Research Study Critique



Research Study Critique

Mary Dewitt and Terri Sand

Ferris State University

Abstract

The content of this paper is based on a review of a research article which focuses on nursing practice. The main focus of the study was to determine whether the implementation of a mobility protocol on hospitalized patients made an effect on patient’s functional status during hospitalization and following discharge. A review of the article along with a formal critique based on the guidelines set forth by Nieswiadomy is presented. Provided are statistical characteristic of the study’s measurements and methodology. The study’s purpose, hypothesis, and data collecting methods are strongly presented, along with its conclusion and implications for future nursing practice.

Keywords: research, statistics, protocols, nursing, evidence

Research Study Critique

This paper provides a critique conducted on a research paper which presents the implementation of nursing mobility protocols. Evidence related to patient’s outcomes, hospital length of stay, and functional status improvement or decline was assessed throughout the study in relation to nursing mobility protocols for patient care. The research process conducted within the article is critiqued using the Nieswiadomy text (2008) criteria for critiquing in order to evaluate the strengths and weakness of the research and determine its usefulness as evidence. The information obtained from the critique will determine whether the internal and external validity of the research is strong and reliable enough to be used as evidence for guiding nursing practice.

Purpose and Problem

Evidence

“The purpose of the study was to determine the impact of a nurse-driven mobility protocol on functional decline” (Padula, Hughes, & Baumhover, 2009, p. 325). It is important for older adults to maintain activities of daily living, especially those that are pertinent to self-care according to the authors. Nurses can minimize functional decline in hospitalized patients by initiating a mobility protocol. The purpose was to “lay the foundation for the development of standards of care for mobility in the hospitalized patients” (Padula et al., 2009, p. 325).

Support

A research problem addresses areas that need additional study in nursing care. The problem states the area that needs additional studying. “In a published study, the purpose frequently is reflected in the title of the study stated I the study abstract and restated after the literature review” (Burns & Grove, 2011, p. 145). A research purpose focuses on the specific goal of the study according to Burns & Grove (2011). “The purpose also includes the variables, the population, and often the setting for the study” (Burns & Grove, 2011, p. 146). While the purpose in the mobility study does indicate the population as “hospitalize patients”, it also addresses the setting, “the hospital”, it does not reflect variables.

Analysis

The problem statement is strong as the statement is clear and expresses the goal of the study. It is stated in the abstract. The problem statement is written in a single declarative sentence. The problem stated does not indicate that the study will be ethical and there is no mention of ethics. However, it does imply that the study can help prevent decline. Therefore, it can be assumed its intention is not to harm patients. This study does make the feasibility of the study apparent in the reading of the problem statement. This study clearly indicated its significance to nursing practice, as its impact is intended to develop standards of care to improve care.

Review of Literature

Evidence

The article presents a review of literature related to the study during its introduction and problem statement section. References are made regarding research results of multiple study’s which are related to the problem. These are examples of what information is known about the problem and what information the study will focus on in order to gain more evidence related to the problem. The article sources 28 different references of which 19 of the references are cited during the review of related literature section. The references are cited as secondary references and there is no evidence that these articles were critiqued. The references cited are dated ranging from the 1980’s to 2008 (Padula, Hughes, & Baumhover, 2009).

Support

The review of literature in published studies provides a background for the problem being studied (Burns & Grove, 2011, p.189). This is an important section of a research article. The scope of a literature review must be both broad enough to allow the reader to become familiar with the research problem and narrow enough to include only the most relevant sources (Burns & Grove, 2011, p.190). Relevant resources should be directly related to the topic of the study and current. Current sources are those published within 5 years before acceptance of the manuscript publication (Burns & Grove, 2011, p.190). The literature reviewed section should be easy to identify and contain primary resources. A good-quality literature review logically builds a case for the study being reported (Burns & Grove, 2011, p.193).

Analysis

The article provides the reader with multiple research references related to the study and the identified problem. The references provide a background for the problem but some of them are outdated. There is no heading identifying the Review of Literature section of the study. This makes it difficult to follow the focus of the study. Most of the references are secondary sources which creates a potential for interpretations. Most of the citations are paraphrased. This also adds to the potential for interpretations. I think the Review of Literature section of this article is a weak area because it lacks organization and proof that the articles presented have been critiqued to provide evidence of their quality.

Theoretical/Conceptual Model

Evidence

The article begins with multiple references from studies which are related to the problem being stated. The goal of the study, “the goal of this study was to determine the impact of a mobility protocol on functional decline in hospitalized patients” is presented amongst these examples (Padula et al., 2009, p. 325). The goal is clear but the actual theory and conceptual model of the study is not clarified. Results of previous studies related to mobility and patient outcomes are provided. There is not a defined heading which clearly states the Theory or Conceptual Model of the study.

