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Himmelfarb Library, The George Washington Health Sciences

Health, Human Function, and Rehabilitation Health, Human Function, and Rehabilitation Sciences Faculty Publications Sciences

5-1-2020

The of Research.

Yoon Soo Park

Lars Konge

Anthony R. Artino George Washington University

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APA Park, Y., Konge, L., & Artino, A. R. (2020). The Positivism Paradigm of Research.. Academic medicine : journal of the Association of American Medical Colleges, 95 (5). http://dx.doi.org/10.1097/ ACM.0000000000003093

This Journal Article is brought to you for free and by the Health, Human Function, and Rehabilitation Sciences at Health Sciences Research Commons. It has been accepted for inclusion in Health, Human Function, and Rehabilitation Sciences Faculty Publications by an authorized administrator of Health Sciences Research Commons. For more , please contact [email protected]. 14 In the purest the purest In 8–10 12,13 Positivist Positivist 8 11 view, positivism is rooted in the following positivism is rooted view, in the Mill principles by as categorized A System of : text, classic help strengthen or refine ; refine or help strengthen for the a that confirms example, ofeffectiveness an instructional approach of group a new to learners can help theory. inform and refine Positivism: Definition and of components Definition and positivism hypothetico- the on relies Positivism a priori verify method to deductive stated often hypotheses that are functional where quantitatively, between can be derived relationships causal and explanatory factors variables)(independent and outcomes variables).(dependent of 1 lists definitions termskey Box 2 Box withassociated positivism. a list ofprovides for materials useful further reading. A primary goal of positivist is explanatory associations generate to that ultimately causal relationships or of and control the lead to in question. phenomena findings from large sample sizes are sample sizes are large findings from generalizable this regard, favored—in of findings, and , been experimentation have controlled . principles guiding positivist the quality Criteria for evaluating discussed. are of positivist research health An example from to guide is provided study and positivist thinking in implementation. research, however, does not always rely rely not always does however, research, an example, For methods. quantitative on the effects examining experimental study of qualitative through an intervention fits within the positivist paradigm. Academic Medicine, Vol. 95, No. 5 / May 2020 95, No. 5 / May Academic Medicine, Vol.

7 We present examples of examples present We 1,5,6 historic formation, components, and components, formation, historic paradigm- Understanding assumptions. as specific is important, assumptions of deeper understanding they provide is operationalized and of science how legitimate that promote components and criteria for solutions, problems, . and rigor). Positivism is aligned with Positivism is aligned and rigor). model of the hypothetico-deductive verifying a priori science that builds on by hypotheses and experimentation and measures; operationalizing variables used hypothesis testing are from science. Studies to inform and advance generally focus aligned with positivism associations or on identifying explanatory quantitative through causal relationships empirically based where approaches, positivist research and applications that applications and positivist research of understanding facilitate this research its use in health including paradigm, and in scientific education professions with conclude We broadly. more research ofa a clinician–educator how withworking the positivist paradigm a specific case. might approach The Hypothetico-Deductive Model The Hypothetico-Deductive Model of Science is aligned with the hypothetico-Positivism such, As deductive model of science. identifying the structure and basis of positivism the hypothetico- through start. to place a useful is lens deductive The hypothetico-deductive method is a The hypothetico-deductive that begins with process theorycircular testable (1) build to the literature from (2) design an s, hypothese operationalizing variablesthrough (i.e., identifying and variables manipulate to assignments), group through measure an empirical study and (3) conduct experimentation.based on Ultimately, are a study such the findings from help inform theoryused to and thereby the literature, to contribute (theory process the circular completing → hypothesis → operationalizing variables → experimentation→ theory). the empirical can study Findings from 3,4 which guide guide which 2 These research are These research 1

