Health care is a dynamic and forever changing field, and the professionals working within the health care field are not any different. Initial and continuing education is necessary to provide relevant and current nursing care. Critiquing research is one way to expand understanding of a subject, and ultimately make changes in practice in response to the current research knowledge obtained from studies. Additionally, nurses becoming a part of the research and critique process will often provide a background for conducting further study (Burns & Grove, 2007).
Two articles describing two different research studies were examined by the writers of this article. One was a qualitative study regarding what nursing care was regularly missed on medical-surgical units as well as the reasons for missed care. The other study was a quantitative study to compare one behavioral counseling session with five behavioral counseling sessions in the effectiveness of increasing moderate-intensity physical activity, muscle strengthening, and stretching activities in older women.
In the following paragraphs, the critiquing process will be used to evaluate the articles and corresponding research study. Problems and Purposes In the qualitative study, the missed nursing care and the regret, guilt, and frustration that followed the nurses was reported as the problem. Kalisch clearly stated that “the purpose of this study was to determine nursing care regularly missed on medical-surgical units and reasons for missed care” (Kalisch, 2007, p. 306). Although the focus group interviews provided open discussion of the reported problem, it led to a fairly big database.
Nine elements of missed care and seven themes of why care was missed were identified. Further research in each of these areas would be helpful in developing changes in nursing practice for more positive outcomes. In the quantitative study, the problem is women engage in less vigorous exercise and leisure-time activity than men, and their level of activity decreases further as they age that in turn leads to greater health problems.
The purpose of this study was to compare the effectiveness of five versus one behavioral counseling session to facilitate change in moderate- or reater-intensity physical activity, muscle strengthening, and stretching; determine the percentage of women who reach the Healthy People 2010 goal of 30 minutes of moderate-intensity physical activity five or more days of the week among sedentary women 50 to 65 years of age in a 12-week period” (Costanzo, Walker, Yates, McCabe & Berg, 2006, p. 789). Although the behavioral counseling sessions could be done by healthcare professionals other than nursing, the research is still relevant to nursing because of the negative health problems associated with lack of activity.
Nurses remain a large force in getting health education to the public. Research Objectives, Questions, and Hypotheses In the qualitative study, two research questions were clearly defined.
- What nursing care is regularly missed on medical-surgical units in acute care hospitals?
- What are the reasons nursing staff give for not completing these particular aspects of care?
The quantitative study did not present the research study in question form.
However, the research question appears to ask whether or not five behavioral counseling sessions is more effective than one behavioral counseling session in creating a physical activity behavior change with older women (Costanzo et al. , 2006). In this latter discussed study, it is inferred that the authors believe that increasing the number and length of behavioral counseling sessions and using the 5A’s can have a positive influence in helping older women increase their physical activity levels. This would be their hypothesis for the quantitative study.
A hypothesis is not needed in a qualitative study, but an aim or purpose should be stated. Variables in Published Studies Variables are only found in quantitative research because they are measurable. In the examined quantitative article, the independent variable was the number of behavioral counseling sessions. The test group had five sessions, whereas the control group only had one session. Three measurements of variables were noted: moderate- or greater-intensity physical activity, muscle-strengthening activity, and stretching activity.
These varying levels of activity were the dependent variables. The Literature Review In the qualitative study, the background states that research studies show that there are links between the levels of nurse staffing with negative patient outcomes. References are given for these sources; however, the resources are all over five years old. Kalisch concluded that there is a lack of studies regarding missed nursing care and the reasons given by nursing staff for missing these cares (Kalisch, 2007, p. 306). This in itself provides a background that further studies need to be conducted.
In the quantitative study, the authors provide more of an understanding of what the problem is and what research has already been done on the subject. Several resources such as Healthy People 2010 and the U. S. Department of Health and Human Services are provided, but again, the references are older than five years. With a new literature review conducted, it is likely that similar information could be located via the credible sources mentioned above. Framework of the Study The qualitative study focused on the subjective information that was discussed and collected from the focus group interviews.
