Category Archives: Outcome measurement

Testing the Test (or an intro to “Does the measurement measure up?”)

When reading a research article, you may be tempted only to read the Introduction & Background, then go straight to the Discussion, Implications, and Conclusions at the end. You skip all those pesky, procedures, numbers, and p levels in the Methods & Results sections.

Perhaps you are intimidated by all those “research-y” words like content validity, construct validity, test-retest reliability, and Cronbach’s alpha because they just aren’t part of your vocabulary….YET!

WHY should you care about those terms, you ask? Well…let’s start with an example. If your bathroom scale erratically measured your weight each a.m., you probably would toss it and find a more reliable and valid bathroom scale. The quality of the data from that old bathroom scale would be useless in learning how much you weighed. Similarly in research, the researcher wants useful outcome data. And to get that quality data the person must collect it with a measurement instrument that consistently (reliably) measures what it claims to measure (validity). A good research instrument is reliable and valid. So is a good bathroom scale.

Let’s start super-basic: Researchers collect data to answer their research question using an instrument. That test or tool might be a written questionnaire, interview questions, an EKG machine, an observation checklist, or something else. And whatever instrument the researcher uses needs to give them correct data answers.

For example, if I want to collect BP data to find out how a new med is working, I need a BP cuff that collects systolic and diastolic BP without a lot of artifacts or interference. That accuracy in measuring BP only is called instrument validity. Then if I take your BP 3 times in a row, I should get basically the same answer and that consistency is called instrument reliability. I must also use the cuff as intended–correct cuff size and placement–in order to get quality data that reflects the subject’s actual BP.

The same thing is true with questionnaires or other measurement tools. A researcher must use an instrument for the intended purpose and in the correct way. For example, a good stress scale should give me accurate data about a person’s stress level (not their pain, depression, or anxiety)–in other words it should have instrument validity. It should measure stress without a lot of artifacts or interference from other states of mind.

NO instrument is 100% valid–it’s a matter of degree. To the extent that a stress scale measures stress, it is valid. To the extent that it also measures other things besides stress–and it will–it is less valid. The question you should ask is, “How valid is the instrument?” often on a 0 to 1 scale with 1 being unachievable perfection. The same issue and question applies to reliability.

Reliability & validity are interdependent. An instrument that yields inconsistent results under the same circumstances cannot be valid (accurate). Or, an instrument can consistently (reliably) measure the wrong thing–that is, it can measure something other than what the researcher intended to measure. Research instruments need both strong reliability AND validity to be most useful; they need to measure the outcome variable of interest consistently.

Valid for a specific purpose: Researchers must also use measurement instruments as intended. First, instruments are often validated for use with a particular population; they may not be valid for measuring the same variable in other populations. For example, different cultures, genders, professions, and ages may respond differently to the same question. Second, instruments may be valid in predicting certain outcomes (e.g., SAT & ACT have higher validity in predicting NCLEX success than does GPA). As Sullivan (2011) wrote: “Determining validity can be viewed as constructing an evidence-based argument regarding how well a tool measures what it is supposed to do. Evidence can be assembled to support, or not support, a specific use of the assessment tool.”

In summary….

  1. Instrument validity = how accurate the tool is in measuring a particular variable
  2. Instrument reliability = how consistently the tool measures whatever it measures

Fun Practice: In your own words relate the following article excerpt to the concept of validity? “To assess content validity [of the Moral Distress Scale], 10 nurses were asked to provide comments on grammar, use of appropriate words, proper placement of phrases, and appropriate scoring. From p.3, Ghafouri et al. (2021). Psychometrics of the moral distress scale in Iranian mental health nurses. BMC Nursing. https://doi.org/10.1186/s12912-021-00674-4

“How many articles are enough?” Is that even the right question?

How do you know when you have found enough research evidence on a topic to be able to use the findings in clinical practice? How many articles are enough? 5? 50? 100? 1000? Good question!

You have probably heard general rules like these for finding enough applicable evidence: Stick close to your key search terms derived from PICOT statement of problem; Use only research published in the last 5-7 years unless it is a “classic; & Find randomized controlled trials (RCTs), meta-analyses, & systematic reviews of RCTs that document cause-and-effect relationships. Yes, those are good strategies. The only problem is that sometimes they don’t work!

Unfortunately, some clinical issues are “orphan topics.” No one has adequately researched them. And while there may be a few, well-done, valuable published studies on the topic, those studies may simply describe bits of the phenomenon or focus on how to measure the phenomenon (i.e., instrument development). They may give us little to no information on correlation and causation. There may be no RCTs. This situation may tempt us just to discard our clinical issue and to wait for more research (or of course to do research), but either could take years.

In her classic 1998 1-page article, “When is enough, enough?” Dr. Carol Deets, argues that asking how many research reports we need before applying the evidence may be the wrong question! Instead, she proposes, we should ask, “What should be done to evaluate the implementation of research findings in the clinical setting?”