cientific research, the systematic the systematic research, cientific

690 Acad Med. 2020;95:690–694. Acad Med. First published online November 26, 2019 doi: 10.1097/ACM.0000000000003093 Please see the end of this article for information about the authors. Soo to Yoon should be addressed Correspondence Park, Department of , College of Medicine, University of Illinois at Chicago, 808 South St., 963 CMET (MC 591), Chicago, IL 60612- Wood 7309; telephone: (312) 355-5406; : yspark2 @YoonSooPark2. @uic.edu; Twitter: by employees of the Federal work prepared Written Government duties is, under as part of their official the U.S. Copyright Act, a "work of the United States under Government" protection for which copyright Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. In this article, we focus on the research the research focus on we this article, In paradigm of positivism—its definition, S s Note: This article is part ofEditor a ’s Note: of CommentariesInvited exploring of the Science. guide scientific paradigms Research their assumptions discoveries through paradigm- and principles. Understanding helps illuminate specific assumptions that support the quality of findings identify gaps in scientific studies and This article generating sound evidence. paradigm of focuses on the research positivism, examining its definition, (, and assumptions history, , , , The Positivism Paradigm of Research Paradigm Positivism The PhD R. Artino Jr, PhD, and Anthony PhD, Lars Konge, MD, Soo Park, Yoon Invited Commentary: Philosophy Commentary: Invited quest for , can be considered can be considered knowledge, for quest that paradigms research different through the world about how assumptions make operates. the ofthe philosophies science, the way science is conducted by shaping by is conducted science the way ontology elements: the following core epistemology is viewed), (how of the is knowledge (how axiology and values (the role conceived), methodology process), of the research the paradigm(how processes defines withassociated science), conducting and rigor (the criteria the justify used to quality in the paradigm). of research

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individual thinking and the Box 1 of objective knowledge. Reflecting this Key Terms and Definitions Related to Understanding the Research Paradigm of history, the development of positivism is Positivism characterized by a move away from social elites (e.g., royalty) defined by via Dependent variable: Measures of interest (outcomes) in the study; unlike independent variables, dependent variables can only be measured, not manipulated. decree, and toward discovering objective, evidence-based truth through Dualism: Separation of researcher and participants in study design and collection to minimize . well-described experimentation. Examples of who contributed : Quantified metric reflecting the impact of an intervention, expressed in standardized units to allow comparison across studies. to positivist views include Copernicus and Galileo, both of whom challenged Functional relationship: Association between a study’s independent and dependent variables, and redefined of nature through often expressed quantitatively, through direct or indirect effects (e.g., increase in independent experimentation and the collection of variables also increases the dependent variable). Functional relationships can also be causal, where data to make and causal the impact of independent variables causes the results of the outcome to change. inferences. To date, positivist thinking Hypothesis: A statement or idea derived from theory or literature that can be tested through still dominates modern research in experimentation. clinical and basic sciences, as evidenced by international standards for science Hypothetico-deductive model: Scientific model based on forming a testable hypothesis and in leading journals and professional developing an empirical study to confirm or reject the hypothesis. organizations.7 As such, positivist Independent variable: Factors that influence outcomes of the study; independent variables can be thinking influences the advances in manipulated (e.g., assigning study participants to treatment or control groups) or measured. science and the approach that clinicians take to scholarly understanding.8 Internal : Evidence and supporting the “causal” relationship between the independent and dependent variables. Philosophical Foundations of the Laws of nature: Synthesis of scientific discoveries and that form the foundation of how nature operates; examples include our scientific understanding of how time and operate, Positivist Paradigm through scientific findings in . Ontology: Nature of reality

