Running head: GROUP CRITIQUE
Group Critique of: Impact of a Nurse-Driven Mobility Protocol on
Functional Decline in Hospitalized Older Adults
Kristine Cargill, Cheryl Nienaber, Bailey Sundberg
Ferris State University
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Abstract
The purpose of this paper is to take a quasi-experimental research study, Impact of a
Nurse-Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults
(Padula et al., 2009), and critique it for the proper use of the 14 steps of the quantitative
research process. The authors use Burns and Groves’ (2011) book, Understanding
Nursing Research: Building an Evidence-based Practice, to support their reasoning of
finding the study weak in all areas except for the authors’ purpose statement.
Keywords: quantitative research, quasi-experimental study, problem, purpose,
literature review, theory and conceptual framework, hypotheses, research design,
sample, measurement and data collection, instruments, data analysis, study
findings, study discussion, study conclusion
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Group Critique: Impact of a Nurse-Driven Mobility Protocol on
Functional Decline in Hospitalized Older Adults
Nursing research is the foundation for nursing practices. As defined by Burns and
Grove (2011) “nursing research is a scientific process that validates and refines existing
knowledge and generates new knowledge that directly and indirectly influences nursing
practice” (p. 4). Solid, detailed research helps to develop, guide, and improve evidence
based nursing practices. The research process of the article, Impact of a Nurse-Driven
Mobility Protocol on Functional Decline in Hospitalized Older Adults (Padula, Hughes,
& Baumhover, 2009) will be critiqued in this paper. The group used the textbook,
Understanding Nursing Research: Building an Evidence-based Practice (Burns & Grove,
2011) to guide and support the critiquing process, while evaluating the strengths and
weaknesses of the study.
Purpose Statement
Evidence
This article focused on mobility issues of elderly patients related to
hospitalization, with the purpose of the study “to determine the impact of a nurse-driven
mobility protocol on functional decline in hospitalized older adults” (Padula, Hughes, &
Baumhover, 2009, p. 326). For this study, participants were 60 or older, with a hospital
stay of three or more days. Previous studies have documented the increase in
dependencies of activities of daily living [ADL] and functional decline in older adults
after hospitalization. The researchers hope to decrease the length of stay [LOS] of older
patients and keep or increase their functionality with a mobility protocol (Padula et al.,
2009, p. 325).
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Support
Purpose statements describe the focus of the study, or why the study is being
conducted (Burns & Grove, 2011). According to Burns and Grove (2011) “the goal of a
study might be to identify, describe, or explain a situation; examine the effectiveness of
an intervention, or determine outcomes of health care” (p. 146). Included in purpose
statements are several additional components including: where the study takes place, the
subjects being studied, and other variables. The purpose gives direction for the research
study and without a purpose the audience would not know why a study is being
conducted.
Analysis
The article clearly defines and includes the components of a purpose, making the
purpose statement a strong section of the study. A clearly defined purpose statement
informs the reader where the author is going with the study. The purpose statement in the
article describes the components as follows: the population as older hospitalized adults,
the independent variable as the mobility protocol and the dependent variable as the length
of stay and functional status (Padula et al., 2009, p. 325). The authors’ purpose describes
the goal of the study and how it may impact those involved.
Problem Statement
Evidence
Research has shown a positive correlation between lack of mobility in acute care
settings and increased LOS. The importance of achieving optimal health in order to
promote continued independence, and the ability to maintain ADL are addressed (Padula
et al., 2009, p. 325-326). While studies have shown that older adults who are a part of
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early mobilization, physical, and occupational therapies have a higher rate of positive
outcomes, evidence based guidelines have not been published (Padula et al., 2009,
p.325).
Support
According to Burns and Grove (2011) “a research problem is an area of concern
in which there is a gap in the knowledge base needed for nursing practice” (p.146). There
are three distinct areas that need to be addressed in order to define the problem. First,
what is the concern and why is it important to this population? Next, why is this
significant to the population that is studied? And third, what is the current situation that
needs to be studied and changed if relevant (Burns & Grove, 2007, p.146).
Padula et al. (2009) state, "research has demonstrated that low mobility and bed
rest are common during acute hospitalization" (p.1). Because of this research the authors
hope that their study would, “lay the foundation for the development of standards of care"
(p. 1). The authors support the significance of the problem by reminding the reader, "that
given the majority of hospitalized patients in the United States are older than 65 years,
this is a problem of great clinical significance" (p. 1).
