Art & science research series: 13
Using the Delphi technique in nursing research Wilkes L (2015) Using the Delphi technique in nursing research. Nursing Standard. 29, 39, 43-49. Date of submission: January 30 2014; date of acceptance: April 14 2014.
Abstract The Delphi technique is often used when consensus views of experts are sought in nursing education, management and clinical work. This article discusses the usefulness of the technique for research in nursing, using personal experience, past critiques and examples from contemporary nursing research.
Author Lesley Wilkes Director, Centre for Nursing Research and Practice Development, University of Western Sydney, Penrith, New South Wales, Australia. Correspondence to:
[email protected]
Keywords Clinical practice, consensus technique, Delphi studies, Delphi technique, nursing research
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are vailable at: journals.rcni.com/r/author-guidelines THE DELPHI TECHNIQUE is favoured by nurses conducting research exploring topics such as role delineation (Duffield 1988, White and Wilkes 1998), research priorities (Bayley et al 2004, Annells et al 2005), tool development (Wilkes et al 2010), standards in nursing practice (Cutting 2005) and curriculum development (Fraser 1999). It was developed by Norman Dalkey and colleagues in the 1950s and 1960s and was originally designed to obtain consensus of opinion from a group of experts using controlled feedback (Dalkey and Helmer 1963). Broader definitions have since evolved, with Linstone and Turoff (2002) defining it as a way of group communication, allowing participants to deal with a complex problem. Whatever the definition, the Delphi technique aims ‘to predict and explore
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group attitudes, needs and priorities’ (Hasson and Keeney 2011). The main features of the classic Delphi analysis are anonymity, iteration, controlled feedback and statistical aggregation of group responses (Rowe and Wright 1999). However, there are many modifications of the Delphi technique in the literature (Hasson et al 2000, Skulmoski et al 2007). It is one of two common forms of consensus techniques used in research, the other being the nominal group technique (Delbecq et al 1975), which is similar to the face-to-face (real-time) Delphi technique. Many disciplines use the Delphi technique because of its convenience and low cost. Articles in nursing and other disciplines provide processes for conducting research using the technique, as well as critiques of its advantages and disadvantages with regard to research quality and integrity. These issues will be addressed in this article, which draws on such critiques of the technique, personal experience as well as a collection of articles that applied the Delphi technique and were published in English-language nursing journals.
Process of the Delphi technique The typical Delphi technique process involves: identifying a research problem, reviewing the literature and refining the research question, choosing a methodology, developing expertise criteria and identifying a panel of experts, selecting the number of participants, number of rounds, mode of iteration and methodological rigour, data analysis and presentation of the results. The steps in the Delphi process are considered in turn, using critiques of the methodology and selected examples of recent articles (Table 1). The 12 articles in Table 1 apply the Delphi technique to a research problem in nursing and were published between 2010 and 2013 in three high-impact, generic nursing journals popular with nurse researchers (Wilkes and Jackson 2011). Three articles were used from the International Journal of Nursing Studies (impact factor = 2.075) (Elsevier 2014), five from the Journal of Advanced may 27 :: vol 29 no 39 :: 2015 43
Art & science research series: 13 TABLE 1 Studies using Delphi technique between 2010 and 2013 discussed in this article Reference number
Authors, country (Journal)
Topics
Panel
Mode of iteration
Rounds and participant numbers
1
Cowman et al 2011, Ireland (Journal of Clinical Nursing)
Research and education priorities, nursing practice – wound management.
International panel from 37 wound care organisations.
Email distribution with link to online survey.
Round 1: 350 responses from unknown number of requests. Round 2: 205 responses from 350. Round 3: 80 responses from 205. Round 4: results sent to all email addresses.
2
Blackwood et al 2010, Ireland (Journal of Advanced Nursing)
Research priorities and mixed nursing practice and workplace issues.
Adult intensive care clinical nurses, nurse managers, nurse researchers and nurse educators. All members of the European Critical Care Association.
Email.
Round 1: 110 responses from unknown number of requests. Round 2: 65 responses from 110. Round 3: 58 responses from 110.
3
Wilson et al 2010, Australia (Journal of Clinical Nursing)
Research priorities and nursing practice – priorities for infants, children and adolescents.
Nurses, nurse specialists and nurse managers randomly selected in a specialist children’s hospital.
Internal hospital mail and request for return of email contact details.
Round 1: 47 responses from 217 requests. Round 2: 63 responses from 217. Round 3: 47 responses from 63.
