Western Mindanao State University Basilan State College COLLEGE OF NURSING Isabela City, Basilan NURSING RESEARCH I

Course Name: Nursing Research I Course Code: NRes 1 Course Description: This is an introductory course intended to equip the nursing students with concepts, principles in research starting from an overview of the major phases of the research process. The course will include discussion from formulation to dissemination of research findings, focus on the formulation of research problem to the selection of research design, planning and choosing the appropriate research tool for data gathering. This course will require the students/group to present a research proposal in a colloquium to apply knowledge and demonstrate skills and attitude in the conceptual, design, and planning phases of the research process. Course Credit: 2 units lecture/1 unit RLE Contact Hours/Sem: 36 lecture/51 RLE hrs Prerequisite: BIOSTATISTICS Placement: 3rd yr/2nd Semester Course Objectives: At the end of the course and given actual situation, the student will be able to: 1. Discuss major phases of the research process, and 2. Present a group research proposal based on an identified clinical/situational problem Course Outline: A. Introduction to Nursing Research 1. Definition of Nursing Research 2. The Importance of Research in Nursing 3. Roles of Nurses in Research 4. Purposes of Nursing Research B. Overview of the Research Process in Quantitative/ Qualitative Studies: 1. Major Phases of a Research Process a. The Conceptual Phase Formulating and Delimiting the Problem Sources of Research Problem Criteria of Evaluating a Research Problem Criteria in Stating a Research Problem b. Reviewing the Related Literature Purpose of Literature Review Categories of References Locating Relevant Literature for Research Review c. Defining the Framework and Developing Conceptual and Theoretical Frameworks d. Definition of Important Terms: Concept, Construct, Conceptual Models, and Statistical Models e. Formulating Hypothesis Purpose of Research Hypothesis Types of Hypotheses Criteria Considered when Stating Hypothesis 2. The Design and Planning Phase a. Selecting a Research Design b. Major Categories of Research Design Experimental Non-Experimental Qualitative Designs c. Characteristics of Research Design

M. A. Flores, R.N.

d. Identifying the Population to be Studied Difference between Total and Target Population How to Determine Sample e. Design the Sampling Plan Methods of Sampling f. Specifying Methods to Measure Variables Primary Methods Self-Report/Questionnaire Observation Interviews Bio-physiologic Measurements Secondary Methods C. Ethical Aspects of Nursing Research 1. Ethical Principles for Protecting Study Participants a. Beneficence b. Respect for Human Dignity c. Justice 2. Procedures for Protecting Study Participants a. Informed Consent b. Risk/Benefit Assessment c. Confidentiality Procedures d. Debriefings and Referrals e. Treatment of Vulnerable Groups f. Institutional Reviews, Boards, and External Reviews D. Steps in Writing a Good Research Proposal TOPICS: I - Definition of Terms II - Variables III - Purposes of Research/Basic Steps in Planning Nursing Research IV - Types of Research - general classification : Basic/Pure/Applied - levels of investigation: Exploratory/Descriptive - time element: Historical/Descriptive - duration: Longitudinal/Cross-Sectional Study - research design: Experimental/Non-Experimental/Quasi-Experimental V - Overview of the Research Process VI - Review of the Literature VII - Principles of Research Design VIII - Qualitative Research IX - Quantitative Research X - Measure of Central Location and Variability XI - Graphical Presentation of Data XII - The Research Process XIII - Techniques for Data Gathering XIV - Characteristics of Data Gathering Instruments XV - Data Analysis The human mind is always questioning. As children we asked: Why is the grass green? What makes the sun go down? Why does my cat have fur? Why do I always fall down instead of up? --Most adults would answer the questions with Because, which satisfied us as a statement of fact. But I we found a different opinion in every answer, or if we have heard

M. A. Flores, R.N.

I dont know, we kept asking questions because, as human beings, WE HAD TO KNOW! -Pamela J. Brink & Marilyn J. Woods

INTRODUCTION
I DEFINITION OF TERMS A. RESEARCH a collection of data in a rigorously controlled situation fro the purpose of explanation or prediction; it is more formal, more systematic and more intensive in carrying on a scientific method of analysis. RESEARCH means delving into problem. Kerlinger (1976) Research is a systematic, controlled, empirical, and critical investigation of hypothetical propositions about a presumed relation among natural phenomena. George Mouly (1982) calls research as a systematic analysis and conclusion. Kuan (1998) Research looks into the past in order to predict the future.