This article did not clearly define the theoretical framework; however the framework was inferred. The theory inferred in this study was that quality of care is important for patient recovery and satisfaction. The quantitative study stated that the health promotion model provided the framework for the intervention. Nora Pender’s HPM was designed to be a “complementary counterpart to models of health protection” and focuses on individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes (Current Nursing, 2010, para. )
The integral components of the behavioral counseling intervention were based on the behavior-change intervention research from Pender’s health promotion model (Costanzo et al. , 2006, p. 787,788). Study Design The qualitative study adopts a grounded theory design which “explores how people define reality and how their beliefs are related to their reactions” (Burns & Cook, 2007, p. 66). The choice to use grounded theory research may have been influenced by the minimal amount of previous research onducted on this topic as this research design can provide a solid groundwork for other theory development. The quantitative study used “an experimental pretest/posttest comparison group design” (Costanzo et al. , 2006, p. 789) meeting the three criteria for experimental research;
- controlled manipulation of one variable (Independent)
- exposure to treatment of the experimental group while the control group has no exposure to treatments
- random assignment of subjects to either group. Adequacy of the Sample
The population sample in the qualitative study consisted of 173 individuals that worked on medical-surgical units consisting of “107 registered nurses (RNs), 15 licensed practical nurses (LPNs), and 51 nursing assistants (NAs)” (Kalisch, 2006, p. 306). Information was not presented on how the participants were selected and no further description of the participants is given. In qualitative research, quality often determines sample size instead of quantity; making the sample for this study adequate to the subject being studied.
The quantitative study used power analysis to calculate the needed sample size with a power of . 80. A minimum of 19 women were needed for each group and the study had 21 women in the intervention group and 25 in the comparison group. Inclusion/exclusion criteria were developed to assist in selecting the representative sample. The sample size was adequate for this study although the opportunity of bias exists because “the PI, who was not blinded to group assignment, conducted both the assessment and intervention” (Costanzo et al. , 2006, p. 799).
Directness of Measurement During the qualitative study, information was collected in focus group interviews with tape recorders and then fully transcribed and analyzed. Concrete measurements were not available for analysis creating an indirect level of measurement for this study. The quantitative study measured three variables with behavioral and biomarker instruments. The first variable, moderate-or greater-intensity physical activity, used the Rockport Fitness Walking Test to calculate an estimated VO^2 max for the biomarker measurement; a form of direct measurement.
The second variable was muscle-strengthening activity and was measured with two tools; a hand dynamometer and a timed sit-to-stand test. The two tools measured upper-body and lower-body strength respectively yielding a direct form of measurement. The final variable in this study was stretching activity. The sample population was tested for flexibility using a sit-and-reach test providing another form of concrete data and direct measure. During the quantitative study, behavioral markers were also part of the data collected.
For the moderate-or greater-intensity physical activity, an instrument known as the Modified 7-Day Activity Recall was used. For the remaining two variables, an activity log was to be kept by the women, however “inconsistency in return of the activity logs and lack of documentation on the activity logs yielded insufficient data for analysis” (p. 794). Measurement Error The qualitative study did not yield any numerical, measured data. The data that was used was empirical and categorized by themes. Measurement error cannot be determined in the qualitative study.
However, three opportunities for measurement error exist in the quantitative study although in a critique “you will not be able to judge the extent of measurement error directly” (p. 361). With the moderate-or greater-intensity physical activity variable, measurement error is low due to the use of an equation to calculate estimated VO^2 max. Measurement error in muscle strengthening is high unless the hand dynamometer was calibrated; however the study does not indicate if this was done. Instead, a method of taking three measurements and selecting the best of the three was used.
Measurement error in stretching activity is also high because of the possibility of operator error during the measurement process. The researcher may not have been as precise in every measurement taken and the best of three methods was used again in this test. Level of Measurement Although the qualitative study does not present data figures, it does use a nominal level of measurement. Nominal measurement is used “when data can be organized into categories of a defined property but the categories cannot be compared” (Burns & Cook, 2007, p. 363).
An example of nominal data within the study includes the seven themes defined as reasons nursing care is missed: too few staff, time required for the nursing intervention, poor use of existing staff resources, ‘it’s not my job’ syndrome, ineffective delegation, habit, and denial. The quantitative study uses two levels of measurement, interval and ratio. The moderate-or greater-intensity physical activity data is presented in ratio level measurement because it has a defined absolute zero; no activity equals zero minutes. For muscle strength and flexibility, interval level measurement is used because no absolute zero exists.
Reliability and Validity In every research study, it is important to make sure that the instruments used to test and analyze are both reliable and valid. An individual reading the study article should be able to do a small amount of research and find information about the instruments used. Reliability takes into account such characteristics as dependability, consistency, accuracy, and comparability (Burns & Cook, 2007, p. 364). The validity of an instrument is a determination of how well the instrument reflects the abstract being examined (Burns & Cook, 2007, p. 364).
The instruments used in the qualitative study were discussed under ‘Directness of Measurement’. Empirical data was extracted from the interviews of staff from two separate hospitals. This was reviewed to confirm the grounding of the analysis in the data. The interviews were tape-recorded and analyzed by NVivo, software by QRS International. QRS International is a dependable company with three international offices, four industry awards, 12 software releases and over 400,000 clients from more than 150 countries. Unfortunately, the qualitative study does not mention reliability or validity of this instrument in text.
