vironments, in which neither performance nor
project with the possibility of expansion at some point, independence are essential, support this objective.
as the long-range goal was to infuse a more sensory- Sensory-based approaches “stimulate the primary
based assessment into the occupational therapy evalu- senses without the need for intellectual activity in an
ation, to educate and train all facility staff in this atmosphere of trust and relaxation. It is a failure free
approach, and to have items available for them to use approach insofar as there is no pressure to achieve”
on a routine basis in the common resident areas. (Burns et al., 2000, p. 120).
Finally, but probably most importantly, was the Sensory functions and pain appear under the Client
need for financial support. Financial support was Factors area in Occupational Therapy Practice Framework
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Appendix C ■ Example of Evidence-Based Practice Project 237

(AOTA, 2008). Review of typical evaluations used in (1998) propose that “if we cannot couple the addition
the skilled nursing facility reveals a lack of attention of years to our life with the infusion of life to our years,
to this vital area. Honing in on one’s sensory modu- then the recent longevity revolution may merely trans-
lation abilities can provide insight into behavioral late into a sickness revolution” (p. 107). This evidence-
issues and activities that derive pleasure and meaning. based practice project has the potential to impact the
Considering sensory functions can also increase use provision of services within the facility and the quality
of a truly holistic approach to treatment. of life of clients with dementia via use of a unique
As this sensory program is based highly on current approach to management of negative behaviors.
literature and evidence, the project provides a model
for others to engage in evidence-based practice. Syn- Synopsis of This Evidence-Based
thesis of critically appraised research articles for de- Practice Project
sign of this program adds to the existing body of
evidence on use of sensory approaches in clients with The following is a preview of the remaining chapters
dementia. Education of the public is also an impor- of this evidence-based practice project. Chapter 2
tant facet of this evidence-based project. Use of the (of this project) includes a review of 25 research articles
sensory approach involves collaboration with the on the use of sensory-based treatments and describes
resident, families, nurse aides, nurses, social service, common themes in the literature. Chapter 3 (of this
case management, and facility administration. This project) discusses the project’s methodology, including
project provides a perfect platform to accentuate a description of any models of practice used to guide
occupational therapy’s niche in our ever-changing the project and how the procedures will be altered to
healthcare system. meet each client’s needs. Chapter 4 (of this project)
Occupational therapists, as well as other healthcare reports the outcomes, both quantitative and qualita-
providers, are charged with the following priorities: tive, of the project after it was implemented. Finally,
Chapter 5 (of this project) offers an evaluation of the
■ Assisting the elderly to age in place when possible
entire evidence-based practice project as well as a cor-
■ Supporting caregivers
relation of the outcomes with the literature described
■ Promoting increased quality of life for those
earlier in Chapter 2 of this project. Limitations as well
living in institutional settings (AOTA, 2007).
as recommendations for future policy, practice, and
The goals of this evidence-based project support education are also presented in this closing chapter.
these priorities. Attention to quality-of-life issues has Please note that a sample chapter outline for
grown in recent years with the corresponding growth an evidence-based practice project is provided in
of the elderly population. Carlson, Clark, and Young Chapter 10.
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Appendix D

Outline for an Informed

Consent
Title: You must be 18 years of age or older to consent to
Principal Investigator: participate in this study. If you consent to participate
in this study and to the terms above, please sign your
Advisor:
name and indicate the date below. You will be given a
1. Purpose: copy of this form to keep for your records.
2. Procedures:
3. Discomforts and Risks: ____________________ ____________________
4. Benefits: Participant Signature Date
5. Duration or Time:
6. Statement of Confidentiality: I, the undersigned, verify that the above informed
7. Right to Ask Questions: You have the right to consent procedure has been followed.
ask questions and to have questions answered. ____________________ ____________________
8. Compensation: You will not receive monetary
Investigator Signature Date
compensation for participating in this study.
9. Voluntary Participation: You do not have to
participate in this study. You can end your partic-
ipation at any time by telling the person in charge.
You do not have to answer any questions that
you do not want to answer.

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Appendix E

Guidelines for Informed

Consent for Human Subjects
in a Study
One of the most important components of research parents, or guardians are incapable of comprehend-
involving human subjects is that of informed consent. ing this information, the executive officers should be
For the purpose of these guidelines, informed con- notified and a member of the Consent Committee
sent will be defined as: Consent freely given by a partici- will be made available. In cases of a language barrier,
pant in a research project based upon full disclosure of the the executive officer will obtain the assistance of
procedures that the individual will undergo. a knowledgeable person in that language to translate
the informed consent or interpret during the
explanation. Should the participant have questions,
General Information
and so forth, regarding the research once it has
The consent form should be written in terms compre- begun, the participant will again be provided with an
hensible to the lay person and should include all in- interpreter.
formation about the study that any reasonable person
would need and want to know. It should, realistically A. Written Informed Consent
and honestly, express what a participant may expect,
and should avoid persuasion by raising false hopes. A standardized format has been devised in order to
Informed consent forms used for research pro- facilitate writing of informed consent.
grams are not legal documents, although there have Using the standardized format, the following
been adverse legal decisions in cases where informed elements should be included:
consent was felt to be sufficiently lacking. ■ Description and explanation of procedure
Informed consent is to be obtained from every per- ■ Risks and discomforts
son who agrees to participate in any program falling ■ Potential benefits
under the jurisdiction of the Consent Committee. ■ Alternatives
The consent form for each study is to be submitted ■ Consent
to the Committee with the approved protocol before
the beginning of any part of the investigation.
1. Description and Explanation
All efforts should be made so that the participant
of Procedure
fully understands the information obtained in the
informed consent, despite any complicating factors, The basic procedures of the research should be stated
such as mental incompetence, language difficulties, clearly and concisely in nontechnical terms. Special
illiteracy, age, and so forth. If it appears that patients, note must be made of any part of these procedures

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242 Appendix E ■ Guidelines for Informed Consent for Human Subjects in a Study

that are experimental. The purpose of the study a patient feel pressured into participating because the
should be described, and the reason this person is alternatives are made to sound much less desirable.
being asked to participate should be explained.

5. Consent
2. Risks and Discomforts
The following additional items must be contained in
List in simple terms the most serious risks and those
every consent form.
most likely to occur. For each risk or hazard, when-
ever applicable, answer such questions as: ■ The assurance that full information regarding the
study has been given to the subject.
■ How much will it hurt?
■ The fact that the physician or investigator is avail-
■ How long will it take?
able to answer any inquiries concerning the study.
■ What danger will the patient be in?
■ The option of subjects to withdraw from the
■ What will be done to counteract adverse effects?
project at any time without any effect on their treat-
■ Are the side effects reversible?
ment or, if hospital employees, their employment.
■ What will be done beforehand to minimize risk or
discomfort? The following paragraphs are part of the standard
■ Is there inconvenience to the patient regarding format and should be included at the end of the
time or cost? consent document:
■ Could there be psychological harm, invasion of I have fully explained to_____________________
privacy, loss of confidentiality, embarrassment, or (insert participant’s/patient’s/guardian’s name) the
social injury? nature and purpose of the above-described procedure
and the risks involved in participation. I have an-
It is important to state whether risks of experimental
swered and will answer all questions to the best of my
procedures or side effects are known.
ability. I will inform the participant of any changes in
the procedure or the risks and benefits if any should
3. Potential Benefits occur during or after the course of the study.
Potential benefits are considered to be either (a) of _____________________ Primary Investigator's
direct benefit to the subject or (b) of value to future signature and date
patients or society as a whole. If physical or emotional I have been satisfactorily informed of the above-
problems might be uncovered during a study, it described procedure with its possible risks and ben-
might be desirable to state that professional services efits. I consent to participation in this study. I know
would be offered to help the problem. If appropriate, that _______________ (Insert primary investiga-
results of testing, questionnaires, or interviews might tor's name or contact) will be available to answer
be offered to the subject’s school or physician if the any questions I may have. I understand that I am
parent or subject requests it. free to withdraw this consent and discontinue par-
ticipation in this project at any time and it will not
affect my care. I have been offered a copy of this
4. Alternative form.
There are sometimes alternative procedures or med- ____________________ Date:_________________
ications to the ones described, and these should be Participant Signature
listed to give the subject a clear choice. The risks and
benefits of each alternative also should be stated. ____________________ Date:_________________
Where there are no alternatives to a particular treat- Witness Signature
ment, this should be noted. If the only alternative is
____________________ Date:_________________
nonparticipation, the section can be omitted. This
section has to be carefully worded so as not to make Parent or Guardian signature (if applicable)
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Appendix E ■ Guidelines for Informed Consent for Human Subjects in a Study 243

Modification of the wording in these paragraphs ■ Short form. Occasionally, because of a study’s
may be made in certain cases, depending on the complexity, it is not possible to write a concise con-
nature of the study. sent form. In such instances, the investigator may
The parent or legal guardian must sign the docu- explain the procedure orally and at length, but
ment, as well as the physician or investigator, and wit- present the patients with only a short form to sign.
ness. The witness is to the signatures only. In cases The short form will indicate that all the require-
where witnesses to the explanation are required, a ments for informed consent have been met by
member of the Consent Committee will fulfill this means of the oral explanation and will include the
function. standard closing paragraphs of written consents. If
The consent form containing the original signa- such form of consent is used, a written summary
tures must be placed in the medical record. If there is of what is told to the patient should be part of the
no medical record—as for volunteers, students, and protocol and must receive Committee approval.
so forth—then the signed copy must be kept in the
investigator’s files. A copy of the consent form should
C. Participation of Children in Consent
always be offered to the participant.
Process
If new information occurs during the course of a
study, the investigator has the obligation to inform Children should be involved in the consent process
the subject. The consent form should then be revised whenever appropriate or feasible. They should be as
accordingly and the changes communicated to the fully informed about the research project as is appro-
executive officer. priate for the child’s age and should be given the right
to refuse participation. It is recommended that a child
not be used as a subject in research if there is a conflict
B. Other Types of Consent
between parent and child regarding participation.
■ Letter or e-mail. In some instances, the Committee It is recommended that children younger than
will approve consents in letter or e-mail form, 18 years of age who are capable of understanding a
particularly when they involve questionnaires or procedure and its ramifications and who agree to par-
other low-risk studies. These generally occur in ticipate sign a separate consent form, often referred
school populations or retrospective studies of to as an assent form along with the parent or
former patients when mailings are sent out to guardian's consent form. This process is left to the
individuals not likely to be at the facility. investigator’s discretion.
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Appendix F