Burns and Grove (2011) state, “not all published studies include a clearly
expressed problem, but the problem can usually be identified in the first page of the
paper” (p. 146). According to Padula et al. (2009), “a stay in the hospital often results in
complications that lead to functional decline” (p.1). While this information may be true,
reasons for the increased complications and LOS are unknown. Padula et al., (2009) also
goes on to state, “new functional deficits during hospitalization are also less likely to
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recover lost function” (p. 326). The problem statement is vague, and the reader must
uncover the true problem while reading through a majority of the first two pages.
Analysis
The problem statement is not strong in the groups’ opinion. Although the problem
statement in the article and textbooks are similar, the article lacks concrete statistical
information in the opening paragraphs to invite the reader to continue with the research.
The article clearly states that the study is in regards to older population however it fails to
list a range of participants at this point in the research.
By reviewing the problem area of this article, it is possible that this would have
been placed in the recycle bin. A clear problem statement would enhance the knowledge
of the audience. While information is given throughout the article, the lack of interest
would not have allowed for those seeking information to reach the target information.
Literature Review
Evidence
Padula et al. (2009) used a variety of sources in what is assumed to be the review
of literature section. The section is not clearly defined with its own heading, instead it is
presented in the introduction section prior to the purpose statement. The authors listed 28
references at the end of their study, 16 of which are present in the assumed review of
literature section. Five relevant primary sources were used. Upon research of the group
these sources were found to consist of: one prospective multi-center study, one
correlation research, two prospective cohort studies, and one quasi-experimental study.
However, only two of the five primary and relevant sources were discussed in the
narrative by name, and both lacking description as to the type of study done, and the year
GROUP CRITIQUE
done. These studies were completed by, “Brown CJ, Friedkin RJ, and Inouye SK (2004)”
and “Brown CJ, Roth DL, Peel C, and Allman RM (2006)” (Padula, et. al, 2009, p. 331).
The authors also included seven primary sources that were outside the five-year
time frame to be considered relevant. The age range of these sources is from 1993-2003.
Upon further research by the group into these seven sources it was found that all of them
seem to have direct correlation with the purpose of this study based on their abstracts.
Five of these sources were mentioned in the narrative by name, however, again lacking
the year the study was completed. In some instances such as the description of study
performed by Covinsky KE, Palmer RM, Fortinsky RH, et al (2003), the authors included
that this was a “descriptive study of 2293 older adults’ ADL function during an acute
hospital stay, found that 35% of patents had worse ADL function at discharge compared
with preadmission baseline” (Padula, et al., 2009, p. 326).
The final four sources used by Padula, et al. (2009) were secondary sources, two
of which upon further investigation by group, and based on abstracts listed in the
CINAHL database had no direct relationship to the purpose of their study. Only one of
the secondary sources were cited in the narrative by their names, Callen BL, Mahoney
JE, Wells TJ, Enloe M, and Hughes S. (2004) with a brief mention that Callen, et al,
“found little research specific to mobility changes during hospitalization” (Padula, et al.,
2009, p. 326).
Support
Burns and Grove (2011) state, “a review of literature provides you with the
current theoretical and scientific knowledge about a particular problem, enabling you to
synthesize what is known and not known” (p. 189). After the authors of a study have
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stated their problem statement the literature review should then provide the reader with
three concepts: “a description of the current knowledge”, “identification of the gaps in
this knowledge base”, and “the contribution of the present study to the building of
knowledge in this area” (p.189). However, it is important to note that whether primary or
secondary sources are used, the source must be relevant. Burns and Grove (2011) define
relevant sources as those “with direct bearing on the problem of concern…and published
within five years of the acceptance of the manuscript for publication” (p.190). Finally the
difference between primary sources and secondary sources is the author. In a primary
source the author is also the one who completed the study or research, and thus provides
any researcher with highly credible information regarding the topic (Burns & Grove,
2011, p. 191-92). A secondary source “summarizes or quotes content from primary
sources” which could result in the authors’ works being interpreted differently (Burns &
Grove, 2011, p.192).
Analysis
The Review of Literature [ROL] section was not labeled, and actually based on
assumption of the section considered review of literature preceded the purpose statement.
The ROL section was comprehensive in the fact that it covered much material, however,
not concise or even cohesive. It was difficult at times to determine why this information
presented was important to the article. This could have been relieved by having the ROL
section follow the purpose statement and clearly identified with a heading. Further, as
previously assessed by group the problem statement in this article was unclear, and based
on ROL section it remains unclear. The authors used many sources: five primary sources
that were less than five years old at time of publication, seven primary sources greater
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than five years old, including two studies that could be considered landmark sources.
Finally there were four secondary sources, two of which had no bearing on topic of this
article.
