Evaluating Nursing Interventions: A Theory-Driven Approach

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Souraya Sidani & Carrie Jo Braden

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  • Dedication

    To our families, mentors, and colleagues

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    Preface

    Evaluating the effectiveness of interventions in achieving the desired outcomes is a prerequisite for using interventions in clinical practice. To be able to implement a particular intervention and to use it appropriately in practice, clinicians require knowledge of the specific activities or components of the intervention, their related strength or dosage, the mechanisms underlying the intervention effects, the intervention's intended and unintended effects, the client population that would most benefit from the intervention, and the context in which the intervention is useful. In other words, clinicians need to know which intervention components, at which dosage, under what circumstances, and with which clients, result in which outcomes. This kind of information is essential for expanding the knowledge base for practice and for assisting clinicians in selecting and prescribing the most appropriate intervention to their clients.

    Developing this kind of knowledge base for practice necessitates a change in the conceptual analysis and the methodology used in intervention effectiveness research. At the conceptual level, the change has to do with the assumptions underlying clinical effectiveness research. The notion that the intervention will produce the same response in all participants needs to be modified to allow for individual variations in response. Factors other than the intervention that are believed to influence the outcomes of an intervention should be identified a priori and incorporated in a theoretical framework that explains the mechanisms responsible for producing the desired outcomes. At the methodological level, the changes in conducting effectiveness research include judicious use of various types of research design to maximize the validity of the study conclusions when the study is conducted in a clinical setting where multiple extraneous factors have the potential of affecting the intervention outcomes, empirically examining the effects of extraneous factors such as client and setting characteristics on clients' response to treatment, examining the effects of the intervention at the individual or subgroup level, representing the various components of the intervention and the dosage received by the participants as the measure of the independent variable in the data analysis, and using different types of statistical approaches for analyzing the data. In short, the changes are directed toward a more comprehensive approach to effectiveness research for the purpose of developing clinically relevant knowledge that guides practice.

    Our contention in this book is that the development of clinically relevant knowledge rests on identifying factors related to the intervention, the intervener, the clients, and the setting that influence the clients' response to the intervention and on determining the impact of these factors on outcome achievement. The identification and analysis of these factors' effects should be guided by the theory underlying the intervention. The intervention theory specifies the nature of the intervention, the nature of the effects expected of the intervention, processes mediating the expected effects, and the conditions under which the intervention processes take place. The intervention theory provides answers to the clinical questions about which intervention would be appropriate for what client population under which circumstances. The intervention theory directs the implementation of the intervention and all aspects of a study aimed at evaluating the effectiveness of the intervention in producing the desired outcomes. It forms the basis for selecting the study design, setting, sample, variables, and measures; for developing the treatment protocol; for formulating and carrying out the data collection procedure; for conducting the analyses; and for interpreting the results, whether favorable or unfavorable. Briefly, the intervention theory provides the rationale for the intervention and dictates research methods. In turn, findings of intervention evaluation research provide feedback for consolidating or refining the intervention. A close link between theory and research is essential for expanding knowledge.

    The primary goals of this book are to present a comprehensive and in-depth analysis of the contribution of various factors to the validity of the study findings, to examine how these factors operate, to delineate the role of theory identifying and examining the effects of these factors, and to provide strategies for dealing with these factors successfully. Conventional strategies for dealing with these factors are reviewed and their limitations when used in the field settings are explained. Alternative strategies are suggested. The alternative strategies are geared toward operationalizing the theory-driven approach to effectiveness research that incorporates the conceptual and methodological changes needed for developing clinically relevant knowledge. Expanding clinically relevant knowledge is a means for reducing the gap between research and practice.

    The book is intended to expand clinical effectiveness research methods available for investigators. The proposed research methods are most appropriate for evaluating the effectiveness of interventions or programs in practice, that is, under “real-life” conditions; the principles underlying these methods can also be used to guide the initial testing of the intervention efficacy under ideal conditions, however. The content of this book builds on basic intervention/program evaluation topics and addresses advanced issues in detail. The intervention evaluation methods covered in this book should be of interest to graduate students and to junior and senior researchers planning or conducting a study aimed at evaluating interventions. The book content pertinent to the factors that influence the outcomes expected of an intervention could assist investigators conducting meta-analyses examining the effectiveness of a particular intervention and clinicians reviewing or critically appraising the effects of an intervention in preparation for using it in their practice. Whenever possible, examples are provided to illustrate major points of discussion. Readers are strongly encouraged to think of their own work to put the issues discussed in a more familiar context. The book is designed to provide readers with the principles of effectiveness research methodology; we hope that readers will find them useful and will apply them in their own work.

    Acknowledgments

    The authors gratefully acknowledge the thoughtful comments and constructive feedback and suggestions offered by Diane Irvine and Lee Sechrest.

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    About the Authors

    Souraya Sidani, PhD, RN, is Assistant Professor at the Faculty of Nursing, University of Toronto. She teaches courses related to research methods and instrumentation. She consults with researchers and clinicians about issues related to the design and implementation of research projects and to the analysis of data. Her research areas of interest focus on evaluating health-related interventions and refining research methods and health-related measures for determining the clinical effectiveness of interventions. She developed and tested a conceptual framework for evaluating interventions, which formed the basis for this book. She has been involved in projects evaluating various interventions (such as the use of sedative music to relieve dyspnea in COPD patients, exercise to assist women with breast cancer in managing fatigue, and the use of an abilities-focused program of morning care in elderly with dementia), nursing care delivery models (such as the introduction of a collaborative care model), and educational programs (such as the primary care nurse practitioner program), with the primary responsibility of designing the evaluation study, managing data collection and entry, and conducting the statistical analyses. The topics of her publications relate to methodological issues, such as the comparison of quantitative and qualitative research methods, the comparison between repeated measures analysis of variance and individual regression analysis, the use of case studies in evaluation research, the application of the multitrait-multimethod logic for examining family relational data, and a discussion of methodological issues in assessing outcomes of care.

    Carrie Jo Braden, PhD, RN, FAAN, is Associate Professor at the College of Nursing, University of Arizona. She teaches courses related to the development of middle-range theories and evaluation in nursing. She developed and tested the middle-range nursing theory of learned response to chronic illness experience. She also developed and evaluated a self-help intervention for patients with systemic lupus erythematosus and for women with breast cancer. Her research areas of interest include further testing of the learned response to chronic illness middle-range theory and evaluation of self-help interventions. The topics of her publications relate to the description and testing of the learned response to chronic illness theory and the evaluation of testing the effectiveness of the self-help interventions.


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