B. NURSING RESEARCH - includes the breadth and depth of the discipline of nursing as well as the preparation of practitioners and personnel involved in the total nursing sphere. In systematic research, a general system is followed whose elements are: a. b. c. d. e. f. g. h. identification of a problem extensive review of literature formulation of the conceptual framework and hypotheses designing its design and methodology data collection data analysis through the use of statistics and interpretation drawing conclusions and giving recommendations

Importance of Nsg. Research: It discovers newer trends of dealing with problematic situations effectively; Education is modified, enhanced, and improved; Professionalism is refined; It makes our interventions relevant and effective; Sense of accountability is deepened and actualized; Grounds nursing theories; Contributes to nursing science

NSG. SCIENCE is based on KNOWLEDGE from:

M. A. Flores, R.N.

1. Tradition many questions are answered and problems solved on the basis of inherited customs, and traditions. It facilitates communication by providing a common foundation of accepted truth. 2. Authority the originator or the people with specialized expertise in certain fields. 3. Experiences of Trial and Error our own experiences represent a familiar functional source of knowledge. 4. Logical Reasoning logical thought, ground or motion. It combines experience, intellectual faculties, and formal systems of thought.

a. (INDUCTIVE REASONING) Specific General Cardiovascular Heart Disease (specific) Contributory Factors DIET, EXERCISE, VICES, STRESS (general)

b. (DEDUCTIVE REASONING) General Specific Cardiovascular Disease Contributory Factor DIET (general) Food intake, quantity, quality, food prep., eating habits (specific)

5. Scientific Method most sophisticated of acquiring knowledge that humans have developed. A systematic approach to problem solving and to the expansion of knowledge. An informal application of problem identification, hypothesis formulation, observation, analysis, and conclusion.

Characteristics of Scientific Method: 1. Order and Control- the investigator progresses logically through a series of steps (systematic). - involves improving conditions on the research situations so that biases and confounding factors are minimized. 2. Empiricism - the process whereby evidence rooted in objective reality and gathered directly or indirectly through the human senses (basis for generating knowledge). 3. Generalism - the important goal of SCIENCE is to understand phenomena. This pursuit of knowledge, however, is focused not on a more generalized understanding of phenomena and how they are interrelated. Instead, it implies bringing knowledge into general use. 4. Theory- a plan, scheme, or procedure used as a basis or technique for doing something.

M. A. Flores, R.N.

- comes from the Greek word theoria which means an observer or one who has an instinct or vision. - is defined as an explanation or principle which has been tested and accepted. - it is a detailed explanation of how phenomena has happened. - may be viewed as vision giving intellectual insight into phenomena, but for significance and impact, it should be explanatory or predictive in nature so as to guide professional practice. Limitations of Scientific Method: 1. General Limitations a. expensive b. time consuming 2. Moral and Ethical Issues a. concerns constraints on what is acceptable in the name of science with regards to therights of living organisms b. the kind of problem that can be solved using scientific method. 3. Human Complexity each human being is essentially unique with respect to his or her personality, social environment, mental capacity, values and lifestyle. 4. Measurement Problem accurate measures of psychologic phenomena have not yet been developed. 5. Control Problem adequate control is often difficult to achieve. Priorities for Nursing Research: Healthcare and Prevention of Illness Development of cost-efficient delivery systems or nursing care Development of strategies that provide effective nursing care to high-risk groups

Different Areas of Nursing: Administration Mngt/Leadership/ Expertise Service Nsg.Practice, Resources, Staffing or Manpower Education Teaching-Learning Process Research Utilization of Research Findings

Concept abstraction that is formulated by generalizing from particular manifestations of certain behaviors or characteristics Ex: Good Health Pain Emotional Disturbance Grieving

M. A. Flores, R.N.

Conceptualization refers to the process of developing and refining abstract ideas. Construct refers to the abstraction or mental representation that is deliberately inferred (or constructed) by researchers for a specific scientific purpose. Ex: Self-Care (Dorothea Orems Model)

