Critical appraisal
Order Instructions:
This critical appraisal must be written in narrative format. Use headings for each section of the paper as identified in the guidelines, such as Strengths, Weaknesses, and Evaluation. You can also use subheadings of Problem and Purpose, Literature Review, and so forth as needed to organize your paper. Do not use outline numbers in this paper (i., ii., iii., etc.) or present the paper in outline format. This assignment is worth 100 points.
Guidelines for Preparing Critical Appraisal:
A. Review the chapters of your textbook (Grove, Burns, & Gray, 2013) and other research sources (i.e., Grove, 2007, articles and assigned readings, discussion board, research textbook from undergraduate program) to determine what is quality research.
B. Compare the steps in this study to criteria established in your textbook or other research sources to determine the study’s strengths and weaknesses. You can use the questions on pages 459-462 in Grove et al. (2013) to help you identify study strengths and weaknesses.
C. Evaluate the study findings using the questions in your text as a guideline (Grove et al., 2013, p. 462).
D. Prepare the critical appraisal using the following guidelines:
- Paper should be a maximum of 15 double-spaced pages of text (excluding reference list).
- Use appropriate documentation and develop a reference list using APA (2010) format.
- Write in a narrative style, not an outline format.
E. Document throughout your paper using your textbooks and other research sources to support the statements you making in your critical appraisal of the article.
Format for Critical Appraisal #2
A. Discuss the strengths and/or weaknesses of each part of the study. Compare the steps in the study with published research sources(s) to determine if the step is a strength or weakness and provide a rationale to support your decision. Document throughout. Example: The statistical conclusion design validity is a strength in this study since the researchers consistently implemented the intervention in the study based on a detailed protocol (Grove et al., 2013).
- Purpose/Problem
- Literature review
- Framework
- Objectives, questions, and/or hypotheses
- Definition of variables
- Study design: Strengths and threats in the areas of statistical conclusion validity, internal validity, construct validity, and external validity
- Intervention (if applicable)
- Sampling process
- Measurement methods
- Data collection
- Data analysis
- Discussion Section: Findings, limitations, generalizations, implications for practice, and future research.
B. Develop a final evaluation of the quality of the study. Do not just restate strengths and weaknesses. Discuss:
- Your confidence in the study findings.
- Consistency of this study’s findings with the findings from other studies.
- Readiness of findings for use in practice.
- Contribution of the study to nursing knowledge.
Document your statements with references from nursing research literature and your research textbooks.
SAMPLE ANSWER
Critical Appraisal
Cossette, S., Frasure-Smith, N., Dupuis, J., Juneau, M., & Guertin, M. (2012). Randomized Controlled Trial of Tailored Nursing Interventions to Improve Cardiac Rehabilitation Enrollment. Nursing Research, 61(2): 111-120
Purpose/Problem
The strength of this purpose section is that the problem is adequately delimited in scope so that it is actually researchable and not trivial. The problem is researchable since it is not very complex, it is important, and it can be conducted with adequate support. The other strength of this purpose section is that it narrows and clarifies the aim of the study being carried out by the researchers. It has narrowed and made clear the aim as being to establish if a nursing intervention that is focused in individual acute coronary syndrome patients’ perceptions of their illness and treatment would increase rehabilitation enrollment following discharge (Cossette et al., 2012).
The other strength of the problem is that it is significant to clinical practice and nursing. This is primarily because it illustrates whether individualized, progressive nursing interventions would lead to greater rehabilitation enrollment, and in so doing improving long-term outcome. The approach that the researchers apply in the study provides a clinical pathway to addressing the significant concerns encountered by patients following a cardiac event (Cossette et al., 2012). Equally important, this study was feasible to carry out in terms of the availability of subjects and ethical consideration. It is of note that 242 ACS patients who had been hospitalized to a specialized tertiary cardiac center were available to take part. The Research Ethics Board of the hospital reviewed and approved this research study, and there was informed consent (Cossette et al., 2012).