Example of Informed
Consent—Practitioner
Study
Electromechanical Games and Exploration Behavior in No discomfort or risks are anticipated for this inter-
Adults With Moderate Developmental Disabilities vention. It is hoped that the Participant, with permis-
sion of the Parent or Guardian, will enjoy interacting
Name(s) of Investigator:________________________
with the game and may benefit from doing so by learn-
Name of Participant: __________________________
ing more about his or her environment. Information
The Participant, with permission of the Parent or from this study will be anonymously coded to ensure
Guardian, has been selected to take part in a research confidentiality and the Participant will not be person-
study on the effect of electromechanical games on ally identified in any publication containing the results
exploration behavior. The purpose of the study is to of this study.
see if electromechanical games will encourage the The videotapes and written material from the
Participants who have diminished interest in their study will be kept in a locked cabinet. The videotape
surroundings to explore and interact with the game. recordings will be viewed solely by investigator(s) of
The Participant, with permission of the Parent or the study and will be destroyed upon completion of
Guardian, will be given a battery-powered game for data analysis.
15 minutes, 3 days per week for 6 weeks at his or her The Parent or Guardian may view any videotape of
group home. His or her behavior will be recorded in the Participant which is filmed for the study.
writing by the Investigator of this study to see if his _________________________________________,
or her exploration behavior changes and if the game primary investigator of this study, may be reached
interests him or her. Behavior will be videotaped on at_____________________/___________________
two separate occasions. (phone number/e-mail), anytime and will be available
The Participant, with permission of the Parent to answer any questions the Parent or Guardian may
or Guardian, will have the choice whether or not to have concerning the study, the procedures, and any
interact with the game. Participation is entirely vol- risks or benefits that may arise from participating in
untary and Participant or Parent or Guardian has the the study.
right to withdraw consent and discontinue participa- As Parent or Guardian of the previously named
tion in the study at any time without prejudice to Participant, I give permission for him or her to
present or future care. There is no cost for any part of participate in the research study described.
the study. A copy of this consent form has been given to me.

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246 Appendix F ■ Example of Informed Consent—Practitioner Study

Signed:

_______________ Date:___________________
Parent or Guardian

_______________ Date:___________________
Principal Investigator’s Signature

_______________ Date:___________________
Witness Signature
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Appendix G

Example of Informed
Consent—Student Thesis
Massage Therapy Patients’ or Clients’ Compliance With The transcribed stories will not be printed for pub-
Treatment From the Therapists’ Perspective lic use, but short excerpts will be taken from them
__________________ (Hereafter known as the and included in the Investigator’s thesis and in pos-
“Investigator”) has asked ____________________ sible future publications.
(Hereafter known as the “Participant Therapist”) to The Investigator will be available to answer further
take part in a study regarding massage therapy questions regarding any aspect of the study or partic-
patients and their compliance with treatment. ipation therein _____________/________________
The Participant Therapist will be asked to tell the (phone/e-mail).
Investigator two stories, one about a patient or client I understand that members of the Human Subjects
the Participant Therapist perceived as successful and Committee of the ______________________are also
one about a patient or client the Participant Therapist available to answer questions and their names, phone
perceived as unsuccessful. He or she will also be asked numbers, and e-mails are as follows:
to discuss what elements he or she thinks make a
patient or client successful or unsuccessful. The In-
vestigator will audiotape the stories and all questions
and answers.
Participation in the study is voluntary and the
Participant Therapist has the right to discontinue I agree to participate in the study described above.
participation at any time without repercussions. I have been given a copy of this form.
There are no discomforts or risks associated with the Signed:
study.
__________________ Date:___________________
Information from the study will be coded to ensure
confidentiality, and the Participant Therapist will not Participant Therapist
be identified in any publication that may result from
__________________ Date:___________________
the study. The audiotapes will be heard by the Inves-
tigator, a transcriber, and possibly by another occu- Investigator
pational therapy student (who will aid in selecting __________________ Date:___________________
relevant portions of the tape for transcribing), and
the three faculty advisers to the investigator. Witness

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APPENDIX H

Example of a Permission
Form for Photographs and Other
Media Materials
I give permission to ___________________________. understanding that I may see the materials before
(Name of facility) confirming consent or before the material is re-
leased. Also, it is my understanding that I will receive
to use materials identifying____________________ verbal notification before any material is used, and
in the following situations: (Name of client) that I may place the following restrictions on the
material or its use, including time limits:
_____External publications (e.g., professional journals,
I give this consent voluntarily, without threat of
newspapers, magazines)
punishment or promise of special reward. I have been
_____Radio programs
given an opportunity to fully discuss the release and
_____Television programs
to have my questions answered. I understand that I
_____Internal publications (e.g., facility publications)
may withdraw consent at any time prior to release
_____Internal/residential building displays (e.g., bul-
without fear or punishment.
letin boards, photo albums)
Signature: ____________________ Date:__________
_____Conference materials (e.g., slides, overheads)
(Client)
_____Other__________________________________
Signature: ____________________ Date:__________
(Specify)
(Parent or Guardian, if applicable)
In many cases, the use of the patient’s (client’s) first
I have fully explained the information above and
and last name is not necessary, but can add to the
answered all questions to the best of my ability. It is
completion of the story or photo. If you do not want
my opinion that consent has been given knowingly
the last name used, please indicate below:
and freely.
_____NO, the use of first and last name is not
Signature: ____________________ Date:__________
permissible
(Person obtaining consent)
_____YES, the first and last names may be used
__________________________________________
_____Only the first name and last initial may be used
(Title or position)
I give consent on the condition that the material
be used only for the above purpose(s). It is my

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Appendix I

Professional Journals
and Publishers
This is not intended to be an exhaustive list; however it will
be helpful in discerning where to search for assistance
during the inquiry and/or when publishing outcomes. To
access web information, simply copy/paste the title into your
preferred search engine.

HEALTHCARE ADMINISTRATION HEALTHCARE RELATED COMPUTER

Administration and Policy in Mental Health and Mental Health Service
TECHNOLOGY
Research Computers in Human Behavior
Journal of Healthcare Management Computers in the Schools
Hospitals and Health Networks Health Management Technology
Journal of Long-Term Care Administration Journal of Technology in Human Services
Journal of Rehabilitation Administration
Modern Healthcare
HEALTH CARE
Home Health Care Services Quarterly
AGING Home Health Care Management and Practice
Activities, Adaptation and Aging Journal of Allied Health
American Journal of Geriatric Psychiatry The Journal of Women’s Health Care
Clinical Gerontologist Occupational Therapy in Health Care
International Journal of Aging and Human Development
International Journal of Geriatric Psychiatry HOSPICE
Journal of Aging and Physical Activity American Journal of Hospice and Palliative Care
Journal of Aging and Social Policy Home Health Care Services Quarterly
Journal of Aging Studies Journal of Palliative Care
Journal of Applied Gerontology
Journal of Geriatric Psychiatry and Neurology OCCUPATIONAL HEALTH
Journals of Gerontology International Journal of Sports Medicine
Journal of Women and Aging Journal of Health and Social Behavior
Physical and Occupational Therapy in Geriatrics Journal of Occupational Rehabilitation
The Gerontologist Occupational Health and Safety

251
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252 Appendix I ■ Professional Journals and Publishers

Occupational Health Nursing Journal of Hand Therapy

Occupation, Participation and Health Journal of Rehabilitation Research and Development
Journal of Sport Rehabilitation
PEDIATRICS AND EARLY INTERVENTION Lab Medicine
Child Development Massage Therapy Journal
Infants and Young Children Occupational Therapy International
Journal of Early Intervention Physical Therapy
Journal of Pediatric Psychology Physiotherapy Journal
Pediatric Physical Therapy Physiotherapy Canada
Physical and Occupational Therapy in Pediatrics Public Health Journal
Physical Disabilities: Education and Related Services Radiologic Technology Journal
Topics in Early Childhood Special Education Rehabilitation Counseling Bulletin
Respiratory Care Journal
PHYSICAL MEDICINE AND REHABILITATION
American Journal of Physical Medicine and Rehabilitation MENTAL HEALTH & WELL-BEING
Journal of Occupational Rehabilitation American Journal of Health Promotion
Journal of Orthopaedics & Sports Physical Therapy Canadian Journal of Community Mental Health
Journal of Rehabilitation Research and Development Community Mental Health Journal
Physical Medicine and Rehabilitation Clinics of North America International Journal of Qualitative Studies on Health & Well-being
Physiotherapy Theory and Practice Journal of Family Psychotherapy
Rehabilitation Counseling Bulletin Journal of Health and Social Behavior
Rehabilitation Research, Policy, and Education Journal of Organizational Behavior Management
Sexuality and Disability Occupational Therapy in Mental Health
Work: A Journal of Prevention, Assessment and Rehabilitation Residential Treatment for Children and Youth
The Clinical Supervisor
PROFESSIONAL ASSOCIATION JOURNALS
Art Therapy: Journal of the American Art Association RESEARCH
American Journal of Occupational Therapy American Journal of Medicine
American Journal of Medical Technology Health Services Research Journal
British Journal of Occupational Therapy Journal of International Medical Research
Clinical Laboratory Science Journal of Multidisciplinary Healthcare
International Journal of Yoga Therapy Qualitative Health Research
Journal of Allied Health The New England Journal of Medicine
Journal of the American Academy of Physician Assistants The Qualitative Report
Journal of Athletic Training
3916_App J_253-256 20/10/14 10:19 AM Page 253

Appendix J

Indexes and Abstracts

This is not intended to be an exhaustive list; however, it
will be helpful in discerning where to search for assistance
during the inquiry or when publishing outcomes. To access
Web information, simply copy and paste the title into your
preferred search engine.