When research evidence is minimal, then careful process and outcome evaluation of its use in clinical practice can: 1) Keep patient safety as the top priority, 2) Document cost-effectiveness and efficacy of new interventions, and 3) Facilitate swift, ethical use of findings that contributes to nursing knowledge. At the same time, Deets recognizes that for many this idea may be revolutionary, requiring us to change the way we think.

So back to the original question…How many articles are enough? Deets’ answer? “One study is enough” if we build in strong evaluation as we translate it into practice.

Reference: Deets, C. (1998). When is enough, enough? Journal of Professional Nursing, 14(4), 196. doi.org/10.1016/S8755-7223(98)80058-6

“Please answer!” – How to increase the odds in your favor when it comes to questionnaires

Self-report by participants is one of the most common ways that researchers collect data, yet it is fraught with problems.   Some worries for researchers are: “Will participants be honest or will they say what they think I want to hear?”   “Will they understand the DifferentGroupsquestions correctly?”  “Will those who respond (as opposed to those who don’t respond) have unique ways of thinking so that my respondents do not represent everyone well?” and a BIG worry “Will they even fill out and return the questionnaire?”

One way to solve at least the latter 2 problems is to increase the response rate, and Edwards et al (2009 July 8) reviewed randomized trials  to learn how to do just that!!Questionnaire faces

If you want to improve your questionnaire response rates, check it out!  Here is Edwards et al.’s plain language summary as published in Cochrane Database of Systematic Reviews, where you can read the entire report.

Methods to increase response to postal and electronic questionnaires

MailPostal and electronic questionnaires are a relatively inexpensive way to collect information from people for research purposes. If people do not reply (so called ‘non-responders’), the research results will tend to be less accurate. This systematic review found several ways to increase response. People can be contacted before they are sent a postal questionnaire. Postal questionnaires can be sent by first class post or recorded delivery, and a stamped-return envelope can be provided. Questionnaires, letters and e-mails can be made more personal, and preferably kept short. Incentives can be offered, for example, a small amount of money with Remember jpga postal questionnaire. One or more reminders can be sent with a copy of the questionnaire to people who do not reply.

 

Critical/reflective thinking:  Imagine that you were asked to participate in a survey.  Which of these strategies do you think would motivate or remind you to respond and why?

For more info read the full report: Methods to increase response to postal and electronic questionnaires

 

Nightingale: Avant garde in meaningful data

In honor of Nurse Week, I offer this tribute to the avant garde research work of Florence Nightingale in the Crimea that saved lives and set a precedent worth following.

Nightingale was a “passionate statistician” knowing that outcome data are convincing when one wants to change the world.  She did not merely collect the data, but also documented it in a way that revealed its critical meaning for care.

As noted by John H. Lienhard (1998-2002): Nightingale coxcombchart“Once you see Nightingale’s graph, the terrible picture is clear. The Russians were a minor enemy. The real enemies were cholera, typhus, and dysentery. Once the military looked at that eloquent graph, the modern army hospital system was inevitable.  You and I are shown graphs every day. Some are honest; many are misleading….So you and I could use a Florence Nightingale today, as we drown in more undifferentiated data than anyone could’ve imagined during the Crimean War.” (Source: Leinhard, 1998-2002)

As McDonald (2001) writes in the BMJ free, full-text,  Nightingale was “a systemic thinker and a “passionate statistician.”  She insisted on improving care by making policy & care decisions based on “the best available government statistics and expertise, and the collection of new material where the existing stock was inadequate.”(p.68)

Moreover, her display of the data brought its message home through visual clarity!

Thus while Nightingale adhered to some well-accepted, but mistaken, scientific theories of the time (e.g., miasma) her work was superb and scientific in the best sense of the word.   We could all learn from Florence.

CRITICAL THINKING:   What issue in your own practice could be solved by more data?  How could you collect that data?   If you have data already, how can you display it so that it it meaningful to others and “brings the point home”?

FOR MORE INFO:

HAPPY NURSE WEEK TO ALL MY COLLEAGUES.  

MAY YOU GO WHERE THE DATA TAKES YOU!

What are you asking? (or “Can HCAHPS sometimes be a DIRECT measure?”)

In a prior blog (Direct speaking about INdirect outcomes: HCAHPS as a measurement*), I argued that HCAHPS questions were indirect measures of outcomes.  Indirect measures are weaker than direct measures because they are influenced by tons of variables that have nothing to do with the outcome of interest.  But wait!! There’s more!  HCAPS can sometimes be a DIRECT measure; it all depends on what you want to know.

(If you know this, then you are way ahead of many when it comes to measuring outcomes accurately!!)