Property a concept or a logical construct that describes a particular characteristic which is common to all. Ex: Punctuality Healthy Loyalty Honesty Indicants something that points to the property and helps define it Ex: A. Punctuality is never late in the class (property) (indicants) B. Honesty is never a lie (property) (indicants) C. Socioeconomic Status: (Income Bracket) (Class) a. High a. High b. Average b. Middle c. Low c. Below poverty line Relationships refer to the bond or connection between two entities. 2 Types: 1. Direct 2. Inverse Theory an abstract generalization that present a systematic explanation about the interrelationship among phenomena. Variables something that varies - are concepts that assume more than one value - takes different values as the situation changes

Ex: ANXIETY varies in level a. Mild b. Moderate c. Severe Kinds of Variables: Continuous expressed in whole numbers and fractional units and fractions which can be broken to the smallest decimal. Categorical represents the discrete categories rather than the incremental placement of a continuum.

Types of Categorical Variable: 1. Two Category Variables or Dichotomous Variable 2. Multiple Category Variables 3. Discrete Variables 4. Confounding/Extraneous/Intervening Variables 5. Organismic Variables 6. Heterogeneous Variables 7. Homogeneous Variables 8. Antecedent Variables

M. A. Flores, R.N.

Definition of Different types of Variables: Independent -stands alone - CAUSE - Comes First Intervening/ Extraneous -comes between I.V. and -is affected by the I.V. D.V. - may interfere - Comes Between (may mask the effect of the I.V A. The Relationship between Exposure to Mass Media and Smoking Habits among Young Adults. - EFFECT - Comes Last Dependent

Exposure to Mass Media (Independent Variable) B. Effect of Peer Counseling on the Students Study Habits

Smoking Habits
(Dependent Variable)

Study Habits Exposure to Peer C. Knowledge ofCounseling the Dangers of Smoking, Attitudes towards Life, and the

Smoking Habits of Young Professionals.

(Dependent Variable)

(Independent Variable)

Knowledge of the Dangers of Smoking

(Independent Variable)

Attitudes towards Life (Intervening Variable)

Smoking Habits (Dependent Variable)

Antecedent Variable occurs earlier than the independent variable and bears a relationship both to the independent and the dependent variable.

D. Extent of Exposure to Print Media and Reading Ability of College Freshmen Sex, Residence, Parents Education (Antecedent Variable)
(Independent Variable) (Dependent Variable) Extent of Exposure to Print Media Reading Ability

How Variables are Measured?

M. A. Flores, R.N.

Variables are measured according to what you want to know about them as well as according to the amount of knowledge available from the literature. The Four Basic Measurement are: 1. NOMINAL 2. ORDINAL 3. INTERVAL and 4. RATIO The way you study your variable depends on what you want to know. Your choice of measurement scale depends on your answer you want from your data. -If you want great precision, you will use an interval (and ratio) scale; -If you want to rank people or things in some order, you need an ordinal scale; -If you simply want to contrast things, and dont care much about precision and measurement, you will choose the nominal scale. 1. NOMINAL SCALE - is a Qualitative Scale, in that the qualities of a variable are examined rather than its quantities. - the only specified relationship between the categories in nominal scale is that they are different from one another: that is they contrast with one another; they is no suggestion of any magnitude or quality differences.

The classic example of a NOMINAL SCALE is the variable SEX Everyone can be categorized as MALE or FEMALE (contrasting categories) There is no magnitude to maleness or femaleness NOMINAL SCALE demands a system of classification that is mutually exclusive. Each person must fit into ONE and ONLY ONE category of a given variable. A person cannot be a part MALE and part Female.
Other examples of variables under nominal scale: -Marital Status -Political Parties

AGE

young adult old

an individual cant be rated as both young and old at the same time!

M. A. Flores, R.N.

2. ORDINAL SCALE - this differs from nominal scale in that they rank a variable on a scale of INCREASING MAGNITUDE and follow a particular ordering system. For example, to measure AGE in an ordinal scale, you would develop categories such as:

Many nursing studies use ordinal scales. In attitudinal research for instance, people are asked to rank their opinions (on the basis on whether they agree or disagree with a statement) on a scale from Strongly Disagree to Strongly Agree. -Classic Likert Scale-

INTERVAL (AND RATIO) SCALE - In contrast to nominal and ordinal scales, the interval (and ratio) scale is a quantitative scale. Its significant feature is that the numbered intervals between the points are equidistant, whether those intervals are measured in miles, centimeters, pounds or degrees.