Social Work Abstracts. Quarterly. Abstracts from bioinstrumentation, environmental biology, genetics,
journals of social work under social policy and action, nutrition, and public health.
service methods, fields of service, the social work pro- Child Development Abstracts. Three times per
fession, history of social work, and related fields in year. Abstracts of articles and books in a wide
the social sciences. variety of fields as they relate to infancy and child
Abstracts of Hospital Management Studies. Quar- development.
terly. International abstracts of studies on manage- Combined Health Information Database. Pro-
ment, planning, and public policy related to healthcare duced by National Institutes of Health. More than
delivery. 24,000 documents combining four health-related
Ageline. Produced by American Association for databases: arthritis, diabetes, health education, and
Retired Persons. More than 16,500 documents on all digestive diseases. Quarterly updates.
aspects of gerontology. Bimonthly updates. Compendex. Produced by Engineering Information
Bibliography of Bioethics. Since 1975, covers English- Inc. More than 1,102,100 documents on all aspects of
language literature on ethical issues related to health engineering and technology including rehabilitation
care. Includes journals, court decisions, government engineering. Monthly updates.
documents, audiovisuals, newspapers, and books. Cumulative Index to Nursing and Allied Health
Published annually. Literature (CINAHL). Print version from 1956 to
Biological Abstracts. Semimonthly. International present; online version from 1982 to present. Indexes
abstracts of periodicals including behavioral sciences, all major nursing journals and over 125 allied health

253
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254 Appendix J ■ Indexes and Abstracts

journals, plus book reviews, pamphlets, films, and International Nursing Index. From 1966 to pres-
recordings. Bimonthly updates. ent. Indexes 270 international nursing journals and
Current Index to Journals in Education (CIJE). nursing articles from 2,600 nonnursing materials
Paper abstracts of education-related journals by listed in Index Medicus. Published quarterly and
subject, author, and journal content. Usually used in cumulated annually.
conjunction with RIE and ECER; these three form Linguistics and Language Behaviors Abstracts.
the online version, ERIC. Produced by Sociological Abstracts, Inc. More than
Dissertation Abstracts International. Comprehen- 72,000 documents on language problems, speech and
sive paper abstracts of dissertations by title, author, hearing problems, learning disabilities, and special
and subject. Volumes divided into sciences or engi- education. Quarterly updates.
neering and humanities or social sciences. MEDLINE. Online version of Index Medicus.
DSH Abstracts. Quarterly from Deafness, Speech More than 1,600,000 entries on medicine, including
and Hearing Publications, Inc., Gallaudet College, biomedicine, and humanities as they relate to
Washington, DC. Abstracts articles related to hearing, medicine. Includes occupational and physical ther-
hearing disorders, speech, and speech disorders. In- apy, nursing, social work, biology and physiology,
cludes foreign journals. Education Index. From 1932 and so forth. Updated monthly and cumulated
to the present. Indexes articles from educational annually.
periodicals, conference proceedings, and yearbooks. OT Search. Online information system with literature
ERIC (Educational Resources Information Center). in database. Organized by author, subject, and title.
Produced by Council for Exceptional Children. More ProQuest. Designed to support the needs of aca-
than 589,000 documents on special education materi- demic researchers; they offer the greatest expanse of
als. Monthly updates. Compilation of paper indexes: high-quality research and curricula-aligned content
RIE, CUE, and ECER. in a wide-range of subjects.
Exceptional Child Educational Resources (ECER). PsycINFO. Online version of Psychological Ab-
Abstracts education materials related to children with stracts. Entries listed by title, author, and subject;
special needs, by subject and author. Usually used in divides psychology into 16 major categories.
conjunction with RIE and CUE; these three form the PsychLit. Online database of psychology books, jour-
online version, ERIC. nals, and other materials. Comprehensive. Organized
Excerpta Medica. A subsidiary of Elsevier Science by author and subject.
Publishing in the Netherlands, first published in PubMed. Sponsored by the National Library of
1946. Covers both research and clinical biomedical Medicine of the National Institutes of Health (NIH).
literature on a worldwide basis. Fifty-two sections PubMed comprises millions of citations of biomed-
including Rehabilitation and Physical Medicine, ical literature from MEDLINE, life science journals,
Gerontology and Geriatrics, Psychiatry, Occupational and online books.
Health, and Industrial Medicine. REHABDATA. Produced by National Rehabilita-
Hospital Literature Index. From 1945 to the pres- tion Information Center (NARIC). More than 16,000
ent. Indexes studies on administration, planning, and documents on rehabilitation including commercial
financing of hospitals and related healthcare institu- publications, government reports, journals, and un-
tions. All types of healthcare facilities are included. published documents. Monthly updates.
Published quarterly and cumulated annually. Research Education Complete. Database encom-
Index Medicus. Full and abridged versions available. passing scholarly research in all areas of education.
Documents from approximately 4,680 medically Research Quarterly, American Alliance for Health,
related journals. Updated monthly and cumulated Physical Education, and Recreation. Covers litera-
annually. Online version is MEDLINE. ture pertaining to physical health, physical education,
3916_App J_253-256 20/10/14 10:19 AM Page 255

Appendix J ■ Indexes and Abstracts 255

and recreation. Cumulative in 10-year indexes from data, analyze trends, journals and researchers, and share
1930 to present. their findings. Overcome information overload and
Science Citation Index. Indexes literature from the focus on essential data from 3,000 of the world's leading
scientific disciplines including medicine, behavioral social sciences journals across 50 disciplines.
sciences, substance abuse, and some nursing journals. Sociological Abstracts. 1952 - present. Updated
Published bimonthly with an annual cumulation monthly, with approximately 30,000 records added
from 1955. per year. Abstracts and indexes the international lit-
Social Services Abstracts. Social Services Abstracts erature in sociology and related disciplines in the so-
provides bibliographic coverage of current research fo- cial and behavioral sciences. Provides abstracts of
cused on social work, human services, and related journal articles and citations to book reviews drawn
areas, including social welfare and social policy. The from over 1,800+ serials publications, and also pro-
database abstracts and indexes over 1,300 serial publi- vides abstracts of books, book chapters, dissertations,
cations, and includes journal articles, dissertations and and conference papers.
book reviews. Searches link to Community of Scholars: U.S. Superintendent of Documents, Monthly Cat-
Social Sciences alog of United States Government Publications.
Social Science Citation Index. Social Sciences Citation 1895 to present. Lists publications issued by all
Index®, accessed via Web of Science™ Core Collection, branches of the U.S. government, both the Congres-
provides researchers, administrators, faculty, and stu- sional and the department and bureau publications.
dents with quick, powerful access to the bibliographic Current issues indexed by author, title, subject, and
and citation information they need to find research series or report.
3916_App J_253-256 20/10/14 10:19 AM Page 256
3916_App K_257-258 20/10/14 10:19 AM Page 257

Appendix K

Evidence-Based Practice
Resources by Healthcare
Discipline
The following list of resources, separated by healthcare
discipline, provides a starting point for anyone beginning
the evidence-based practice process. An Internet search
of any resource titles will guide you in obtaining these
recommended resources.

GENERAL HEALTH CARE Price, C. P., Glenn, J. L., & Christenson, R. H. (2009). Applying evidence-based
Hall, H. R., & Roussel, L. A. (2012). Evidence-based practice: An integrative laboratory medicine: A step-by-step guide. Washington, DC: American
guide to research, administration, and practice. Burlington, MA: Jones & Association for Clinical Chemistry.
Bartlett Learning.
Houser, J., & Oman, K. S. (2010). Evidence-based practice: An implementation MASSAGE THERAPY
guide for healthcare organizations. Sudbury, MA: Jones & Bartlett. Andrade, C., & Clifford, P. (2008). Outcome-based massage: From evidence to
Rubin, A., & Bellamy, J. (2012). Practitioner’s guide to using research for practice (2nd ed.). Baltimore, MD: Lippincott Williams & Wilkins.
evidence-based practice. Hoboken, NJ: John Wiley & Sons, Inc. Dryden, T., & Moyer, C. (2012). Massage therapy: Integrating research and
practice. Champaign, IL: Human Kinetics.
HEALTH AND FITNESS OR SPORTS MEDICINE Holey, E. A., & Cook, E. M. (2011). Evidence-based therapeutic massage: A
Dugdill, L., Crone, D., & Murphy, R. (2009). Physical activity and health pro- practical guide for therapists (3rd ed.). Philadelphia, PA: Churchill Living-
motion: Evidence-based approaches to practice. United Kingdom: Blackwell stone Elsevier.
Publishing Ltd.
Higdon, J., & Drake, V. J. (2011). An evidence-based approach to vitamins and NURSING
minerals: Health benefits and intake recommendations. New York, NY: Brown, S. J. (2010). Evidence-based nursing: The research-practice connection.
Thieme Medical Publishers. Sudbury, MA: Jones & Bartlett.
MacAuley, D., & Best, T. (2007). Evidence-based sports medicine (2nd ed.). Melnyk, B. M., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing
Malden, MA: Blackwell Publishing. & healthcare: A guide to best practice (2nd ed.). Philadelphia, PA:
Martin, L., Haskard-Zolnierek, K., & Dimatteo, M. R. (2010). Health behav- Lippincott Williams & Wilkins.
ior change and treatment adherence: Evidence-based guidelines for improving Schmidt, N. A., & Brown, J. M. (2011). Evidence-based practice for nurses:
healthcare. New York, NY: Oxford University Press, Inc. Appraisal and application research. Sudbury, MA: Jones & Bartlett.

