Summary Computer Use in Nursing Research
engine that health systems put to work to research
CHAPTER OUTLINE
Introduction
1. Overview
a. Nursing research involves a plethora of tools and resources
that researchers employ throughout the research process
(1) From the individual or collaborative project
initiation, through refinement of the idea, selection of
approaches, development of methods, capturing the
data, analyzing the results, and disseminating the
findings, computer applications are an indispensable
resource for the researcher
(2) The investigators must be well prepared in a
variety of computerized techniques for research
activities as they are employed in the domain of
knowledge that will be investigated
(3) Without the power of technology, contemporary
research would not reach the levels of sophistication
required to discover and understand health and
illness today
b. In addition to the traditional approaches of the scientific
method, researchers today have new avenues to explore in the
development of knowledge
(1) New opportunities to mine existing data for
evaluation and discovery are forming a bridge
between the process of conducting research and the
products of discovery
(2) New tools for automatic capture and analysis are
changing the methods textbooks
(3) New online strategies and apps are being
implemented as the process of researching health
and the product of researched interventions in health
(4) From mobile applications that are downloadable
to smartphones for researchers or patients or both,
to tools for exploring large data sets that have been
already captured, computer use in nursing has
exploded concomitantly with computers in
healthcare
c. What is also of importance for computer use in nursing is the
research on computerized applications and nursing
informatics, which is revolutionizing how health information is
documented in the Electronic Health Record (EHR) and
producing pools of searchable secondary data waiting to be
tapped
(1) The context for nursing informatics research has
proliferated since the National Institute of Nursing
Research (NINR) published an agenda outlining the
need for nursing informatics research in the Nursing
Informatics Research Agenda
(2) Other reports called for organizing priorities and
con- structing models to develop a context
connecting nursing and informatics that would
provide the basis for studying the practice of nursing
informatics
(3) Today, hospital wide information technology (IT) is
the spine of all healthcare delivery, which is tied to
1
reimbursement, and which inevitably forms the data
improvement and outcomes-driven questions
(4) It is therefore imperative to understand the
underlying terminologies and sources of data,
communication of those connected pieces of
information, and the elements in the nursing
environments through informatics research if one is
to understand how computers and nursing research
coexist
d. Outside the EHR and computerized health systems, in the
rapidly changing world of Internet technologies, information
management, and computer-enhanced intervention research
on the use of computers has produced a new body of science
that will continue to grow
(1) Blending the focus of computer use in research
(tools and process) and research on computer use
(informatics research) calls for an understanding of
process and products
(2) This chapter will provide an overview of the
research process for two separate and fundamentally
different research approaches—quantitative and
qualitative— and discuss select computer
applications and uses relative to these approaches
(3) The discussion will be supplemented by examples
of current science and the trajectory of research on
the impact of informatics, electronic records,
treatments, and integrated technologies using the
computer as a tool
e. The computer has been a tool for researchers in many
aspects of the research process and has gone beyond its
historic application once limited to number crunching and
business transactions
(1) Field-notes binders, ring tablets, index cards, and
paper logs have all but disappeared in the
researcher’s world
(2) Personal computers (PCs), laptops, PC-tablets and
iPads, and handheld devices have become part of the
researcher’s necessary resources in mounting a
research project or study
(3) Wireless technologies are ubiquitous and connect
people to people as well as researchers to devices
(4) Cloud computing today connects diverse
enterprises with stable sources of software and data
that can be shared or used by anyone, at any time, or
any place
(5) Numerous enhancements have been added to the
well-known text processing software products that
reduce time and effort in every research office
(6) In addition, a wide range of new technologies for
database management of subjects, contacts, or
logistics have emerged in the research product
marketplace
(7) Nurse researchers use a range of hardware and
soft- ware applications that are generic to research
development operations in addition to the tools and
 devices that are specific to research data collection,
analysis, results reporting, and dissemination
(8) New apps appear continuously, customized to the
data collection, management, or analysis process
f. In today’s electronic healthcare environment, numerous
advances have been made with the sources of data collection
relative to general clinical applications in nursing, health, and
health services
(1) System implementations for large clinical
enterprises have also provided opportunities for
nurses and health service researchers to identify and
extract information from existing computer-based
resources
(2) In an era when the federal government is calling
for comparative effectiveness research (CER) to
address the rising costs of healthcare, the richness of
capturing nursing data that can be managed and
mined for advanced analyses should be recognized in
the development of EHRs and other sources
g. In addition, the era of Web-based applications has produced
a wide range of innovative means of entering data
and, subsequently, automating data collection in ways that
were not possible before
(1) With the advancements in clinical systems, accept-
able terminology and vocabularies to support nursing
assessment, interventions, and evaluation,
computers are increasingly being used for clinical and
patient care research
(2) Although research is a complex cognitive process,
certain aspects of carrying out research can be aided
by software applications
(3) It is noteworthy when hospital systems today can
use analytics across institutions with large samples of
existing data to compare and predict best outcomes
with select interventions, for example, examining
preoperative procedures that minimize postoperative
complications
h. With a wider view of computer use in nursing research, the
objective of this chapter is fourfold
(1) To provide an overview of general computer and
soft- ware applications related to the stages of the
research process
(2) To describe how computers facilitate the work of
the researcher in both quantitative and qualitative
aspects
(3) To highlight research on computer use in
healthcare
(4) To give attention to the explosion of research in
categories delineating clinical and nursing informatics
research
i. These will serve as a snapshot of the research on computer
use for the future with contextual influences
j. To begin, the chapter will focus on some of the
considerations related to the logistics and preparation of the
research proposal, project planning, and budgeting, followed
by the implementation of the proposal with data capture, data
management, data analysis, and information presentation
2
(1) The general steps of proposal development,
preparation, and implementation are applicable to
both quantitative and qualitative approaches
(2) However, no discussion about computer use in
research could be complete without acknowledging
the range of
research now appearing in the literature that
examines the trajectory of new technologies and
computer use in patient care
(3) With increasing emphasis on cost and quality of
health- care, the computer-sources-of-data and
computer-as- intervention must be part of
understanding computer use in nursing research
today
Proposal Development, Preparation, And Implementation
1. Overview
a. All research begins with a good idea
(1) The idea is typically based on the nurse
researcher’s identification of a problem that is
amenable to study using a philosophical and
theoretical orientation
(2) The philosophical aspect sets the stage for
selecting one’s approach to investigating the problem
or developing the idea
(3) Good clinical ideas often come from personal
experiences, based on the researcher’s foundation of
knowledge that aids in drawing inferences from real
clinical situations
(4) These unfold by way of iterative consideration of
problem and process—leading the investigator to
evolve an approach to the problem, and subsequently
a theoretical paradigm to address the problem
(5) Because the theoretical paradigm emerges from
these iterative considerations, and because the
theoretical perspective will subsequently drive the
organization of the research study, it is important to
distinguish between these two distinct approaches
(6) Each theoretical paradigm directs how the
problem for study will unfold
(7) The researcher uses a selected theoretical
approach and operationalizes each step of the
research process that will become the research
design and methodology, either qualitative,
quantitative, or some combination of both in mixed
methods
(8) Each approach can be facilitated at different
points along the proposal process with select
computer applications
(9) These will be described as they relate to the
methodology
2. Quantitative or Qualitative methodology
a. The important distinction to be made between the
quantitative and qualitative approaches is that for a
quantitative study to be successful, the researcher is obliged
to fully develop each aspect of the research proposal before
collecting any data, that is, a priori; whereas, for a qualitative
study to be successful, the researcher is obligated to allow the
data collected to determine the subsequent steps as it unfolds