Support

Theory is defined as an integrated set of defined concepts and statements that present a view of a phenomenon and can be used to describe, explain, predict, and control that phenomenon (Burns & Grove, 2011, p.249). Theories are expressed in an abstract manner. “Abstract means that the theory is an expression of an idea, apart from any specific instance” (Burns & Grove, 2011, p.228). An abstract idea is a general idea. A Conceptual Model is closely related to a theory but it is even more general in nature and broadly explains a phenomenon, expresses assumptions, and reflects a philosophical stance (Burns & Grove, 2011, p. 228). It is important to have a strong framework in a study. A framework must identify and define the concepts and the relational statements or propositions being tested and sometimes includes a model or map (Burns & Grove, 2011, p. 249).

Analysis

Through analysis of the study, the Theoretical/Conceptual Model section of the article is weak. The author presents a goal for the study, but there is no clear presentation of the theory’s concepts. Without defined concepts, there are no propositional statements to guide the research. The study lacks defined concepts, variables, or terms used within the article. The author fails to identify the concepts of the study or provide a framework in which the proposed idea is to be tested. There is no heading which introduces the framework or definition of the terms. The lack of organization throughout the material presented makes it difficult to follow the logic of the research.

Hypothesis and Research questions

Evidence

The study hypotheses were stated clearly under the Study Purpose headings. The study hypotheses were: (1) older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge and (2) older adults who participate in a mobility protocol will have a reduced LOS (Padula et al, 2009, p. 327). A clearly stated list of research questions were not found in the article.

Support

“A hypothesis is a formal statement of the expected relationships between two or more variables in a specified population” (Burns & Grove, 2011, p.167). It is important for a research study to have a clearly identified hypothesis. “A clearly stated hypothesis includes the variables to be manipulated or measured, identifies the population to be examined, and indicates the proposed outcomes for the study” (Burns & Grove, 2011, p. 167). Along with a clearly stated hypothesis, a quality research study should have clearly defined research questions. Clearly defined research questions provide clear direction for the conduct of the study (Burns & Grove, 2011, p. 164). Research questions in a study should be precisely presented, reflects the study’s purpose, and is presented with a clear focus (Burns & Grove, 2011, p. 163).

Analysis

This area of the study is mixed in strength. The hypotheses of the study are clearly stated. They are clearly stated and written in the present tense. The stated hypotheses identify an independent variable. The research design of the study is identified, which includes a defined control group along with the independent and dependent variables. The population of the study is vague as it is presented as “older adults”. There are directional statements present in the research hypothesis of the article but they are difficult to associate with the theory because the article lacks propositions. The conceptual framework of the study is weak, which makes it difficult to associate the hypotheses statements to the framework of the study. Although the presence of a defined hypothesis makes this section a stronger area of the study, the lack of a precise population and research questions weakens the ability of the study to provide a critical appraisal of the research. This also makes the hypothesis difficult to test.

Research (Study) Design

Evidence

“This study used a nonequivalent control group design” (Padula et al., 2009, p. 327). The study included an independent variable of the mobility protocol and the dependent variables of functional status and length of stay.

Support

“Research design is a blueprint for conducting a study” (Burns & Grove, 2011, p. 254). “The purpose of a design is to maximize control over factors that can interfere with the validity of the study findings” (Burns & Grove, 2011, p. 253). The concepts important to design according to Burns and Grove (2011), include causality which discusses the basic cause and effects of a study (p. 253). This leads us to multi-causality, which refers to a more complicated multiple cause of a given to a single phenomena. The probability in a study, “addresses relative rather than absolute causality. A cause may not produce a specific effect each time that particular cause occurs (Burns & Grove, 2011, p. 254). Bias is deviation from what is expected and control is a very important element in a research design as it indicates the “power to direct or manipulate factors to achieve a desired outcome” (Burns & Grove, 2011, p. 255). In the use of a nonequivalent control group design we are aware that the control group is not selected by random means. According to Burns & Grove (2011), control groups are not used because of the difficulty of obtaining them. In some studies experimental and comparison subjects are selected from the same pool of potential subject (p. 255). “These groups cannot be considered equivalent, however because of the subjects in the comparison group usually differ in important ways from those in the treatment group” (Burns & Grove, 2011, p. 271).