Literature review
The strength of the literature review section is that it is organized to show the progressive development of evidence from previous research. This is evident from the fact that Cossette et al. (2012) have critically analyzed several actual research studies whose main objective was to increase enrollment to rehabilitation. Another strength is that a summary of the empirical knowledge in the subject of the research study is presented clearly and concisely. In literature review, Cossette et al. (2012) included four randomized controlled trials (RCTs) whose aims were to increase rehabilitation enrollment. Three sorts of interventions were tested in the trials including liaison, automatic referrals, and a combination of liaison and automatic referrals. Of the four RCTs, three of them actually showed a considerable increase in rehabilitation enrollment with intervention, and one did not. The knowledge from the four RCTs has been presented in a terse and succinct manner such that the readers will find it rather easy to read and understand. Furthermore, the literature review section actually identifies what is unknown and what is already known as regards the research problem and it offers direction for the formation of the research purpose. Thus, Cossette et al. (2012) point out that there is lack of randomized and controlled trials that evaluate the effect of interventions on enrollment.
The major weakness is that the researchers focused largely on empirical knowledge in the subject matter and have not provided a summary of the current theoretical knowledge, which is of great importance for the purpose and problem of the study. Another weakness is that out of the four RCTs summarized in the review of literature, two of them are not current since they are older than 10 years. In essence, one study was conducted in 1999, the second one in 2001, the third and forth ones in 2007, hence only the last two studies that were reviewed can be considered as current.
Theory framework
The strength is that the researchers have applied a theoretical framework and it is presented in the article. Cossette et al. (2012) used the self-regulation theory, which states that people’s perception of their disease regulates their health behavior as well as risk factor management. According to this theory, cognitive and emotional processes determine disease perceptions, and thus the plan of action in a health crisis (McNamara, 2011). Ryan (2006) stated that it is essential for investigators to link the research framework they use to the purpose of the research. In this research study, Cossette et al. (2012) have linked Leventhal’s self-regulation theory to the research purpose, and this is a strength. Cossette et al. (2012) pointed out that interventions could be obtained from this self-regulation theory, and they added that nursing interventions have to strive to reframe the more conceptual representations of the event to one that are more tangible.
For research studies conducted that pertain to nursing and clinical practice, a framework should be employed by the investigators that actually relates to the body of knowledge in nursing and clinical practice (Breslow & Day, 2012). In this study, self-regulation theory applied relates to the body of knowledge in clinical practice and nursing, and this is a major strength. In this study, there is no relationship or proposition from a theory that needs to be tested; hence no proposition is identified and linked to the hypothesis of the research study.
Variable definitions
The strength of variable definitions section is that the variables are reflective of the concepts identified in the framework. It is of note that the primary outcome in this study was enrollment in the free-access rehabilitation program that was situation close to the hospital in which the patients were recruited. Enrollment for this research study was defined as having attended at least 1 session of rehabilitation within a period of six weeks following discharge from the hospital. Enrollment data were gathered in a computerized database. The other independent entry of data was also carried out by the coordinating center (Cossette et al., 2012). Secondary outcomes have been identified and included anxiety level, medication adherence, family support, and illness perception.
A major weakness of this section is that variables are not clearly defined conceptually. Nonetheless, they are clearly defined operationally. The other strength is that the variables are based on a theory, Leventhal’s self-regulation theory in particular (Cossette et al., 2012) since the 38-item Revised Illness Perception Questionnaire (IPQ-R) comprised seven dimensions of illness perception, basing on Leventhal’s self-regulation theory. Another weakness is that since there is no conceptual definition of variables in the study, the conceptual definition of a variable cannot be considered as being consistent with the operational definition.
Objectives and hypothesis
The strength of this section is that the objectives and hypothesis of the research study are expressed clearly. Cossette et al. (2012) stated that the aim of their study was to find out whether a nursing intervention focused on individual acute coronary syndrome patients’ perceptions of their illness and treatment would actually increase rehabilitation enrollment following discharge. The hypothesis is also clearly stated. Cossette et al. (2012) hypothesized that patients in the experimental group would demonstrate greater rehabilitation enrollment within a period of six months following hospital discharge after an Acute Coronary Syndrome than would patients in the control group. This hypothesis is stated to direct the conduct of quasi-experimental and experimental research, and this is another major strength of this section.