in the process and/or the analysis
(1) Quantitative research is derived from the
philosophical orientations of empiricism and logical
positivism with multiple steps bound together by
precision in quantification
(2) The requirements of a hypothesis-driven or
numerically descriptive approach are logical
consequences of, or correspond to, a specific theory
and its related tenets
(3) The hypothesis can be tested statistically to
support or refute the prediction made in advance
(4) Statistics packages are the mainstay of the
quantitative methodologist, but are not the only
connection to computers for the researcher
b. The qualitative approaches offer different research
traditions (e.g., phenomenology, hermeneutics, ethnography,
and grounded theory to name a few) that share a common
view of reality, which consists of the meanings ascribed to the
data such as a person’s lived experiences
(1) With this view, a theory is not tested, but rather,
perspectives and meaning from the subject’s point of
view are described and analyzed
(2) For nursing studies, knowledge development is
generated from the participant’s experiences and
responses to health, illness, and treatments
(3) The requirements of the qualitative approach are
a function of the philosophical frames through which
the data unfold and evolve into meaningful
interpretations by the researcher
(4) A variety of software applications assist the
qualitative methodologist to enter, organize, frame,
code, reorder and synthesize text, audio, video, and
sometimes numeric data
3. General considerations in proposal preparation
a. Several computer applications have become indispensable
in the development of the research proposal and generally in
planning for the activities that will take place when
implementing the study
(1) These include broad categories of office programs
including word processing, spreadsheet, and
database management applications
(2) According to Forrester Research, an independent
research firm, Microsoft Office products currently
capture 80% of users with 64% of enterprises using
Office 2007
(3) Office 365 is the new release from Microsoft,
programs with cloud capability that continue to offer
improved clerical tools to manage the text from
numerous sources and assemble them in a cogent
and organized package
(4) The cloud connectivity gives researchers access to
all programs and data virtually from anywhere. PC,
Mac, and Droid tablets and smartphones extend the
3
reach of all connectivity with a range of text
processing and data management standard tools
b. Microsoft Office products provide capabilities and a plat-
form into which other off-the-shelf applications can be
integrated
(1) Tables, charts, and images can be inserted, edited,
and moved as the proposal takes shape, with final
products in publishable forms
(2) PC applications that allow inserting simple graphic
designs give the researcher a powerful means of
expressing concepts through art
(3) Line art and scanned images using Adobe industry
standards such as Illustrator CC or Photoshop CC, now
with cloud capability, can be integrated into the
document for clear visual effects
(4) These offer the researcher and grants managers
tools to generate proposals, reports, and manuscripts
that can be submitted electronically directly or
following conversion to portable document formats
(pdf) using Adobe Acrobat or other available
conversion products
c. There are a variety of reference management software
products available as add-ons to word processing, with ranging
prices and functionalities
(1) Bibliographic management applications emerge
frequently and librarians often help sort out best
ways to keep reference materials in order
(2) Common programs such as Reference Manager,
Procite, and Endnote are products of the Thomson
Corporation, the industry standard software tools for
publishing and managing bibliographies on the
Windows and Macintosh desktops
(3) RefWorks adds another option for reference
management from a centrally hosted Web site
(4) Searching online is one function of these
applications, and then working between the
reference database and the text of the proposal
document is efficient and easy, calling out citations
when needed with “cite as you write” capability into
the finished document
(5) Output style sheets can be selected to match
publication or proposal guidelines
d. Research applications and calls for proposals are often
downloadable from the Internet into an interactive form
where individual fields are editable and the documents can be
saved in a portable format such as Adobe Acrobat, printed, or
submitted from the Web
(1) The Web also allows the researcher to explore
numerous opportunities for designing a proposal
tailored to potential foundations for consideration of
funding
(2) Calls for proposals, contests, and competitive
grants may provide links from Web sites that give the
researcher a depth of understanding of what is
expected in the proposal
 (3) There are more and more homegrown submission
procedures today for grants and journal manuscripts
with Web-based instructions
(4) These often convert the documents automatically
to portable formats (pdf) for submission with key data
fields organized and sorted for easier review
procedures. Instructions are customized for the user
4. Research study implementation
a. A funded research study becomes a logistical challenge for
most researchers in managing the steps of the process
(1) Numerous demands for information management
require the researcher to maintain the fidelity of the
procedures, manage the subject information and
paper flow, and keep the data confidential and secure
(2) These processes require researchers to use a
database management system (DBMS) that is reliable
(3) Several DBMS software applications exist and have
evolved to assist the researcher in the overall process
of study implementation
(4) These applications are operations oriented, used
in non-research programs and projects as well, but
can assist the researcher in management of time,
personnel, money, products, and ultimately
dissemination, with reporting capability for reviews
and audits
b. The ubiquitous Microsoft Office suite includes programs
that manage data in a relational database (Microsoft Access)
and number crunch in a flat database (Microsoft Excel)
available to every researcher
(1) Proprietary database applications and new
customized, more sophisticated, integrated, and
proprietary database management applications from
companies such as Oracle and Lotus provide the
researcher with ways to operationalize the personnel,
subjects, forms, interviews, dates, times, and/or
tracking systems over the course of the project
(2) Most of these applications require specially
designed screens that are unique to the project if the
research warrants complicated connections such as
reminders, but simple mailing lists and zip codes of
subjects’ addresses and contact information in a
generic form can also be extremely useful for the
researcher
(3) Some of these applications are beginning to
include add-ons to increase application portability
with devices such as the smartphones and tablets,
and mini-tablets
c. Several other generic computer programs can aid the
researcher in daily operations and project management
(1) Spreadsheet applications are invaluable for
budgeting and budget planning, from proposal
development through project completion
(2) One multipurpose Microsoft Office application is
Microsoft Excel
(3) Universally understood and easy to use, Excel
allows the researcher to manage costs and calculate
4
expenses over the course of the project period,
producing a self- documenting plan by categories to
track actual spending and money left
d. Templates can be developed for repetitive tasks
(1) Scheduling and project planning software is also
available from Microsoft including Microsoft Project
that allows the project director to organize the work
efficiently and track schedules and deadlines using
Gantt charts over the lifetime of the project
(2) In more sophisticated research offices, customized
tracking and data capture devices, programs and
systems have been launched, including the exemplar
of data management tools from the recent US Census
that have captured and made data available to
researchers with data tools
e. One other important consideration related to research
proposal implementation for the seasoned researcher or the
novice, doctoral dissertation investigator is the essential step
of submitting the proposal to the Institutional Review Board
(IRB)
(1) Home institutions that have IRBs will have specific
procedures and forms for the researcher who can
benefit from the proposal development electronically
(2) In some institutions, the IRB document
management has been done through contracts with
outside Internet organizations providing mechanisms
for posting IRB materials, managing the online
certifications required, and communicating with the
principle investigators
f. In summary, the general considerations of developing and
conducting a research study are based on philosophical
approaches and will dictate which methodology the researcher
will use to develop the study
(1) Although this will subsequently influence the
research and computer applications to be used in
carrying out the project, the steps of proposal
preparation are less specific, and the computer
applications are useful in both quantitative and
qualitative studies
(2) After identifying the research problem, however,
the researcher must proceed through the steps of the
process, where computers play an important role that
is unique to each of the methodologies
The Quantitative Approach
1. Data capture and data collection
a. Data capture and data collection are processes that are
viewed differently from the quantitative and qualitative
perspectives
(1) Nurses may already be familiar with data
collection that is focused on the management of
patient care
(2) Patient monitoring, patient care documentation,
and interview data are collected by nurses, although
not always for research purposes
 (3) Data collection can take a number of forms
depending on the type of research and variables of
interest