4
Wilson et al 2011, Australia (Journal of Clinical Nursing)
Nursing practice and quality indicators – nursing practice in hospital.
Experts contacted through national paediatric nursing groups and through referrals to clinicians, managers and academics.
Email and online survey from literature.
Round 1: 51 responses from 71 requests. Round 2: 38 responses from 51. Round 3: 38 responses from 51.
5
Rauta et al 2012, Finland (Journal of Clinical Nursing)
Nursing practice – define core elements in perioperative nursing.
Expert nurses nominated by national work group.
Electronic questionnaire.
Round 1: 49 responses from 55 requests. Round 2: 27 responses from 49.
6
Lodewijckx et al 2012, Belgium (Journal of Advanced Nursing)
Nursing practice and quality indicators – care pathways, process and outcomes for chronic obstructive pulmonary disease.
International panel of doctors, nurses and physiotherapists through international institutes and societies and those contributing to specialist monographs.
Electronic basis, no further detail provided.
Round 1: 35 responses from 50 requests. Round 2: 35 responses from 35.
7
Boldt et al 2012, Switzerland (Journal of Advanced Nursing)
Nursing practice – spinal cord injury disability functioning and classification.
Nurses from international Email. associations.
Round 1: 35 responses from unknown number. Round 2: 27 responses from 35. Round 3: 25 responses from those who had responded to either round 1 or round 2.
8
Beeckman et al 2010a, Belgium (International Journal of Nursing Studies)
Assessment tool development – psychometric evaluation of assessment tool of attitudes to pressure ulcer prevention. Delphi technique used to construct tool.
Experts for round 1 were from the European Pressure Ulcer Advisory Panel. Round 2: nurses and nursing students.
Round 1: nine responses (total accessed). Round 2: five nurses, five students (total accessed).
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Email – not clear if online survey.
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Nursing (impact factor = 1.527) (Impact Factor List Scijournal.org 2014a) and four from the Journal of Clinical Nursing (impact factor = 1.316) (Impact Factor List Scijournal.org 2014b). Selected aspects of the Delphi processes for these articles are summarised in Table 1. Numbers in parentheses in the following discussion refer to a specific article or articles in the table.
Identifying the research problem The Delphi technique should be chosen for research problems linked to organised group communication which may lead to a consensus from individual opinions, arriving at a final decision and gaining empirical insights into an area where knowledge is incomplete (Linstone and Turoff 2002, Powell 2003). An example of a research question suitable for the Delphi process might be: ‘What is the role of the GP liaison nurse?’ The research problems in the articles in Table 1 were related to education priorities (1, 11, 12), research priorities (1-3), nursing practice issues
and quality of care (1-7), and assessment tool development in education and nursing practice (8-11). These topics were selected for the Delphi process by the researchers because of a perceived need for clarification and expert consultation.
Choosing a methodology and survey focus A quantitative method is typically used in the Delphi technique, but some researchers use qualitative methods. The initial Delphi survey round may have a broad or narrow focus. Most early researchers (Adler and Ziglio 1996, Linstone and Turoff 2002) suggest using a broad focus to capture a wider range of responses. However, using a narrow list of concepts, issues or questions may focus the expert panel while long lists may make analysis of responses more time-consuming. There is no consensus on the best method of initiating the Delphi round. Open-ended responses are often elicited in the first round of Delphi surveys (1, 2, 3, 7), which will assist in forming more quantitative scales for future
TABLE 1 Studies using Delphi technique between 2010 and 2013 discussed in this article (continued) Reference number
Authors, country (Journal)
Topics
Panel
Mode of iteration
9
Beeckman et al 2010b, Belgium (International Journal of Nursing Studies)
Assessment tool development in nursing practice – knowledge of pressure ulcers.
Experts from European Pressure Ulcer Advisory Panel.
Email, not clear Round 1 and 2: nine responses. if online survey
10
Chang et al 2010, Australia (Journal of Advanced Nursing)
Assessment tool development in nursing practice – content validity of advanced practice nurse role assessment tool.
Experts used to determine Email and content validity of tool online survey. developed by researchers. Sixteen experts invited including clinicians, educators, managers, and advanced practice nurses in metropolitan and remote areas.
Round 1: 16 responses from 16 for items relating to advanced practice nurse activities. Round 2: same survey, 15 responses.
11
Cheng et al 2010, Taiwan (International Journal of Nursing Studies)
Assessment tool development in education – content validity of assessment tool for self-directed learning ability of nursing students.