Objectivity: Absence of bias due to researcher influences, flaws in experimental design, or outliers The positivist paradigm is based in the in data. assumption that a single tangible reality exists—one that can be understood, 1. Goals of science: Social and natural and prediction based on the identified, and measured. This allows sciences should focus on of hypothetico-deductive model. explanation and prediction in a causal laws that facilitate explanation and framework to operate naturally, as prediction. Within this focus is the notion that large causal inferences rely on (1) temporal sample sizes are valued over smaller precedence (i.e., for X to cause Y, X must 2. Methodology: Social and natural samples (i.e., objective data collected precede Y in time), (2) association (i.e., sciences should use the same across a large sample are superior to X and Y are correlated), and (3) lack of methodology based on the data gathered through smaller samples). confounders (i.e., no factors besides hypothetico-deductive model Larger samples improve the identified factors affect the outcome; of science (theory, hypothesis, in data and representation of the X is the only cause of Y within the space , experimentation). 7,17 population characteristics, facilitating identified). 3. Laws of nature: Basic laws of nature, better generalizations regarding the Epistemology: Nature of knowledge formed through replication and causes of phenomena in nature. What is syntheses of scientific discoveries and more, to make stronger claims regarding Positivists contend that knowledge can theories, assert the of a single generalizations, replication of findings is and must be developed objectively, true and identifiable reality. also valued through systemic and controlled without the values of the researchers or .15 In this way, positivist participants influencing its development. 4. Evidence for : Laws of nature are research focuses on verifying theories.16 Knowledge, when appropriately derived from empirical data. developed, is truth—that is, it is certain, 5. Sampling and inference: Larger History of positivism congruent with reality, and accurate. To samples are favorable over smaller, The history of positivism dates back to appropriately develop truth, absolute idiosyncratic samples; larger samples the Enlightenment period of the 17th and separation must exist between the reveal generalizable tendencies, causes, 18th centuries, inspired by and the researcher. and the nature of reality. Descartes and Locke. The scientific To achieve this separation, positivists community at the time promoted a operate in dualism and .16,18 Based on these principles, positivism movement away from medieval notions In other words, positivist thinking seeks to discover laws of nature, of totalitarianism based on royal asserts that participants and researchers expressing them through decrees. During the Enlightenment, can actually be separated (dualism). of theory. These theories focus on philosophers and scholars valued Moreover, by following strict protocols,