(4) Computers are used in data collection for paper-
and- pencil surveys and questionnaires as well as to
capture physiologic and clinical nursing information in
quantitative or descriptive patient care research
(5) There are also unique automated data capturing
applications that have been developed recently that
facilitate large group data capture in single contacts
or allow paper versions of questionnaires to be
scanned directly into a database ready for analysis or
provided online with Web-based survey tools
b. Paper and pencil questionnaires
(1) Paper and booklet surveys do still exist today in
data collection, but new enhancements aid the
researcher in time-saving activities
(2) Surveys and questionnaires can be scanned or
programmed into a computer application either in a
microcomputer or on a Web site accessed through
the Internet
(3) Computers are being used for direct data entry in
studies where subjects enter their own responses via
a computer, and simultaneous coding of response to
questions and time “online” can be captured or Web
surveys can be distributed widely
(4) These online survey tools can provide a wide range
of applications, including paper or portable versions,
and range in price and functionality
(5) The use of notebook microcomputers, tablets, and
mini-tablets have gained popularity in recent years
for allowing the user to enter the data directly into
the computer program at the time of the interview
with a subject, with innovations emerging in touch
screens, screen pens, and even wireless data entry
with smartphones
(6) Responses to questions can be entered by the
respondent or a surrogate directly into the computer
or Web site through Internet access
(7) There are several research study examples where
patients with chronic conditions used a computer
application or the Internet as the intervention as well
as the data capture device; patients or caregivers
responded to questions directly and the data were
processed with the same system
(8) Other examples of unique data capture in research
include individual devices such as the “Smart Cap”
used to measure patient compliance with
medications
(9) The Medication Event Monitoring System
(MEMS®6) automates digitized data that can be
downloaded for analysis in research such as patient
adherence studies
(10) A variety of online survey tools also provide
researchers the power to collect data from a distance,
without postage, using the Internet
5
(11) These applications can present questionnaire
data in graphically desirable formats, depending on
the price and functionality of the software, to subjects
delivered via e-mail, Web sites, blogs, and even social
networking sites such as Facebook or Twitter if
desirable
(12) Social media mechanisms such as blogs and
tweets are often providing sources of data analyses,
albeit questionably scientific, that have sometimes
been harnessed to extract meaning for researchers
(13) Web surveys, although often criticized for
yielding poorer response rates than traditional mail
are becoming increasingly popular for their cost and
logistical benefits
(14) The data from the Internet can be downloaded
for analysis and several applications provide instant
summary statistics that can be monitored over the
data collection period
(15) Several of these programs are available for free
with limited use; others yield advanced products that
can be incorporated into the research, giving mobility
(e.g., smartphones) and flexibility (e.g., scanning or
online entry) to the data capture procedures
(16) Several of these applications include:
(1) Survey Monkey
(2) E-Surveys Pro
(3) Survey System
(4) Qualtrics
(5) SNAP Survey software
(17) Many of these products continue to enhance
functionality and delivery modes as well as
integration with statistical analyses programs and
qualitative narrative exportability
(18) Several special applications have been used in
nursing research that can facilitate large group data
capture
(19) Group use applications in specially designed
facilities have been developed to engage an audience
in simultaneous activity, recording their impressions
through electronic keypads located proximal to the
users, and capturing that information for display or
later analysis
(20) One type of application, Expert Choice 11.5 uses
the analytic hierarchy process (AHP), a mathematical
technique, with handheld keypad technology to elicit
group responses and automatically score, analyze,
prioritize, and present information back to the group
graphically
(21) AHP has been used as the multiple criteria
decision making analysis technique in nursing
research studies, and the Expert Choice software
allows for group data entry
(22) This kind of groupware for collaborative decision
making can supplement data collection from a focus
group to add a quantitative component to the
subjective question as it elicits and captures opinion
via pairwise comparisons
 (23) Software packages also exist that can be
integrated with the researcher’s scanner to optically
scan a specially designed questionnaire and produce
the sub- jects’ responses in a database ready for
analysis
(24) OmniPage 18 is a top rated optical character
recognition (OCR) program that converts a scanned
page into plain text
(25) Programs such as SNAP Survey software and
Remark Office OMR 8 can facilitate scanning large
numbers of questionnaires with speed and accuracy
(26) These products, enhanced even more with Web-
based products such as Remark Web Survey, increase
the accuracy of data entry with very low risk of errors,
thereby improving the efficiency of the data capture,
collection, and entry processes
c. Physiologic data
(1) The collection of patient physiologic parameters
has
long been used in physiologic research
(2) Some of these parameters can be measured
directly from patient devices such as cardiac
monitoring of heart rhythm, rate, and fluid or
electrolytes and be captured in the patient care
records of the hospital systems
(3) Now that many measurements taken from various
types of imaging (e.g., neurologic, cardiovascular, and
cellular) have become digitized, they can also be
entered directly from the patient into computer pro-
grams for analysis
(4) Each of these applications is unique to the
measures, such as systems to capture cardiac
functioning and/ or pulmonary capacity, devices that
can relay con- tractions, or monitors that pick up
electronic signals remotely
(5) Numerous measurements of intensity, amplitude,
pat- terns, and shapes can be characterized by
computer programs and used in research
(6) Each of these measurement systems have evolved
with the unfolding of research specific to their
questions, and within each community of scholars,
issues about the functionality, accuracy, and
reliability of electronic data extracted from these
physiologic devices are debated
(7) Along with the proliferation of clinical diagnostic
measurement systems, there has been a rapid
expansion of unique computer applications that have
emerged for the data analysis aspects of these clinical
systems, physiologic and record sources
(8) Millions of gigabytes of data are stored in
machines that can be tapped for multiple studies on
the existing data
(9) Data mining is a powerful tool in the knowledge
discovery process that can now be done with a
number of commercial and open-source software
packages
6
(10) Data mining and the evolving “big data”
initiatives to make patient care data available
introduces new ways to manipulate existing
information systems
(11) With increased attention to CER, several
government and private organizations are
encouraging researchers to hone the techniques to
extract valid and reliable information from these large
data sets
(12) Data mining is a mechanism of exploration and
analysis of large quantities of data in order to discover
meaningful patterns and rules, applied to large
physiologic data sets as well as clinical sources of data
(13) The nature of the data and the research question
determine the tool selection (i.e., data-mining
algorithm or technique)
(14) Tools and consultants exist to help researchers
unfamiliar with data mining algorithms to use data
mining for analysis, prediction, and reporting
purposes
(15) Many of the first commercial applications of data
mining were in customer profiling and marketing
analyses
(16) Today, many special technologies can be applied,
for example, to predict physiologic phenomena such
as genetic patterns in tumors that might respond to
therapy based on classification of primary tumor gene
expression or tissue rejection post-heart
transplantation from blood samples and biopsies
(17) The National Institutes of Health (NIH) is
undertaking several initiatives to address the
challenges and opportunities associated with big data
(18) As one component of the NIH-wide strategy, the
Common Fund in cooperation with all NIH Institutes
and Centers is supporting the Big Data to Knowledge
(BD2K) initiative, which aims to facilitate broad use of
biomedical big data, develop and disseminate
analysis methods and software, enhance training for
disciplines relevant for large-scale data analysis, and
establish centers of excellence for bio- medical big
data
d. Unique nursing care data in research
(1) Scientists and technologists from a variety of
disciplines are working hard to identify the domain of
data and information that is transferable across
situations, sites, or circumstances that can be
captured electronically for a wide array of analyses to
learn how the health system impacts the patients it
serves
(2) The American Nurses Association (ANA) has sup-
ported the need to standardize nursing care terms for
computer-based patient care systems
(3) The clinical and economic importance of
structured recording to represent nursing care was
recognized by the acceptance of the nursing
minimum data set (NMDS)
 (4) The ANA has accepted seven systems of
terminology for the description of nursing practice
(1) The North American Nursing Diagnosis Association
(NANDA) taxonomy of nursing diagnosis
(2) Georgetown Home Healthcare Classification
(renamed Clinical Care Classification [CCC] System)
(3) Nursing Interventions Classification (4) Nursing