KEYKEY POINTS:

  • If your research question is what do patients remember about hospitalization then HCAHPS is a DIRECT measure of what patients remember.  
  • However if your research question is what did hospital staff actually do  then HCHAPS is an INDIRECT* measure of what staff did. 

What is HCAHPS?  HCAHPS (pronounced “H-caps”)  questions are patient perceptions of what happened, which may or may not be what actually happened.    Patients are asked to remember their care that happened in the past, and memories may be less than accurate. (See this link for more on what HCAHPS is: http://www.hcahpsonline.org/Files/HCAHPS_Fact_Sheet_June_2015.pdf )

Example:  HCAHPS question #16 is, “Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?”    Whether the patient answers yes or thinkerno, the response tells us only how the patient remembers it.

Why is this important?     

  • Because if you want to know whether or not RNs actually taught inpatients about their medications, then for the most direct & accurate measure you will have to observe RNs .
  • However, if you want to know whether patients remember RNs teaching them about discharge medications, then HCAHPS question #16 is one of the most direct & accurate measure of what they remember.

*FOR MORE INFORMATION on why you want to use DIRECT measures SanDiegoCityCollegeLearningResource_-_bookshelfsee https://discoveringyourinnerscientist.com/2016/11/04/direct-speaking-about-idirect-outcomes-hcahps-as-a-measurement/

CRITICAL THINKING Pick any HCAHPS question at this link and write a research question that for which it would be a DIRECT outcome measure: question(http://www.hcahpsonline.org/files/March%202016_Survey%20Instruments_English_Mail.pdf)

For your current project, how are you DIRECTLY measuring outcomes?

Bake it into your project cake!

In the last post we compared stronger direct measures of outcomes with weaker indirect
measuremeasures of project outcomes.

So…what direct measures are you “baking into your project cake”? What do you hope will be your project outcome & what measurement will show that you achieved it? –pain scores? weight? skin integrity? patient reports of a sound night’s sleep?  Share your story.  Help others learn.

Or if you just stuck with HCAHPS (or other) as outcome measure, explain why that was the best choice for your project.  (Maybe in your case it was a direct measure!)

Happy measuring!

For More Info on direct vs. indirect measures & Critical thinking: Check out t Direct speaking about INdirect outcomes: HCAHPS as a measurementquestion

Direct speaking about INdirect outcomes: HCAHPS as a measurement

When you first plan a project, you need to know what OUTCOMES you want to achieve.  You need STRONG outcomes to show your project worked! imagesCALQ0QK9

Outcome measures are tricky & can be categorized into Indirect & Direct measures:

  1. INDIRECT outcome measures are often affected by many factors, not just your innovation
  2. DIRECT outcome measures are specific to what you are trying to accomplish.

For example: If you want to know your patient’s weight, you put them on the scale (direct). weight-scaleYou don’t merely ask them how much they weigh (indirect).

Another example?  If you planned music to reduce pain, you might a) measure how many patients were already using music and their pain scores (& perhaps those not using music and their pain scores), b) begin your music intervention, and c) thmusicen directly measure how many patients started using it after you started your intervention and their pain scores.  These data DIRECTLY target your inpatient outcomes versus looking at INDIRECT HCAHPS answers of discharged patients’ feelings after the fact in response to “During this hospital stay, how often was your pain well controlled?”

Nurses often decide to measure their project outcomes ONLY with indirect HCAHPS scores.  I hope you can see this is not as good as DIRECT measures.

So why use HCAHPS at all?measuring-tape

  • They reflect institutional priorities related to quality and reimbursement
  • Data are already collected for you
  • Data are available for BEFORE and AFTER comparisons of your project outcomes
  • It doesn’t cost you any additional time or money to get the data

Disadvantages of indirect HCAHPS measures?

  • HCAHPS data are indirect measures that are affected by lots of different things, and so they may have little to do with effect of your project.
  • HCAHPS responders often do Not represent all patients because the number responding is so small–sometimes just 1 or 2

Still, I think it’s good to include HCAHPS.  Just don’t limit yourself to that. Include also a DIRECT measure of outcomethat targets the precisely what you hope will be the result of your study.

imagesCALQ0QK9You need STRONG outcomes to convince others that your project works to improve care!

CRITICAL THINKING:  McClelland, L.E., &  Vogus, T.J. (2014) used HCHAPS as an outcome measure in their study, Compassion practices & HCAHPS: Does rewarding and supporting questionworkplace compassion influence patient perceptions?    What were the strengths & weaknesses of using HCHAPS in this study? [hint: check out the discussion section]  What would be a good direct measure that you could add to HCAHPS outcomes to improve the study?

FOR MORE INFORMATION:  Whole books of measurement instruments are available through the library or a librarian can help you search for something that will measure motivation, pain, anxiety, medication compliance, or whatever it is you are looking for!!  You can limit your own literature searches by selecting “instrument” as part of your search, or you can consult with a nurse researcher for more help.

Making research accessible to RNs

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