Experts: adult educators, higher education educators and nurse educators.
Not clear how distributed.
Round 1: 16 responses from 16 requests. Round 2: 16 responses from 16.
12
Dekker-Groen et al 2011, Netherlands (Journal of Advanced Nursing)
Education – teacher competencies in developing reflective skills of nursing students.
Expert group: 18 teachers at different institutes, four managers, six researchers.
Face-to-face instructions by researcher. Participants completed questionnaire.
Round 1 and round 2: 28 responses from 28 requests.
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Rounds and participant numbers
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Art & science research series: 13 rounds (Hasson and Keeney 2011). Additional items may be requested by the panel and added to the researcher-generated lists (4, 5). This provides involvement, maintains the interest of panel members and extends the list. For example, in our study of the role of the breast care nurse, the panel added 41 items to the original 19 items in the first-round survey (White and Wilkes 1998), which had been constructed from a review of the literature. Use of the literature to construct lists is not uncommon (1, 4, 6) and can produce extensive lists, as is the case when panel members are asked to provide them. The researcher or researchers may then analyse the list for content and reduce the number of items without consultation (1, 2, 7). However, this may lead to difficulty in determining priority and consensus in later survey rounds. In some cases, respondents are asked to provide written comment at each round. These comments are qualitatively analysed and may be used in deciding whether to add or delete items for future rounds. All articles but one (12) reported using comments to assist in data analysis and consensus building within the expert panel. The use of comments was noted as an important component of the method in these articles.
Identifying the expert panel The panels are usually composed of experts who have (Adler and Ziglio 1996): Knowledge and experience with the issue under investigation. Capacity and willingness to participate. Sufficient time to participate. Effective communication skills. Commitment to participate can be inferred by ongoing response to multi-round Delphi surveys. In many cases, respondents are lost throughout the process, particularly when large samples are used in early rounds. For example, 350 responses in round 1 in (1) resulted in only 80 responses in round 3. From personal experience, participants with greater expertise are more likely to maintain their motivation and continue to participate in later rounds. Using special interest groups and associations (1, 2, 5, 6, 7, 8 and 9) may be useful but is no guarantee of expertise, since membership may be open to individuals with a broad range of expert and specialist knowledge as well as experience, and these groups may be heterogeneous. It could be argued that using nursing students as experts in (8) is not appropriate.
Number of participants Convenience samples are used, and there are no definitive rules to determine sample size in 46 may 27 :: vol 29 no 39 :: 2015
a Delphi study. Considerations in determining the size and composition of the sample should include: use of a homogenous versus heterogeneous sample, the trade-off between decision making and manageability of the Delphi study, and internal versus external verification (Skulmoski et al 2007). If a homogeneous group is used, the sample may be smaller (ten to 15 people): they are more likely to answer and data analysis is much easier. A wide variety of sample sizes is apparent in Table 1. Response rates appeared superior with the smaller, more homogeneous samples (5, 11 and 12). However, the expertise of the group may be more important than the actual size of the sample. As the sample size increases, there is a reduction in group errors, but for a marginal advantage the Delphi manageability trade-off may not be worthwhile. Internal and external verification may be achieved only by doing follow-up studies (Rowe and Wright 2011) or as a separate phase of a study (8). For example, the violence assessment tool developed using a Delphi technique (Wilkes et al 2010) was verified by an observational predictive study (Jackson et al 2013). Similarly, a follow-up qualitative interview study (White and Wilkes 1999) was conducted to enhance data from the Delphi study on elements of the role of the breast nurse (White and Wilkes 1998).
Number of rounds There is no general agreement on the required number of rounds in the Delphi study, but most involve two to three (Linstone and Turoff 2002, Powell 2003). In article 10 only one round was used because the tool had been developed previously, while in article 1 four rounds were noted, although the last involved providing a final list of research priorities. It is important to consider that, as the number of rounds increase, the motivation of participants may decrease, which may result in lower response rates. Another consideration is that homogenous groups may require fewer rounds to come to consensus but heterogeneous groups may be important in obtaining the views of all those involved (2, 3, 11, and 12).
