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1. Using the Veteran research article, summarize the data analysis addressing all the questions below.

a. List the data analysis procedures (what statistical tests were conducted with the data [quantitative: Chi-square, ANOVA, regression, etc.; qualitative: Categories, Codes, Themes]).

b. Why were these specific tests conducted?(what do they tell you about the data in relation to the study objectives/questions and/or hypotheses [cause and effect relationship, correlation, frequency, etc.])?

Identifying contextual factors that impact community
reintegration in injured female Veterans
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 – Monday, January 18, 2021 3:54:24 AM – IP Address:
Haley K. Griffithsa, Brent L. Hawkinsb, Brandi M. Crowec
Introduction: Women are an ever-growing and integral part of the U.S. military. However, the research on community
reintegration (CR) for injured female Veterans is limited. The purpose of this study was to identify the contextual
factors influencing CR for injured female Veterans. Methods: Female Veterans reporting a physical or psychological
injury acquired during military service (N = 31) completed the Community Reintegration of Service Members’ Extent
of Participation (EOP) and Satisfaction with Participation (SWP) subscales, the Craig Hospital Inventory of Environ­
mental Factors, and the New General Self-Efficacy Scale to identify personal and environmental factors affecting CR.
Statistical analyses were conducted to determine the clustering of participants on the basis of CR scores and the effect
of environmental factors and self-efficacy on CR. Results: Levels of CR were organized into low, moderate, and high
CR clusters. General self-efficacy was significantly related to CR, and a significant difference was observed between
high and low CR clusters. CR was not related to time served in the military, total time deployed, history of suicidal
ideation, or having a dependable social support system. Discussion: Findings indicate that general self-efficacy had the
strongest relationship with CR for injured female Veterans. Results also suggest that participants had varying levels of
CR, and those with lower levels of CR were more likely to perceive environmental factors as barriers to CR. Future
research should explore the influence of environmental barriers on CR for injured female Veterans with a larger sample.
Keywords: community reintegration, Community Reintegration of Service Members Extent of Participation (EOP),
Craig Hospital Inventory of Environmental Factors, injured female Veterans, New General Self-Efficacy Scale,
rehabilitation, Satisfaction with Participation (SWP) subscales, U.S. Army
Introduction : Les femmes sont partie intégrante et croissante des Forces armées américaines. Cependant, peu de
recherches portent sur la réinsertion dans la communauté (RC), des vétéranes blessées. La présente étude visait à déter­
miner les facteurs contextuels qui ont une influence sur la RC des vétéranes blessées. Méthodologie : Les vétéranes qui
déclaraient avoir subi une blessure physique ou psychologique pendant leur service militaire (n = 31) ont rempli la sous­
échelle de l’étendue de la participation des membres des forces armées à la réinsertion sociale (EOP), la sous-échelle de
satisfaction à la participation (SWP), l’inventaire des facteurs environnementaux du Craig Hospital et la nouvelle échelle
générale d’autoefficacité pour établir quels facteurs personnels et environnementaux influent sur la RC. Grâce à des anal­
yses statistiques, les auteurs ont regroupé les participants d’après les données de RC, de même que l’effet des facteurs envi­
ronnementaux et de l’autoefficacité sur la RC. Résultats : Les taux de RC étaient divisés en groupes de RC faible, modérée
et élevée. L’autoefficacité générale était reliée de manière significative à la RC, et les chercheurs ont constaté une différence
significative entre les groupes de RC élevée et faible. La RC n’était pas liée à la durée du service dans les forces armées, à la
durée totale du déploiement, aux antécédents d’idées suicidaires, ni à un système de soutien social fiable. Discussion : Selon
les observations, l’autoefficacité générale présentait le lien le plus solide avec la RC chez les vétéranes blessées. Les résultats
indiquent également que les participantes présentaient divers taux de RC, et celles dont les taux étaient les plus bas étaient
plus susceptibles de percevoir les facteurs environnementaux comme des obstacles à la RC. De futures recherches devront
explorer l’influence des obstacles environnementaux sur la RC auprès d’un plus vaste échantillon de vétéranes blessées.
Mots-clés : la nouvelle échelle d’autoefficacité générale, réadaptation, réinsertion dans la communauté (RC),
Community Reintegration of Service Members Extent of Participation (EOP), vétéranes blessées, armée américaine,
la sous-échelle de satisfaction à la participation (SWP), l’inventaire des facteurs environnementaux du Craig Hospital
Department of Kinesiology, Recreation, and Sport Studies, University of Tennessee, Knoxville
School of Health and Applied Human Sciences, University of North Carolina Wilmington
Department of Parks, Recreation, and Tourism Management, Clemson University, Clemson, South Carolina
Correspondence should be addressed to Haley K. Griffiths at hgriffi2@utk.edu.
Journal of Military, Veteran and Family Health
doi:10.3138/jmvfh-2018-0043 6(1) 2020
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 – Monday, January 18, 2021 3:54:24 AM – IP Address:
Female Veteran Community Reintegration
After nearly two decades of conflict in the Middle East,
there has been an increase in the number of women
joining the military, deploying, and engaging in com­
bat. There are more than 2 million U.S. female Veter­
ans across the world, and more than 1,000 women have
been wounded serving in the Global War on Terrorism
(GWOT).1,2 The Direct Exclusion Combat Rule pre­
venting women from entering combat-duty assignments,
including infantry and special operations, was rescinded
in December 2015.3 Although combat positions have
only recently been opened to women, they have been
providing direct support to combat units throughout
the GWOT.4,5 An increase in the number of women
seeking care for physical or psychological injuries sus­
tained while serving has contributed to female Veterans
becoming the fastest growing group seeking health care
from Veterans Health Administration (VHA) hospitals
and facilities.6–10
As a result of the nature of the non-linear battle­
field, female service members often find themselves fac­
ing direct fire, improvised explosive devices, and other
causes of injury.4,11 Increased combat positions lead to
increases in combat-related injuries, such as traumatic
brain injuries, spinal cord injuries, limb loss, and post­
traumatic stress disorder (PTSD).4,7 These injuries result
in more female Veterans needing health care and
reintegration support services. However, much of the
research on combat experiences and community rein­
tegration (CR) has focused exclusively on male service
members, with female service members often underrep­
resented.4,11–13 Researchers have called for the VHA to
lead the changes in perceptions and attitudes regarding
female Veterans.6 Additional research is needed to under­
stand how to assist their transition from military service
to civilian living by identifying and addressing the factors
related to CR. Therefore, the objective of this study was
to identify the contextual factors that influence CR for
female Veterans who acquired physical or psychological
injuries during military service.
Community reintegration
CR after a military deployment or discharge can be a
difficult transition for Veterans. If Veterans were also
injured during military service, they may face addi­
tional CR-related challenges. CR is described as an
individual’s return to activities of daily living and
productive activities while living in their home com­
munity. CR is suggested to be influenced by contextual
factors, including personal and environmental factors
such as self-efficacy, policies, attitudes, social support,
and accessibility. Contextual factors can act as barriers
or facilitators influencing an individual’s CR.13–15 Ser­
vices and assistance, attitudes and support in the com­
munity and home, and policies are the environmental
barriers reported most likely to affect CR.6,15 General
self-efficacy (GSE) has been identified as the strongest
personal factor and overall contextual factor affecting
injured Veterans’ CR.15 A qualitative study indicated
self-efficacy and social support were the primary influ­
encers of CR among a sample of injured Veterans. Also,
Veterans with a lower level of GSE were more likely to
report environmental factors and their injuries as barri­
ers to CR than those with higher GSE.9
Female Veterans
Service members, regardless of gender, are at risk for sus­
taining injuries during military service.8,16 However, the
risk for certain injuries increases depending on a service
member’s job and exposure to combat. Men are more
likely to be diagnosed with a traumatic brain injury, spi­
nal cord injury, or limb loss because they occupy most of
the combat positions.4,9,16 Whether gender differences
exist in psychological injury post-deployment is incon­
clusive. For example, one study found no significant
differences between men and women in mental health
or PTSD symptoms post-deployment. 6 However, oth­
er studies have found that women are at an increased
risk for mental health diagnosis, military sexual trauma,
unemployment, and homelessness post-deployment.9,16,17
With regard to seeking and receiving supports and
services, female Veterans report travel distance, missing
work, finding child care for appointments, and navi­
gating the VHA medical system as barriers.6 The fear
of having a mental health diagnosis on one’s military
record and being perceived as weak have been found
to be the greatest barriers preventing male and female
Veterans from seeking help.18 Having quality mental
health services was identified by many female Veterans
as an important, but lacking, service in their geographical
areas. Many women chose not to participate in commu­
nity Veteran programs because attendees were mostly
men. 6,19 Female Veterans more frequently use avoid­
ant coping strategies and are less likely to reach out to
friends and family for help.7 Despite these challenges
and times of feeling isolated, many female Veterans are
Journal of Military, Veteran and Family Health
6(1) 2020 doi:10.3138/jmvfh-2018-0043
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 – Monday, January 18, 2021 3:54:24 AM – IP Address:
Griffiths, Hawkins, and Crowe
proud of their service and view their time in the military
as an important factor in their self-identity.6
These barriers affect many aspects of female Vet­
erans’ lives, but less is known about whether or how
they affect female Veterans’ overall CR.4,13–15 More spe­
cifically, few studies have focused on the personal and
environmental factors influencing female Veterans’
CR. Personal factors consist of the individual’s cogni­
tive and affective background (e.g., self-efficacy, selfregulation), and environmental factors consist of the
physical, social, and attitudinal environment in which
people live and conduct their lives. 20,21 In one study,
injured female Veterans reported that participating in
Veteran-focused programs, having a strong social sup­
port system, and having personality traits such as moti­
vation, optimism, and self-determination were the stron­
gest facilitators of their CR. These same female Veterans
identified insufficient services, accessibility of services,
lack of social support, and difficulty trusting others as
barriers to CR.6,13 Further research on injured female
Veterans and CR is necessary for service providers to
better understand the needs of female Veterans and to
provide supportive programs that will increase success­
ful CR and their quality of life.