LABORATORY SCIENCE OCCUPATIONAL THERAPY

Laboratory Medicine Best Practices. Retrieved from www.futurelab- Kielhofner, G. (Ed.). (2006). Research in occupational therapy: Methods of inquiry
medicine.org for enhancing practice (Section 9, pp. 656–706). Philadelphia, PA: F.A. Davis.
Marchevsky, A. M., & Wick, M. (2011). Evidence based pathology and laboratory Law, M., & MacDermid, J. (Eds.). (2014). Evidence-based rehabilitation: A guide
medicine. New York: Springer Science + Business Media, LLC. to practice (3rd ed.). Thorofare, NJ: SLACK Incorporated.

257
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258 Appendix K ■ Evidence-Based Practice Resources by Healthcare Discipline

Taylor, M. C. (2008). Evidence-based practice for occupational therapists RADIOLOGIC SCIENCE

(2nd ed.). Malden, MA: Blackwell Publishing. Medina, L. S., Blackmore, C. C., & Applegate, K. (2011). Evidence-based
imaging: Improving the quality of imaging in patient care (revised ed.). New
York: Springer Science + Business Media, LLC.
PHYSICAL THERAPY
Cameron, M. H., & Monroe, L. (2007). Physical rehabilitation: Evidence-based ex- Medina, L. S., Sanelli, P. C., & Jarvik, J. C. (2013). Evidence-based neuroimaging
amination, evaluation, and intervention. St. Louis, MO: Saunders Elsevier. diagnosis and treatment: Improving quality of neuroimaging in patient care.
New York: Springer Science + Business Media, LLC.
Fetters, L., & Tilson, J. (2012). Evidence based physical therapy. Philadelphia,
PA: F.A. Davis.
Jewell, D. V. (2010). Guide to evidence-based physical therapist practice (2nd ed.). SOCIAL WORK
Sudbury, MA: Jones & Bartlett. Grinnell, Jr., R. M., & Unrau, Y. A. (2010). Social work research and evaluation:
Foundations of evidence-based practice. New York, NY: Oxford University
Press, Inc.
PHYSICIAN ASSISTANT
Petr, C. G. (2008). Multidimensional evidence-based practice: Synthesizing knowl-
Pines, J. M., Carpenter, C. R., Raja, A. S., & Schuur, J. D. (2013). Evidence-
edge, research, and values. New York, NY: Routledge.
based emergency care: Diagnostic testing and clinical decision rules. Hoboken,
NJ: John Wiley & Sons, Ltd. Thyer, B. A., Dulmus, C. N., & Sowers, K. M. (Eds.). (2013). Developing
evidence-based generalist practice skills. Hoboken, NJ: John Wiley &
Straus, S. E., Glasziou, P., Richardson, W. S., & Haynes, R. B. (2011).
Sons, Ltd.
Evidence-based medicine: How to practice and teach it (4th ed.). Maryland
Heights, MO: Elsevier Churchill Livingstone.
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Appendix L

Author Guidelines for Health

Professional Journals and
Publications
Below are direct links to peer-reviewed journals and
practice-related publications.
The purpose of the list is to give the reader a starting point
to review author guidelines—it is by no means an exhaus-
tive list of opportunities to publish one’s work.

Athletic Training Journal of Clinical Laboratory Sciences

http://www.ascls.org/professional-development/
International Journal of Athletic Therapy & Training publications/instructions-for-authors-reviewers
http://journals.humankinetics.com/authorship- Laboratory Medicine
guidelines-for-ijatt/authorship-guidelines-
http://labmed.ascpjournals.org/
for-ijatt/apaq-authorship-guidelines
Society for Laboratory Automation and Screening
Journal of Athletic Training
http://www.slas.org/publications/journals.cfm
http://www.nata.org/journal-of-athletic-training
Journal of Sports and Exercise Psychology
http://journals.humankinetics.com/for-jsep-authors Massage Therapy
American Massage Therapy Association
Clinical Laboratory Sciences http://www.amtamassage.org/articles/3/mtj/
index.html
Clinical Chemistry
International Journal of Therapeutic Massage and Body-
www.aacc.org/publications/clin_chem/ work: Research, Education & Practice
Journal of Clinical Laboratory Analysis http://www.massagetherapyfoundation.org/
http://onlinelibrary.wiley.com/journal/10.1002/ massage-research/ijtmb/
(ISSN)1098-2825

259
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260 Appendix L ■ Author Guidelines for Health Professional Journals and Publications

Nursing Journal of Orthopaedic and Sports Physical Therapy

http://www.jospt.org/aboutus/for_authors.asp
American Journal of Nursing
Pediatric Physical Therapy
http://journals.lww.com/ajnonline/_layouts/1033/
http://journals.lww.com/pedpt/Pages/
oaks.journals/informationforauthors.aspx
InformationforAuthors.aspx
Journal of Professional Nursing
Physical Therapy in Sport
http://www.professionalnursing.org/authorinfo
http://www.elsevier.com/journals/physical-
therapy-in-sport/1466-853X/guide-for-authors
Occupational Therapy
American Journal of Occupational Therapy Radiologic Technology
http://ajot.submit2aota.org/journals/ajot/forms/ American Society of Radiologic Technologists
Ajot_guidelines.pdf
http://www.asrt.org/main/news-research/
Australian Journal of Occupational Therapy asrt-journals-magazines
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)
1440-1630/homepage/ForAuthors.html
Social Work
British Journal of Occupational Therapy
http://www.cot.co.uk/contribute-and-submit- National Association of Social Work Press
bjot/publish-bjot http://www.naswpress.org/authors/index.html
Canadian Journal of Occupational Therapy
http://www.caot.ca/default.asp?pageid=162 Yoga and Bodywork
Occupational Therapy Practice
International Journal of Yoga
http://www.aota.org/Publications-News/otp/
Author.aspx http://www.ijoy.org.in/
Journal of Bodywork and Movement Therapies
Physician Assistant http://www.journals.elsevier.com/journal-
of-bodywork-and-movement-therapies/
Journal of the American Academy of Physician Assistants Yoga Journal
http://journals.lww.com/jaapa/Pages/author- http://www.yogajournal.com/
guidelines.aspx

Physical Therapy
Journal of American Physical Therapy Association
http://ptjournal.apta.org/
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Appendix M

Guidelines for Contributors to

American Journal of Occupational Therapy
Note. The Guidelines for Contributors is also available To submit manuscripts, go to http://ajot.sub-
at the American Journal of Occupational Therapy mit2aota.org/ and follow the online instructions.
manuscript processing system website; go to http:// Manuscripts must be submitted with the authors’
ajot.submit2aota.org and click on “Instructions for explicit written assurance that the manuscript is not
Authors.” simultaneously under consideration by any other
The American Journal of Occupational Therapy (AJOT) publication. The journal cannot assume responsibility
is the official peer-reviewed journal of the American for the loss of manuscripts.
Occupational Therapy Association (AOTA). We wel-
come the submission of manuscripts that are relevant Authors’ Responsibilities
to the study of occupation and the practice of occu-
Signatures. Before publication of any accepted manu-
pational therapy. Categories of peer-reviewed articles
script, all authors must provide original signatures
include feature-length articles, case reports, brief
for the statement of authorship responsibility, the
reports, and issue papers.
statement of financial disclosure, and the statement
Publication goals include the following:
of copyright release. The Copyright Transfer/ Author
■ Effectiveness studies (outcome studies), system- Certification/Financial Disclosure Form may be
atic reviews, and meta-analyses downloaded from the AJOT submission website.
■ Efficiency studies (studies assessing interventions Signed forms must be submitted upon acceptance of
for such things as patient satisfaction or cost and a manuscript for publication.
time efficiency) The statement of authorship responsibility is cer-
■ Studies establishing the reliability and validity of tification that each author has made substantial con-
occupational therapy instruments tributions to (1) the study conception and design,
■ Studies linking occupational engagement to acquisition of data, or analysis and interpretation of
participation and health data; (2) the drafting and revision of the article; and
■ Studies exploring a currently debated topical or (3) the approval of the final version. Moreover, each
professional issue (The Issue Is articles). author takes public responsibility for the work.
AJOT uses the sixth edition of the Publication Author order. The order of authors in the byline fol-
Manual of the American Psychological Association (APA, lows APA guidelines. The principal contributor ap-
2010) as the style guide. Consult this manual for pears first, and subsequent names are in order of
style questions unless specified otherwise in these decreasing contribution. Authors are encouraged to
guidelines. limit the number of coauthors to six or fewer.