Ex: If you want to study on runners fatigue and you decided to test fatigue levels by the presence of blood in the urine, you could set up your study on the basis of: A. Nominal Scale: a. Presence of blood in the urine b. No observable blood in the urine

-This scale would not measure the amount of blood in the urine or the degree of fatigue expressed in terms of severity of bleeding. What is desired in this case is a mutually exclusive statement on the PRESENCE or ABSENCE of blood. B. Ordinal Scale: to measure the presence of blood, you would rank the amount of blood by the color of the urine: Ex: none (clear/yellow), a little (pink),moderate (light red), much (bright red), a lot (dark red). C. Interval (and Ratio) Scale: You would test samples of urine for the number of red blood cells present a PRECISE measurement of the amount of blood.

A. Discover new facts about known phenomena. B. Find answers to problems which are only partially solved by existing methods and information. C. Improve existing techniques and develop new instruments or products. D. Discover previously unrecognized substances or elements. E. Discover pathways of action of known substances and elements.

M. A. Flores, R.N.

F. Classify and arrange in order related and valid generalizations into systematized science. The basic purpose of research is to answer QUESTIONS! But not all questions can or need to be answered by research.

What then is a RESEARCH QUESTION? - a RESEARCH QUESTION is an explicit query about a problem or issue that can be CHALLENGED, EXAMINED, and ANALYZED, and that can/will yield useful new information! ANSWERS to research questions add to our general knowledge. They can be used by other people in other places because the answers are valid no matter WHO asked the QUESTION or WHERE the ANSWER was found. ANSWERS must be FACTS, not OPINIONS!!! How to write a RESEARCHABLE question? In order to do RESEARCH, the first step is to find a TOPIC to research. Where can topics be found, and how do you know they are researchable? Where do you look for research topics? The MOST fruitful area for RESEARCH TOPICS is your: OWN THOUGHTS, OBSERVATIONS, and EXPERIENCES!

Topic Selection _Look for Research Topics_ Research Topics arise out of the natural areas such as from your own thoughts, observations and experiences: that you know something about the SUBJECT. You have some facts or opinions that contrast with anothers point of view,

The 2nd aspect of TOPIC SELECTION is that irritation or frustration indicates INTEREST in the subject being discussed. Just hoe interested you are depends on how long your reactions linger. In short, knowing enough about your topic and being interested in it are the basic requirements for selection.

M. A. Flores, R.N.

>What have you been reading lately? >Who have you been talking to? .>What have you been talking about?

Knowing enough about your SUBJECT means that you know what you are specifically interested in; that is you must identify your POINT OF VIEW! NURSING RESEARCH TOPICS include: 1.studies of patient populations and potential patient populations; or 2. studies of peoples responses to health problems or potential health problem; 3. theoretical issues: provide an entire area of research topics. > ROLE THEORY for instance offers innumerable ideas, whether relating to singular roles, such as SICK ROLE, or studies of roles in interaction, such as Patient Role vs. Nurse Role. 4. testing assessment and intervention strategies: is another field of exploration. How these strategies are used and developed, and who uses them for what, are areas open to divergent (various) opinions and fact building. Valid Primary Categories of Research Topics: I Observations arise from real-life situations that can be see, smelled, touched, tasted, or heard by any individual. Often, an OBSERVATION is stated as a generalization about a repeating occurrence. It is a generalization that is usually tested in the research project. Ex: - Some patients refuse medications - Some patients are called demanding - Some call lights arent answered - Mastectomy seems to affect some women more than others - Detoxification programs dont always work on others II Behaviors are specific type of observations that can be seen and thought about. It is frequently seen as purposive or goal-oriented. However, analysis of behavioral intent is more abstract and more removed from a reality than a direct personal observation. Ex:

III Concepts a symbolic statement for describing a phenomena or class of phenomena. These are single abstract ideas, often expressed in a single word that represents two or more interrelated ideas. These can represent a single group of observations or facts that are closely linked to one another. Ex: - Addiction - Privacy -Ethnicity

M. A. Flores, R.N.

Listening Eating Touching Distancing Avoiding Talking

Dependency Hopelessness Independence Nausea

- Isolation - Assertiveness - Burnout - Patient care

- Pain

IV Theory is a statement that purports to account for or characterize some phenomena. FAWCETT defines a theory as Maybe a description of a particular phenomenon, an explanation of a relationship among phenomena, or the prediction of the effects of one phenomenon on another. In RESEARCH, you must relate THEORY into FACTS!

