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Quantitative and Qualitative Research Article CritiqueWIKI formatTifenie Harris, Michelle Johnston, Rhonda Jones, Rebecca H. Joostens and Dana SartoriusFerris State UniversityQuantitative Research EvaluationQualitative Research EvaluationArticle: Massey, R.L. (2010). A randomized trial of rocking-chair motion on the effect of postoperative ileus duration in patients with cancer recovering from abdominal surgery. Applied Nursing Research, 23, 59 – 64. doi: 10.1016/j.apnr.2008.06.001Article: Aadal, L. & Kirkevold, M. (2011). A model for neurorehabilitation after severe traumatic brain injury: Facilitating patient participation and learning. Advances in Nursing Science, 34(1), E1 – E17Did the abstract include key elements of purpose, design, sample, selected results, and conclusion?Not all of the elements are offered in the abstract. The abstract does offer the purpose, design, sample, and selected results; however, it does not provide any conclusion from the results.At what level does this article fit into the Hierarchy of Evidence? This article is a single qualitative study which identifies itself as a Level VI on the Hierarchy of Evidence. (Ursuy, 2013)What is the study problem/purpose? Does the study have the potential to help solve a problem that is currently faced in clinical practice?The study problem is that post abdominal surgery patients commonly have a form of gastrointestinal dysfunction in the first week postoperatively called postoperative ileus (POI). POI presents as absent, abnormal, or disorganized motor function of the stomach, small bowel, and colon resulting in the accumulation of gas that cannot be dissipated causing abdominal distention, nausea, vomiting, and severe pain that can last for up to 7 days after surgery, complicating a full and timely recovery (Massey, 2010). Currently there are no interventions that have been proven to prevent or resolve POI.According to Massey (2010), the studies purpose “was to test the effect of a nurse-derived intervention, rocking-chair motion on POI duration, total pain medication received, and time to discharge in patients with cancer recovering from abdominal surgery” (p. 60).The study does have the potential to help solve a problem currently faced in clinical practice. Complications from POI can prevent a patients’ full recovery and lead to a lengthy and costly hospital stay.Provide a ‘face’ evaluation of the article. The article seems readable and relatable upon the face evaluation. The “Background” section indicates that it is a challenge to rehabilitate patients with traumatic brain injuries (TBI) due to changed learning abilities. This leads into the reason the researchers have conducted the study. The purpose of the study is to create a model for neurorehabilitation and determine whether it will improve the results of rehabilitation through testing and evaluation. (Aadal & Kirkevold, 2011) The researchers want to determine whether this model will help reinforce the positive interventions the rehabilitators have been using. This indicates the need to research this topic to influence professional practice. It used a qualitative approach that was inspired by action research and was clear in the methods used and the results found. The major findings of the study show that the model the researchers propose was successful in expanding and systematizing what the rehabilitators have experienced and the interventions they use to help the patients. (Aadal & Kirkevold, 2011) The article is a recent publication in the journal Advances in Nursing Science. This journal is a reliable source that contains peer-reviewed articles. The authors are doctorate level nurses with reputable connections in the nursing profession. The article on initial examination appears to be a credible and readable study.Does the literature review include current, relevant previous studies and theories?The literature review includes previous studies and theories though they are not current. Two different studies were reviewed. One study from 1990 found that mothers who rocked after cesarean birth had more positive outcomes than those who did not (Massey, 2010). Another study from 1995 had similar findings on women after hysterectomy, but no current studies were reviewed (2010). The previous theory that is used in Massey (2010) is that “the gentle, rhythmic, repetitive motion of rocking stimulates the vestibular nerves to send signals of pleasure and alertness to the Reticular Activating System, which is the body's “flight or fight” response center (DeMarco-Sinatra, 2004; Moore et al., 1995). The gentle rhythmic, repetitive motion of rocking is hypothesized to have a modulating effect on the stress response, thereby mediating the symptoms of POI” (p. 60).Critique the ‘purpose of the study’ statement is this qualitative research article. Aadal & Kirkevold (2011) state the purpose of the article is “To develop, initially test, and evaluate a model for neurorehabilitation, aimed at systematizing and facilitating professionals’ efforts of promoting patients’ participation and learning.” Nieswiadomy (2012), states that the purpose of the study should highlight why the study is being conducted. The purpose is clear and concise. It explains why they are working on the model for neurorehabilitation , and shows the need for the study to benefit current practice. There are added details in the ‘AIM’ section of the article that specifies they are looking at the rehabilitation of activities of daily living after a TBI. (Aadal & Kirkevold, 2011) It could have been included in the purpose statement to further identify the direction of the article. The qualitative approach used was based off of action research, and also stated it utilized the hermeneutic approach, and ethnographic data from past studies was analyzed. (Nieswiadomy, 2012) The feasibility of the study is sound. The