261
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262 Appendix M ■ Guidelines for Contributors to American Journal of Occupational Therapy

Types of Articles should not exceed two double-spaced typed pages and
can be submitted by going to AJOT online at http://
Feature-Length Article ajot.aotapress.net/, navigating to the article, and
Feature-length articles include (1) original research re- clicking on “submit a response.” Letters may be edited
ports that focus on philosophical, theoretical, educa- for length and to conform with AJOT editorial style.
tional, or practice topics and (2) critical reviews Manuscripts for all categories above, except Letters
(including meta-analyses) that offer systematic review to the Editor, are peer reviewed.
and critical analysis of a body of literature as related Note: Consistent with the Guidelines for Supervision,
to occupation and occupational therapy. Feature- Roles, and Responsibilities During the Delivery of Occupa-
length articles should include a section summarizing tional Therapy Services (AOTA, 2009), the roles of
the implications of the research for occupational ther- the occupational therapist and occupational therapy
apy practice; this section should include a bulleted list assistant shall be considered, and when appropriate,
of the key points. (25 pages maximum or 5,000 words, role distinctions shall be clarified.
including title page, abstract, acknowledgments, ref-
erences, tables, figures, and illustrations) Manuscript Preparation
For format and reference style, consult the APA style
Brief Report manual and recent issues of AJOT. Careful attention
A Brief Report is a short report of original research to style details will expedite the peer review process.
that is of a pilot or exploratory nature or that ad- Authors are responsible for ensuring that a blind
dresses a discrete research question and lacks broad review process can take place by submitting a masked
implications. (15 pages maximum or 3,000 words, in- version of the manuscript, which contains no identi-
cluding title page, abstract, acknowledgments, refer- fying information, including names and affiliations
ences, tables, figures, and illustrations) of all authors and acknowledgments. Unmasked
articles will be returned for masking before they are
Case Report reviewed. Authors of manuscripts that are accepted
A Case Report is a short report of original work that will be asked to provide an unmasked version.
focuses on a case example of a clinical situation using Double-space the entire manuscript, including
baseline and outcome measures. The focus can be on abstract, text, quotations, acknowledgments, tables,
a patient or client, a family, an institution, or any figure captions, and references. Leave 1-inch margins
other defined unit. The case should represent ele- on all sides, and keep the right side unjustified. Num-
ments of practice that are not already represented in ber all pages, starting with the title page, and use
the literature. (20 pages maximum or 4,000 words, line numbering in the text. Use only Times New
including title page, abstract, acknowledgments, Roman 12-point font. Manuscripts are compiled and
references tables, figures, and illustrations) converted to pdf format during the online submis-
sion process. Specific instructions are provided at
The Issue Is http://ajot.submit2aota.org/.
The Issue Is articles address timely issues, policies,
or professional trends or express opinions that are Title Page
supported by cogent argument from the literature. The title should be short (no more than 10 words)
(18 pages maximum or 3,500 words, including title and reflect the primary focus of the article. On the
page, abstract, acknowledgments references, tables, unmasked copy (which will be requested if the man-
figures, and illustrations) uscript is accepted for publication), list full names,
degrees, titles, and affiliations of all authors. Desig-
Letters to the Editor (published online) nate the corresponding author by providing his or her
Letters discussing a recent AJOT article or other broad full address, telephone and fax numbers, and e-mail
issue relative to the journal are welcome. Letters address.
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Appendix M ■ Guidelines for Contributors to American Journal of Occupational Therapy 263

Abstract and Key Words ■ Journal Article (online version, with digital object
An abstract of no more than 150 words and at least 3 identifier
MeSH key words are required for all articles. Abstracts Arbesman, M., & Lieberman, D. (2011). Method-
may be structured (organized with the subheadings ology for the systematic reviews on occupational
Objective, Method, Results, and Conclusion) or un- therapy for adults with Alzheimer’s disease and
structured (narrative description of the focus and key related dementias. American Journal of Occupational
content of the article). Note that MeSH key words are Therapy, 65, 490-496. http://dx.doi.org/10.5014/
reviewed by an indexer and may be edited. ajot.2011.00257
■ Journal Article (online version, no DOI):
Implications for Occupational Therapy Gram, M., & Smed, K. (2011). We can drink our
Practice Section coffee more slowly: Discursive uses of age in rela-
Feature-length articles, including evidence reviews, tion to holiday consumption—Examples among
should include a separate section summarizing the Danish and German mature travellers. E-Journal
implications of the research for occupational ther- of Applied Psychology, 7(1), 2-7. Retrieved from
apy practice. This section should consist of a short http://ojs.lib.swin.edu.au/index.php/ejap/
paragraph followed by a bulleted list of the practice article/view/229/241
implications. ■ Book With Corporate Author and Author as Publisher:
American Psychiatric Association. (2000). Diagnos-
Acknowledgments Page tic and statistical manual of mental disorders (4th ed.,
The acknowledgments page is in- cluded in the un- text rev.). Washington, DC: Author.
masked copy only. This page follows the last page ■ Book With Author(s):
of the text and precedes the reference list. Brief ac- Frank, G. (2000). Venus on wheels: Two decades of
knowl- edgments may include names of persons who dialogue on disability, biography, and being female in
contributed to the research or article but who are not America. Los Angeles: University of California
authors (e.g., a statistician) followed by acknowledg- Press.
ments of grant support. Prior presentation of the ■ Edited Book:
paper at a meeting should be briefly described last. Law, M. (Ed.). (1998). Client-centered occupational
therapy. Thorofare, NJ: Slack.
References
■ Chapter in Edited Book:
Follow the sixth edition of the Publication Manual of Case-Smith, J. (2010). Evidence-based practice in
the American Psychological Association (APA, 2010) for ref- occupational therapy for children with an autism
erencing. List references in alphabetical order starting spectrum disorder. In H. M. Kuhaneck & R. Watling
on the page after the last page of text (in the masked (Eds.), Autism: A comprehensive occupational therapy
version) or after the acknowledgments (in the un- approach (3rd ed., pp. 701–742). Bethesda, MD:
masked version). In-text citations should use author- AOTA Press.
date format. Personal communications or other
nonretrievable citations are described in the text only; Tables
provide a name and date for a person and a name, date, Provide full titles and begin each table on a new
and address for an organization. Authors are solely re- page following the references. Number the tables
sponsible for the accuracy and completeness of their consecutively as they appear in the text. Data ap-
references and for correct text citation. pearing in tables should supplement, not duplicate,
Below are examples of commonly used reference the text. Double-check column totals. Be sure that
listings: any numbers repeated in the text match the num-
■ Journal Article (hard copy or not available online): bers that appear in the table. Define all abbrevia-
Dunton, W. R., Jr. (1926). An historical note. Occu- tions and explain any empty cells in a footnote to
pational Therapy and Rehabilitation, 5(6), 427–439. each table.
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264 Appendix M ■ Guidelines for Contributors to American Journal of Occupational Therapy

Figures and Illustrations Permissions

Number figures in order of mention in the text. Authors who wish to reprint tables, figures, or long
Figures (including charts, diagrams, and photo- quotations from other sources are responsible for ob-
graphs) must be submitted as high-resolution digi- taining permission from the copyright holder. Letters
tized electronic files (minimum 600 dpi). Figures of permission with original signatures from the copy-
must be submitted in black and white. Each figure right holder or an authorized representative must be
should be uploaded to the BenchPress system as submitted to the editor at the time of the initial sub-
a separate file that is named in accordance with the mission. AOTA does not reimburse authors for any
figure number (e.g., “Figure 1. tif ”). expense incurred when obtaining permission to
Provide a caption for each figure. List all captions reprint. The need for permission applies to adapted
on one page, double-spaced. Place the figure caption tables and figures as well as to exact copies.
page after the references. Provide source information Signed statements of permission to publish must
for photographs and line art, and ensure that permis- accompany all photographs of identifiable persons at
sion has been obtained to reprint figures that have the time of submission.
been previously published or have not been created Authors must provide signed statements of per-
by the article authors (see “Permissions” below). mission from people cited for personal communica-
tions at the time of submission.
Note: Limit on Number of Tables and Figures
No more than four art elements—that is, any combi- Derivative Work
nation of tables and figures—may be submitted with
each article. Authors who submit more than four Authors who are submitting derivative work using a
items total will be asked to edit their submission ac- data set from which other papers were published
cordingly. Authors who believe readers will benefit must provide the publication information for those
from additional tables or figures may submit those other papers in the cover letter.
items as supplemental materials. Supplemental ma-
terials are not typeset and are posted, at the editor- Manuscript Review
in-chief’s discretion, with the online version of the ar- Manuscripts and reviews are confidential materials.
ticle exactly as they are submitted. The existence of a manuscript under review is not re-
vealed to anyone beyond the editorial staff. All sub-
Statistics
mitted manuscripts are initially reviewed by the editor
Authors must provide references for statistical tests for suitability for the journal. Suitable manuscripts
used or described in the article. When reporting F are then sent to editorial board members or guest re-
and x2 statistics, provide degrees of freedom (df ). viewers for peer review. The identities of the reviewers
and of the authors are kept confidential. Initial and
Tests and Assessment Tools
subsequent review takes approximately 3 months.
Authors must provide references for all tests and as- All accepted manuscripts are subject to copyediting.
sessment tools mentioned in the article or used in the Authors will receive a copy of the edited manuscript
research being described, including tools mentioned for review and final approval, as well as reprint order
in tables or lists of assessments. Tests and assessment forms, before publication. The authors assume final
tools listed in supplemental evidence tables, however, responsibility for the content of articles, including
do not need to be referenced. changes made in copyediting.
Abbreviations
Copyright and Patent
Do not use abbreviations in the title or abstract of the
article; the use of abbreviations in the text should be On acceptance of the manuscript, authors are re-
kept to a minimum. quired to convey copyright ownership to AOTA.
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Appendix M ■ Guidelines for Contributors to American Journal of Occupational Therapy 265