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study is to examine the explanatory or is measured (i.e., assessment validity), Box 2 causal relationships between variables in (4) statistical regression: tendency for Additional Resources on the study, as is done in the natural sciences. scores to regress toward the mean in Understanding the Research Paradigm As such, experimental are favored follow-up , (5) testing of Positivism in the positivist paradigm, including effect: effect of testing on subsequent • Creswell JW. : Qualitative & quasi-experimental designs.17 Results from measurements, (6) selection: preexisting Quantitative Approaches. Thousand Oaks, experiments are used to confirm or refine differences in participants, (7) mortality: CA: ; 1994. theories, which, in turn, can lead to new participant attrition, and (8) • Bunniss S, Kelly DR. Research paradigms hypotheses and questions for new studies. in medical education. Med Educ. of selection and maturation: differences 2010;44:358–366. between groups that cause changes in Rigor: Criteria for evaluating quality of the groups at different rates. Studies • Hoyle RH, Harris MK, Judd CM. Research research Methods in Social Relations. New York, NY: conducted in the positivist paradigm Wadsworth; 2009. A key goal in positivist experimentation pay careful attention to these threats to • Ponterotto JG. in is to isolate and control the influence of and work to generate counseling : A primer on all factors so that only the key variables research paradigms and philosophy of study designs that allow the associated science. J Coun Psych. 2005;52:126–136. of interest are studied (e.g., only X could confounders to be controlled.21 have caused Y). In this regard, positivist researchers are most interested in the It is a deeply rooted assumption the 2 entities are separated to reduce bias study’s internal validity—how well the that quantitative foundations using in the study (objectivity). study design and evidence gathered to estimate the support claims for . effects of a given experiment are key Axiology: Values of the research process Internal validity that focuses on to the rigor of the positivist research Positivism relies heavily on objectivity should not to be confused with assessment paradigm. This quantitative focus and so dismisses the importance of validity that deals with how well a requires sufficient sample size and individuals’ subjective and particular (e.g., educational power to detect meaningful effect sizes values—be they the experiences and assessment, psychological measure) is based on appropriate statistical tests. values of research participants or of measured. While other research paradigms may researchers. These subjective experiences and values are seen as unimportant Rigor in the positivist paradigm— not place heavy emphasis on large in positivist thinking. This requires particularly quantitatively oriented social sample sizes, the use of and reliance on the researcher to stay objective and science research—is evaluated based statistical principles requires that the not interact with participants during on the degree to which the researcher positivist researcher carefully consider . Further, it requires the has been able to minimize threats to study designs that determine a priori researcher to not be involved in the internal validity.20 Such threats include, hypothesized effect sizes. That is, experiment in any meaningful way. In for example: (1) maturation: naturally before the study, the researcher must some domains, such objectivity can be occurring changes in participants over determine the anticipated size of the implemented in rather straightforward time, (2) history: events that take place between the control and ways. For example, one can imagine during research that influence results, treatment groups that be considered an experimental physicist conducting (3) instrumentation: meaningful.21 Larger sample sizes reduce research in a vacuum, where no external issues that reflect how well the construct in statistical results and yield factors beyond the systems studied are part of the experiment. This objectivity is more difficult to Box 3 realize in other domains. For instance, Sample Casea positivism can be applied to research—albeit with a bit more Lee was a resident assigned to monitor a post-op patient. The patient had a periodically low difficulty—since it requires the use of respiratory rate and lower-than-normal pulse and blood pressure. Narcan was ordered on an “as needed” basis, to be given in doses of 0.2 mg intravenously. In checking the patient’s vitals, Lee rigid and strict study protocols that decided it was time to administer an intravenous (IV) dose of Narcan. in as little researcher bias as possible. Once Lee injected the vial of Narcan into the IV port, Lee noticed it was labeled “2 milligrams per 1 milliliter (ml)”—the entire vial should not have been injected. Feeling panicky, Lee reported Methodology: How to conduct scientific the mistake to an attending and rushed back to the patient’s side to monitor the vital signs. research Lee was surprised to find that the patient’s vitals had come up to normal rates, and the patient Positivist methodology emphasizes was actually much more alert. When Lee reported this change to the attending surgeon and anesthesiologist, they told Lee to continue to monitor the patient closely, remarking that it may engaging in research in settings have been just what the patient needed. where variables can be controlled and manipulated.19 In the social sciences, Lee felt hugely relieved, but was still overwhelmed and very upset. In most cases, giving 10 times a normal dose of any medication could have led to extremely serious consequences, and even this requires that the researcher creates death. Still, Lee managed to remain outwardly composed, and took the time to complete an somewhat artificial environments where incident report. At the end of the day, when Lee finally sat down to rest, the incident played over other extraneous factors, beyond the study and over again. Lee did not sleep. variables, are minimized. In the purest aThis sample case is used throughout the Philosophy of Science Invited Commentaries to illustrate form of positivism, the sole focus of the each research paradigm.

692 Academic Medicine, Vol. 95, No. 5 / May 2020 Invited Commentary: Philosophy of Science stronger confidence in findings; this is a significant improvement in outcomes, hoping to conduct research in fundamental law of inferential . which allows calculating the required interdisciplinary fields such as medical sample size and power for recruiting education. learners. Case Study: Lee’s Experiment Funding/Support: None reported.