This study mirrors a previous study that identi­
fied contextual factors of CR among injured Veter­
ans, but this study’s demographic sample differs in
that we focused solely on female Veterans rather than
a mixed-gender sample.14 The objectives of the current
study were to determine (1) the contextual factors asso­
ciated with CR in injured female Veterans and (2) the
impact of total time in military service, time deployed,
history of suicidal ideation, and a dependable social sup­
port system on injured female Veterans’ CR.
This study’s methods replicate those of a previous study
conducted with a mixed-gender sample14 to identify and
understand the impact of contextual factors specifically
related to injured female Veterans’ CR. An online sur­
vey instrument was administered via Qualtrics survey
software (Qualtrics, Provo, UT) to a sample of female
Veterans over a six-month period. Eligible participants
served in the military during the time frame of the
GWOT, were not required to have been deployed to a
combat zone, reported a physical or psychological injury
during military service, and resided in the community.
Journal of Military, Veteran and Family Health
doi:10.3138/jmvfh-2018-0043 6(1) 2020
Recruitment was completed through flyers and word of
mouth with organizations that provide services to Veter­
ans, such as advocacy groups, online support programs,
professional Listservs, and adaptive sport programs. The
study used maximum variation sampling with these or­
ganizations to elicit participants across the spectrum of
CR (i.e., differences in years since injury, rehabilitation
services received).22
Participants provided personal information (name,
age, phone number, email address) for potential follow-up
studies. They were asked questions regarding their mili­
tary history, such as years served, branch served, military
job titles, number and length of deployments, and inju­
ries sustained with an open-text option to provide spe­
cific details about their injuries. Participants were asked
to identify their perceived level of disability (i.e., slight,
moderate, severe, not disabled). The survey also includ­
ed questions regarding personal relationships, social
support, work, and mental health (i.e., substance abuse
and suicidal ideation). The survey settings prevented
“ballot box stuffing” and did not allow participants
to complete the survey more than once. Institutional
review board approval was received before the start of
the study.
An online survey instrument was used to administer
measures in the following areas.
Community reintegration
The Community Reintegration of Injured Service
Members (CRIS) was developed to measure injured ser­
vicemembers’ CR using three standalone subscales: Per­
ceived Limitations (PL), Extent of Participation (EOP),
and Satisfaction with Participation (SWP).23,24 The
EOP and the SWP subscales were used in this study.
The PL subscale was excluded because we instead used
a measure of environment-specific barriers, which bet­
ter corresponded with the study’s purpose. The CRIS
reported a reliabilities of 0.91 and 0.90, respectively, for
EOP and SWP. Individuals can score between 10 and
70 on each subscale, with a higher score indicating a
higher level of CR.23,24
Environmental factors
The Craig Hospital Inventory of Environmental Factors
(CHIEF) measures the frequency and impact of envi­
ronmental factors on individuals with a disability. The
CHIEF Short Form (CHIEF–SF) consists of 12 items
that measure environmental factors that can potentially
Female Veteran Community Reintegration
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 – Monday, January 18, 2021 3:54:24 AM – IP Address:
influence female Veterans’ CR (i.e., services and assis­
tance, policies, physical and structural, work and school,
and attitudes and support). Scores range from 0 to 8,
and the measure has a reliability of 0.93. Higher scores
indicate that a factor is a greater barrier to CR.25
The New General Self-Efficacy scale (NGSE) includes
eight items that measure traits that influence an individ­
ual’s GSE, such as an individual’s perception of her or
his personal ability to accomplish a task. NGSE scores
range from 1 to 5, and a higher score is associated with
higher GSE. The NGSE has yielded a high internal con­
sistency reliability (Cronbach’s as = 0.86 and 0.90).26
We used IBM SPSS Software (Version 25.0; IBM Cor­
poration, Armonk, NY) to analyze data. Correlations
and scatter plots between EOP and SWP were used to
determine participants’ overall level of CR. A K-means
cluster analysis organized the participants’ CR lev­
els into clusters. A multivariate analysis of covariance
(MANCOVA) tested the effect that GSE, as measured
by the NGSE, and the five environmental factors from
the CHIEF–SF had on CR while controlling for per­
ceived level of disability. A least significant difference
(LSD) post hoc test analyzed differences between con­
textual factors and each CR cluster. Pearson χ2 test was
used to analyze the influence of suicidal ideations and
having dependable social support on CR.
A total of 31 injured female Veterans, aged 28–59 years
(mean = 44 y), participated in the study. The majority
of participants had served in the military for more than
10 years (74.3%; mean = 16.52). A large percentage of
the sample was injured while on active duty (87.1%)
and served in Operation Enduring Freedom (70.9%).
A majority of the sample served in the Army (48.4%).
PTSD (96.8%) and depression (77.4%) were the most
frequently self-reported injuries, followed by brain
injury (54.8%; four participants reported mild traumat­
ic brain injury, two reported moderate brain injury, one
reported severe brain injury, three did not specify), and
generalized anxiety disorder (41.9%). The majority of
participants reported more than two injuries (80.6%).
More than half of the sample reported a history of
suicidal ideation (58.1%) and a dependable social sup­
port system (54.8%). Participants reported attending
rehabilitation at private hospitals, Army medical cen­
ters, Warrior Transition Battalions, and VHA hospitals
across the county. Refer to Table 1 for more participant
descriptive information.
Table 1. Participant descriptive statistics (N = 31)
n (%)
Military branch
15 (48.4)
Air Force
9 (29.0)
5 (16.1)
National Guard
2 (6.5)
Marine Corps
3 (9.7)
1 (3.2)
Time served, yr
10 (32.3)
Conflict involvement
Operation Iraqi Freedom
14 (45.2)
Operation Enduring Freedom
22 (70.9)
Operation New Dawn
1 (3.2)
11 (35.5)
No. of combat deployments
Not deployed
2 (6.5)
9 (29.0)
11 (35.5)
4 (12.9)
5 (16.1)
When injured
Active duty
27 (87.1)
4 (12.9)
Type of injury
Spinal cord injury
Brain injury
9 (29.0)
17 (54.8)
2 (6.5)
Sensory impairment
12 (38.7)
Post-traumatic stress disorder
30 (96.8)
24 (77.4)
Generalized anxiety disorder
13 (41.9)
10 (32.3)
>2 injuries
25 (80.6)
Journal of Military, Veteran and Family Health
6(1) 2020 doi:10.3138/jmvfh-2018-0043
Griffiths, Hawkins, and Crowe
Table 1. (Continued)
n (%)
Time since injury, yr
13 (41.9)
18 (58.1)
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 – Monday, January 18, 2021 3:54:24 AM – IP Address:
Perceived level of disability, handicap, or both
Not disabled
1 (4.8)
3 (9.7)
6 (28.6)
Somewhat severe
9 (42.9)
Very severe
5 (23.8)
Attended rehabilitation
14 (45.2)
Received CR training during rehabilitation
11 (35.5)
Past problems with alcohol, substances, or both
9 (29.0)
Suicidal ideation
18 (58.1)
Intimate relationship
17 (54.8)
Separated or divorced
4 (12.9)
16 (51.6)
Dependable family or friends in community
17 (54.8)
Note: Not all categories equal 31 participants or 100
percent due to multiple answers (i.e., type of disability).
CR = community reintegration.