Outcomes Classification (5) Patient care data set
(6) Omaha Home Healthcare
(7) The International Classification of Nursing Practice
(5) The Clinical Care Classification System nursing
terminology has been accepted by the US
Department of Health and Human Services (HHS) as a
named standard within the Healthcare Information
Technology Standards Panel (HITSP) Interoperability
Specification for Electronic Health Records,
Biosurveillance and Consumer Empowerment as
presented to a meeting of the American Health
Information Community (AHIC), a federal advisory
group on health IT
(6) Although none of the above has emerged as a
single standard, national efforts and collaborative
efforts with the International Classification of Nursing
Practice (ICNP) from the International Council of
Nursing (ICN) are underway to “harmonize” the data
elements in the NMDS and SNOMED CT (Systematized
Nomenclature of Medicine Clinical Terms)
(7) With a structured coding system to record patient
care problems that are amenable to nursing actions,
the actual nursing actions implemented in the care of
patients, and the evaluation of the effectiveness of
these actions, researchers can analyze large nursing
data
(8) Outcomes research and quality indicators
extracted from health information systems (HIS) have
become the data end-points that can justify
healthcare services
(9) The American Recovery and Reinvestment Act
(ARRA) of 2009 called for increased development,
certification, and wide-range “meaningful use” of
EHRs across healthcare
(10) The federal government has incentivized
development of cross-platform compatibility and
collaboration
(11) Research on outcomes of care is one of the
center- pieces of this massive policy that has begun to
show an impact on integrated information
technologies in healthcare that can transform
practice
(12) Nursing research on nursing practice captured
from standardized terminology will be essential to
document outcomes of nursing care
2. Data coding
a. In most quantitative studies, the data for the variables of
interest are collected in a numerical form
7
(1) These numerical values are entered into
designated fields in the process of coding
(2) Coding may be inherent in software programs for
the physiologic data and many of the electronic
surveys
(3) The coding may be generated by a computer
program from measurements directly obtained
through imaging or physiologic monitoring, or
entered into a computer by a patient or researcher
from a printout or a questionnaire or survey into a
database program
(4) Most statistical programs contain data editors that
permit the entry of data by a researcher as part of the
statistical application
(5) In such a situation, fields are designated and
numeri- cal values can also be entered into the
appropriate fields without the use of an extra
program
(6) For mechanisms that translate and transfer source
data to prepare it for analysis, generic programs such
as Microsoft Excel serve multiple needs
(7) In addition to allowing simple transfers of data
from source to a statistical analysis package, Excel has
its own powerful, but simple, analysis capabilities and
exceptionally easy to use graphic translators that can
turn statistics into visual graphs and charts
(8) Coding data is a precise operation that needs
careful consideration and presents the researcher
with challenges that warrant technical or cognitive
applications
(9) Coding data is a combination of cognitive decisions
and mechanical clerical recording of responses in a
numerical form with numerous places for error to
occur
(10) There are several ways of reviewing and
“cleaning” the data prior to analysis
(11) Some computer programs allow for the same
data to be entered twice called double-data entry or
two-pass verification
(12) This is done preferably by different people to
check for errors, with the premise that if the double
entry does not match, one entry is wrong
(13) One also must check for missing data and take
them into consideration in the coding and analyses
(14) New versions of advanced statistical software
help in these activities
(15) Reviewing data for values outside of those
allowable is another way of examining the data for
errors
(16) It can best be done by examining the multiple
print- outs produced by the statistical software
packages or procedures invoked in the statistical
application and by carefully perusing for outliers or
artifacts
(17) Another type of data coding can be described in
the example of the process of translating data from
documentation of patient care using coding strategies
 (18) Current research on coding nursing data using
standardized nursing terminology from standardized
codes is evident in several research studies in the
literature
(19) In several studies by Saba and Taylor, Moss and
Saba, and Saba and Arnold, researchers have
discussed mechanisms of aggregating nursing action
types, for example, assess, perform, teach, or
manage, into aggregated information on the amount
of time or effort a nurse spends in a day and
concomitant costs
associated
(20) Another application of coding data occurs with
map- ping concept codes from one terminology to
another
(21) These translations of codes support the ever-
evolving interoperable computer systems that
produce nursing data reports which can cross
platforms or institutions
b. Descriptive and exploratory analysis
3. Data analysis
a. Data analysis in a quantitative study combines a variety of
techniques that apply statistical procedures with the
researcher’s cognitive organization of research questions,
results, and visual or textual information, translated into
tables, charts, and graphs to make the data meaningful
(1) It translates the numeric and conceptual elements
of the inquiry into meaningful representations of
information
(2) In general, the statistical analyses are ordered by
the conceptual arrangement of hypotheses,
variables, measurements, and relationships, and
ultimately answer the research questions
(3) There are many ways to consider data analysis
(4) The presentation below is organized around the
broad types of research of interest in nursing and
general research goals or questions
(5) The researcher may use different types of analyses
depending on the goal of research
(6) These goals may require different statistical
examinations: descriptive and/or exploratory
analyses, hypothesis testing, estimation of
confidence intervals, model building through
multivariate analysis, and structural equation model
building
(7) Various types of nursing research may contain a
number of these goals
(8) Quality improvement, patient outcome, and
survival analysis studies may likewise contain a
number of different types of analyses depending on
the specific research questions
(9) In general, the statistical analysis steps of the
research process rely heavily on the functions specific
to a variety of statistical software applications
(10) Two of the most popular programs in use today
are the IBM SPSS Statistics 22 (formerly Statistical
8
Package for Social Sciences) and Statistical Analysis
Services
(SAS Version 9.2), however a variety of other pack-
ages and programs exist, such as STATA or Minitab 17
unique to particular scientific disciplines
(11) Which package one selects depends on the user’s
personal preference, particular strengths, and limits
of the applications including number of variables,
options for analyses, and ease of use
(12) These packages have given the user the power to
manipulate large data sets with relative ease and test
out statistical combinations that have exponentially
improved the analyses possible in a fraction of time
that it once took
(13) The different types of analyses required by the
goals of the research will be addressed further
(14) This description will be followed by examples of
types of nursing research that incorporate some of
these types of analyses
(1) The researcher may first explore the data means,
modes, distribution pattern, and standard deviations,
and examine graphic representations such as scatter
plots or bar graphs
(2) Tests of association or significant differences may
be explored through chi-squares, correlations, and
various univariate, bivariate, and trivariate analyses,
and an examination of quartiles
(3) During this analysis process, the researcher may
recode or transform data by mathematically
multiplying or dividing scores by certain log or factor
values
(4) Combining several existing variables can also
create new variables
(5)These transformations or “re-expressions” or
“dummy-coding” allow the researcher to analyze the
data in appropriate and interpretable scales
(6) The researcher can then easily identify patterns
with respect to variables as well as groups of study
subjects of interest
(7) Both commercial statistical packages provide the
ability to calculate these tests and graphically display
the results in a variety of ways
(8) IBM SPSS Statistics 22 (IBM SPSS, 2010) provides
the user with a broad range of capabilities for the
entire analytical process
(9) SPSS is a modular, tightly integrated, and full-
featured software comprised of the SPSS base and a
range of add-on modules
(10) With SPSS, the researcher can generate decision-
making information quickly using a variety of
powerful statistics, understand and effectively
present the results with high-quality tabular and
graphical output, and share the results with others
using various reporting methods, including secure
Web publishing
 (11) SAS 9.2 provides the researcher with tools that
can help code data in a reliable framework, extract
data for quality assurance, exploration, or analysis,
per- form descriptive and inferential data analyses,
maintain databases to track, and report on
administrative activities like data collection, subject
enrollment or
grant payments, and deliver content for reports in the
appropriate format
(12) SAS allows for creating unique programming
within the variable manipulations and is often the
format for large publicly available data sets for
secondary analysis
(13) Stata 13 and SYSTAT 13 are also fully integrated
statistical packages with full database management
capabilities and a range of sophisticated statistical
tests particularly useful for epidemiologists and