Another strength of this section is that the objectives and hypothesis are logically linked to the research purpose. In the objectives section, Cossette et al. (2012) have pointed out that the objective of the Transit-CCU clinical trial was to evaluate the effectiveness of the CCU transit nursing intervention on rehabilitation enrollment 6 months after discharge from hospital in patients who had been admitted for an acute coronary syndrome. Moreover, the objectives and hypothesis are logically linked to the concepts as well as relationships/propositions in the framework.
Study design
Validity
Construct validity is understood as to whether the operational definition of a given variable in reality reflects the factual theoretical meaning of a concept. It ensures that the researcher is actually measuring the construct that she or he wants to study, and it measures how well an experiment or test measures up to its claims (Breslow & Day, 2012). In this study, some of the threats to construct validity include (i) the apprehension of study participants about being evaluated by the researchers, and (ii) bias introduced in the research study by expectancies on the part of the researchers. The strength of construct validity as applied in this study is that the study actually evaluated the effectiveness of CCU transit nursing intervention on rehabilitation enrollment within six weeks of discharge from hospital in patients who had been admitted for an ACS.
Internal validity occurs when one can make cause and effect statements basing on the research study. Internal validity is essentially the approximate truth with regard to inferences about causal or cause-effect relationships (Breslow & Day, 2012). In this study, the strength of internal validity is that the researchers were able to conclude that their intervention made a difference. From their study, Cossette et al. (2012) found that there was a considerably higher rate of rehabilitation enrolment in the intervention group compared with the control group. For the secondary outcomes, the researchers reported that the personal control dimension of illness perception was substantially improved with the intervention.
External validity as used in research addresses the issue of the ability to generalize the research findings to other persons, places, and times (Ryan, 2006). Since this study was conducted in only one setting – a specialized cardiac hospital in Montreal, Quebec – the generalizability of the findings is limited. The threats to external validity are being able to obtain similar findings if the study was carried out in a different setting, and if similar results would be found with a different sample.
Intervention if applicable
The strength of the intervention section is that the treatment is described clearly. The intervention was based upon empirical evidence that suggested a progression in disease perceptions from the acute hospital to post-discharge. The intervention comprised three encounters. Another strength of this section is that the study framework, which is Leventhal’s self-regulation framework, explains the links between the proposed outcomes/dependent variables, and the treatment/independent variables (Cossette et al., 2012). The treatment is appropriate for examining the study purpose as well as hypothesis, and this is another major strength of this section. The researchers monitored the implementation of the treatment to ensure consistency in all the three encounters.
The design is logically linked to the sampling method as well as statistical analyses, a noteworthy strength. Another strength is that two groups were used and they appear equivalent: both the intervention group and usual care group consisted of 121 participants each. Moreover, the subjects were randomly assigned to the treatment group and comparison group. Cossette et al. (2012) point out that the participants were randomized to either the usual-care group or the intervention group, and this is a major strength of this section. The comparison and treatment group assignments were appropriate for the purpose of the study since each comprised 121 participants; an adequate number of participants that is actually appropriate for the study purpose. One weakness is that a protocol was not developed for promoting consistent implementation of the treatment to ensure intervention fidelity since it is not described in the article.