Mean scores were 40.81 (SD = 8.34) on the EOP and
39.52 (SD = 10.34) on the SWP, indicating moderate
levels of CR. A significant positive correlation (r = 0.818,
p < 0.001) existed between participants’ EOP and SWP scores. GSE had a significant positive correlation with both EOP (r = 0.688, p < 0.001) and SWP (r = 0.767, p < 0.001) scores. We found no significant correlations between CHIEF–SF barrier scores, total time in service, or total time deployed and EOP and SWP. Refer to Ta­ ble 2 for correlations between contextual factor measures (CHIEF–SF and NGSE) and EOP and SWP scores. A K-means cluster analysis was used to group partici­ pants’ overall CR scores, based on EOP and SWP scores, into three clusters (i.e., low, moderate, and high CR) to identify the barriers influencing varying levels of CR. Seven cases were assigned to the low CR cluster, 20 to the moderate cluster, and four to the high CR cluster. Figure 1 illustrates the clusters based on EOP and SWP scores. Five participants did not fully complete the NGSE or the CHIEF–SF, so their data were excluded from this portion of the analysis (n = 26). The MANCOVA results showed that GSE was the only contextual factor that had a statistically significant between-subjects effect on CR (partial ƞ2 = 0.469, F2 = 10.164, p < 0.001). LSD 42 Journal of Military, Veteran and Family Health doi:10.3138/jmvfh-2018-0043 6(1) 2020 Table 2. Correlations between contextual factors and CR measures EOP SWP General Self-Efficacy Pearson r 0.688 0.767 p (2-tailed) 0.000* 0.000* Policy Barriers Pearson r –0.168 –0.174 p (2-tailed) 0.411 0.394 Pearson r –0.239 –0.286 p (2-tailed) 0.239 0.216 Pearson r –0.341 –0.256 p (2-tailed) 0.088 0.207 Pearson r –0.259 –0.287 p (2-tailed) 0.202 0.155 Pearson r –0.346 –0.317 p (2-tailed) 0.083 0.115 Physical and Structural Barriers Work and School Barriers Attitudes and Support Barriers Services and Assistance Barriers Note: CR = community reintegration; EOP = Extent of Participation; SWP = Satisfaction with Participation. * Indicates significant correlations. post hoc indicated a statistically significant difference between the high and low CR clusters (mean differ­ ence = 1.948, p < 0.001) and the moderate and low CR clusters (mean difference = 1.0182, p < 0.002) for GSE. This finding suggests that individuals categorized in the high and moderate CR clusters scored higher on GSE than those in the low CR cluster. Veterans in the high and moderate CR clusters most common­ ly reported physical–structural and attitude–support environmental barriers to CR. Individuals in the low CR cluster reported the five barriers to CR more frequently than did individuals in the high or moderate CR clus­ ters. Table 3 indicates the estimates of contextual factors and the three CR clusters. Pearson χ2 tests indicated that suicidal ideation and having a dependable social support system had no sig­ nificant difference in observed counts between any CR clusters. Pearson χ2 tests were also conducted between other descriptive variables (i.e., substance abuse, intimate relationship, children, and perceived level of disability) and the low, moderate, and high CR clusters to deter­ mine potential significant differences. No significant https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 - Monday, January 18, 2021 3:54:24 AM - IP Address: Female Veteran Community Reintegration Figure 1. Community Reintegration (CR) Clusters EOP = Extent of Participation, SWP = Satisfaction with Participation. Table 3. Estimates for contextual factors on CR clusters Contextual and descriptive variables General self-efficacy CR clusters, mean (SD) Low Moderate High 2.05 (0.307) 3.11 (0.179) 3.87 (0.356) Physical and 3.04 (0.734) 2.09 (0.429) 1.96 (0.852) structural barriers Service and assistance barriers 4.11 (1.083) 1.71 (0.633) 1.26 (1.257) Work and school barriers 2.60 (0.921) 1.01 (0.538) 0.805 (1.069) Attitude and support barriers 2.85 (0.953) 1.98 (0.557) 1.56 (1.106) Policy barriers 3.96 (0.759) 1.25 (0.443) 0.829 (0.880) Note: Controlling for Perceived Disability. CR = community reintegration. difference in observed counts was indicated for any CR clusters and the descriptive variables. DISCUSSION The aim of this study was to identify contextual factors influencing injured female Veterans’ CR. A positive cor­ relation existed between EOP and SWP scores. Individ­ uals’ level of CR was organized into low, moderate, and high CR clusters. Analysis of contextual factors revealed that GSE had a significant effect on CR and significantly accounted for variance in CR scores between individu­ als in the low and high CR clusters and the moderate and low CR clusters. This finding supports GSE’s strong influence on CR for injured female Veterans. No oth­ er variables had a statistical association with CR cluster affiliation. It was found that 87.1% of injured female Veterans scored in a low to moderate CR range, which is con­ siderably higher than the findings from a study with a mixed-gender sample, in which 62% of injured Veterans were classified as having low or moderate CR.14 The literature suggests that female and male Veter­ ans face different challenges during CR and that women have unique needs compared with men. 6,16,19 Differ­ ences between the women in this study were identi­ fied when compared with findings from the study that involved women as part of a larger, mixed-gender sam­ ple. Most notable was that environmental factors were not a significant barrier to CR for women in this study (despite a negative correlation), whereas they were a sig­ nificant barrier for men and women, collectively, in the mixed-gendered study and in other studies of CR.13–16,18 Although a significant relationship between CR and environmental barriers was not found in the current Journal of Military, Veteran and Family Health 6(1) 2020 doi:10.3138/jmvfh-2018-0043 43 https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 - Monday, January 18, 2021 3:54:24 AM - IP Address: Griffiths, Hawkins, and Crowe study, participants in the high and moderate CR clus­ ters were most likely to report physical–structural and attitude–support as environmental barriers. The leading result from this study was the association between GSE and CR. The importance of GSE is syn­ onymous with previous research that examined personal and environmental factors influencing injured Veterans’ CR.9,13,14 A possible explanation for why environmental barriers were not significantly related to CR in this study may be that GSE mediates the impact of environmental barriers on CR. The authors did not test this mediating relationship because of sample size limitations. Future research should further explore the influence of envi­ ronmental barriers on injured female Veterans and the relationship between personal factors such as GSE and environmental factors in the context of CR. Another possible explanation for why self-efficacy was significantly related to CR but environmental bar­ riers were not related is that the majority of the sam­ ple was living at home in their community, more than five years post-injury. At this point in their CR process, the individuals may have been educated or have acquired the skills necessary to navigate environmental barriers, resulting in an increase in barrier negotiation ability and higher self-efficacy. This may also help explain why female Veterans in the moderate and high CR clusters reported fewer environmental barriers than those in the lower CR cluster. Previous studies suggest that Veterans who served in the GWOT report more than one injury.12,14 In this sample, 80.6% reported more than two injuries sustained during military service. There are variations in the litera­ ture concerning male and female Veterans’ susceptibility to certain diagnoses. Some studies have proposed that no differences exist between men and women reporting mental health symptoms post-deployment.6 Other stud­ ies suggest that men are more commonly diagnosed with PTSD than women.4,7 In this study, 96.8% of women reported PTSD, which was much higher than reports from the previous study, in which 64.7% of the sample reported PTSD,13 and much higher than a VHA study that ranked PTSD as the most prevalent service-related disability of all female Veterans at 11.8%.27 This study controlled for perceived level of disability, but it did not attempt to examine the effect of specific injuries on CR. Future research should examine the effect inju­ ries may have on CR – specifically, examining rates of PTSD among female Veterans because PTSD has been suggested to be associated with lower CR.12 44 Journal of Military, Veteran and Family Health doi:10.3138/jmvfh-2018-0043 6(1) 2020 This study found that 58.1% of the sample reported a history of suicidal ideation, which is higher than pre­ vious studies.14,16 Although the aim of this study was not to understand suicidal ideation among women, individ­ uals who reported a history of suicidal ideation indi­ cated having multiple injuries, had a high prevalence of military sexual trauma, and exhibited low to moderate CR scores. Future research should investigate the pos­ sible relationships between these variables and suicidal ideation because findings could be valuable for identify­ ing suicide risk and prevention among female Veterans. In the current study, it was found that female Vet­ erans reported a lower percentage of dependable social support (54.8%) in their community compared with the previous study, in which 74.5% of Veterans reported having dependable social support.14 The influence that lack of social support may have on female Veterans’ CR should be further examined, taking into consideration increased feelings of isolation during and underrepre­ sentation of women in Veteran programs.13,16 Overall, this study supports previous research demonstrating the integral role of GSE in CR.9,14 Agen­ cies that provide services for Veterans should consider incorporating programs that promote GSE. One ave­ nue for promoting CR is the use of recreation, sport, outdoors, and nature-based programs as well as recre­ ational therapy. These types of programs and services can help promote GSE by providing injured Veterans with opportunities to overcome challenges, increase self-esteem, improve