study was able to be conducted in the environment that was picked. There were available subjects and support for the project. This study has the potential to influence current nursing practice relating to neurorehabilitation. The information gathered can help identify successful aspects of rehabilitation used and reinforcing their use. The study builds on past research as is highlighted in the “Background” section of the article. The study promotes theory testing when it calls for more research on this topic to fill a lack of “common strategies in terms of how and when to promote participation during the rehabilitation process.” (Aadal & Kirkevold, 2011)Are the major variables identified and defined? Identify and define these variables.The major variables are identified in section 1.3 Research Questions and defined throughout the study. The three research questions evaluated were:Does the rocking intervention reduce the mean time in days to passage of first flatus compared to standard care? Does the rocking intervention reduce the total mean pain Morphine Equivalent Dose (MED) medication in milligrams received compared to standard care? Does the rocking intervention reduce the mean time in days to hospital discharge compared to standard postoperative care compared to standard care? (Massey, 2010, p. 60).The major variables are the rocking intervention, reduction in the mean time in days to passage of first flatus, reduction in total mean pain MED, reduction in mean time in days to hospital discharge. Where the rocking intervention is the independent variable and the outcomes of reduction in pain, time to passage of first flatus and time to hospital discharge are the dependent variables.Have the researchers identified why the phenomenon requires a qualitative format of study? Have the researchers described the philosophic underpinnings of the research? The researchers stated that they used a qualitative approach based off of action research and the hermeneutic approach. The researchers did not come out and specify why they chose this style of qualitative research, but did note that they wanted a “humanistic perspective” on their research topic. This leads to the qualitative approach because it is based more on the individuals and subjective feelings. (Nieswiadomy, 2012) The researchers utilized information from focus group interviews which are used to gain an individual’s perspective of the topic being researched. This humanistic approach is characteristic of qualitative research. (Nieswiadomy, 2012) The researchers formulated a model based off of Hiim and Hippe’s didactic relation model. (Aadal & Kirkevold, 2011) This was used to look at the main things influencing teaching and learning and how they are formed from tasks and practice. The researchers focused on six areas that support this of initial learning premises, environmental framework, goal of the learning activity, content, learning process, and evaluation. (Aadal & Kirkevold, 2011) The researchers also used several theoretical concepts to help identify important areas of rehabilitation practice of “community of practice”, “legitimate peripheral participation” and “trajectories” from a theory called the situated learning theory. The last area they utilized to formulate their model was neuropsychological categories of “perception, attention, memory, language, emotion, and physical competencies”. Each area was used to compare and analyze the data they collected from the research.How were study procedures implemented and data collected during the study?The study had a control group, which was given only standard care after their surgery. This care included walking and sitting up in a chair that did not rock starting the first day following their surgery. The experimental group received care that included walking and rocking in a rocking chair starting the first day following their surgery. The patients were given a pen and paper and were instructed to record the date and time that they first passed flatus following their surgery. An investigator met with the patients on a daily basis to collect the data from the patients until the patients passed flatus for the first time following the surgery. The investigator also reviewed the medication records to see how much pain medications that the patients received. Finally, they looked at the length of the hospital stay following the surgery. How were subjects chosen for this study? Were inclusion and exclusion criteria appropriate? Were the selected subjects able to provide data relevant to the study purpose and research questions?The subjects were chosen because they were patients being rehabilitated from a TBI at the wards the researchers were conducting the study. There were two sets of inclusion data used in this study. One was for the preliminary testing of the model and the next set was for the interviews conducted before the patients were discharged. The inclusion criteria were appropriate to protect the subjects and to ensure that pertinent information was gathered for the research. The inclusion data greatly limited the number of participants chosen to ensure that they were able to provide information relevant to the research. Is there adequate assurance that the rights of human subjects were protected?There is adequate assurance that the rights of human subjects were protected. All of the patients had to be 21 years of age or older in order to participate in the study. The study was approved by the institutional review board prior to the study. Informed consent was obtained from each patient before they enrolled in the study. Each patient had to be able to read and speak English to be able to be eligible to participate in the study.Are you able to determine from the article that the researchers were aware of the need to protect human participants?It is implied that the researchers were aware of the need to protect human rights. Permission