Manuscripts published in the journal are copyrighted ■ Pages are numbered, starting with abstract and
by AOTA and may not be published elsewhere key words on page 2.
without permission. To obtain permission to reprint ■ Lines are numbered in the main text.
journal material, go to the Copyright Clearance ■ A section including a bulleted list summarizing
Center website at www.copyright.com. the implications of the research for occupational
Any device, equipment, splint, or other item de- therapy practice is included.
scribed with explicit directions for construction in an ■ Written permissions have been obtained as
article submitted to AJOT for publication is not pro- needed for photographs, personal communica-
tected by AOTA copyright and can be produced for tions, and copyrighted material.
commercial purposes and patented by others, unless ■ Digital files and captions are provided for all
the item was already patented or its patent is pending figures.
at the time the article is submitted. ■ All material is double-spaced (including abstract,
references, quotations, figure captions).
■ The Copyright Transfer/Author Certification/
Checklist for Authors Financial Disclosure Form as been signed by each
■ Register at http://ajot.submit2aota.org/ and author.
follow on-line submission instructions.
REFERENCES
■ Submitted manuscript contains no identifying American Occupational Therapy Association. (2009). Guidelines for su-
information about specific people and places. pervision, roles, and responsibilities during the delivery of occupa-
tional therapy services. American Journal of Occupational Therapy, 63,
■ All references are in APA (sixth ed.) style and have
797-803. http://dx.doi.org/10.5014/ajot.63.6.797
been checked for accuracy and completeness and American Psychological Association. (2010). Publication manual of the
for exact match between list and text. American Psychological Association (6th ed.). Washington, DC: Author.
3916_App M_261-266 20/10/14 10:20 AM Page 266
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Appendix N

Author Guidelines for

International Journal
of Yoga Therapy
Instructions to Contributors Issues in Yoga Therapy
International Journal of Yoga Therapy publishes schol- The journal welcomes scholarly articles that address
arly articles about yoga therapy, yoga practice, and issues, challenges, and controversies in the research
yoga philosophy. We encourage submissions from re- and practice of yoga therapy. Articles in this category
searchers, scholars, yoga therapists, yoga teachers, include, but are not limited to, considerations of pol-
and healthcare professionals. The journal aims to icy issues related to the integration of yoga and health
represent views, practices, and research from all care, explorations of common challenges that yoga
major traditions in yoga and from modern health therapists and teachers face in their work, and discus-
care, integrative medicine, and psychology. sions of yoga philosophy as it relates to contemporary
yoga therapy practice. Articles in this category must
Research include references to relevant yogic texts and support-
The journal publishes high-quality reports of original ing materials, all of which are to be cited using APA
empirical research. Manuscripts must adhere to format, and should not be based largely on the expe-
conventional reporting guidelines and include a title, rience or opinions of the author(s).
abstract, introduction, methods section, results, and
discussion. We welcome scientific articles regarding Yoga Therapy in Practice/The Yoga Tradition
pilot studies and encourage authors to publish find- Yoga Therapy in Practice/The Yoga Tradition articles
ings that may benefit other researchers and practi- should review a topic of importance and relevance to
tioners. Case studies are empirical reports using a very practicing yoga teachers, yoga therapists, and health-
small sample. They should be reported in the context care providers. Articles in this category include, but
of a thorough review of the relevant literature, include are not limited to, discussions of specific populations
quantitative or qualitative results, and a broad discus- or medical conditions and recommended best prac-
sion of the cases’ implications for future research or tices, reviews of research on a topic of relevance to yoga
practice. Names and other identifying information therapy, or reviews of the history of some aspect of
must be changed to protect individuals’ privacy. All yoga therapy or yoga philosophy. Articles must be sup-
research involving human participants must have re- ported by published research, research in progress,
ceived prior approval by an Institutional Review established interventions at yoga therapy clinics, clas-
Board for the protection of human subjects. Study sical yoga texts, or original interviews, all of which are
protocols and previously published materials cannot to be cited using APA format. They should not
be considered. be based largely on the experience or opinions of the

267
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268 Appendix N ■ Author Guidelines for International Journal of Yoga Therapy

author(s). Review articles must contribute something ([email protected]) and indicate which article category
new to the literature. the intended submission falls into. The editor makes
the final decision to accept or reject a manuscript.
Most manuscripts go through multiple rounds of
Perspectives
revisions before they are accepted. Following accep-
The journal invites submissions of Perspectives re- tance, articles are edited for clarity and adherence to
garding any topic relevant to the research and practice journal style guidelines.
of yoga therapy. Perspectives are not peer reviewed
and are limited to 500–1,500 words. Perspectives
Preparation and Submission
should be written in a scholarly style. First person
of Manuscripts
narratives and personal accounts are discouraged.
Perspectives are typically solicited by the editor. Please All articles are to be submitted via e-mail to
contact the editor for guidance before submitting a [email protected]. Include a brief introductory note and
Perspective, at [email protected] article abstract in the body of the e-mail and attach
the manuscript as a Word document. All manu-
scripts must be written and formatted according
Review and Selection of Manuscripts
to the APA Publication Manual, sixth edition
All articles are initially evaluated by the editor for suit- (www.apastyle.org). Research articles must include a
ability of topic and format. Articles that meet the note acknowledging any funding sources or potential
basic requirements are assigned to a minimum of two conflicts of interest, a statement of adherence to eth-
peer reviewers chosen on the basis of their expertise ical guidelines for the use of human participants, and
and experience. Peer review is blind, meaning that the informed consent to use photographs of or publish
author’s identity is not revealed to reviewers. Review- case information about students or clients. We en-
ers and the editor evaluate the article’s contribution courage authors to provide a limited number of high-
to the field of yoga therapy and make specific sugges- resolution photos and well-drawn figures, particularly
tions for revisions. When making a recommendation for descriptions of yoga practices or discussions of
to publish or reject an article, reviewers take into ac- anatomy. Please do not e-mail photos, figures, refer-
count the quality of scholarship, the use of writing ence sections, or appendixes as separate files. Articles
that is appropriate for a scholarly journal, and the are limited to 4,000 to 6,000 words unless authors
relevance of the topic to yoga therapists, researchers, have received prior approval from the editor.
and practitioners. Potential authors wishing to view Reprinted with permission from Dr. Grace Bul-
the current peer review guidelines for the type of lock, PhD, RYT, Editor in Chief. Weblink: http://www
article they plan to submit should e-mail the editor .iayt.org/?page=IJYTSubGuidelines.
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Appendix O

Outline of a Grant
Proposal
Grant Proposal Format d. If applicable, names of other faculty or students
who will participate in this project; location of
Proposals should adhere closely to the following research site.
directions and include all of the components listed. e. Plans for disseminating the project’s results,
such as conferences, workshops, exhibitions and
A. ABSTRACT publications, or other appropriate venues.
Include a brief abstract that provides a summary of f. Potential sources of external monies to which
the proposal (a brief rationale for the project, the you anticipate applying for further funding.
methods to be used, and the expected results and out- g. An explanation of the candidate’s prior work in
comes). Abstracts should be understandable by someone the field and how the current project fits within
who is not necessarily in the field of expertise of the proposer. the larger scholarly or professional agenda.
The abstract should answer the following questions: h. A description of the contribution that the suc-
cessfully completed project will make to the
a. Why should the project be funded?
candidate’s scholarly or professional field.
b. What problem is the project trying to solve or
what are the issues being addressed?
c. How will the proposal go about solving the C. ATTACHMENTS
problem or addressing the issue? a. Project budget (use form provided below)
d. What are the expected findings? b. Brief resume
e. What are the implications of the findings?
f. How will these be disseminated?
Grant Proposal Budget
B. NARRATIVE BUDGET ITEM AMOUNT
Include the following components (maximum five
Personnel
pages):
Equipment
a. Central question being explored or objective
■ List items with prices.
being pursued.
■ Include a rationale for items.
b. Rationale and significance of project: how this
project will contribute to the applicant’s discipline, Travel
overall research agenda, or university initiatives.
TOTAL BUDGET REQUESTED
c. Description of project methodology.
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Index
A block diagram, data displays, 168
abstracts books, literature review, 21–22
literature search, 19–21
sample of, 18, 19 C
use of, 31 Campbell Collaboration, The, 129
writing of, 171 case series designs, 55–61
Academic Search Premier, 132 case study research
active voice, 173 qualitative, 109–110
adaptations, as topic, 15 quantitative, 58–61, 100
adult learning theory, 10, 12–13 causality, historical research, 111–112
AMA style (American Medical Association), 171 central tendency, 84
American Association of Public Opinion Research, 74 Centre for Evidence Based Medicine, 133
American Physical Therapy Association, 79 chalkboards, 180
American Psychological Association, 20–21, 171 chaos theory, 104
American Statistical Association, 81 Chicago Manual of Style, 171
analysis, data, 36 chi-square, 83, 85–86
survey research designs, 57–58 CINAHL (Cumulative Index to Nursing and Allied Health
analysis of covariance (ANCOVA), 83, 89 Literature), 20, 132
analysis of variance (ANOVA), 83, 89 citation tracking, 132
APA style (American Psychological Association), 171 client adaptations, research for, 15
appendices, reports, 162 client-centeredness, 126–127
archival strategies, 99 Clinical Evidence, 129
argumentation, historical research, 112 clinical practice guidelines, 136
articles, literature review, 21–22, 133–139 clinical research, 5
assessments, data collection, 36, 78–80 closed-ended questions, 74–75
assumptions, identifying, 39–41 cluster sampling, 71
assumptions, qualitative research, 115–116, 117 Cochrane Collaboration, 129
asynchronous presentation, 187–189 cohort designs, 54–55
audits, 62 comparable case, 105
author guidelines, 196–197 comprehensive case, 105
autoethnography, 103 conceptual framework, 42
conclusions
B qualitative research, 121–122
background information, study topic, 28–29 quantitative research, 90–91
Bandolier, 129 report sections, 162, 170–171
bar graphs, 167–170, 169 research process, 3–4
basic research, 5 confidence interval, 72
bias confidence level, 72
ethnography and, 106 confidentiality, 153
random assignment and, 48 Confucius, 17
validity and, 64 consent, participants, 151–153, 158
biography, 99 constructionism, 103