social skills, and acquire new skills.9,28,29 Many of these community-based programs are designed and implemented by credentialed recre­ ational therapists, who are educated and trained to use recreation as a treatment modality to meet the unique needs and interests of military Veterans.30 A growing body of literature is emerging that supports the use of recreation and recreational therapy with injured Veter­ ans and their supporters.28–36 Limitations Because of the small sample size, it is challenging to generalize results to other injured female Veterans. A power analysis was not conducted to determine ade­ quate sample size before recruitment, in part because of the study’s exploratory nature to identify relationships between contextual factors and CR among female Vet­ erans. Future studies should use this study as a baseline to recruit larger samples to enhance the explanatory ability of the results, as determined by a power analysis. Female Veteran Community Reintegration https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 - Monday, January 18, 2021 3:54:24 AM - IP Address: In addition, having more diversity in participants’ age and time in military service could allow for greater gen­ eralizability among female Veterans. Participants in this study were more than three years post-injury, so the au­ thors could not adequately measure the implication of time since injury on CR. It is important to note that injuries were self-reported and not verified with medical documentation. CONCLUSION This study indicated the significant association between GSE and injured female Veterans’ satisfaction with and extent of participation in CR. Findings identified per­ ceived barriers for each CR cluster, whereby those with low levels of CR were most likely to report environmen­ tal barriers to CR. The study contributes to the growing body of literature on female Veterans by examining con­ textual factors influencing CR. Enhancing self-efficacy and training to overcome environmental barriers may have the greatest influence on successful reintegration of female Veterans. As the number of injured female Vet­ erans increases, it is important that additional research be conducted to provide practitioners with the evidence and knowledge to offer the most effective CR services. Understanding the facilitators of and barriers to CR will assist providers in offering services designed to meet the specific needs of injured female Veterans and equip them with the skills necessary for successful CR. REFERENCES 1. U.S. Department of Veterans Affair. Women Veterans population fact sheet. Washington (DC): U.S. Depart­ ment of Veterans Affairs; 2016. 2. Defense Manpower Data Center. Defense casualty anal­ ysis system. Alexandria (VA): DMDC ; 2017. Available from: https://dcas.dmdc.osd.mil/dcas/pages/main. xhtml. 3. Kamarck KN. Women in combat: issues for Congress. R42075 Report No. 7–5700. Washington (DC): Con­ gressional Research Service ; 2016. 4. Dye JL, Eskridge SL, Tepe V, et al. Characteri­ zation and comparison of combat-related inju­ ries in women during OIF and OEF. Mil Med. 2016;181(1 Supplement):92–8. https://doi. org/10.7205/milmed-d-15-00237. Medline:26741907 5. Leslie LA, Koblinsky SA. Returning to civilian life: family reintegration challenges and resilience of women Veterans of the Iraq and Afghanistan wars. J Fam Soc Work. 2017;20(2):106–23. https://doi.org/10.1080/1 0522158.2017.1279577. 6. Brooks E, Dailey NK , Bair BD, et al. Listening to the patient: women Veterans’ insights about health care needs, access, and quality in rural areas. Mil Med. 2016;181(9):976–81. https://doi.org/10.7205/ milmed-d-15-00367. Medline:27612340 7. Goldstein LA, Dinh J, Donalson R , et al. Impact of military trauma exposures on posttraumatic stress and depression in female Veterans. Psychiatry Res. 2017;249:281–5. https://doi.org/10.1016/j. psychres.2017.01.009. Medline:28135599 8. Mattocks KM, Haskell SG, Krebs EE, et al. Women at war: understanding how women Veterans cope with combat and military sexual trauma. Soc Sci Med. 2012;74(4):537–45. https://doi.org/10.1016/j. socscimed.2011.10.039. Medline:22236641 9. Maguen S, Luxton DD, Skopp NA, et al. Gender dif­ ferences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghani­ stan. J Psychiatric Res. 2012;46(3):311–16. https://doi. org/10.1037/e533652013-475. 10. Hamilton AB. Enhancing mental and physical health of women through engagement and retention (EMPOW­ ER). Washington (DC): Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs; 2018. 11. Street AE, Vogt D, Dutra L. A new generation of women Veterans: stressors faced by women deployed to Iraq and Afghanistan. Clin Psychol Rev. 2009; 29(8):685–94. https://doi.org/10.1016/j.cpr. 2009.08.007. Medline:19766368 12. Mota NNP, Medved M, Wang J, et al. Stress and mental disorders in female military personnel: comparisons between sexes in a male dominated profession. J Psychiatric Res. 2012;46(2):159–67. https://doi.org/ 10.1016/j.jpsychires.2011.09.014. Medline:22024487 13. Hawkins B, Crowe B. Contextual facilitators and barriers in community reintegration among injured female military Veterans: a qualitative study. Arch Phys Med Rehabil. 2017;99(2):S65–S71. https://doi. org/10.1016/j.apmr.2017.07.018. Medline:28866010 14. Hawkins BL, McGuire FA, Britt TW, et al. Identi­ fying contextual influences of community reintegra­ tion among injured servicemembers. J Rehabil Res Dev. 2015;52(2):235–46. https://doi.org/10.1682/ jrrd.2014.08.0195. Medline:26237496 15. Hawkins BL, McGuire FA, Linder SM, et al. Under­ standing contextual influences of community reinte­ gration among injured servicemembers. J Rehabil Res Dev. 2015;52(5):527–42. https://doi.org/10.1682/ jrrd.2014.08.0196. Medline:26436882 16. Randolph BJ, Nelson LM, Highsmith MJ. A review of unique considerations for female Veterans with amputation. Mil Med. 2016;181(S4):66–8. https://doi. org/10.7205/milmed-d-16-00262. Medline:27849464 Journal of Military, Veteran and Family Health 6(1) 2020 doi:10.3138/jmvfh-2018-0043 45 https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 - Monday, January 18, 2021 3:54:24 AM - IP Address: Griffiths, Hawkins, and Crowe 17. Hamilton AB, Williams L, Washington DL. Mili­ tary and mental health correlates of unemployment in a national sample of women Veterans. Med Care. 2015;53(4):S32–38. https://doi.org/10.1097/ mlr.0000000000000297. Medline:25767973 18. Demers A. When Veterans return: the role of commu­ nity in reintegration. J Loss Trauma. 2011;16(2):160– 79. https://doi.org/10.1080/15325024.2010.519281. 19. Gutierrez PM, Brenner LA, Rings JA, et al. A qualita­ tive description of female Veterans’ deployment-related experiences and potential suicide risk factors. J Clin Psychol. 2013;69(9):923–35. https://doi.org/10.1002/ jclp.21997. Medline:23775338 20. Bandura A. Social cognitive theory: an agentic perspective. Ann Rev Psychol. 2001;52:1–26. https://doi.org/10.1146/annurev.psych.52.1.1. Medline:11148297 21. World Health Organization. The international clas­ sification of functioning, disability and health: short version. Geneva : World Health Organization; 2001. 22. Onwuegbuzie A, Collins K . A typology of mixed meth­ ods sampling designs in social science research. Qual Rep. 2007;12(2):281–316. 23. Resnik L, Gray M, Borgia M. Measurement of commu­ nity reintegration in sample of severely wounded ser­ vicemembers. J Rehabil Res Dev. 2011;48(2):89–102. https://doi.org/10.1682/jrrd.2010.04.0070. Med­ line:21480084 24. Resnik L, Plow M, Jette A. Development of CRIS: measure of community reintegration of injured service members. J Rehabil Res Dev. 2009;46(4):469. https://doi.org/10.1682/jrrd.2008.07.0082. Med­ line:19882482 25. Whiteneck GG, Harrison-Felix CL, Mellick DC, et al. Quantifying environmental factors: a measure of physical, attitudinal, service, productivity, and policy barriers. Arch Phys Med Rehabil. 2004;85(8):1324–35. https://doi.org/10.1016/j.apmr.2003.09.027. Med­ line:15295760 26. Chen G, Gully SM, Eden D. Validation of a New General Self-Efficacy Scale. Organ Res Methods. 2001;4(1):62–83. https://doi. org/10.1177/109442810141004 27. U.S. Department of Veterans Affairs. The past, present, and future of women Veterans. Washington (DC): U.S. Department of Veterans Affairs; 2017. 28. Hawkins BL , Townsend JA , Garst BA . Nature-based recreational therapy for military service mem­ bers: a strengths approach. Ther Recreation J. 2016;50(1):55–74. https://doi.org/10.18666/trj­ 2016-v50-i1-6793. 29. Wilder A, Craig P, Sable J, et al. The PATH-way home: promoting access, transition, and health for Veterans 46 Journal of Military, Veteran and Family Health doi:10.3138/jmvfh-2018-0043 6(1) 2020 30. 31. 32. 33. 34. 35. 36. with disabilities. Ther Recreation J. 2011;45(4):268– 85. https://doi.org/10.1589/rika.22.177. Bennett JL, Piatt JA, Van Puymbroeck M. Outcomes of a therapeutic fly-fishing program for Veterans with combat-related disabilities: a community-based rehabilitation initiative. Community Ment Health J. 2017;53(7):756–65. https://doi.org/10.1007/s10597­ 017-0124-9. Medline:28303444 Hawkins BL, Townsend JA, Heath SE, et al. The preliminary effects of a recreation-based military family camp on family functioning. Am J Recreat Ther. 2018;17(3):15–24. https://doi.org/10.5055/ ajrt.2018.0164. Townsend J, Hawkins BL, Bennett JL, et al. Preliminary long-term health outcomes associated with recreationbased health and wellness programs for injured service members. Cogent Psychol. 