The quantitative study used five instruments for data measurement. Two instruments in the moderate-or greater-intensity physical activity were the Modified 7-Day Activity Recall that is reported to have “sensitivity, construct, and concurrent validity” (Costanzo et al. , 2006, p. 792) and the Rockport Fitness Walking Test that has test-retest reliability in women aged 50-69 and validity (p. 793). Muscle –strengthening activity used two instruments as well, the hand dynamometer and the time sit-to-stand test.
The former has “test-retest reliability and predictive validity for upper-extremity strength” (p. 93) and the latter has “test-retest reliability, criterion-related validity, and discriminate validity” (p. 793). Finally, stretching activity used a sit-and-reach test that has “high test-retest reliability and criterion-related validity for hamstring flexibility in women” (p. 793). Statistical Tests In the qualitative study, strength of data analysis is reviewed instead of statistical tests because no numerical data is generated to assess. The article does not mention how many research associates were involved in the analysis of the initial transcribed interview; however it alludes to it being a single person.
At the end of the report, the results were compared to other research studies that have been performed that corroborate the findings. The categories and themes of the study are revisited although no concrete solutions were drawn. The quantitative study used RM-ANOVA “to assess and determine differences in the effectiveness of the interventions” (Costanzo et al. , 2006, p. 794). A nonparametric statistic, Ridit Analysis, was used to determine the proportion of women who met the Healthy People 2010 goal of increased physical activity.
With the use of independent t-tests, the groups were compared from baseline to 12 weeks on all study variables. Findings/Significance The results from the qualitative study determined that nine themes existed as regularly missed nursing care: ambulation, turning, delayed or missed feedings, patient education, discharge planning, emotional support, hygiene, intake and output documentation, and surveillance. Seven themes were also identified as causes for these missed cares: too few staff, time required for a nursing intervention, poor use of existing staff resources, ‘It’s not my job syndrome’, ineffective delegation, habit, and denial.
It was found that increased staffing may help to alleviate these disparities in nursing care, however would not alone solve all of the problems. Education is a starting point to help heal the causes of missed nursing care. This study has clinical significance to the nursing field because it validates issues that many nurses already sense but cannot express. It includes supporting documentation of previous studies and recommends further quantitative research. The results in the quantitative study found “no significance differences…between the groups” (Costanzo et al. , 2006, p. 794).
This result may have no clinical significance to the field of nursing; however significance was found regarding the Healthy People 2010 goal of increased physical activity. After 12 weeks, 47. 8% of the intervention group and 40. 0% of the comparison group “exceeded the Healthy People 2010 goal of 30. 0%” (p. 797). Statistical significance could be applied in future studies. Implications The implications for evidence-based practice cannot from this single qualitative study be determined. Instead, it could be used as a reference for future studies, such as quantitative research to develop evidence-based practice.
The quantitative study article was can not provide clear support for the use of behavioral counseling sessions to increase activity in older women from a pure statistical aspect. However, the second goal for the study was met; it provided evidence that the 5 A’s and behavioral counseling can help women meet the Healthy People 2010 goal for increased activity in older women. The clinical and statistical significance differed in the quantitative study. Generalizing the Findings The results of the qualitative findings were not conclusive by themselves.
Other research was used to support the validity of the results and further research will be needed to confirm or create any changes in evidence-based practice. Understanding the cares that are missed in nursing practice and reasons why those cares are missed is an important piece of knowledge to affect change in the future. The quantitative findings were separated into two parts. The statistical information that focused on the three variables could not provide significant differences in the two experimental groups.
The second part of the study that focused on the Healthy People 2010 goal showed significant data that this research study could help the population meet this goal. Conclusion Evidence-based practice is a goal that the nursing profession strives for. Critiquing studies, along with synthesizing the findings and applying the scientific evidence, is an essential step in practicing evidence-based nursing. ”An intellectual research critique is a careful, complete examination of a study to judge its strengths, weaknesses, logical links, meaning, and significance” (Burns, 2007, p. 445).
Critique guidelines provide the researcher a tool to identify the strengths and weaknesses of a study, which can lead the direction of future research. Differences exist between qualitative and quantitative research studies. Identifying the research type is an initial step in the critiquing process. Applying the research to nursing practice is the next step to building the evidence-based practice that this profession is striving toward. The two articles included in this study, qualitative and quantitative, provide examples of how both types of research are needed to build a stronger foundation for health care.