physical scientists
(14) All of these statistical packages have evolved to
pro- vide an integrated collection of tools that assist
in aspects of research study management—from
planning to dissemination—in addition to the
reputable statistical analyses and data manipulation
capabilities that they have provided for many years
(15) As part of exploratory analysis, simple, binary,
and multiple regression analyses can be used to
examine the relationships between selected variables
and a dependent measure of interest
(16) Certain models can be developed to determine
which collection of variables provides the best
prediction of the dependent measure
(17) Printouts of correlation matrices, extensive
internal tests of data assumptions on the sample, and
regression analysis tables provide the researcher with
condensed, readable statistical information about the
relationships in question
c. Hypothesis testing or confirmatory analyses
(1) Hypothesis testing or confirmatory analyses are
based on an interest in relationships and describing
what would occur if a hypothesis was true
(2) The analysis of data allows us to compare the
actual outcomes with the hypothesized outcomes
(3) Inherent in hypothesis testing is the probability (P
value) of an event occurring given a certain
relationship
(4) These are conditional relationships based on the
variables selected for study, and the typical
mathematical tables and software for determining P
values are accurate only insofar as the assumptions of
the test are met
(5) Certain statistical concepts such as statistical
power, type II error, selecting alpha values to balance
type II errors, and sampling distribution are decisions
that the researcher must make regardless of the type
of computer software
9
(6) These concepts are covered in greater detail in
research methodology courses and are outside the
scope of the present discussion
d. Model building
(1) An application used for a confirmatory hypothesis
testing approach to multivariate analysis is structural
equation modeling (SEM)
(2) Byrne describes this procedure as consisting of
two aspects
i. The causal processes under study are
represented by a series of structural (i.e.,
regression) equations
ii. These structural relations can be modeled
pictorially to enable a clearer
conceptualization of the theory under study
(3) The model can be tested statistically in a
simultaneous analysis of the entire system of
variables to determine the extent to which it is
consistent with the data
(4) If goodness of fit is adequate, the model argues for
the plausibility of postulated relationships among
variables
(5) Most researchers may wish to consult a statistician
to discuss the underlying assumptions of the data and
plans for testing the model
(6) Traditionally, different types of modeling
programs, such as LISREL or EQS are commercially
available
(7) The researcher will identify latent (unobservable)
variables of interest (e.g., emotions) and link them to
those that are observable (direct measurement) and
plan with the statistician to specify and examine the
impact of one latent construct on another in the
modeling of causal direction
(8) IBM SPSS 22 (IBM SPSS Software Inc.) offers Amos
22, a powerful SEM and path analysis add-on to
create more realistic models than if using standard
multivariate methods or regression alone
(9) Amos is a program for visual SEM and path analysis
(10) User-friendly features, such as drawing tools,
configurable toolbars, and drag-and-drop capabilities,
help the researcher build structural equation models
(11) After fitting the model, the Amos path diagram
shows the strength of the relationship between
variables
(12) Amos builds models that realistically reflect
complex relationships because any variable, whether
observed (such as survey data) or latent (such as
satisfaction or loyalty) can be used to predict any
other variable
e. Meta-analysis
(1) Meta-analysis is a technique that allows
researchers to combine data across studies to achieve
more focused estimates of population parameters
and examine the effects of a phenomenon or
intervention across multiple studies
 (2) It uses the effect size as a common metric of study
effectiveness and deals with the statistical problems
inherent in using individual significance tests in a
number of different studies
(3) It weights study outcomes in proportion to their
sample size and focuses on the size of the outcomes
rather than on whether they are significant
(4) Although the computations can be done with the
aid of a reliable commercial statistical package such
as Meta- Analysis, the researcher needs to consider
the following specific issues in performing the meta-
analysis
i. Justify which studies are comparable and
which are not
ii. Rely on knowledge of the substantive area
to identify relevant study characteristics
iii. Evaluate and account for differences in
study quality
iv. Assess the generalizability of the results
from fields with little empirical data
(5) Each of these issues must be addressed with a
critical review prior to performing the meta-analysis
(6) Meta-analysis offers a way to examine results of a
number of quantitative research that meet meta-
analysis researchers’ criteria
(7) Meta-analysis overcomes problems encountered
in studies using different sample sizes and
instruments
(8) The software application Meta-Analysis provides
the user with a variety of tools to examine these
studies
(9) It can create a database of studies, import the
abstracts or the full text of the original papers, or
enter the researcher’s own notes
(10) The meta-analysis is displayed using a schematic
that may be modified extensively, as the user can
specify which variables to display and in what
sequence
(11) The studies can be sorted by any variable,
including effect size, the year of publication, the
weight assigned to the study, the sample size, or any
user-defined variables to facilitate the critical review
done by the researcher
f. Graphical data display and analysis
(1) There are occasions when data need to be
displayed graphically as part of the analysis and
interpretation of the information or for more
fundamental communication of the results of
computations and analyses
(2) Visualization software is becoming even more
useful as the science of visualization in combination
with new considerations of large data from the
“Fourth Paradigm” unfolds
(3) These ideas begin with the premise that
meaningful interpretation of data intensive
discoveries need visualizations that facilitate
understanding and unfolding of new patterns
10
(4) Nurses are currently discovering new ways to
present information in meaningful ways through
these visualization techniques
(5) Most statistical packages including SPSS, SAS, and
STATA, and even spreadsheets such as Excel, provide
the user with tools for simple to complex graphical
translations of numeric information, thus allowing the
researcher to display, store, and communicate
aggregated data in meaningful ways
(6) Special tools for spatial representations exist, such
as mapping and geographic displays, so that the
researcher can visualize and interpret patterns
inherent in the data
(7) Geographic information system (GIS) technology is
evolving beyond the traditional GIS community and
becoming an integral part of the information infra-
structure of visualization tools for researchers
(8) GIS technology illustrates relationships,
connections, and patterns that are not necessarily
obvious in any one data set, enabling the researcher
to see overall relevant factors
(9) ArcGIS 10 system is a GIS for management,
analysis, and display of geographic knowledge, which
is represented using a series of information sets
(10) The information sets include maps and globes
with 3-dimensional capabilities to describe networks,
topologies, terrains, surveys, and attributes
(11) In summary, the major emphasis of this section
has provided a brief discussion about the range of
traditions, statistical considerations, and computer
applications that aid the researcher in quantitative
data analysis
(12) As computers have continued to integrate data
management functions with traditional statistical
computational power, the researchers have been
able to develop more extensive and sophisticated
projects with data collected
(13) Gone are the days of the calculator or punch
cards, as the computing power now sits on the
researchers’ desktops or laptops, with the speed and
functionality at their fingertips
The Qualitative Approach
1. Data capture and data collection
a. The qualitative approach focuses on activities in the steps
of the research process that differ greatly from the
quantitative methods in fundamental sources of data,
collection techniques, coding, analysis, and interpretation
(1) Thus, the computer becomes a different kind of
tool for the researcher in most aspects of the research
beginning with the capture and recording of narrative
or textual data
(2) In terms of qualitative research requiring narrative
content analysis, the computer can be used to record
the observations, narrative statements of subjects,
 and memos of the researcher in initial word
processing applications for future coding
(3) Software applications that aid researchers in
transcription tasks include text scanners, such as
OmniPage 18
(4) Other devices include vocal recorders or speech
recognition software such as consumer priced Dragon
Naturally Speaking 12, where the researcher can
input the information into text documents by
speaking into a microphone without typing
(5) New digital recorders are also on the market that
use sophisticated and higher cost voice recognition
software
(6) From these technologies, researchers or
transcriptionists can easily manipulate the recording
and type the data verbatim
(7) Even iPhones and smartphones have high-quality
recording applications that aid the qualitative
research capture narrative statements
(8) These narrative statements, like the quantitative
surveys, can be either programmed for use in other
applications or subjects’ responses can be entered
directly into the computer
b. Qualitative data collection
(1) Audiotaping is often used for interviews in