2018;5(1). https://doi.org/ 10.1080/23311908.2018.1444330. Vella EJ, Milligan B, Bennett JL. Participation in outdoor recreation program predicts improved psychosocial well-being among Veterans with post-traumatic stress disorder: a pilot study. Mil Med. 2013;178(3):254–60. https://doi.org/10.7205/ milmed-d-12-00308. Medline:23707110 Bennett JL, Lundberg NR , Zabriskie RB, et al. Addressing posttraumatic stress among Iraq and Afghanistan Veterans and significant others: an intervention utilizing sport and recreation. Ther Recreation J. 2014;48(1):74–93. Lundberg N, Jessie B, Smith S. Outcomes of adaptive sports and recreation participation among Veterans returning from combat with acquired disability. Ther Recreation J. 2011;45(2):105–20. Dawson S, Gilbert K , Gilbert R , et al. Family Battle Buddies program: a therapeutic program for reinte­ grating National Guard families. Am J Recreation Ther. 2016;15(2):29–38. https://doi.org/10.5055/ ajrt.2016.0103. AUTHOR INFORMATION Haley K. Griffiths, PhD, CTRS, is Assistant Professor of Practice in Therapeutic Recreation, Department of Kinesiology, Recreation, and Sport Studies, University of Tennessee, Knoxville. Brent L. Hawkins, PhD, CTRS, is Associate Professor of Recreation Therapy in the School of Health and Applied Human Sciences at the University of North Carolina Wilmington. Brandi M. Crowe, PhD, LRT/CTRS, is Assistant Professor of Recreational Therapy, Department of Parks, Recreation, and Tourism Management, Clemson University, Clemson, South Carolina. Female Veteran Community Reintegration COMPETING INTERESTS None declared. This article has been peer reviewed. CONTRIBUTORS FUNDING None declared. https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh-2018-0043 - Monday, January 18, 2021 3:54:24 AM - IP Address: All authors conceived, designed, researched, and drafted the manuscript and approved the final version submitted for publication. All authors significantly contributed to the development of study and the manuscript. Journal of Military, Veteran and Family Health 6(1) 2020 doi:10.3138/jmvfh-2018-0043 47 1 Identifying the Problem, Literature review, and Identifying the Variables: Factors impacting community reintegration in injured female veterans Problem Identification The study aims at identifying contextual factors that impact community reintegration in injured female veterans. It is because female military officers serve a very integral part of the US forces. These female veterans always fall victims of physical and psychological injury, which 2 they normal acquire in their service delivery in protecting the civilians and the borders of their jurisdictions (Griffiths et al. 2020). Self-efficacy has a more substantial relationship for community reintegration for injured female veterans. There are varying community reintegration levels whereby those with lower community reintegration levels are likely to experience environmental factors barring them from community reintegration. Literature Review The study has a literature review part, reflecting the critical issues such as environmental factors and personal factors and physical and psychological injuries. Almost half of the female veterans have experienced physical and mental injuries like traumatic brain injury, spinal cord injury, limb loss, and post-traumatic stress disorder (PTSD). Most female veterans fail to participate in the community because male dominance makes them strain; therefore, they feel isolated. Personal factors that affect female veterans include a cognitive and affective background such as self-regulation while the environmental factors have a physical, social and attitudinal environment (Griffiths et al. 2020). These injured females identified some factors such as participation in veterans-focused programs, a robust social support system and social support. Self-efficacy and social support are the primary factors that affect the community reintegration of injured female veterans. Both female and male veterans are likely to experience psychological injury post-deployment. Whereas other studies argued that there is no relative difference in the rate of both male and female veterans fall victims to these injuries (Griffiths et al. 2020). On the contrary, others examined that females are likely to suffer from these injuries more than male veterans, such as military sexual trauma, unemployment and mental health diagnosis. Female veterans experience difficulties in seeking support in their areas; hence, it interferes with their mental health. Other factors such as insufficient service provision, lack of social services, and 3 difficulty trusting others have contributed to their failure to reintegrate into the community. Therefore, it is for the service providers always to understand the need for injured female veterans in their activities; consequently, it will improve their community reintegration. The references in the study are not that old. The reference list has 16 sources from the last five years and 20 sources from last ten years. Also, the study lacks a written summary of the synthesized scholarly reviewed literature. Identifying Variables Four types of the variable are independent, dependent, research, and extraneous variables. Independent variables influence changes in the dependent variables. Therefore, injured female veterans are the independent variable, while the contextual factors and personal factors are the dependent variables. The research variables entail the characteristics, qualities and properties in research purpose after investigation, and they are also result of observation and measurement in the study. The research investigates contextual and personal factors that impact on the community reintegration of injured female veterans. Extraneous variables influence the outcome of the study by altering the independent and dependent variables. The extraneous variables are neglect by the service providers to provide safe reintegration, poor working conditions of the militia members. Reference Griffiths, H. K., Hawkins, B. L., & Crowe, B. M. (2020). Identifying contextual factors that impact community reintegration in injured female Veterans. Journal of Military, Veteran and Family Health, 6(1), 38-47. 4 YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK! Evolve Student Resources for Grove: Understanding Nursing Research: Building an Evidence-Based Practice, 6th Edition, include the following: • Review Questions • Research Article Library • Appraisal Exercises • Key Points Activate the complete learning experience that comes with each textbook purchase by registering at http://evolve.elsevier.com/Grove/understanding/ REGISTER TODAY! You can now purchase Elsevier products on Evolve! Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products. CONTENTS 1 Introduction to Nursing Research and Evidence-Based Practice, 1 2 Introduction to Quantitative Research, 31 3 4 5 6 Introduction to Qualitative Research, 66 Examining Ethics in Nursing Research, 93 Research Problems, Purposes, and Hypotheses, 129 Understanding and Critically Appraising the Literature Review, 162 7 Understanding Theory and Research Frameworks, 189 8 Clarifying Quantitative Research Designs, 210 9 Examining Populations and Samples in Research, 248 10 Clarifying Measurement and Data Collection in Quantitative Research, 281 11 Understanding Statistics in Research, 317 12 Critical Appraisal of Quantitative and Qualitative Research for Nursing Practice, 361 13 Building an Evidence-Based Nursing Practice, 414 14 Outcomes Research, 466 Glossary, 500 Index, 515 This page intentionally left blank 6th Edition Understanding Nursing Research Building an Evidence-Based Practice Susan K. Grove, PhD, RN, ANP-BC, GNP-BC Professor Emerita College of Nursing The University of Texas at Arlington Arlington, Texas; Adult Nurse Practitioner Family Practice Grand Prairie, Texas Jennifer R. Gray, PhD, RN, FAAN George W. and Hazel M. Jay Professor, College of Nursing Associate Dean, College of Nursing The University of Texas at Arlington Arlington, Texas Nancy Burns, PhD, RN, FCN, FAAN Professor Emerita College of Nursing The University of Texas at Arlington Arlington, Texas; Faith Community Nurse St. Matthew Cumberland Presbyterian Church Burleson, Texas 3251 Riverport Lane St. Louis, Missouri 63043 UNDERSTANDING NURSING RESEARCH: BUILDING AN EVIDENCE-BASED PRACTICE, EDITION SIX ISBN: 978-1-4557-7060-1 Copyright © 2015, 2011, 2007, 2003, 1999, 1995 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4557-7060-1 Executive Content Strategist: Lee Henderson Content Development Manager: Billie Sharp Content Development Specialist: Charlene Ketchum Publishing Services Manager: Deborah L. Vogel Project Manager: Bridget Healy Design Direction: Maggie Reid Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 C O N T R I B U TO R A N D REVIEWERS CONTRIBUTOR Diane Doran, RN, PhD, FCAHS Professor Emerita Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Revised Chapter 14 REVIEWERS Lisa D. Brodersen, EdD, MA, RN Professor, Coordinator of Institutional Research and Effectiveness Allen College Waterloo, Iowa Sara L. Clutter, PhD, RN Associate Professor of Nursing Waynesburg University Waynesburg, Pennsylvania Jacalyn P. Dougherty, PhD, RN Nursing Research Consultant JP Dougherty LLC Aurora, Colorado Joanne T. Ehrmin, RN, COA-CNS, PhD, MSN, BSN Professor University of Toledo, College of Nursing Toledo, Ohio Betsy Frank, PhD, RN, ANEF Professor Emerita Indiana State University College of Nursing Health, and Human Services Terre Haute, Indiana Tamara Kear, PhD, RN, CNS, CNN Assistant Professor of Nursing Villanova University Villanova, Pennsylvania Sharon Kitchie, PhD, RN Adjunct Instructor Keuka College Keuka Park, New York Madelaine Lawrence, PhD, RN Associate Professor University of North Carolina at Wilmington Wilmington, North Carolina Robin Moyers, PhD, RN-BC Nurse Educator Carl Vinson VA Medical Center Dublin, Georgia Sue E. Odom, DSN, RN Professor of Nursing Clayton State University Morrow, Georgia Teresa M. O’Neill, PhD, APRN, RNC Professor Our Lady of Holy Cross College New Orleans, Louisiana Sandra L. Siedlecki, PhD, RN, CNS Senior Nurse Scientist Cleveland Clinic Cleveland, Ohio Sharon Souter, PhD, RN, CNE Dean and Professor University of Mary Hardin Baylor Belton, Texas v vi CONTRIBUTOR AND REVIEWERS Molly J. Walker, PhD, RN, CNS, CNE Professor Angelo State University San Angelo, Texas Cynthia Ward, DNP, RN-BC, CMSRN, ACNS-BC Surgical Clinical Nurse Specialist Carilion Roanoke Memorial Hospital Roanoke, Virginia Angela Wood, PhD, RN, Certified High-Risk Prenatal Nurse Associate Professor and Chair Department of Nursing Carson-Newman University Jefferson City, Tennessee Fatma A. Youssef, RN, DNSc, MPH Professor Emerita Marymount University School of Health Professions Arlington, Virginia To all nurses who change the lives of patients through applying the best research evidence. —Susan, Jennifer, and Nancy To my husband Jay Suggs who has provided me endless love and support during