Sample selection
The weakness of this section is that the sampling method was insufficient to produce a sample that is representative. This is because the subjects were not representative of the population: 85% of them were men, and there were children or minorities. In essence, this section did not include an understudied population such as minority or young subjects, since the participants comprised largely of elderly ≥ 65 years old, and adult male patients. The strength is that the sampling criteria were appropriate for the type of study conducted. The criteria for exclusion included being discharged to a long-term care or to a short-term rehabilitation center; being unable to speak English or French; living over 50 miles from the rehabilitation center. Other exclusion criteria included having psychological, physical, or cognitive problems; already receiving outpatient follow-up; referred for surgery; having a final diagnosis besides ACS; or previously completed a rehabilitation program (Cossette et al., 2012). As such, the exclusion criterion was appropriate for the type of study conducted. The potential biases in the sampling method include excluding subjects because of the aforesaid exclusion criteria, and this is a strength since it allowed the researchers to obtain a sample that is appropriate for the study. Moreover, the sample size is adequate to avoid a type II error considering that the sample size comprised 242 participants, and this is a noteworthy strength. The other strength is that the setting used in the study is typical of clinical settings since the study was carried out in adult patients admitted for a suspected ACS at the medical ward or CCU of a specialized cardiac hospital in Montreal, and this is a strength (Cossette et al. (2012). The refusal to participate rate was not a problem since only one participant refused the initial hospital encounter because of hurry to go home, and participants filled a consent form, and this is a strength.
Measurement tools
A key strength of this section is that the measurement methods selected for the study adequately measure the variables of the study; data on enrolment were derived from a computerized database that records each appointment in the rehabilitation program. One weakness is that the measurement methods are not sufficiently sensitive to detect small differences between the subjects. As such, additional methods of measurements should have been utilized to improve the quality of the study. A noteworthy strength of this section is that the measurement methods used have adequate reliability and validity; they actually measure what they were intended to measure and have consistency since with the use of the same measurements methods, the same findings could be obtained in a similar study.
Moreover, the instruments used in the study are clearly described as Cossette et al. (2012) point out that illness perceptions were assessed with the use of a 38-item Revised Illness Perception Questionnaire, and basing on Leventhal’s theory, this questionnaire consisted of seven dimensions of illness perception. A 14-item Family Care Climate Questionnaire-Patient version was also used. The researchers assessed anxiety with the use of the state portion of the State-Trait Anxiety Inventory comprising 20 items. Another strength is that the instrument development process has been described satisfactorily considering that the instrument was developed particularly for this study. In addition, the reliability and validity of instruments have been described amply. Cossette et al. (2012) stated that they assessed concurrent validity by examining correlation coefficients with related constructs, and there was test-retest reliability.
Data collection & Data analysis
An important strength of this section is that the data collection process is described clearly. The authors used a 14-item Family Care Climate Questionnaire-Patient version, a 38-item Revised Illness Perception Questionnaire, and a 20-item state portion of the State-Trait Anxiety Inventory. A 4-item Self-Reported Medication-Taking Scale was also used to collect data, in addition to the “Are You Eating Healthy?” scale, which had 20 questions. The other strength is that the forms used to collect data are organized to facilitate computerizing the data. Moreover, the process of data collection is conducted in a manner that is consistent, and this is a key strength of this strength of this section.
Another strength is that the collected data actually address the research hypothesis and the research objectives. For instance, the Revised Illness Perception Questionnaire comprised a total of seven aspects of illness perception, and the patients’ perceptions of the support offered by their family members and relatives relating to their health situation were evaluated with the use of the 14-item Family Care Climate Questionnaire-Patient Version. Medication adherence and anxiety were also assessed. The data gathered using the various instruments address the objectives and hypothesis. No adverse events occurred during collection of data, and this is also a strength of this section. Another strength of this section is that the training of data collectors is clearly described and is adequate. Cossette et al. (2012) pointed out that they provided the study nurses with a box of sealed opaque envelopes which they opened after every patient had completed the baseline questionnaire.
The procedures for data analysis are appropriate for the type of data collected and this is a strength. Clinical and sociodemographic variables were summarized as mean ± standard deviation for continuous variables and as percentage and count for categorical variables. The procedures for data analysis are described clearly, which is also a strength of this section. The chi-square test was applied by Cossette et al. (2012) for the primary outcome. The researchers used logistic regression to evaluate models adjusting for baseline variables that were thought to influence the findings (Cossette et al., 2012). The secondary outcomes were analyzed with the use of analysis of covariance models and including the baseline score as a covariate. The other strength is that the results are presented in an understandable way by narrative and includes participant flow, sample description, intervention description, primary outcome, and the secondary outcomes (Cossette et al., 2012). Additionally, the results of the study are interpreted aptly and this is also a strength of this section. Cossette et al. (2012) reported that the findings are in line with three of the four published Randomized Controlled Trials evaluating rehabilitation enrolment after a liaison kind of intervention.