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272 Index

constructivism, 103 reports, writing of, 164–170

content analysis, 99 statistics, overview, 80–81, 83
control groups tests for correlation, 87–88
case studies, 60 t tests, 86
cohort designs, 54–55 Wilcoxon rank tests, 86–87
convenience sampling, 54 data as thick description, 97–98
descriptive statistics, 81, 84 databases, literature search, 19–21, 129, 131–133
evidence-based designs, 134, 135, 137–138 data collection methods
experimental designs, 49–50 assumptions about, 39–41
factorial designs, 52 case study, 109–110
Mann-Whitney test, 87 ethnography, 108
overview of, 5, 36, 41, 42, 43, 153 evidence-based practice, 140–141
Pearson’s chi-square, 85 formative research, 62
qualitative designs, 97 historical research, 110–112
quantitative designs, 45, 46–49, 65 interviews, 72–73
quasi-experimental designs, 53–54 narrative analysis, 112–113
random assignment, 48 observation, 72
Solomon four-group design, 51, 52 overview of, 36
statistical significance, 85, 86 peer-reviewed articles, 197–200
time-series designs, 56 qualitative research, 105, 118–121, 120
t tests, 86 record review, 77–78
variance, analysis of, 89 reports, writing of, 163–164
convenience samples, 54, 70, 71 summative research, 62
correlated t test, 86 surveys, 73–77
correlation, tests for, 86–88 data displays, reports, 165–170
correlational research, 57 data reports, 90–91
cost-benefit analysis, 62 Declaration of Helsinki, 152
critical case, 105 deductive reasoning, 3
Critically Appraised Papers (CAPs), 133–139 defining terminology, 39, 40
Critically Appraised Resources (CARs), 133–139 dependent variables, 46
Critically Appraised Topics (CATs), 133–139 descriptive statistics, 81, 84
critical theory, 104 design, research. See evidence-based practice; qualitative
CIJE (Current Index to Journals in Education), 21 research; quantitative research; research methodologies
culture, ethnography and, 99–100 developmental theories, 10
Cumulative Index to Nursing and Allied Health Literature deviant case, 104–105
(CINAHL), 20, 132 diagrams, data displays, 168
cyber presentations, 187–189, 191 discussion
peer-reviewed articles, 199–200
D report section, 162, 170–171
data analysis dissertations, literature search, 20
comparison of multiple variables, 89–90 document review, data collection, 36, 77–78, 108
descriptive statistics, 84 double-blinded randomized trials, 49–50
historical research, 111–112
inferential statistics, 84–90 E
interval data, 82 ECER (Exceptional Child Educational Resource), 21
Mann-Whitney test, 87 ecological psychology, 104
nominal data, 81–82 educational goals, 13
ordinal data, 82 electronic catalog, 19
overview, 36 Eliot, T. S., 95
parametric and nonparametric data, 82–84 embedded video, 188–189
Pearson’s chi-square, 85–86 environmental adaptations, 15, 65
peer-reviewed articles, 197–200 equipment, use in research, 78
qualitative research, 105, 120, 121–122 equipment needs justification, as topic, 144–145
ration data, 82 ERIC, 20, 132
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Index 273

ethical issues grammar, 172–173

controls, quantitative research, 46–47 grant funding
human participants committees, 151–153, 158 enablers and barriers, 205–207
overview of, 154–155 planning for, 203–204
quasi-experimental designs, 53, 54 Skill-Building Tips, 207
ethnographic case study, 109–110 sources for, 207–208
ethnography, 99–100, 103, 106–109 writing skills and knowledge, 204–205
ethnomethodology, 99, 103 graphics, presentations, 182, 185–186
etiquette, oral presentations, 182
evaluation, report section, 162, 170–171 H
evaluation research designs, 62 handouts, oral presentations, 180
Evidence-Based Medicine database, 129 Hawthorne effect, 64
Evidence-Based On-Call database, 129 healthcare evaluation procedures, 15
evidence-based practice healthcare program management, 15
applying evidence (project plan), 136, 139–141 health professions databases, 19–21
challenges to, 127–129 hermeneutics, 104, 111
evaluating evidence, 133–136 heuristic inquiry, 103
evaluating project, 141–142 Hissong, A., 115
needs assessment, 129 historical research, 99, 100–101, 110–112
overview of, 125–127 history, validity and, 63
question, defining, 129–131 human participants committees, 151–153
resources for, 129 hypothesis
searching for evidence, 131–133 formation of, 3–4
Skill-Building Tips, 146–147 reporting data and conclusions, 90–91, 170–171
stories of, 142–146
Exceptional Child Educational Resource (ECER), 21 I
exclusion criteria, 47 ideological principles, 39–41
experimental designs, types of, 49–52 impact analysis, 62
experimental research, 5 implementation, report section, 162, 164–170
exploratory studies, 59 importance of study, statement of, 29–30
external reliability, 120 inclusion criteria, 47
external validity, 47, 63–64 independent samples t test, 86
extreme case, 104–105 independent variables, 46
indexes, literature search, 19–21
F inductive reasoning, 3
factorial designs, 51–52, 53 inferential statistics, 81, 84–90
feminist inquiry, 104 informant choices, reliability and, 120
fieldwork, ethnography, 106–109 informed consent, 152
figures, data displays, 167–170, 182, 185–186 Institutional Review Board, 151–153, 158, 196
Fisher’s extract, 83 instrumentation, validity and, 63
flip charts, 180 intellectual rigor, 119
flowcharts, data displays, 168, 169 internal reliability, 120–121
focus groups, 36 internal validity, 47, 63
formative research, 62 International Statistics Institute, 81
F ratio, 89 interrater reliability, 72, 79
funding. See grant funding interval data, 82, 83
future implications, report conclusions, 171 interventions, peer-reviewed articles, 197–200
interviews. See also surveys, data collection methods
G case studies, 109–110
generalizability, validity and, 64 ethnography, 107–108
goals overview, 36, 72–73
for inquiry process, 13 research strategies, 99
purpose of study statement, 29 intrarater reliability, 72, 79
government documents, 19–20 introduction, report, 161–162
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274 Index

inventories, data collection, 78–80 methodology. See also qualitative research; quantitative
investigative journalism, 99 research; research methodologies
peer-reviewed articles, 197–200
J report sections, 162, 163–164
judgment sampling, 70–71 mixed methods designs, 37–39
Skill-Building Tips, 43–44
K MLA style (Modern Language Association), 171
Kafka, Franz, 151 mode, statistics, 84
Kendall’s tau, 83 moderators, 182
key events, 108 Montgomery, L. M., 203
keywords, topic selection and, 14 motivation, 145–146
Kruskal-Wallis test, 83, 89 multiple-case studies, 58–61
multiple-choice items, surveys, 76
L multiple regression analysis, 90
language choices, writing skills, 172–173 multiple researchers, 121
learning styles, 179 multiple treatments, validity and, 64
learning theory, 10, 12–13 multistage sampling, 71
lectures, 179–183
Likert scale, 75–76, 82 N
limitations of study narrative analysis inquiry, 101, 104, 112–113
peer-reviewed articles, 199–200 narratology, 104
qualitative research, 115–116, 117 National Guideline Clearinghouse, 129
report conclusions, 170–171 naturalistic settings, 97, 102
study design, 42–43 negative cases, 119
line graphs, data displays, 167–170, 169 nominal data, 81–82, 83
List of Assessment Tools Used in Pediatric Physical Therapy, 79 nonexperimental designs, 57–62
literary criticism, 99 nonlinear dynamics, 104
literature review nonparametric data, 82–84
evidence-based practice projects, 131–133 non-peer-reviewed publications, 196
length of, 23 nonprobability sampling, 70–71
literature sources, 18–22 nonreactive research, 99
organizing materials, 22–23 nonverbal communication, 73
purpose of, 17–18
report sections, 162–163 O
Skill-Building Tips, 24 observations
writing of, 22–23 case studies, 109–110
lived experience, 98 ethnography, 107–108
local groundedness, 97 overview, 3–4, 36, 72
longitudinal studies, 55–61 participant observation, 99
low-inference descriptions, 121 observer studies, 99
one-group pretest-posttest design, 54
M online databases, 19–21
manipulation of variables, 45–46 open-ended questions, 75
Mann-Whitney test, 83, 87 operationalizing terminology, 39, 40
maturation, validity and, 63 oral history, 99, 110–112
mean, statistical, 84 oral presentations, 179–183, 189–190, 191
measures of variation, 84 ordinal data, 82, 83
mechanically recorded data, reliability and, 121 organization, writing skills, 172–173
median, statistical, 84 orientational perspective, 104
Medline, 132 Osgood, Charles, 75
mentoring, 145–146 OT Search, 20
MeSH headings, 21 OT Seeker, 129
methodological research designs, 61–62 outcome analysis, 62
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Index 275