my development of research textbooks over the last 30 years. —Susan To my husband Randy Gray who is my love and my cheerleader. —Jennifer To my husband Jerry who has supported all of my academic endeavors through 58 years of marriage. —Nancy P R E FAC E Research is a major force in nursing, and the evidence generated from research is constantly changing practice, education, and health policy. Our aim in developing this essentials research text, Understanding Nursing Research: Building an Evidence-Based Practice, is to create an excitement about research in undergraduate students. The text emphasizes the importance of baccalaureate-educated nurses being able to read, critically appraise, and synthesize research so this evidence can be used to make changes in practice. A major goal of professional nursing and health care is the delivery of evidence-based care. By making nursing research an integral part of baccalaureate education, we hope to facilitate the movement of research into the mainstream of nursing. We also hope this text increases student awareness of the knowledge that has been generated through nursing research and that this knowledge is relevant to their practice. Only through research can nursing truly be recognized as a profession with documented effective outcomes for the patient, family, nurse provider, and healthcare system. Because of this expanded focus on evidence-based practice (EBP), we have subtitled this edition Building an Evidence-Based Practice. Developing a sixth edition of Understanding Nursing Research has provided us with an opportunity to clarify and refine the essential content for an undergraduate research text. The text is designed to assist undergraduate students in overcoming the barriers they frequently encounter in understanding the language used in nursing research. The revisions in this edition are based on our own experiences with the text and input from dedicated reviewers, inquisitive students, and supportive faculty from across the country who provided us with many helpful suggestions. Chapter 1, Introduction to Nursing Research and Evidence-Based Practice, introduces the reader to nursing research, the history of research, and the significance of research evidence for nursing practice. This chapter has been revised to include the most relevant types of research synthesis being conducted in nursing—systematic review, meta-analysis, meta-synthesis, and mixedmethods systematic review. The discussion of research methodologies and their importance in generating an evidence-based practice for nursing has been updated and expanded to include the exploratory-descriptive qualitative research method. A discussion of the Quality and Safety Education for Nursing (QSEN) competencies and their link to research has been included in this edition. Selected QSEN competencies are linked to the findings from studies presented as examples throughout the text to increase students’ understanding of the importance in delivering quality, safe health care to patients and families. Chapter 2, Introduction to Quantitative Research, presents the steps of the quantitative research process in a concise, clear manner and introduces students to the focus and findings of quantitative studies. Extensive, recent examples of descriptive, correlational, quasi-experimental, and experimental studies are provided, which reflect the quality of current nursing research. Chapter 3, Introduction to Qualitative Research, describes five approaches to qualitative research and the philosophies upon which they are based. These approaches include phenomenology, grounded theory, ethnography, exploratory-descriptive qualitative, and historical research. Data collection and analysis methods specific to qualitative research are discussed. Guidelines for reading and critically appraising qualitative studies are explained using examples of published studies. viii PREFACE ix Chapter 4, Examining Ethics in Nursing Research, provides an extensive discussion of the use of ethics in research and the regulations that govern the research process. Detailed content and current websites are provided to promote students’ understanding of the Health Insurance Portability and Accountability Act (HIPAA), the U.S. Department of Health and Human Services Protection of Human Subjects, and the Federal Drug Administration regulations. Guidelines are provided to assist students in critically appraising the ethical discussions in published studies and to participate in the ethical review of research in clinical agencies. Chapter 5, Research Problems, Purposes, and Hypotheses, clarifies the difference between a problem and a purpose. Example problem and purpose statements are included from current qualitative, quantitative, and outcome studies. Detailed guidelines are provided with examples to direct students in critically appraising the problems, purposes, hypotheses, and variables in studies. Chapter 6, Understanding and Critically Appraising the Literature Review, begins with a description of the content and quality of different types of publications that might be included in a review. Guidelines for critically appraising published literature reviews are explored with a focus on the differences in the purpose and timing of the literature review in quantitative and qualitative studies. The steps for finding appropriate sources, reading publications, and synthesizing information into a logical, cohesive review are presented. Chapter 7, Understanding Theory and Research Frameworks, briefly describes grand, middle range, physiological, and scientific theories as the bases for study frameworks. The purpose of a research framework is discussed with the acknowledgement that the framework may be implicit. Guidelines for critically appraising the study framework are presented as well. The guidelines are applied to studies with frameworks derived from research findings and from different types of theories. Chapter 8, Clarifying Quantitative Research Designs, addresses descriptive, correlational, quasiexperimental, and experimental designs and criteria for critically appraising these designs in studies. The major strengths and threats to design validity are summarized in a table and discussed related to current studies. This chapter has been expanded to include an introduction to randomized controlled trials (RCT) and mixed-methods approaches being conducted by nurses. Chapter 9, Examining Populations and Samples in Research, provides a detailed discussion of the concepts of sampling in research. Different types of sampling methods for both qualitative and quantitative research are described. Guidelines are included for critically appraising the sampling criteria, sampling method, and sample size of quantitative and qualitative studies. Chapter 10, Clarifying Measurement and Data Collection in Quantitative Research, has been updated to reflect current knowledge about measurement methods used in nursing research. Content has been expanded and uniquely organized to assist students in critically appraising the reliability and validity of scales; precision and accuracy of physiologic measures; and the sensitivity, specificity, and likelihood ratios of diagnostic and screening tests. Chapter 11, Understanding Statistics in Research, focuses on the theories and concepts of the statistical analysis process and the statistics used to describe variables, examine relationships, predict outcomes, and examine group differences in studies. Guidelines are provided for critically appraising the results and discussion sections of nursing studies. The results from selected studies are critically appraised and presented as examples throughout this chapter. Chapter 12, Critical Appraisal of Quantitative and Qualitative Research for Nursing Practice, summarizes and builds on the critical appraisal content provided in previous chapters and offers direction for conducting critical appraisals of quantitative and qualitative studies. The guidelines for critically appraising qualitative studies have been significantly revised and simplified. This x PREFACE chapter also includes a current qualitative and quantitative study, and these two studies are critically appraised using the guidelines provided in this chapter. Chapter 13, Building an Evidence-Based Nursing Practice, has been significantly updated to reflect the current trends in health care to provide evidence-based nursing practice. Detailed guidelines are provided for critically appraising the four common types of research synthesis conducted in nursing (systematic review, meta-analysis, meta-synthesis, and mixed-method systematic review). These guidelines were used to critically appraise current research syntheses to assist students in examining the quality of published research syntheses and the potential use of research evidence in practice. The chapter includes theories to assist nurses and agencies in moving toward EBP. Translational research is introduced as a method for promoting the use of research evidence in practice. Chapter 14, Introduction to Outcomes Research, was significantly revised by Dr. Diane Doran, one of the leading authorities in the conduct of outcomes research. The goal of this chapter is to increase students’ understanding of the impact of outcomes research on nursing and health care. Content and guidelines are provided to assist students in reading and critically appraising the outcomes studies appearing in the nursing literature. The sixth edition is written and organized to facilitate ease in reading, understanding, and critically appraising studies. The major strengths of the text are as follows: • State-of-the art coverage of EBP—a topic of vital importance in nursing. • Balanced coverage of qualitative and quantitative research methodologies. • Rich and frequent illustration of major points and concepts from the most current nursing research literature from a variety of clinical practice areas. • Study findings implications for practice and link to QSEN competencies were provided. • A clear, concise writing style that is consistent among the chapters to facilitate student learning. • Electronic references and websites that direct the student to an extensive array of information that is important