was obtained for the study from the Danish Data Protection Agency and the Regional Committee on Biomedical Research Ethics. Verbal informed consent was obtained from the patients. Written informed consent was obtained from clinical staff members as well as the patient’s family member since this study was being conducted on individuals with TBI. Video recordings were stopped at any signs of distress. Patients were notified they could withdraw from the study at any time without any retribution (Aadal & Kirkevold, 2011).What are identified and potential threats to internal and external validity present in the study?The amount of participants in the study was very small making it difficult to really see if there was a huge difference between the two groups. There were a variety of different diagnoses for the surgery. This could alter the time it takes for a person to pass flatus and it could cause increased pain for the patient. The patients were all given different types of pain medications according to what the doctor ordered for them. Having different pain medications given to different patients makes it difficult to tell if the rocking motion was helping to ease the pain or if was because the patient had a different pain medication given to them that worked a little better. The route of administration for the pain medication was also different. This may have increased or decreased the effectiveness of the medication.Is the data collection focused on the human experience? Does the researcher describe data collection strategies? Is saturation of the data described? Does the researcher describe the strategies used to analyze the data? Do you understand the procedures used to analyze the data? Is the strategy used for analysis compatible with the purpose of the study? Does the researcher address the credibility, auditability, and fittingness of the data? The data collected focuses on the human experiences of study participants, family, and professional staff to develop a neurorehabilitation tool including interactions that were influenced by past and present experiences. An action research model was used for the duration of the study to constantly revise and improve the tool and involved a group of rehabilitation professionals. Ethnographic data was utilized during the field test and testing process of the study to identify the culture and environment of patients with TBI. The authors detailed the strategies used to analyze the data and the reader is able to understand the process. The researched used a hermeneutic approach to analyze written data, observational data, and QSR NVIVO 8 (a computer software program) to assist with analysis of written and transcribed data. The data was interpreted to develop a tool that would encourage patient participation and contribute to the learning process during rehabilitation. Inclusion of a multidisciplinary clinical team, patients, and family contribute to the study’s credibility and the documented findings of each groups experiences on how the tool affected the rehabilitation process. The researchers provided extensive narrative on the procedures and processes used in both the field test study and the focus groups to analyze all data received with many check points to ensure auditability. Fittingness of the model could not definitely be determined the sample size was small and two of the five patients in the intervention portion of the study were not TBI but patients with brain injury of another etiology (Aadal & Kirkevold, 2011).Is the hypothesis stated precisely and in a form that permits it to be tested? Are the objectives, questions, or hypotheses logically linked to the study purpose, framework, design, and results? Are the results for each hypothesis clearly and objectively presented?The hypothesis, under the paragraph with the heading “1.2. Purpose” (60), is stated in a way that permits it to be tested. The questions, stated in the paragraph “1.3. Research” (60) are logically linked to the study. The test was based around the rocking intervention and if it helps to minimize the time that the patient first passes flatus, amount of pain, and total length of time in the hospital following the surgery. The results are clearly stated in the paragraph “3. Results” (61). The results are given in tables and they also explain them in paragraphs following the tables.Are the researchers’ conceptualizations true to the data? Do the researchers place the report in the context of what already is known about the phenomenon? The researchers’ goal was to develop a tool that health professionals could use during a neurorehabilitation process that tailors learning and participation of patients to improve discharge outcomes. Documented experiences during interventions provided positive comments from patients and clinicians that the model facilitated reflection on planning and improved patient participation that focused on individualized teaching and learning. The researcher discussed the fact that there is not a large amount of research on the phenomenon regarding improving patient participation during rehabilitation but discuss in detail several learning and teaching models (Aadal & Kirkevold, 2011). Are the results described in light of the theoretical framework and supporting literature?