qualitative studies, whereby the content is
transcribed into a word processing program for
analysis
(2) The narrative statements are stored for
subsequent coding and sorting according to one’s
theoretical framework
(3) Through analysis, categories from the data emerge
as interpreted by the researcher
(4) It is important to point out that for both
quantitative and qualitative data, the computer
application program is only a mechanical, clerical tool
to aid the researcher in manipulating the data
(5) Using the Internet for indirect and direct data
collection in qualitative studies can also provide a
vehicle for data analysis that yields a quantitative
component as well as the qualitative analysis
(6) Computers are not only able to record the
subject’s responses to the questions, but can record
the number of minutes the subject was online and the
number of times they logged in
(7) Many new online technologies are providing
functionality for qualitative studies: for example,
Audacity, an open source free audio recording
package can edit captured voice and export audio
data to be analyzed; conversely, online survey
packages such as SurveyMonkey, can now export
participants’ free text data into qualitative software
packages
2. Data coding and data analysis
11
a. Historically, qualitative researchers have relied on narrative
notes, often first recorded as audio and later transcribed by a
typist
(1) Coding qualitative text data was a time-consuming
task, often involving thousands of pages of
typewritten notes and the use of scissors and tape for
the development of coding and categories
(2) With the advent of computer packages, the
mechanical aspects of the coding and sorting have
been reduced
(3) The researcher must decide on which text may be
of interest and can use a word processing program to
search for words, phrases, or other markers within a
text file
(4) However, this process is cumbersome and time-
consuming, with limited ways to aggregate text into
meaningful combinations for identifying themes from
the narrative
(5) Some specific software packages developed for
qualitative data analysis (QDA) interface directly with
the most popular word processing software packages
(6) The early application program Ethnograph was
one of the first packages developed specifically for
the purpose of managing some of the mechanical
tasks of QDA
(7) Ethnography 6.0 gave users, a project
management interface with functions to code, edit,
and search data
(8) The older nonnumerical unstructured data
indexing, searching, and theorizing (NUD-IST)
software was another qualitative package commonly
used, now absorbed in other QDA products
(9) This program assisted the researcher to establish
an index of data codes and seek relationships among
the coding categories
(10) The ease with which researchers can code and
recode large amounts of data with the aid of
computerized programs encourages the researcher to
experiment with different ways of thinking about data
and recategorizing them
(11) Retrieval of categories or elements of data is
facilitated by computer storage
(12) Newer technologies have evolved from
Ethnograph and NUD-IST with improved user
interfaces, including the latest versions of NVivo 10
(QSR, 2012), MAXQDA 11, and ATLAS.ti 7
(13) Qualitative research, like quantitative research, is
not a single entity, but a set of related yet individual
traditions, aims, and methods
(14) Some individual traditions within qualitative
research are ethnography, grounded theory,
phenomenology, and hermeneutics
(15) The distinguishing feature of qualitative research
is that the goal is to understand the qualities or
essence of phenomena and/or focus on the meaning
of these events to the participants or respondents in
the study
 (16) The forms of data are usually the words of the
respondents or informants rather than numbers
(17) Computerization is especially helpful to the
researcher in handling large amounts of data
(18) However, it must be stressed that the computer
applications aid the analysis as a management tool
rather than an analytical one
(19) Synthesis of the data is still the interpretive work
of the researcher
b. Computer application programs
(1) A number of general-purpose or specific software
packages can be used in qualitative analysis
i. One package is a free text retrieval
program such as that available in a word
processing program
ii. Another is any number of standard
database management or indexing programs
iii. Third is a program specifically developed
for the purpose of qualitative analysis
c. General purpose software
(1) Word processing programs offer a number of
features useful to the qualitative researcher in the
early stages of analysis
(2) The ability to search for certain key words allows
the researcher to tag the categories of interest
(3) In addition, such features as cut and paste; linking
texts; insertion of pictures, tables, and charts; and the
inclusion of video and audio data enhance the
application
(4) Add-on applications specific to integrating
multiple elements help the researcher organize a
range of data and materials for analysis
(5) These files can then be incorporated into more
sophisticated programs
(6) A comprehensive program is ATLAS.ti (Version 7.0)
a powerful workbench for the qualitative analysis of
large bodies of textual, graphical, audio, and video
data
(7) It offers a variety of tools for accomplishing the
tasks associated with any systematic approach to
“soft” data, such as material that cannot be analyzed
by formal and statistical approaches in meaningful
ways
d. Special purpose software
(1) Several software products have evolved and
improved
for the specific purpose of analyzing qualitative data
(2) Ethnograph from Qualis Research is one such older
program, which is used after the data have been
entered with a word processing program and con-
verted to an ASCII file
(3) Each file can be designated by its context and
identifying features using markers provided by the
computer program
(4) The researcher can have the program produce a
file that numbers each line of the narrative data
12
(5) From this line file, the researcher can begin to
assign each line or paragraph a category
(6) The researcher keeps track of the category
definitions and is alert to dimensions that emerge
(7) Recoding can be done to provide for inductive
thinking and iterative comparisons
(8) Through the use of a search command, the
computer program can be made to search for data
segments by categories throughout the typed
document
(9) NVivo 10 and XSight from QSR provide a new
generation of software tools with multiple
advantages for researchers
(10) Because qualitative research takes many forms,
these two applications can be selected based on the
user’s specific methodologic goals, the nature and
scale of the study, and the computer equipment
(11)
WhileNVivo10supportsfluid,richdata,detailedtext
analysis, and theory building, it also can manage
documents, audio and video files as categories,
attributes or nodes in visual displays that show the
structure and properties of the document
(12) The latest version of NVivo 10 also allows
researchers to import exported data from other
applications such as the online survey tool, Survey
Monkey, as well as bibliographic management
programs, Facebook and Twitter
(13) New analysis tools provide the research ways to
cluster, map and visualize text and images in
meaningful ways to aid the interpretive process in the
qualitative analysis
f. Conceptual network systems
(1) A system known as concept diagrams, semantic
nets, or conceptual networks is one in which
information is represented in a graphic manner
(2) The objects in one’s conceptual system (e.g., age
and experiences) are coded and represented by a box
diagram (node)
(3) The objects are linked (by arcs) to other objects to
show relationships
(4) Like rule-based systems, semantic nets have been
widely used in artificial intelligence work
(5) In order to view the relationships of an object in
the system, the researcher examines the node in the
graph and follows the arcs to and from it
(6) Semantic network applications may be useful in
model building and providing a pictorial overview
(7) Decision Explorer offers the user a powerful set of
mapping tools to aid in the decision-making process
for audience response activities
(8) Ideas can be mapped and the resulting cognitive
map can be further analyzed
(9) The software has many practical uses, such as
gathering and structuring interview data and as an aid
in the strategy formulation process
 (10) The software is primarily described as being a
recording and facilitation tool for the elicitation of
ideas, as well as a tool to structure and communicate
qualitative data
(11) It allows the user to gather and analyze
qualitative data and thus make sense of many pieces
of qualitative data in order to achieve a coherent
picture of a given issue or problem
g. Data analysis for qualitative data
(1) Qualitative data analyses often occur on an
ongoing basis
with data collection in a reflexive and iterative fashion
(2) There is no clear demarcation of when data
collection should end and analysis should begin
(3) The process of obtaining observations, interviews,
and other data over a period of time results in a vast
body of narrative that may include hundreds or
thousands of pages of field notes and researcher
memos
(4) Although computer applications can aid
considerably in organizing and sorting this mass of
data, the theoretical and analytical aspects of
decision making about concepts and themes must be
made by the researcher
(5) Researchers can only use the tools to help in
creating composites described by methodologists in
coding levels and categorical clusters
(6) Once a researcher has determined which parts of
the interviews and observations can be tagged as
categories, certain properties or dimensions can be
deter- mined and coded up through levels
(7) The researcher may engage in “constant
comparison,” comparing the meanings of all incidents
that have been similarly categorized
(8) This process should continue until the researcher
determines that the categories are internally
consistent, fit with the data, and are saturated.