ASK A QUESTION ABOUT THE TOPIC _Start with a SIMPLE Question_ What is a Researchable Question? A researchable question is one that yields HARD FACTS to help solve a problem, produce new research, add to a theory, or improve nursing practice. Research deals with FACTS! that is, with observable phenomena in the real world. a QUESTION that will provide answers that EXPLAIN, DESCRIBE, IDENTIFY, SUBSTANTIATE, PREDICT, or QUALIFY is a researchable question! For this reason: 1.NURSING RESEARCH must be usable. Because research deal with the real world, the findings should add to knowledge that can be used by other researchers, theorists, or practitioners. 2. TO BE OF USE, nursing research question should be NOW QUESTIONS. No matter how good the research question is, if the society does not need it or want the research findings, it will be ignored!\ 3. RESEARCH QUESTIONS need to be CLEAR! Fuzzy questions yield fuzzy answers. The clearer the question, the clearer the answers and more usable in clinical settings. 4. Finally, a researchable question lends DIRECTION to the rest of the research report. If the research questions were about an EVENT, directive questions would ask: a. What happened? b. Wen did it happen? c. In what way did it happen? d. To whom did it happen? e. What difference did it make, now that it has happened? These questions demand more of an answer than a simple YES, NO, or MAYBE. Without some movement in it, the question is us a SITTER!

M. A. Flores, R.N.

Everything in research plan depends on your question. It is the POINT you want to MAKE to EXPLORE, to DESCRIBE, or to KNOW stripped clear of any superfluous verbiage (difficult words). _Asking Research Questions_ RULES of the THUMB! 1st start with a simple question 2nd questions should be ACTION-ORIENTED 3rd ask an ACTIVE QUESTIONS require some form of observation or measurement for an answer. A question, rather than a statement, will provide or DEMAND and ACTION. (a statement of fact demands no action, whereas a question does!) Ex: (Statement) 1. Mastectomy has an effect to women. (Question) What are the reactions of women to mastectomy? (Statement) 2. Age has an effect on convalescence. (Question) What is the relationship between age and convalescence? (Statement) 3. Black women have smaller babies than white women. (Question) What is the relationship between ethnicity and birth size of infants? (Statement) 4. Ice water increases heart rate. (Question) What is the relationship between temperature of drinking water and heart rate? STOPPERS are questions that elicit opinions, not FACTS! Begin with Should or Could or Do. Ex. 1. Should nurses wear white uniforms? 2. Should nurses allow patients to participate in care planning? 3. What should patients do about noisy roomates? 4. Should patient bath in the morning? 5. Do nurses neglect patients? 6. Do all patients respond to pain in the same way? 7. Do doctors give care to patients like nurses do? In asking research questions, try to write questions that begin with What, What is the Relationship, and Why and write working definitions of major terms in your questions. A. SIMPLE QUESTION has one stem and one topic. B. ACTION-ORIENTED QUESTION- demanding some activity on the researcher to provide an answer. C. ACTIVE QUESTION- require measurement for an answer. Implies that the researcher will have to observe something, participate in something or question someone to arrive at an answer. D. MEASUREMENT in the research sense, means examining an abstract idea to derive a concrete answer.

M. A. Flores, R.N.

E. WORKING DEFINITIONS- is the researchers statement of what the term means to him in the context of his question, specific to the study. E. WORKING DEFINITIONS is the researchers statement

M. A. Flores, R.N.

Roles of Nurses in Nursing Research

Although nurses usually interact directly with patients, those in nursing research often work in laboratory environments. The National Institute of Nursing Research defines the field as the process of developing knowledge to "build the scientific foundation for clinical practice, prevent disease and disability, manage and eliminate symptoms caused by illness [and] enhance end-of-life and palliative care." Research nurses work alongside doctors and other scientists to perform experiments and analyze data with the intent of achieving those goals. 1. Job Responsibilities o A research nurse performs a variety of tasks in support of clinical research studies. He recruits patients to serve as subjects, vetting them to ensure they qualify for participation. He compiles data during the studies. In addition to reviewing and assessing the information, he enters it into a database. The technical nature of the role requires him to pay close attention to details so that no errors are made. In some environments, he also assists with surgical procedures. Educational Requirements
o

The first step in becoming a research nurse is to become a registered nurse or RN. Prospective RNs must be from an accredited college or university. In these programs, students get classroom and clinical experience within a variety of scientific medical areas, including anatomy, chemistry, microbiology, nutrition, physiology and psychology. Those who matriculate are awarded a bachelor's degree in nursing or BSN. This takes approximately four years to complete. Some employers specifically seek RNs who have a master's degree in nursing -- known as an MSN -- which typically takes two years to complete. Others only consider those with a doctorate degree.