“Although the exact physiological mechanisms that are influenced by rocking motions are not well known, theorists and researchers hypothesize that the gentle, rhythmic, repetitive motion of rocking stimulates the vestibular nerves to send signals of pleasure and alertness to the Reticular Activating System” (Massey, 2010, p. 60). They found that the patients that who rocked in a rocking chair following surgery passed flatus 0.7 days, or 16.8 hours, earlier than patients who did not rock in a rocking chair following surgery. They found that there were no significant differences between the two groups when it came to pain and time of discharge for the patients.Do the conclusions, implications, and recommendations give the reader a context in which to use the findings? Does the researcher offer recommendations for future study? Has the researcher made explicit the significance the study to nursing?The researchers discuss the usefulness of the data obtained for health care professionals. It provides a structured guide to encourage patient participation and learning during the rehabilitation process. They discuss the possibility of improving the design to make it more user-friendly in future studies. Recommendations for future studies were discussed to include larger population and different facilities with the discussion for the possibility of a quantitative research design that includes a control group. The researchers designed the model to be used with a multidisciplinary team but discussed the importance of the model specific to nursing. They list three areas that the model can contribute to nursing: increase awareness of learning needs to personalize a nursing care plan the model, contributes to interdisciplinary planning and communication, and provides consistent care among all nurses assigned to the patients (Aadal & Kirkevold, 2011).Are the implications of the findings discussed? Are the implications for practice consistent with study conclusions? The article does discuss several implications from the study’s outcomes. First, Massey’s article (2010) states that the findings contribute to evidence-based practice as there are significant statistical and clinical findings. Secondly, the article states that rocking-chair motion is a feasible nursing intervention. Lastly, the article does imply that future research is necessary to further assess POI duration when rocking-chair motion is used. The article reinforces, in the conclusion, that rocking-chair motion does provide earlier relief of POI post operatively and therefore improves post-operative quality of life. (Massey, 2010)Study findings include no statistically significant difference between the non-rocking group and the rocking-chair group in the following areas: duration of hospital stay post-operatively and amount of pain medication needed for pain control. However, there was a statistically significant difference in duration of time between surgery and the passing of flatus. The rocking-chair group passed flatus nearly 17 hours earlier than the non-rocking group. (Massey, 2010)While Massey’s (2010) conclusion is correct in stating there is a shorter duration of POI in the rocking-chair motion group than the nonrocking group, there is no evidence that this improves pain control or shortens length of post-operative stay. Of these three studied outcomes, there was no clinical benefit to the earlier passing of flatus. The article (Massey, 2010) suggests that quality of life via relaxation from the rocking motion may be a significant benefit, however, this was not studied in the project. Based on the outcomes studied, earlier passing of flatus had no measureable benefit and therefore it cannot be said that is a necessary intervention. The article, however words the implication more carefully by saying this is a feasible intervention; which is true as there were no harmful outcomes and both nurses and patients were able to complete the task.What is the level of evidence in the Hierarchy for this study?The study was a posttest-only randomized control trial design which falls under a Hierarchy II level of evidence. Hierarchy II is defined as using one or more well designed randomized control study (Ursuy, 2013).EC: Based upon your analysis of the Massey article, could this practice of providing rocking chairs be implemented on you unit with your support?Based on the summary of the conclusion of this article provided in answer #10, I would feel comfortable using this intervention in my unit. I would feel comfortable because there were no harmful outcomes to the patient and it does not appear to be a difficult or time consuming intervention for the nurse. I would hesitate to create standard work or processes based on this intervention because of the lack of evidence for improved outcomes. While earlier passing of flatus likely improves the patient’s perceived quality of life post operatively, this was not studied. Looking only at the clinical outcomes studied, there was no decrease of pain med use and no shortened length of stay; without solid evidence, I do not feel this intervention could be enforced.EC: The analysis: Provide a supported statement that the research is strong enough or not to be used in Evidence Based Nursing Practice. The researchers were able to provide rationale on the importance in the development of an instrument to use during the rehabilitation process that promotes patient participation, improves learning, and improves outcomes. At the present time the instrument appears to be extremely detailed and a very time consuming process to use in a clinical setting. The current format does not appear to be effective or efficient for larger sample sizes. The presented information is not strong enough to support inclusion in Evidence Based Practice (Aadal & Kirkevold, 2011). References:Aadal, L. & Kirkevold, M. (2011). A model for neurorehabilitation after severe traumatic brain injury: Facilitating patient participation and learning. Advances in Nursing Science, 34(1), E1 – E17.Massey, R.L. (2010). A randomized trial of rocking-chair motion on the effect of postoperative ileus duration in patients with cancer recovering from abdominal surgery. Applied Nursing Research, 23, 59 – 64. doi: 10.1016/j.apnr.2008.06.001Nieswiadomy, R. M. (2012). Foundations of nursing research (6th e.d). Upper Saddle River, NJ: Pearson.Ursuy, Peggy. (2013). Critique of Research [Power Point slides]. Retrived from Ferris State University website: ................
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