Analysis

The design of this study is weak even though the design is clearly identified. There are threats to the internal and external validity of the design due to the non equivalent comparison group. The authors attempted to control threats by using screening tools such as the min-mental exam; however, the groups are not equivalent due to the lack of control group which indicates a selection bias. It is important to have two equal groups to compare to in order to apply to nursing practice.

Sample and Sampling Methods

Evidence

“The researchers recruited a convenience sample (n=50) of adults 60 years or older who were admitted with medical diagnoses to 1 of 2 nursing units (n=25 each)” (Padula et al., 2009, p. 327). The eligibility criteria included length of stay more than three days, an ability to understand the English language, and participants must be without physical impairments that would limit the ability to mobilize. Cognitive status was determined by completion of a mini-mental status examination with a score of 24 or more. Surgical patients were rejected due to limits in mobilization associated with surgery. ”Sample size statistics were conducted to determine adequate power and supported a total number equal to 50” (Padula et al., 2009, p. 327).

Support

According to Burns & Grove, one of the most troublesome questions that arise during the critical appraisal of a study is whether the sample size was adequate, if the study was designed to make comparisons, and significant differences were found” (Burns & Grove, 2011, p.308). In order to analyze the sample size in a quantitative study, a power analysis is done. A power analysis detects the ability to reject the null hypothesis based on whether there was enough evidence to detect differences or relationships that actually exist in a population. "An increasing number of researchers include the power analysis to evaluate sample size and adequacy in a study and these results are posted under the study's Sample and Discussion section" (Burns & Grove, 2011, p.308). “A convenience sampling also called an accidental sampling is a weak approach because it provides little opportunity to control for biases; subjects are included in the study merely because they happen to be in the right place at the right time” (Burns & Grove, 2011, p. 305). According to Burns & Grove, these samples may contain multiple biases some which may be difficult to recognize however they are not always serious biases and a convenience sample is acceptable when it is used with reasonable knowledge and care (2011).

Analysis

The sampling procedure of this study is overall weak. The study does identify the sampling procedure as a convenience sampling and it is described. The sample size of this study is adequate. However, the method of sampling is weak and subject to bias.

Data Collection Methods

Evidence

Data collection tasks include selecting subjects, collecting data in a consistent way, maintaining research controls as indicated in the study design, protecting the integrity of the study, and solving problems that threaten to disrupt the study. Data collected included a sample of 50 adults aged 60 years or older with medical diagnoses. The Criteria used included a length of stay of three or more days and the patients included must be able to understand English. “The research nurse screened a total of 453 patient records for eligibility; of those 84 eligible subjects were enrolled” (Padula et al., 2009, p. 327). According to Padula et. al., 34 subjects were withdrawn from the study, this included a variety of reasons including discharge, transfer off the unit, occurrence of a disqualifying procedure, and one client withdrew because of illness-associated anxiety (2009).

“An advanced practice nurse with expertise in gerontology and geriatrics was hired to collect data and was trained by the geriatric clinical nurse specialist and the principal investigator” (Padula et al., 2009, p. 328). “The training given to the nurse specialist included; human subject’s protection and achievement of high-level proficiency with the protocol and data collection instruments” (Padula et al., 2009, p. 328). A demographic data collection sheet was developed for this study which included such information such as age; gender; primary diagnosis; use of assistive devices; fall-risk assessment; presence of any restrictions to mobility; use of occupational or physical therapy; LOS; first and number of times out of bed; and type of out-of-bed activity were derived from chart review (Padula et al., 2009, p. 328). “Data related to the out-of-bed activity were derived from chart review and corroborated by discussion with nursing staff and individualized patients” (Padula et al., 2009, p. 328).

The data was analyzed using a program called Sigma Stat (Padula et al., 2009, p. 329). According to Padula et. al, sample size statistics were calculated to detect differences between the groups. “Descriptive statistics were completed for study variables and comparisons between the groups on baseline characteristics were examined” (Padula et al., 2009, p. 329). Inferential statistics were used to calculate differences between the treatment group and the control group.

Support

During either quantitative or qualitative research, the investigator performs five tasks during data collection process these tasks are interrelated and run concurrently, rather than in sequence. According to Burns & Grove, these tasks include selecting subject, collecting data in a consistent way, maintaining controls, protecting the integrity and solving problems that threaten to disrupt the study (2011). “Data collection is the process of acquiring the subjects and collecting data for the study” (Burns & Grove, 2011, p. 361). According to Burns & Grove, the researcher focuses on obtaining subjects and collecting data in a reliable fashion (2011). It is important to describe the data collection in such a way to describe the data collection process, maintaining research controls, protecting the integrity of the study, and solving the problems that threaten to disrupt the study. “The result is a step-by-step description of exactly how, where, and in what sequence the researcher collected data” (Burns & Grove, 2011, p. 361).