In Box 3, we present a scenario in which Experimentation Other disclosures: None reported. a resident (“Lee”) injects 10 times the Following appropriate ethical approval, normal medication dose. In this final Lee measures outcomes before Ethical approval: Reported as not applicable. section, we use this sample case to experimentation in both groups. Disclaimers: The views expressed herein are prompt an application of a positivist After the intervention, Lee measures those of the authors and do not necessarily paradigm to design an experiment outcomes again, then compares pre- and reflect those of the Uniformed Services that uses theory, articulates and tests a postintervention outcomes between the 2 University of the Health Sciences, the United hypothesis, operationalizes variables, and groups from the assessment. States Department of Defense, or other federal informs theory. agencies. Results to inform theory After the of administering Y.S. Park is associate and associate head, Lee makes a statistical comparison Department of Medical Education, and director of an incorrect medication dosage under between the outcomes of the 2 groups research, Office of Educational Affairs, University pressure, Lee decides to examine this of Illinois at Chicago College of Medicine, Chicago, and the findings reported to confirm issue further. Lee chooses to design a Illinois; ORCID: https://orcid.org/0000-0001-8583- (verify) the hypothesis. If Lee identifies 4335. study investigating how to improve that mastery-based simulation training to correct medication dosage L. Konge is professor, Copenhagen is more effective than a traditional using different curricular interventions for Medical Education and Simulation, University curriculum in improving application of of Copenhagen, Copenhagen, ; ORCID: (mastery-based simulation versus correct medication doses, then this result https://orcid.org/0000-0002-1258-5822. traditional curriculum). Below are steps contributes to mastery-based learning A.R. Artino Jr is professor and deputy director, Lee would follow to engage in a positivist theory. Specific nuances of the study Graduate Programs in Health Professions study. Education, Department of Medicine, F. Edward findings (e.g., type of mastery-learning Hébert School of Medicine, Uniformed Services Theory-based hypothesis condition or instruction) can help refine University of the Health Sciences, Bethesda, the mastery-based learning theory. Maryland; ORCID: https://orcid.org/0000-0003- Lee approaches the program director 2661-7853. with a proposal to design a mastery- based simulation curriculum that trains Conclusions residents under pressure to apply correct This article provides the definition, References doses of Narcan (Naloxone), specific assumptions, and application examples 1 Creswell JW. Research Design: Qualitative & to patient age and race/ethnicity. Lee of research that can be conducted in Quantitative Approaches. Thousand Oaks, CA: Sage; 1994. hypothesizes that using a mastery-based a positivist paradigm, summarized as simulation curriculum approach can 2 Varpio L, MacLeod A. Introduction to the follows: philosophy of science series: Harnessing the improve trainees’ ability to identify and multidisciplinary edge effect by exploring administer correct medication doses • Scientific research in a positivist paradigms, , , under pressure, relative to traditional paradigm focuses on explanation and axiologies, and . Acad Med. instruction she received through direct prediction. 2020;95:686–689. patient contact (non-simulation-based 3 Bunniss S, Kelly DR. Research paradigms • The hypothetico-deductive model of in medical education research. Med Educ. training). science is used to facilitate the research 2010;44:358–366. process, taking a theory-verification 4 Kneebone R. Total internal reflection: An essay Operationalizing variables on paradigms. Med Educ. 2002;36:514–518. approach. 5 Guba EG, Lincoln YS. Competing paradigms Under the supervision of the in qualitative research. In: Denzin NK, program director, Lee recruits 2 • Research operates in a dualistic Lincoln YS, eds. Handbook of Qualitative groups of learners—an experimental and objective world, where the Research. Thousand Oaks, CA: Sage; 1994; (intervention) group who receive the researcher does not interact with study 105–117. mastery-based simulation training for participants to minimize bias. 6 Schrag F. In defense of positivist research paradigms. Educ Res. 1992;21:5–8. applying correct medication doses under • Theories of nature depend on empirical 7 Hoyle RH, Harris MK, Judd CM. Research pressure, and a control group of learners data, with larger samples used to make Methods in Social Relations. New York, NY: Wadsworth; 2009. who are trained under the traditional generalizations. curriculum.21 All other learning 8 Ponterotto JG. Qualitative research in conditions are comparable. Lee designs a : A primer on research paradigms and philosophy of science. J Coun simulation-based assessment to compare While different research paradigms Psych. 2005;52:126–136. the 2 groups of learners following provide their unique in advancing 9 Cacioppo JT, Semin GR, Berntson GG. their training. Measures that define science, positivism has been a dominant Realism, , and scientific outcomes (e.g., correct medication dose, form of research in basic and clinical symbiosis: Psychological theory as a search 6,8,22 for truth and the discovery of solutions. Am duration of medication application) science for over 150 years. As such, Psychol. 2004;59:214–223. are identified. The literature informs understanding positivism and its 10 McGrath JE, Johnson BA. 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