Mode of iteration In the classic Delphi technique, pen-and-paper questionnaires are used. However, following increased use of the internet, a more user-friendly and electronically based mode of iteration is favoured by researchers. Due consideration should be given when distributing a survey to locations with no or slow internet access (Cowman et al
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2011). Email permits quick turnover and this can maintain the motivation and enthusiasm of the original sample. Analysis is easier if online survey software is used. Some form of email was used in all cases in Table 1 except (12). A face-to-face (real-time) Delphi technique is similar to the nominal group technique and has the advantage of having the group in one place, enabling a repeat round on the same day. The main issue with this, in our experience, is quantifying results within a limited time period to provide feedback for the next round (Wilkes et al 2013). The real-time Delphi technique is usually conducted on a single day, but subsequent confirmation of results may also be used (Wilkes et al 2013). A similar, more advanced iteration technique was proposed by Gordon and Pease (2006) which provided on-the-spot analysis, reducing time lags and the need for multiple rounds.
Methodological rigour The rigour of the Delphi technique has been debated in the general and nursing literature. Keeney et al (2001) suggest that the Delphi technique should not be judged by the psychometric criteria used for more positivist approaches, but that criteria such as transferability, credibility, applicability and conformability may be useful (Lincoln and Guba 1985). Powell (2003) outlines similar means of checking the scientific merit of the Delphi technique. Skulmoski et al (2007) suggest the processes used should be well documented and an audit trail kept. Hasson and Keeney (2011) provide a review of suggested methods to increase reliability and validity. Most authors consider these methods hard to achieve, because of the lack of accountability of individual views and high dropout rates. Internal and external validity may be difficult to achieve (Hasson and Keeney 2011). The useful concept of content validity is also discussed (Hasson and Keeney 2011, Skulmoski et al 2007) and is usually achieved when 70% of respondents agreed to inclusion of items. Linstone and Turoff (2002) maintain the Delphi technique’s usefulness and studies such as Landeta (2006) uphold it as a valid means of social research. Some of the studies (2, 4, 5, 6, 9, 10, 11 and 12) listed in Table 1 address these issues.
Data analysis and reporting Data analysis and reporting of the Delphi technique are related to the type of questions used. For example, when lists are requested
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from respondents, qualitative content analysis may be used, and the number of items selected is often determined by the researchers (1, 2 and 7). However, this may lead to content validity issues. Comments provided by respondents may be content-analysed for themes and reported in the results. In a few studies (1, 2 and 7) these comments were used to add extra items to the next rounds of the survey. Linstone and Turoff (2002) and Holey et al (2007) are useful resources for a fuller discussion. Some studies use vague terms in reporting results such as ‘most respondents agreed’ or ‘results are implied’. Generally these should be avoided. Other researchers use stability between rounds. For some, no statement of how consensus was reached is documented (Powell 2003). In most of the studies listed in Table 1, Likert scales were used, with a variety of methods of analysis including means and standard deviations (2-4), percentage of responses (1, 7, 10), content validity index (4, 8-10), comparison (stability) of round results using t-test (12), and other statistical tests. A summary of points for researchers to consider when conducting the Delphi technique is provided in Box 1.
Conclusion Using the Delphi technique appears to be a quick and simple method to gain data in the shortest time possible. However, researchers should consider whether it will provide sufficient scientifically verifiable data to answer their research question. The Delphi technique is most suitable where knowledge is incomplete. It is useful when examining practice or teaching outcome criteria, in element delineation such as
BOX 1 Points to consider when using the Delphi technique When publishing the results of a Delphi study, it is useful to include details of the tool and the processes used, so that readers can evaluate the study and gain insight for future studies. Smaller samples may be better than larger samples, homogeneous samples better than heterogeneous samples. Recruitment and retention may be improved by using electronic media or real-time techniques. It is also important to take the time to develop and improve questions, to use simple, unambiguous language and to undertake a pilot study before the first round, which may request responses to open-ended questions. Closed responses are easier to analyse and provide an improved chance of gaining consensus. Quantitative data from the Delphi rounds may be enhanced by analysing and reporting qualitative comments. Combining the Delphi technique with other research designs, such as survey or focus groups, should also be considered.
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Art & science research series: 13 in role descriptions of nurses, and in identifying items for future surveys or assessment tools. It may be used to advantage in nursing practice situations where relevant verifiable, consensus data are needed to address clinical issues which require speedy action. It can be difficult to decide the best approach, because of the variety of processes described in the literature, and time should be taken to consider the issues discussed in this article. When publishing the results of
Delphi studies, it is useful to include details of the tool and the processes used so that readers can be discriminating in their engagement and gain insight for future studies NS Acknowledgement Nursing Standard wishes to thank Leslie Gelling, reader in nursing at Anglia Ruskin University, for co-ordinating and developing the research series.
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