Analysis

The data collection was overall strong as this study is a convenience sampling and this report has described in detail the subject recruitment process. Consistency has been maintained during the data collection for each collection event. This supports the validity of the data collection process. While there are little controls in a convenience sampling the author has described in detail factors which eliminated subjects from participating in this process. This study also describes in detail the training of the individual who performs the data collection. However this study does not describe the Sigma Stat program nor does it discuss how the research controls were maintained.

Measurement (Instrument)

Evidence

The article presents the instruments in which it uses to measure the findings and outcomes of the study. Various tests are described. These include the Barthel Index (BI), and the Up and Go test. "The BI is a subjective measure that measures the capacity of an individual to perform identified ADL (personal hygiene, bathing, feeding, toileting, stair-climbing, dressing, bowel control, bladder control, ambulation, and chair/bed transfer)"(Padula, 2009, p. 328). It also stated that a modified version was used which added a 5-point rating scale for each item to improve sensitivity to detecting change (Padula, 2009, p. 328). A quantitative estimate of level of dependence was obtained, ranging from 0 (totally dependent) to 100 (totally independent) (Padula, 2009, p. 328). The Get Up and Go test was described and its use in the measurement of the study was explained. This test is an objective assessment that measures subjects’ ability to stand from an armchair, walk 3 m, turn around, return, and sit down in the chair again (Padula, 2009, p. 328). The Mini-Mental State Examination was explained including the scoring scale and its focus. "A Mini-Mental State Examination was routinely conducted to evaluate cognitive status (Padula, 2009, p. 329).

Support

It is important that studies present their method of data measurement. These rules allow individuals to be consistent in how they perform measurements; thus, a measurement method used by one person will consistently produce similar results when used by another person (Burns & Grove, 2011, p. 328). The purpose of measurement is to produce trustworthy evidence that can be used in examining the outcomes of research (Burns & Grove, 2011, p. 366). Also included in the study, is information related to the study's reliability and validity. It is important to critically appraise the measurement methods and data collection process of a published study for threats to validity (Burns & Grove, 2011, p. 367).

Analysis

The study provides a good description of the measurement tools used to evaluate the study's outcomes. Statistical values and programs were included in the article which would allow others to duplicate the tests. Included was the identification of subjective and objective material and the adjustments that were made to the measurement tools to make them more sensitive. Overall, I feel that the measurement section of this article is a strong section of the study.

Data Analysis (Descriptive and Inferential Statistics)

Evidence

The use of Descriptive and Inferential Statistics was presented with this study. Descriptive statistics were completed for variables and comparisons between the groups on baseline characteristics were examined (Padula, 2009, p. 329). Characteristics of the sample included adults 60 years or older, hospital LOS of 3 or more days, ability to understand English, without a physical impairment that would significantly limit ability to mobilize, and cognitively intact (Padula, 2009, p. 327). Sample size statistics were conducted to determine adequate power and supported a total number equal to 50 (Padula, 2009, p. 327). Characteristics of the nursing staff involved during the study are presented in Table 1 (Padula, 2009, 327). Differences between the treatment and control group on the dependent variable were calculated using inferential statistics (Padula, 2009, p.329). Table 2 provides a good display of statistical information regarding study subjects.

Support

In any study in which the data are numerical, data analysis begins with descriptive statistics (Burns & Grove, 2011, p. 383). Researchers use descriptive statistics primarily to describe the characteristics of the sample from which the data were collected and to describe values obtained from the measurement of dependent or research variables (Burns & Grove, 2011, p.383). The research study sample is grouped using a frequency distribution method. Grouped frequency distributions are used when continuous variables are being examined (Burns & Grove, 2011, p. 384). Many measurements are taken during data collection. These include weight, age, and scale scores. The data are measured using a continuous scale and rules have been established to guide classification systems (Burns & Grove, 2011, p.384). The ungrouped frequency distributions of descriptive statistics are presented in Table 1 of the article. Descriptive statistics can be used to describe differences between either groups or variables and these values may be summarized in a table (Burns & Grove, 2011, p.389).