Saturation is achieved when the researcher can find
no more properties for a category and new data are
redundant with the old
(9) Classic qualitative methods experts Strauss and
Corbin suggested that in the later stages of research,
the researcher may engage in axial coding
(10) In this stage, the researcher elaborates and
explains key categories, considering the conditions
under which the event occurs, the processes that take
place, and possible consequences
(11) Another well-known methodologist, Glaser
indicated that the researcher may engage in
theoretical sampling, which is a deliberate search for
episodes in incidents that enlarge the variances of
properties and place boundaries around categories
(12) Using software, these cognitive processes are
applied by the researcher in data analysis of narrative
inter- views, field notes, and supplementary data
h. Uses and caution
13
(1) Software programs exist for qualitative research
that save researcher time doing file management,
reducing the manual labor of cutting, pasting, sorting,
and manual filing
(2) They may also encourage the researcher to
examine the data from different perspectives,
recoding and reorganizing the data in different
frameworks
(3) However, one must be mindful that qualitative
analysis is a cognitive process, not a mechanical one
(4) The essence of qualitative research is the meaning
and interpretation of the data within context
(5) The ability of software enhancements to generate
quasi-frequency distributions and cross-tabulations
tend to further increase the investigator’s confidence
in believing such findings and relationships, when in
fact these may be an artifact of the way in which the
data are manipulated
(6) While computer programs facilitate coding,
organization of data, and preparation of the data for
interpretation, they cannot replace the thinking and
decision making that is at the heart of qualitative
analysis
(7) As in all research, the burden of analysis and
interpretation rests with the researchers
3. Dissemination of results
a. While dissemination of results continues to occur by
traditional means such as presentations at professional
meetings and publication in journals and monographs, online
reporting is becoming increasingly common
(1) Some Web sites frequented by nurses are peer-
reviewed journals such as Online Journal of Nursing
Informatics and selected nursing articles on various
Web sites such as that of the ANA
(2) Nursing forums sponsored by various professional
nursing organizations (e.g., American Journal of
Nursing, Sigma Theta Tau, and National League for
Nursing) often allow participants to chat online with
presenters or authors of certain articles on
designated dates during scheduled times
(3) Nearly all organizations have their own Web sites
(4) The Cochran Collection has numerous centers all
over the world through the Cochrane Collaborative
(5) As with all publications, online as well as hardcopy,
the information accessed must be evaluated by the
users regarding appropriateness for the purpose for
which it was retrieved
(6) Reports to most government and some
nongovernment agencies require the researcher to
submit a con- verted document online
(7) Grant proposals submitted to the federal
government currently require online submission with
conversion to PDF
(8) NIH applicants are directed to a page with
downloadable programs to convert the documents
before sub- mitting them
 (9) In fact, there is a trend for all manuscripts to be
submitted online for print, online, or both
(10) Online journals continue to grow
(11) In addition, there has been a rise in the number
of open access journals that give researchers more
options for dissemination
(12) Online journals have been discussed in the
nursing and academic community with mixed
reception; while it allows the researcher-consumer of
articles the ability to search wider publicly available
science, other stakeholders in the publishing and
academic worlds have been concerned on the
ramifications of this disruptive innovation
(13) Regardless of the method of submission and
medium for publication, the published article may be
incorporated into one or several online bibliographic
retrieval systems
(14) The researcher is not finished until the work is
disseminated
(15) This chapter has summarized the processes of
quantitative and qualitative research and described
select computerized tools that can assist the
researcher in proposal preparation, data collection,
data coding, data analysis, and dissemination for both
types of research
(16) The following section highlights examples for
three categories of research on computer use and
nursing informatics in
i. Electronic data, such as data mining large
electronic data sets and electronic nursing
documentation
ii. Web-based interventions
iii. Specialized computer applications in
clinical
practice
(17) The examples include both quantitative and
qualitative studies in which the nurse researchers
inevitably used a variety of software tools in the
proposal development, data collection, measurement
of variables, analysis, and dissemination activities
Examples of Research Studies
1. Overview
a. Computers are inextricably tied to the process of conducting
research, but there are also good examples of research on
computer use in the nursing literature
(1) Several of the following examples also describe
computerized processes for conducting quantitative
and qualitative research approaches
(2) These examples provide focus on nursing research
related to computer use and informatics as well as
using computers in the process of doing the research
2. Clinical interventions with computers
a. Over the past 10 years, Internet applications have been
introduced into practice and tested in a variety of clinical trials
aimed to improve conditions for patients
14
(1) For example, a team of researchers developed the
Personal Patient Profile-Prostate (P3P), a Web-
decision support system for men newly diagnosed
with prostate cancer that assesses patients’
preferences prior to clinic visit and gives providers
and patients information to aid decision making
among choices of treatment
(2) The studies showed that decision support was
feasible with the technology support
(3) Decision regret was significantly influenced by
personal characteristics and posttreatment
symptoms, although the P3P was not itself significant
on the outcomes measured in the study
(4) In another Web-based intervention, caregivers
were randomly assigned to one of two types of online
support groups and compared to non-active
participants on their depressive symptoms, caregiver
burden, and quality of life
(5) In this study, both types of online support groups
reduced depressive symptoms and improved quality
of life over non-active participants
3. Technology, electronic data, and electronic documentation
research
a. There are several different studies that highlight using
electronic data and EHRs in data mining or care documentation
b. Secondary analysis of large data sets
(1) Large public data sets are becoming more
available to
nurse researchers to explore health-related questions
(2) The sites provide tutorials and assistance, making
them more accessible for secondary analyses
(3) One data source is the Medical Expenditures Panel
(MEPS) database, a multiyear set of large-scale
surveys of families and individuals, their medical
providers, and employers across the United States
(4) MEPS is the most complete source of data on the
cost and use of healthcare and health insurance
coverage
(5) Another collection used by a variety of nurse
researchers is the HCUP data from AHRQ
(6) HCUP databases bring together the data collection
efforts of state data organizations, hospital
associations, private data organizations, and the
federal government to create a national information
resource of encounter-level healthcare data
(7) It includes the largest collection of longitudinal
hospital care data that enables research on a broad
range of health policy issues, including cost and
quality of health services, medical practice patterns,
access to healthcare programs, and outcomes of
treatments at the national, state, and local market
levels
(8) The EHRs today are frequently providing source
data for studies
(9) These hospital systems have been used in the
literature
 (10) Westra and colleagues studied urinary and bowel
incontinence for home health patients using EHR data
to predict improvements
(11) In these cases, the EHR served as the data source
(12) Figar and colleagues used a private HIS clinical
documentation system to study whether captured
data could predict influenza outbreaks
(13) They used a local interface terminology server,
which provides support through data auto-coding of
clinical records and analyzed specific data sets to
compare the burden of influenza in epidemiological
weeks identified among 150,000 Health Maintenance
Organization members in Argentina
(14) The HIS detected the outbreak two weeks before
the health department gave a national alert and was
useful in assessing morbidity and mortality during the
2009 influenza epidemic H1N1 outbreak
c. Computerized documentation of nursing care plans
(1) Moss and Saba studied the utility of costing out
nursing care with the CCC terminology on five most
commonly executed interventions
(2) Using an observation study of nurses performing