Discussion
The key strength is that the findings are discussed in relation to the hypothesis and objective. Cossette et al. (2012) stated that the findings of the study demonstrated a virtually doubling of enrolment by the experimental group relative to the control group. They added that the findings are actually consistent with 3 of the 4 published RCTs. The other strength is that the implications that were identified for practice were appropriate based on the study findings as well as the findings from previous studies, and the findings are clinically significant. Cossette et al. (2012) reported that since the literature shows that referral is an essential requirement for enrolment in rehabilitation, their study shows that a nursing intervention is able to provide a considerable benefit beyond simple referral.
The other strength of this section is that the findings are an accurate reflection of reality and valid for use in clinical practice. Another strength of this section is that various explanations for nonsignificant and significant findings are adequately examined. Cossette et al. (2012) reported that a slight but significantly greater increase was found in perceived personal control in the experimental group compared with the usual-care group, which suggests one possible explanation for the increase in rehabilitation experiment.
Confidence in the study findings
There is not much confidence in the findings considering that a small, inadequate sample size was used and this limits generalizability of results; a small proportion of the general CCU population was used. The confidence of the findings is also limited by another weakness of the study in that the study was conducted in only a single setting and did not include minorities and children. This also serves to limit the generalizability of the research findings. The study findings could have been improved if the study was conducted in multiple settings. Furthermore, more children, minorities, and more women – there were only 35 women out of the 242 participants – should have been involved. Nonetheless, the appropriate sample/participants were used, and the methodology applied by the researchers is satisfactory. In addition, the process of data collection and analysis is adequate, and so is the review of existing literature.
Consistency of this study’s findings with the findings from other studies
There is consistency of the results. The results of this research study are in fact consistent with the those of other studies. Cossette et al. (2012) noted that their findings are actually in line with 3 of the 4 published randomized controlled trials that evaluated rehabilitation enrollment after liaison sort of intervention. Just like in the study by Cossette et al. (2012), the interventions in the three trials were bedside practice nursing staff members, or nursing staffs supervising practice nurses or peers.
Readiness of findings for use in practice
Cardiac illnesses are the main causes of mortality as well as hospitalization in industrialized nations. Acute Coronary Syndromes such as unstable angina and myocardial infarction are responsible for most of the cardiac deaths and admissions (Cossette et al., 2012). The approach used by the researchers provides a clinical pathway that can be utilized in addressing the major concerns faced by patients following a cardiac event. Nursing staffs are on the forefront of offering care to cardiac patients and they really require findings such as these on which to base their clinical as well as practice judgment. The research study by Cossette et al. (2012) is a case in point of how scientific knowledge, combined with clinical practice can actually contribute to better outcomes of patients.
Contribution of the study to nursing knowledge
The research study actually contributes to the existing literature by testing a progressive intervention that was tailored particularly to the psychological and clinical trajectories of patients following a cardiac event. Individualized, progressive interventions by nursing staffs led to greater rehabilitation enrolment, thus potentially improving long-term outcomes. The study is of major importance considering that there was a dearth of randomized controlled trials that assess the effect of interventions on enrolment. The study also contributes to nursing knowledge by demonstrating that a nursing intervention could actually offer a considerable benefit beyond referral.
References
Breslow, N. E., & Day, N. E. (2012). The Analysis of Case-Control Studies. IARC Scientific Publications, 32.
Cossette, S., Frasure-Smith, N., Dupuis, J., Juneau, M., & Guertin, M. (2012). Randomized Controlled Trial of Tailored Nursing Interventions to Improve Cardiac Rehabilitation Enrollment. Nursing Research, 61(2): 111-120
McNamara, C. (2011). Analyzing, Interpreting and Reporting Basic Research Results. Boston, MA: CRC Press.
Ryan, A. (2006). Methodology: Analyzing Qualitative Data and Writing Your Findings. Columbus, OH: Springer Publishers.
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