Analysis

The study fails to present critical information required to determine the strength of the statistical methods used for the research, making this a weak section. The article does adequately present research information with a good description of the sample population which was used for the study. The variables being considered are presented clearly along with the statistical programs chosen for the data collection. The treatment and control groups are recognized and the author identifies that the use of inferential and descriptive statistics have been used during the study. The descriptive statistics have presented material regarding demographic characteristics of the treatment and control groups. The article does present Table 1 and Table 2 which provides a good display of the descriptive measurement of the variables in the study. Although it is mentioned that differences between control groups and treatment groups were calculated using inferential statistics, the article does not provide information specifically addressing the particular statistical tests that were used for the study. Without a clear presentation of the inferential testing, degrees of freedom, and the level of significance used to address the inferential statistics for the study, it is difficult to determine whether the study chose the appropriate inferential tests.

Study Conclusions, Implications, & Recommendations

Evidence

“Limitations of the study include the recognition that the lower functional level of the control group, though not significant, could have contributed to increased LOS and/or later ambulation” (Padula et al., 2009, p. 330). “Although differences between the groups on baseline characteristics were not detected, it is possible that the differences existed and affected the findings (Padula et al., 2009, p. 330). Other limitations as discussed by Padula et al. (2011)

include the presence of an advanced practice nurse on the control unit and the use of the “Go test“ as an objective measure in functional levels which remained in question (Padula et al., 2009, p. 330). In this study, ambulating in the hallway seemed to be more effective than chair rest and even ambulating in the room. This may be because ambulation in the hall requires significant strength, balance, and coordination” (Padula et al., 2009, p. 330). Conclusions identified according to Padula et al. (2009) indicate that this research supports existing literature that identifies functional decline actually begins in the preadmission period (Padula et al., 2009, p. 330).

Support

“In forming conclusions, the researcher uses logical reasoning, creates a meaningful whole from pieces of information obtained through data analysis and findings from previous studies, remains receptive to subtle clues in the data and considers alternative explanation of the data” (Burns & Grove, 2011, p. 412). “Recommendations for further study may include replications or repeating the design with a different or larger sample, using different measurement methods or testing a new treatment” (Burns & Grove, 2011, p. 415).

Analysis

Overall this part of the study is somewhat strong. The author makes one very important implication that was derived from this study regarding the importance of walking patients in the hall as opposed to chair rest or walking in the patient’s room. The conclusion of this paper stated that the objectives were met and this study supported current literature that states mobility protocol is the most effective when it is started in the preadmission period. Despite the limitations of this study there are no recommendations for further studies.

Study Findings

Evidence

“Findings suggest that early and ongoing ambulation in the hallway may be an important contributor to maintain functional status during hospitalization and to shortening length of stay” (Padula et al., 2009, p. 329). “Ambulation should be viewed as a priority and as a vital component of quality nursing care” (Padula et al., 2009, p. 330). According to Padula et al. (2009) both hypothesis 1 that older adults will maintain or improve functional status who participate in a mobility protocol, and hypothesis 2; those who participate in a mobility protocol have a reduced length of stay have also been supported in this study (Padula et al., 2009, p. 330).

Support

Results in a study are translated and interpreted to become study findings. “Implications are based on but are more specific than conclusions and they provide specific suggestions for implementing the findings in nursing” (Burns & Grove, 2011, p. 414). “The strongest findings of a study are those that have both statistical significance and clinical importance” (Burns & Grove, 2011, p. 410). Burns & Grove (2011) go on to explain that clinical importance is how the findings are related to the practical relevance of the finding. It is often difficult to judge how much statistical change warrants clinical importance (Burns & Grove, 2011, p. 411).

Analysis

The study findings are moderately strong as they are presented clearly. Each study hypothesis is addressed separately and the findings are supported. Since there is no clear study framework the findings are not described in relation to the study framework. There are clear implications suggested for nursing practice.

Conclusion

The purpose of the study presented in the article was to create a foundation for the development of mobility protocols in hospitalized patients. A summary of the evidence presented throughout the research article provides support that the purpose for the study is significant and there is significant reason to pursue the development of mobility protocols to guide nursing practice. Although the article contains a mix of strong and weak evidence, it does provide support that mobility protocols can improve patient outcomes. Overall, the study presented in the article is a good source of evidence to contribute to the recommendations for mobility protocols but further studies should be conducted to strengthen the existing evidence.

References

Burns, N., & Grove, S.K. (2011). Understanding Nursing Research (5th ed). Maryland Heights, MO: Elsevier Saunders.

Nieswiadomy, R. (2008). Foundations of Nursing Research (5th ed.). Upper Saddle River, New Jersey: Pearson Education.

Padula, Ph.D., RN, C. A. Hughes MSN, N., C., & Baumhover RN, NS, BC, L. (2009, February 24, 2009). Impact of a Nurse-Driven Mobility Protocol on Functional Decline In Hospitalized Older Adults. J Nurs Care Qual, 24(4),325-331.

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