routine care on an acute-care unit, investigators
collected data with a specialized data collection
program entered directly into the PC database
(3) A total of 251 interventions were observed, coded,
and analyzed
(4) From the analysis of time spent on each entered
intervention, researchers could describe the four
action types by average cost and percent of activity
(5) The study demonstrated the feasibility of
valuating the nursing care given to patients based on
the standardized CCC terminology
(6) In a randomized trial on electronic documentation
of nursing care plans, Feeg, Saba, and Feeg tested the
quality of nursing student care planning on a bedside
PC using a standardized nursing terminology in a
specially designed Microsoft Access database
program (Clinical Care Classification System)
compared with an open-text format type-in
application with the same terminology
(7) Students were randomly assigned to one of the
two versions of electronic nursing documentation
formats and interviewed two simulated patients who
served for all of the participants
(8) The simulated patients were interviewed about
their symptoms: one presented with congestive heart
failure, the other with pneumonia
(9) Students were instructed to document the care
immediately following the interview on a laptop
stationed at the patient’s bedside
(10) Measures were developed to assess the quality
of the care plans and the participants’ evaluation of
using the system
(11) Data were analyzed, revealing a statistically
significant difference (p =.05) for the Microsoft Access
care plans completed by students and a statistically
15
significant difference in the students’ reports on using
the system (p = .025)
(12) In a follow-up field study, the system was
implemented on 49 students over three semesters
who documented care for each patient they were
assigned to in their clinical rotations
(13) Students were assessed on their care plan
documentation and they reported usability and
satisfaction with the computer-based documentation
system
(14) Results continued to show that the coded
language and PC care planning method was efficient
and effective
d. Web-based tools and interventions
(1) A significant body of research has been conducted
on using the Internet as a tool for conducting
research, as well as studies on Web-designed
interventions for clinical problems
(2) For example, Yen and Bakken tested the usability
of a Web-based tool for managing open shifts on
nursing units
(3) Using observational and interview approaches,
they evaluated a Web communication tool (BidShift)
designed to allow managers to announce open work
shifts to solicit staff to request their own work shifts
(4) They used specialized software to capture screens
and vocal utterances as participants were asked to
think aloud as they completed three subtasks
associated with the open-shift management process
(5) After task completion, they were asked about the
process and their responses were recorded
(6) Their data were managed and coded using Morae,
specialized software developed for usability testing
(7) This example of qualitative research reported
participants’ patterns of use and themes related to
their perceptions of usability of the communication
tool
(8) In another qualitative study on electronic
encounters using Web-based videoconferencing,
Nystrom and Ohrling created a series of e-meetings
for new fathers of children under one year old to
“meet” in parental support groups
(9) The technology allowed both one-on-one and
group encounters. The fathers were interviewed
using a narrative approach and content analysis was
applied to the interview data
(10) The researchers identified three categories from
the transcripts
i. Being unfamiliar and insecure talking about
fatherhood
ii. Sharing experiences and being confirmed
iii. Being supported and limited by the electronic
encounters
(11) Andersen and Ruland studied an Internet-based
online patient–nurse communication (OPNC) ser- vice
to support patients with prostate and breast cancer
 (12) Using qualitative content analysis, they examined
276 messages in a tailored Internet support
intervention over 15 months
(13) Two main themes emerged
i. Concerns about physical symptoms and
treatment side effects
ii. Worries and questions about treatment
and follow-up
(14) They concluded that the OPNC service can meet
patients’ needs for advice and information, thus
improving the quality of care
(15) In a qualitative study by Lichenstein,
McDonough, and Matura, 98 participants who self-
identified as caregivers for a person with pulmonary
hypertension (PH) engaged in an online discussion
board posted by the Pulmonary Hypertension
Association over an 18-month period
(16) Clinical variables collected were medications and
oxygen use, and years since diagnosis
(17) Thematic analysis yielded four themes: fear and
frustration, questions and concerns, someone to
listen to, and moving on with life
(18) Results showed that caregivers of people with PH
may be ill equipped to care for their loved one
because of lack of knowledge or psychological
distress
(19) In a review of Web-based cognitive behavioral
interventions for chronic pain, researchers conducted
a systematic review and meta-analysis to quantify the
intervention efficacy for treatment of patients with
chronic pain
(20) Using 11 studies from MEDLINE and other data
sources, the investigators found that Web-based
interventions for chronic pain resulted in small pain
reductions in the intervention groups compared with
waiting-list control groups
e. Specialized computer applications in clinical care
(1) Computer-based administration of assessment is a
reliable means of collecting patient assessment data
as demonstrated by the report by Wilkie and
colleagues who evaluated the feasibility and
acceptability of a pentablet-based software program
that assesses patients’ cancer-related symptoms, the
PAIN Report It®
(2) In the study, 131 patients were able to use the
computerized tool and reported high acceptability
scores
(3) Vawdrey and colleagues pilot tested a tablet
computer application for patients to participate in
their hospital care
(4) A prototype application was developed for a tablet
computer using EHR queries and updates in real time
(5) Patients were invited to participate in the study
after consultation between the patient’s providers
and the investigator, an attending cardiologist
(6) They were given an iPad device and encouraged to
use the application
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(7) Structured interviews were used to test the
patient engagement and the tablet usefulness of
having access to patient’s own medication and
hospital history
(8) Mobile technologies have also proliferated in
health-related applications today
(9) For example, systems that support medication
management of patients with SMS texting and Web-
based interface programs have emerged using simple
cell phones and sophisticated smartphones
(10) The MyMediHealth (MMH) is a medication
management system that includes a medication
scheduler, a medication administration reminder
engine, and sends text messages to patient phones
(11) In a review done by Schroeder, a variety of
studies used computerized telephone technologies as
an assessment tool specifically for the collection of
daily, self-reports of HIV-risk behaviors
(12) The review presented advantages of applications
of interactive voice response technology (IVR) to HIV-
risk behavior research, including feasibility studies,
assessment mode comparisons between IVR and
alternative self-reporting methods, and unique
findings derived from event-level data analyses
illuminating risk factors for unprotected intercourse
on within-person level
(13) The author concluded that these specialized
interactive, computerized voice systems are highly
promising tools for various research and healthcare
applications that should be considered more
frequently for use in HIV-risk populations
(14) Some studies that incorporate remote
technologies in special applications have been
described in the literature
(15) Mahoney reported on several mixed methods
studies that describe innovative monitoring
intervention research with older adults and their
informal and/or formal caregivers
(16) The studies were conducted in “real-world”
homes and focused on improved ways to monitor
elders, taking into account the goal of independence
and privacy, to alert caregivers on elders’ activities,
and safety issues
(17) In another collection of case studies, Rantz and
colleagues describe instances of technology-
enhanced monitoring capabilities, using sensors,
alarms, and environmentally embedded devices, that
wirelessly communicate with programmed systems
for the purpose of detecting potential problems
(18) These and other innovations that connect
computer technology with nursing practice have
emerged with research to support their functionality,
ease of adoption, and efficacy
(19) The range of innovation has been astounding as
the technologies have increasingly become less
expensive, smaller, wireless, and now interconnected
with cloud computing
(20) Nursing research and computers today are
inseparable in both areas of using computers for the
research and studying the impact of computers on
patient care

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