outlines, use of, 172 purpose of study statement, 29

overhead projectors, 180 qualitative research, 102–104
OVID, 132 refining, 27–28
research question, statement of, 30
P samples, 28
paired samples (correlated) t test, 86 Skill-Building Tips, 31
parametric data, 82–84 procedures
participant observation, 99 assumptions about, 39–41
participant researchers, 121 peer-reviewed articles, 197–200
participants, reactions to analysis, 119 product moment of correlation, Pearson, 83
participant selection. See sample population program development, evidence-based practice, 142–143
passive voice, 173 project evaluation, evidence-based practice, 141–142
Pearson product moment of correlation, 83, 88 ProQuest Dissertations, 20
Pearson’s chi-square, 83, 85–86 PsycINFO, 20–21
pedagogy, 178 Publication Manual of the American Psychological Association
PEDro Physiotherapy Evidence Database, 129 (2012), 23
peer examination, reliability and, 121 publishing
peer-reviewed articles, format of, 197–200 article format, 197–200
peer-reviewed journals, 195–196 author guidelines, 196–197
permissions, obtaining, 151–153, 158 goals of, 193–195
phenomenological designs, 102, 103 process for, 200–202
phenomenological perspective, 97 selecting a publication, 195–196
phenomenology, 99 Skill-Building Tips, 202
Phillpotts, Eden, 3 PubMed, 20, 132
philosophical research, 99 purpose, of inquiry, 14–15
photography, data collection, 108 purpose of study, statement of, 29
pictograph, data displays, 168, 169 purposive sampling, 70–71
pictures, presentations, 182, 185–186
pie chart, data displays, 168, 169 Q
pilot studies, 155–157 qualitative research. See also presentations; publishing
planning, time estimates, 4–5 assumptions and limitations, 115–116, 117
podcasts, 188–189 case study method, 109–110
positivist approach, 103 common constructs, 96–98
poster presentations, 183–187, 189–190, 191 data analysis and reporting, 105, 121–122
post hoc comparison, 89 data collection, 105
posttest-only designs, 50–51 general features, 35–37, 38
PowerPoint presentations, 180–182, 189–190, 191 historical research, 110–112
presentations narrative analysis, 112–113
additional resources, 191 overview of, 95–96, 99
cyber presentations, 187–189 participant selection, 104–105, 116–117, 118
defined, 178–179 preparing for, 101–102
learning styles, 179 problem and theory, 102–104
oral presentations, 179–183 recurring features, 98
posters, 183–187 reliability, 119–121
reasons for, 177–178 report writing, 105–106
Skill-Building Tips, 189–190 research designs, 106–113
pretest-posttest designs, 49–50 research questions, 103–104
primary sources, 77–78, 111 Skill-Building Tips, 43–44, 113, 122
privacy, participants, 153 validity, 118–119
probability sampling, 71 quantitative research. See also presentations; publishing
problem statement case study research, 58–61
background information, 28–29 controls, 46–47
importance of study, statement of, 29–30 data analysis, overview, 80–81
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276 Index

data collection techniques, 72–80 abstract, 171

data reports and conclusions, 90–91 cyber presentations, 187–189, 191
data types, 81–84 evaluation, discussion, conclusions, 170–171
experimental designs, types of, 49–52 implementation and results section, 164–170
general features, 35–37, 38, 45 introduction and overview, 161–162
manipulation of variables, 45–46 literature review, 162–163
nonexperimental designs, 57–62 methodology section, 163–164
quasi-experimental designs, 52–57 oral presentations, 179–183, 191
random selection, 47–49 poster presentations, 183–187, 191
reliability, 64–65 qualitative research, 105–106, 121–122
sampling decisions, 69–72 quantitative research, 90–91
Skill-Building Tips, 43–44, 66, 91–92 Skill-Building Tips, 174–175
validity of, 62–64 summary outline, 162
quasi-experimental designs, 52–57 writing tips, 171–174
queer theory, 104 reputational case, 105
questions, survey research, 74–77 research
Quivers, Robin, 27 categories of, 5
quota samples, 70, 71 challenges of, 4, 6
quotations, use of, 173 process for, 3–4, 5–6
purpose, identifying, 14–15
R time to complete, 4–5
Radmacher, Mary Ann, 125 researchers
random assignment, defined, 48 bias of, 64
randomization, studies lacking, 54 multiple researchers, 121
randomized controlled trial (RCT), 49–50 participant researchers, 121
random number chart, 48 researcher status, reliability and, 120
random sampling, 71 role of, 36
random selection, 47–49 research log, 132
range, statistics, 84 research methodologies. See also qualitative research;
rank-ordering items, surveys, 76–77 quantitative research
ratio data, 82, 83 assumptions, identifying, 39–41
rationale for project, 129–131 limitations of study, 42–43
readability formulas, 173 mixed methods designs, 37–39
realist approach, 103 overview, 35
reality testing, 103 quantitative and qualitative methods, overview, 35–37, 38
recommendations, making of, 142 reporting of, 162, 163–164, 197–200
record review, 36, 77–78 scope of study, 42
reference books, 19 Skill-Building Tips, 43–44
references terms, defining and operationalizing, 39, 40
peer-reviewed articles, 199–200 research portfolio, 162–163
poster presentations, 186 research protocol review committee, 151–153
presentations, 182 research question. See problem statement
reports, 174 Resources in Education (RIE), 21
regression analysis, 88, 90 response rate, surveys, 73–74
rejection, peer-reviewed articles, 201–202 results
reliability peer-reviewed articles, 197–200
methodological research designs, 61–62 report section, 162, 164–170
observation methods, 72 retrospective studies, 99
qualitative research, 119–121 rho (r), 88
quantitative research, 64–65 RIE (Resources in Education), 21
test instruments, 79–80 risks and benefits, study approval, 152–153
replication, validity and, 64 rival explanations, 118–119
reports. See also publishing Rogers, Carl, 126
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Index 277

Rogers, Fred, 203 social situations, reliability and, 120

Roosevelt, Franklin, 69 software tools
cyber presentations, 187–189
S organizing literature materials, 22
Sackett, David, 125–126 PowerPoint presentations, 180–182
SAGE Publications, 132 statistics, 90, 91
sample population writing, 173
attrition or mortality, 63 Solomon four-group design, 51
cohort designs, 54–55 Spearman rho, 83, 88
decisions about, 70–72 split-half reliability, 79
human participants committees, 151–153, 158 staffing needs, justification for, 144–145
inclusion and exclusion criteria, 69–70 standard deviation, 84
methodology, report section, 163–164 statement of research, 18
qualitative research, 36, 104–105, 116–117, 118 statistical significance, 85–87
quantitative research, 36 statisticians, use of, 80–81
quasi-experimental designs, 52–57 statistics
randomization, 47–49 comparison of multiple variables, 89–90
reliability and, 64–65 descriptive statistics, 81, 84
survey research designs, 58 inferential statistics, 84–90
time-series designs, 55–57 Mann-Whitney test, 83, 87
validity and, 63 overview of, 80–81, 83
sample size, 36, 71–72 Pearson’s chi-square, 83, 85–86
schematic, data displays, 168 reports, writing of, 165–170
scope of study, 42 software for, 90, 91
screencasts, 188–189 tests for correlation, 87–88
search terms, databases, 21 t tests, 86
secondary sources, 77–78, 111 Wilcoxon rank tests, 83, 86–87
semantic differential, 75, 76 stepwise regression, 90
semiotics, 104 stratified random sampling, 71
service needs, justification for, 144–145 study limitations, 42–43
Shirley, Anne, 203 study problem
simple regression analysis, 88, 90 background information, 28–29
single-blinded randomized trial, 50 importance of study, statement of, 29–30
single-case studies, 58–61 purpose of study statement, 29
single sample t test, 86 refining of, 27–28
single-subject studies, 58–61 research question, statement of, 30
Skill-Building Tips samples, 28
evidence-based practice, 146–147 Skill-Building Tips, 31
grant writing, 207 style manuals, 171
literature review, 24 subjects. See sample population
presentations, 189–190 summative research, 62
problem statement, development of, 31 surveys
publishing articles, 202 data collection methods, 73–77
qualitative research, 113, 122 research designs, 36, 57–58
quantitative research, 66, 91–92 Swindoll, Charles R., 161
report writing, 174–175 symbolic interactions, 103
research methodologies, 43–44 synchronous presentation, 187–189
research plans, 6–7 systematic random sampling, 71
topic selection, 15–16 systems theory, 104
slides, presentations, 180–182
small-N studies, 58–61 T
Smart boards, 180 table of contents, reports, 174
snowballing, 71, 132 tables, data display, 165–170, 185–186
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278 Index

tau b, 83 U.S. Department of Education, 20

teamwork, 145–146 U.S. government documents, 19–20
technological adaptations, 15
terminology, database searches, 21 V
terminology, data collection questions, 73 VAK (visual, auditory, kinesthetic) model of
terminology, defining and operationalizing, 39, 40 learning, 179
tests, data collection validity
factorial designs, 51–52, 53 cohort designs, 55
one-group pretest-posttest design, 54 methodological research designs, 61–62
overview, 36, 78–80 qualitative research, 118–119
posttest-only designs, 50–51 quantitative research, 62–64
pretest-posttest designs, 49–50 quasi-experimental designs, 52–57
reliability and, 64–65 randomized controlled trial (RCT), 49–50
Solomon four-group design, 51 random selection and, 47–49
test-retest reliability, 79 test instruments, 79–80
validity and, 63 variables. See also control groups
theory comparison of multiple variables, 89–90
qualitative research, 102–104 correlational research, 57
research process, 3–4 dependent, 46
therapeutic interventions, 15 experimental designs, types of, 49–52
thick description, data as, 97–98 independent, 46
time estimates, 4–5, 10, 11–12 manipulation of, 45–46
time-series designs, 55–57 quantitative case studies, 58–61
topics quasi-experimental designs, 52–57
background information, 28–29 variation, measures of, 84
importance of study, statement of, 29–30 verb tense, 172
purpose of study statement, 29 video, presentations, 188–189
research question statement, 27–28, 30 video conferencing, 188–189
sample statement of study, 28 visuals
selection and development of, 9–10, 13–16 oral presentations, 179–183
Skill-Building Tips, 31 poster presentations, 185–186
transformative learning, 10, 12–13 voice-over-Internet protocols, 188–189
translators, writing report, 174
treatment, withholding of, 153 W
triangulation, 36, 37, 119 web-based presentations, 187–189
t test, 83, 86 whiteboards, 180
typical case, 104 Wilcoxon rank tests, 83, 86–87
Wilma L. West Library of the American Occupational Therapy
U Association, 20
unique case, 105 withdrawal of consent, 153
unique clinical scenarios, guidance for, 143–144 World Medical Assembly, 152
unobstructive research, 99 writing, style manuals, 171
UpToDate, 129 writing, tips for, 171–174
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