in reading, critically appraising, and using research knowledge in practice. This sixth edition of Understanding Nursing Research is appropriate for use in a variety of undergraduate research courses for both RN and general students because it provides an introduction to quantitative, qualitative, and outcomes research methodologies. This text not only will assist students in reading research literature, critically appraising published studies, and summarizing research evidence to make changes in practice, but it also can serve as a valuable resource for practicing nurses in critically appraising studies and implementing research evidence in their clinical settings. LEARNING RESOURCES TO ACCOMPANY UNDERSTANDING NURSING RESEARCH, 6TH EDITION The teaching/learning resources to accompany Understanding Nursing Research have been expanded for both the instructor and student to allow a maximum level of flexibility in course design and student review. Evolve Instructor Resources A comprehensive suite of Instructor Resources is available online at http://evolve.elsevier.com/ Grove/understanding/ and consists of a Test Bank, PowerPoint slides, an Image Collection, Answer PREFACE xi Guidelines for the Appraisal Exercises provided for students, and new TEACH for Nurses Lesson Plans, which replace and enhance the Instructor’s Manual provided for previous editions. Test Bank The Test Bank consists of approximately 550 NCLEX® Examination–style questions, including approximately 10% of questions in alternate item formats. Each question is coded with the correct answer, a rationale from the textbook, a page cross-reference, and the cognitive level in the new Bloom’s Taxonomy (with the cognitive level from the original Bloom’s Taxonomy in parentheses). The Test Bank is provided in ExamView and Evolve LMS formats. PowerPoint Slides The PowerPoint slide collection contains approximately 800 slides, now including seamlessly integrated Audience Response System Questions, images, and new Unfolding Case Studies. The PowerPoints have been simplified and converted into bulleted-list format (using less narrative). Content details in the slides have been moved as appropriate into the Notes area of the slides. New Unfolding Case Studies focus on practical EBP/PICO questions, such as a nurse on a unit needing to perform a literature search or to identify a systematic review or meta-analysis. PowerPoint presentations are fully customizable. Image Collection The electronic Image Collection consists of all images from the text. This collection can be used in classroom or online presentations to reinforce student learning. NEW TEACH for Nurses Lesson Plans TEACH for Nurses is a robust, customizable, ready-to-use collection of chapter-by-chapter Lesson Plans that provide everything you need to create an engaging and effective course. Each chapter includes the following: • Objectives • Teaching Focus • Key Terms • Nursing Curriculum Standards ○ QSEN/NLN Competencies ○ Concepts ○ BSN Essentials • Student Chapter Resources • Instructor Chapter Resources • Teaching Strategies • In-Class/Online Case Study Evolve Student Resources The Evolve Student Resources include interactive Review Questions, a Research Article Library consisting of 10 full-text research articles, Critical Appraisal Exercises based on the articles in the Research Article Library, and new Printable Key Points. • The interactive Review Questions (approximately 25 per chapter) aid the student in reviewing and focusing on the chapter material. xii PREFACE • The Research Article Library is an updated collection of 10 research articles, taken from leading nursing journals. • The Critical Appraisal Exercises are a collection of application exercises, based on the articles in the Research Article Library, that help students learn to appraise and apply research findings. Answer Guidelines are provided for the instructor. • New Printable Key Points provide students with a convenient review tool. Study Guide The companion Study Guide, written by the authors of the main text, provides both time-tested and innovative exercises for each chapter in Understanding Nursing Research, 6th Edition. Included for each chapter are a brief Introduction, a Key Terms exercise, Key Ideas exercises, Making Connections exercises, Exercises in Critical Analysis, and Going Beyond exercises. An integral part of the Study Guide is an appendix of three published research studies, which are referenced throughout. These three recently published nursing studies (two quantitative studies and one qualitative study) can be used in classroom or online discussions, as well as to address the Study Guide questions. The Study Guide provides exercises that target comprehension of concepts used in each chapter. Exercises — including fill-in-the-blank, matching, and multiple-choice questions — encourage students to validate their understanding of the chapter content. Critical Appraisal Activities provide students with opportunities to apply their new research knowledge to evaluate the quantitative and qualitative studies provided in the back of the Study Guide. New to this edition are the following features: an increased emphasis on evidence-based practice; new Web-Based Activities, an increased emphasis on high-value learning activities, reorganized back-matter for quick reference, and quick-reference printed tabs. • Increased emphasis on evidence-based practice: This edition of the Study Guide features an expanded focus on evidence-based practice (EBP) to match that of the revised textbook. This focus helps students who are new to nursing research see the value of understanding the research process and applying it to evidence-based nursing practice. • Web-Based Activities: Each chapter now includes a Web-Based Activity section, to teach students to use the Internet appropriately for scholarly research and EBP. • Increased high-value learning activities: The use of crossword puzzles has been reduced to allow room for the addition of learning activities with greater learning value. • Back matter reorganized for quick reference: The “Answers to Study Guide Exercises” has been retitled “Answer Key” and not numbered as an appendix. Each of the three published studies are now separate appendix (three appendices total), rather than a single appendix. This simplifies cross referencing in the body of the Study Guide. • Quick-reference printed tabs: Quick-reference printed tabs have been added to differentiate the Answer Key and each of the book’s three published studies (four tabs total), for improved navigation and usability. AC KN OWLE D GM E NT S Developing this essentials research text was a 2-year project, and there are many people we would like to thank. We want to extend a very special thank you to Dr. Diane Doran for her revision of Chapter 14 focused on outcomes research. We are very fortunate that she was willing to share her expertise and time so that students might have the most current information about outcomes research. We want to express our appreciation to the Dean and faculty of The University of Texas at Arlington College of Nursing for their support and encouragement. We also would like to thank other nursing faculty members across the world who are using our book to teach research and have spent valuable time to send us ideas and to identify errors in the text. Special thanks to the students who have read our book and provided honest feedback on its clarity and usefulness to them. We would also like to recognize the excellent reviews of the colleagues, listed on the previous pages, who helped us make important revisions in the text. In conclusion, we would like to thank the people at Elsevier who helped produce this book. We thank the following individuals who have devoted extensive time to the development of this sixth edition, the instructor’s ancillary materials, student study guide, and all of the web-based components. These individuals include: Lee Henderson, Billie Sharp, Charlene Ketchum, Bridget Healy, Jayashree Balasubramaniam, and Vallavan Udayaraj. Susan K. Grove Jennifer R. Gray PhD, RN, ANP-BC, GNP-BC PhD, RN, FAAN Nancy Burns PhD, RN, FCN, FAAN xiii This page intentionally left blank CHAPTER 1 Introduction to Nursing Research and Evidence-Based Practice C H A P T E R OV E RV I E W What Is Nursing Research? 3 What Is Evidence-Based Practice? 3 Purposes of Research for Implementing an Evidence-Based Nursing Practice, 6 Description, 6 Explanation, 7 Prediction, 7 Control, 8 Historical Development of Research in Nursing, 9 Florence Nightingale, 11 Nursing Research: 1900s through the 1970s, 11 Nursing Research: 1980s and 1990s, 12 Nursing Research: in the Twenty-First Century, 14 Acquiring Knowledge in Nursing, 15 Traditions, 16 Authority, 16 Borrowing, 16 Trial and Error, 17 Personal Experience, 17 Role Modeling, 17 Intuition, 18 Reasoning, 18 Acquiring Knowledge through Nursing Research, 19 Introduction to Quantitative and Qualitative Research, 19 Introduction to Outcomes Research, 21 Understanding Best Research Evidence for Practice, 21 Strategies Used to Synthesize Research Evidence, 22 Levels of Research Evidence, 24 Introduction to Evidence-Based Guidelines, 25 What Is Your Role in Nursing Research? 25 Key Concepts, 27 References, 28 LEARNING OUTCOMES After completing this chapter, you should be able to: 1. Define research, nursing research, and evidence-based practice. 2. Describe the purposes of research in implementing an evidence-based practice for nursing. 3. Describe the past and present activities influencing research in nursing. 4. Discuss the link of Quality and Safety Education for Nurses (QSEN) to research. 5. Apply the ways of acquiring nursing knowledge (tradition, authority, borrowing, trial and error, personal experience, role modeling, intuition, reasoning, and research) to the interventions implemented in your practice. 6. Identify the common types of research— quantitative, qualitative, or outcomes— conducted to generate essential evidence for nursing practice. 1 2 CHAPTER 1 Introduction to Nursing Research 7. Describe the following strategies for synthesizing healthcare research: systematic review, meta-analysis, meta-synthesis, and mixed-methods systematic review. 