Igniting a spirit of inquiry in clinical practice is the foundation of evidence-based practice (EBP) (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Exposure to undergraduate research education may have a significant effect on nursing students' research skills and use of EBP while minimizing barriers to EBP uptake following licensure (Leach, Hofmeyer, & Bobridge, 2016). Entry-level nurses are expected to be able to read original research reports and have a basic understanding of how evidence is generated (Melnyk et al., 2012), but undergraduate EBP and research courses primarily focus on teaching traditional quantitative and qualitative methods. The infusion of mixed-method Q methodology in undergraduate nursing research courses offers promise toward creating connections in the utilization of EBP (Judge, Opsahl, & Hensel, 2018). There is a growing interest in the use of mixed-method research designs in nursing to uncover relationships and diverse perspectives that may ultimately lead to better outcomes (Shorten & Smith, 2017). This article describes prelicensure nursing students' perceptions following a class session designed to introduce them to Q methodology.

Q methodology can be used to study a wide range of subjective attitudes, beliefs, and opinions. It can be used to generate theory and test hypotheses and is used for program evaluation and quality improvement (Ramlo, 2015, 2016; Tiernon, Hensel, & Roy-Ehri, 2017). As opposed to surveys designed from the researcher's perspective, Q methodology uses a person-centered data collection process known as "sorting or sorts" to enable participants to actively convey their preferences (Ramlo, 2016; Simons, 2013). Q methodology studies correlate participants to each other to find naturalistic groups with similar views, referred to as factors. With small samples and computer-facilitated data analysis, Q methodology combines some of the best features of traditional research methods.

Although statement development can be time-consuming for researchers and the sorting process can be confusing and time-consuming for participants, the most significant advantage to using Q methodology is that qualitative themes emerge from the data, rather than from the researcher's perspective (Killam, Timmermans, & Raymond, 2013; Lobo, Fisher, Baumann, & Akhtar-Danesh, 2012; Simons, 2013). Hensel (2016) suggested that teaching undergraduate nursing honors students to use Q methodology for research studies helped increase their quantitative and interpretive skills, but the benefits of integrating Q methodology to undergraduate nursing research and EBP courses have not been explored. The purpose of this study was to holistically explore student perceptions surrounding Q methodology following a single classroom session.

METHOD

Students enrolled in a traditional prelicensure nursing program at a Midwestern public university participated in an interactive Q methodology class given by a guest lecturer as part of a required nursing research and EBP course. The students were then invited to participate in a Q methodology evaluation of the class. The study was classified as an exempt review by the university institutional review board as research was performed in course evaluation.

Using a Q methodology mixed-methods design, quantitative measures of student perceptions were used to find qualitative viewpoints. Students rank-ordered their levels of agreement and disagreement on a -4 to +4 forced-distribution sorting sheet composed of 35 statements about the class that were gathered from open-ended class evaluation questions. Students also provided written rationale for why selected items were placed in the far right (agree) and left columns (disagree). To protect confidentiality, no identifying information appeared on the data collection tools. Data were analyzed using centroid factor extraction and varimax rotation with PQMethod for Windows Version 2.35 (GNU Public License).

RESULTS

Anonymous responses were returned by all 35 students; two student response sorts had missing data and were excluded from the analysis. Twenty-nine response sorts loaded on one bipolar and two unipolar factors representing four distinct viewpoints: General Confusion (n = 7), Seeing Usefulness (n = 3), Valuing Practice (n = 8), and Ambivalence to Research (n = 11). Two response sorts loaded significantly on more than one factor, indicating that students had hybrid viewpoints. Two response sorts failed to load on any of the factors, indicating students' opinions were not captured. Overall, the interactive format and participation in the step-by-step mock study were positive aspects of the class. Areas for improvement included reducing the amount of material offered in one session and providing prior knowledge of content.

General Confusion

Sixteen percent of the variance was explained by Factor 1. This factor was bipolar with positive and negative loads reflecting opposite viewpoints. Seven students loaded positively on Factor 1a, which was characterized by the statement "I find Q methodology to be very confusing," leading to the factor name of General Confusion. Students with this viewpoint did not find the method easy to use and did not believe that they would ever conduct a Q study in the future.

Seeing Usefulness

The opposite viewpoint was shown by the three students loading on Factor 2b, named Seeing Usefulness. Students loading on this factor had the most favorable attitudes, characterized by perceptions that Q methodology was a good way to find opinions and do patient-centered research. One student was conducting an undergraduate honors research project and shared this opinion: "I can see how Q methodology would have been a much better and effective method for the study that I am working on. I love how in depth it is."

Valuing Practice

Factor 2 was characterized by the belief that Q methodology seemed very complex for beginners, but students liked participating in the step-by-step mock study. One student explained, "Working together and having the instructor walk me through it made understanding easier. I had help and could follow along even if I got confused." This factor had eight positive loads and explained 14 percent of the variance.

Ambivalence to Research

Factor 3 was named Ambivalence to Research. This viewpoint was full of contradiction, for example, agreeing that the interactive format helped students understand while disagreeing that information was presented in a student-friendly format. A distinguishing statement for this group, "I believe research is overemphasized at the BSN level," was rated significantly higher than any other group. With 11 positive loads, Factor 3 explained 15 percent of the variance.

DISCUSSION AND CONCLUSION

We used Q methodology to evaluate affective learning after teaching the same method. We found perceptions surrounding class content, and teaching methods were clustered into four groups. Had the class been evaluated using a survey tool, our interpretation might have been based on overall averaged item scores without understanding the significance of the multiple unique views or areas of consensus (Ramlo, 2015). The most positive outcome from this study was the finding that a group of students loading on Seeing Usefulness valued the content and could see the usefulness of Q methodology for conducting patient-centered research after a very brief exposure. The advanced levels of student engagement with the appropriate synthesis and application of acquired content allow for deeper student learning to take place. We determined that reading an overview of Q methodology should be included prior to future sessions.

This study serves as an exemplar of an alternative method to evaluate student learning outcomes and provides direction for future studies on best practices for teaching prelicensure nursing research. Q methodology studies are meant to find the existence of multiple viewpoints among participants; attempts to generalize the results to other settings should be done cautiously. The findings only capture opinions and do not measure knowledge or skills students may have acquired from the class. The ability to find perspectives comes from the quality of the Q sample, total of all student response sorts. In this study, the Q sample was created naturalistically from responses to open-ended questions following the class. Important student perceptions may not have been solicited, may have limited the viewpoints we were able to identify. As being able to read and interpret research is an essential EBP skill (Melnyk et al., 2012), an important class outcome would have been the ability to read and understand a journal article on a Q methodology study.

There are potential benefits to introducing Q methodology to prelicensure nursing students. Exposure to research points toward improved nursing student skills and utilization of EBP (Leach et al., 2016). Introducing Q methodology in research courses within a nursing program is the first step to generating new nurses who may appreciate and understand the importance of research and EBP in the nursing profession. More research is needed to understand optimal exposure to Q methodology, but this approach might become a definitive educational tool in the development of undergraduate nursing research.

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