Licensing
o

Every state, the District of Columbia and all United States territories require people to become licensed before accepting employment as an RN. In order to get a license, prospective RNs must successfully pass the National Council Licensure Examination, also called the NCLEX-RN. Although the test is administered on a national level, each state maintains unique eligibility requirements. Candidates wanting to sit for the NCLEX-RN may get information regarding eligibility from their state's board of nursing.

M. A. Flores, R.N.

Certificate
o

Some employers require research nurses to have a certificate in clinical research. These programs are offered by formal medical schools across the country. Students are educated in a variety of areas, such as clinical research techniques, biostatistics, ethical research conduct, and data collection and management. In addition, the training provided by clinical research certificate programs is also useful for nurses who ultimately wish to explore related careers, including that of a clinical research associate, clinical research coordinator or clinical investigator.

Earnings
o

Although the United States Bureau of Labor Statistics has not published data specifically regarding nurses who work in research roles, the agency reported that RNs as a whole made a median annual salary of $62,450 in 2008. Among them, the middle 50 percent made salaries ranging from $51,640 and $76,570. In addition, the lowest 10 percent of all registered nurses made less than $43,410; the highest 10 percent made in excess of $92,240.

Organizational Behavior Perceptions & Attributions

Peoples perceptions and attributions influence how they behave in their organization. Perception describes the way people filter, organize and interpret sensory information. Attribution explains how people act, determining how people react to the actions of others as well. Accurate perception allows employees to interpret what they see and hear in the workplace effectively to make decisions, complete tasks and act in ethical manner. Faulty perceptions lead to problems in the organization, such as stereotyping, that lead people to erroneously make assumptions. Managing Perceptions When people in organizations find themselves in unfamiliar, ambiguous situations, they tend to have difficulty coping. Effective business professionals handle objections to their ideas by clearly stating the benefits of their position to all parties. By presenting a compelling case for their ideas, these people get approval for their proposed strategy even if opposed by apathy or confrontation. By actively recognizing peoples perceptions and attributions, effective leaders build justifications for their approach and get support when needed. Handling Attributions People commonly attribute success to skill, luck or chance. People tend to react to situations based on what they think caused the event. Just as perceptions can be faulty, attributions can be inaccurate as well. Organizations can ensure people attribute actions more effectively by providing diversity training. This helps prevent a hostile work environment for people from different cultures. By training people to make more accurate attributions, daily operations run more smoothly. This helps reduce faulty attributions, such as managers who attribute exceptional performance to chance as they resist assigning more challenging work to qualified individuals they view as lucky. Explaining Behavior

M. A. Flores, R.N.

People tend to evaluate other people on their ability, effort or personality. They also attribute luck or the difficulty of task to a success or failure. The attributions people make for their own behavior also influence their performance in the organization. For example, successful workers who succeed at tasks after completing training exercises usually increase their confidence levels. Those who fail may consider themselves unlucky or blame others. Peoples perceptions and judgment of another persons action depend on if reactions occur consistently or inconsistently. Recognizing that people have cultural beliefs, motives and intentions helps explain behavior and helps rectify non-productive situations. By understanding the common causes of behavior, individuals can react more appropriately. Minimizing Bias Minimizing biases that distort attribution can help foster effective team work. Using tips, techniques, tools and resources available from websites such as the Cultural Navigator site, organizations can reduce the rate at which people selectively interpret events based on their experience, background and attitudes. Edward Thorndike, an American psychologist, observed that perception of one trait is influenced by other traits. Known as the halo effect, this bias causes people to judge people they find attractive as smart. Providing training to managers to make more accurate perceptions helps them conduct more effective employment interviews, performance reviews and daily management tasks.

M. A. Flores, R.N.