8. Identify the levels of research evidence available to nurses for practice. 9. Describe the use of evidence-based guidelines in implementing evidence-based practice. 10. Identify your role in research as a professional nurse. KEY TERMS Authority, p. 16 Best research evidence, p. 3 Borrowing, p. 16 Case study, p. 11 Clinical expertise, p. 4 Control, p. 8 Critical appraisal of research, p. 27 Deductive reasoning, p. 18 Description, p. 6 Evidence-based guidelines, p. 25 Evidence-based practice (EBP), p. 3 Explanation, p. 7 Gold standard, p. 25 Inductive reasoning, p. 18 Intuition, p. 18 Knowledge, p. 15 Mentorship, p. 18 Meta-analysis, p. 22 Meta-synthesis, p. 23 Mixed-methods systematic review, p. 23 Nursing research, p. 3 Outcomes research, p. 21 Personal experience, p. 17 Prediction, p. 7 Premise, p. 18 Qualitative research, p. 20 Qualitative research synthesis, p. 23 Quality and Safety Education for Nurses (QSEN), p. 15 Quantitative research, p. 19 Reasoning, p. 18 Research, p. 3 Role modeling, p. 17 Systematic review, p. 22 Traditions, p. 16 Trial and error, p. 17 Welcome to the world of nursing research. You may think it strange to consider research a world, but it is a truly new way of experiencing reality. Entering a new world means learning a unique language, incorporating new rules, and using new experiences to learn how to interact effectively within that world. As you become a part of this new world, you will modify and expand your perceptions and methods of reasoning. For example, using research to guide your practice involves questioning, and you will be encouraged to ask such questions as these: • What is the patient’s healthcare problem? • What nursing intervention would effectively manage this problem in your practice? • Is this nursing intervention based on sound research evidence? • Would another intervention be more effective in improving your patient’s outcomes? • How can you use research most effectively in promoting an evidence-based practice (EBP)? Because research is a new world to many of you, we have developed this text to facilitate your entry into and understanding of this world and its contribution to the delivery of quality, safe nursing care. This first chapter clarifies the meaning of nursing research and its significance in developing an evidence-based practice (EBP) for nursing. This chapter also explores the research accomplishments in the profession over the last 160 years. The ways of acquiring knowledge in nursing are discussed, and the common research methodologies used for generating research evidence for practice (quantitative, qualitative, and outcomes research) are introduced. The critical elements of evidence-based nursing practice are introduced, including strategies for synthesizing research evidence, levels of research evidence or knowledge, and evidence-based guidelines. Nurses’ roles in research are described based on their level of education and their contributions to the implementation of EBP. CHAPTER 1 Introduction to Nursing Research 3 WHAT IS NURSING RESEARCH? The word research means “to search again” or “to examine carefully.” More specifically, research is a diligent, systematic inquiry, or study that validates and refines existing knowledge and develops new knowledge. Diligent, systematic study indicates planning, organization, and persistence. The ultimate goal of research is the development of an empirical body of knowledge for a discipline or profession, such as nursing. Defining nursing research requires determining the relevant knowledge needed by nurses. Because nursing is a practice profession, research is essential to develop and refine knowledge that nurses can use to improve clinical practice and promote quality outcomes (Brown, 2014; Doran, 2011). Expert researchers have studied many interventions, and clinicians have synthesized these studies to provide guidelines and protocols for use in practice. Practicing nurses and nursing students, like you, need to be able to read research reports and syntheses of research findings to implement evidence-based interventions in practice and promote positive outcomes for patients and families. For example, extensive research has been conducted to determine the most effective technique for administering medications through an intramuscular (IM) injection. This research was synthesized and used to develop evidence-based guidelines for administering IM injections (Cocoman & Murray, 2008; Nicoll & Hesby, 2002). Nursing research is also needed to generate knowledge about nursing education, nursing administration, healthcare services, characteristics of nurses, and nursing roles. The findings from these studies influence nursing practice indirectly and add to nursing’s body of knowledge. Research is needed to provide high-quality learning experiences for nursing students. Through research, nurses can develop and refine the best methods for delivering distance nursing education and for using simulation to improve student learning. Nursing administration and health services studies are needed to improve the quality, safety, and cost-effectiveness of the healthcare delivery system. Studies of nurses and nursing roles can influence nurses’ quality of care, productivity, job satisfaction, and retention. In this era of a nursing shortage, additional research is needed to determine effective ways to recruit individuals and retain them in the profession of nursing. This type of research could have a major impact on the quality and number of nurses providing care to patients and families in the future. In summary, nursing research is a scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practice. Nursing research is the key to building an EBP for nursing (Brown, 2014). WHAT IS EVIDENCE-BASED PRACTICE? The ultimate goal of nursing is an evidence-based practice that promotes quality, safe, and costeffective outcomes for patients, families, healthcare providers, and the healthcare system (Brown, 2014; Craig & Smyth, 2012; Melnyk & Fineout-Overholt, 2011). Evidence-based practice (EBP) evolves from the integration of the best research evidence with clinical expertise and patients’ needs and values (Institute of Medicine [IOM], 2001; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Figure 1-1 identifies the elements of EBP and demonstrates the major contribution of the best research evidence to the delivery of this practice. The best research evidence is the empirical knowledge generated from the synthesis of quality study findings to address a practice problem. Later, this chapter discusses the strategies used to synthesize research, levels of best research evidence, and sources for this evidence. A team of expert researchers, healthcare professionals, and sometimes policy makers and consumers will synthesize the best research evidence to develop 4 CHAPTER 1 Introduction to Nursing Research Best Research Evidence Clinical Expertise Patient Needs & Values EvidenceBased Practice FIG 1-1 Model of Evidence-Based Practice (EBP). standardized guidelines for clinical practice. For example, a team of experts conducted, critically appraised, and synthesized research related to the chronic health problem of hypertension (HTN) to develop an EBP guideline. Research evidence from this guideline is presented as an example later in this section. Clinical expertise is the knowledge and skills of the healthcare professional who is providing care. The clinical expertise of a nurse depends on his or her years of clinical experience, current knowledge of the research and clinical literature, and educational preparation. The stronger the nurse’s clinical expertise, the better is his or her clinical judgment in using the best research evidence in practice (Brown, 2014; Craig & Smyth, 2012). EBP also incorporates the needs and values of the patient (see Figure 1-1). The patient’s need(s) might focus on health promotion, illness prevention, acute or chronic illness management, rehabilitation, and/or a peaceful death. In addition, patients bring values or unique preferences, expectations, concerns, and cultural beliefs to the clinical encounter. With EBP, patients and their families are encouraged to take an active role in the management of their health. It is the unique combination of the best research evidence being applied by expert nurse clinicians in providing quality, safe, and cost-effective care to a patient and family with specific health needs and values that results in EBP. Extensive research is needed to develop sound empirical knowledge for synthesis into the best research evidence needed for practice. Findings from a single study are not enough evidence for determining the effectiveness of an intervention in practice. Research evidence from multiple studies are synthesized to develop guidelines, standards, protocols, algorithms (clinical decision trees), or policies to direct the implementation of a variety of nursing interventions. As noted earlier, a national guideline has been developed for the management of hypertension, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). The complete JNC 7 guideline for the management of high blood pressure is available online at www.nhlbi.nih.gov/guidelines/hypertension (National Heart, Lung, and Blood Institute [NHLBI], 2003). In January of 2014, the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) published new clinical practice guidelines for the management of hypertension in the community (Weber et al, 2014). The JNC 7 guideline and the ASH and ISH clinical practice guideline identified the same classification system for blood pressure (Table 1-1). These guidelines include the classification of blood pressure as normal, prehypertension, hypertension stage 1, and hypertension stage 2. Both guidelines also recommend CHAPTER 1 Introduction to Nursing Research TABLE 1-1 CLASSIFICATION OF BLOOD PRESSURE WITH NURSING INTERVENTIONS FOR EVIDENCE-BASED PRACTICE (EBP) NURSING INTERVENTIONS{ CLASSIFICATION OF BLOOD PRESSURE (BP) BP CATEGORY Normal Prehypertension Stage 1 hypertension Stage 2 hypertension 5 SYSTOLIC BP (mm Hg)* DIASTOLIC BP (mm Hg)* LIFESTYLE MODIFICATION{ CARDIOVASCULAR DISEASE (CVD) RISK FACTORS EDUCATION} Purchase answer to see full attachment

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