Many of the secondary sources were used only for their statistical information,
however, all information was paraphrased and the authors also paraphrased several
secondary sources at one time without clearly stating what information came from what
source. Throughout the entire assumed ROL section the authors jumped from sources,
and then would return to sources in another paragraph. This added to the confusion for
the reader trying to keep sources strait. It would have been better if the authors stuck to
one source at a time and critiqued/summarized all of it before moving to the next.
Further, the sources were rarely introduced with the author’s names or the year of
publication leaving the reader to flip from content to reference page through the entire
assumed ROL section.
Of the eight studies called out by name by the authors, seven were primary
sources, however only two sources were within the five-year relevant time frame.
However the other five were credible, significant studies that had direct bearing on the
problem and purpose of this article. Having primary sources greater than five years old
shows that this problem has been researched before and has significant influence on
obtained evidence based practice guidelines for the formation of mobility protocols in the
elderly hospitalized for acute conditions.
In conclusion it is the opinion of the group that had the study of Padula et al.
(2009) should have clearly stated their ROL section with a proper heading that followed
the purpose statement. The authors also should have selected four or five primary
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sources, both within the five-year time frame and those that are considered landmark
sources to fully describe and critique in this section. The authors should have been listed
in the narrative of the ROL section, with the year of publication clearly stated as well. By
reviewing and appraising one source at a time and thoroughly would have helped flow
this section logically and enhanced the importance of the problem being discussed.
Theory and Conceptual Framework
Evidence
The article clearly stated that model and training were provided for staff
members. Evaluation and Specific Interventions for Successful Healing [GENESIS]
“includes a nurse-driven mobility protocol that served as the intervention for this
research” (Padula et al., 2009, p. 328). This study focuses on elderly patients and the
framework appears to be appropriate as the GENESIS model includes a mobility protocol
which states “nurse is directed to question orders for bed rest as well as to routinely
evaluate the necessity of obstacles to mobility such as urinary catheters (Padula et al.,
2009, p. 328). The GENESIS model is suitable to measure the stated goals of the study.
Padula et al., (2009) also used other measurements in the study. The Get Up and
Go test provides an objective assessment with criteria that can be measured not only for
this study but also for future studies. The mini mental exam is used to evaluate patients,
however, “the significant other’s perception of the patient’s abilities was assessed”
(Padula et al., 2009, p. 329). The final measurement tool was the Barthel Index (BI). This
test measures the subjective data in relationship to ten basic ADL’s.
Staff training included four hours of education including the importance of
adhering to the mobility protocol. Ambulation, mealtime activities, restroom concerns,
GROUP CRITIQUE
and barriers were reviewed with staff members prior to the start of the study. The
integrity of the research is strengthened by the clarification that “treatment and control
groups were on different floors of the hospital, and nurses did not float between the units,
minimizing the chance of intervention affecting the control unit” (Padula et al., 2009, p.
328).
Although the sample population selected was a convenience sample, stringent
variables are used to strengthen the overall study. The Mini-Mental Status Exam was one
variable used to measure the ability of the patient to participate in the study. Other
variables included the length of stay, and the ability to understand (Padula et al., p. 327).
The concepts are clearly defined in the research. The audience is able to understand the
connection between the variable and why each one was chosen. The research must be
presented in such a way that removes potential barriers, such as non-English speaking
patients. It is assumed that the population of the site, Miriam Hospital, is a facility that
predominately speaks English.
The variables stated are “the independent variable was mobility protocol;
dependent variables were functional status and length of stay” (Padula et al., 2009, p.
327). Propositional statements that are used to guide the research include the hypothesis
statement, “(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).
Support
When reviewing an article to determine the worthiness of the content, a variety of
thoughts must be considered. A theory is “the initial inspiration for developing a study”
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(Burns & Grove, 2011, p.227). However, what lead to the inspiration of the theory is the
quest for additional knowledge. As concepts are considered, the researcher pulls together
information that seems to support the phenomena to attempt to “describe, explain,
predict, and control” the expected outcome (Burns & Grove, 2011, p. 228).
Burns & Grove (2011) states that a “framework is a brief explanation of a theory
or those portions of a theory that are to be tested in a study” (p. 227). A researcher uses
the framework to build a strong foundation for the study; a stepping-stone to expand on
the current knowledge base. The framework of the theory has four key elements. Each of
the four areas are interwoven to produce the strength of the theory. Burns & Grove
(2011) listed “concepts, definitions of concepts, relational statements, and map or model”
as the elements used to understand theories (p. 230).
Concepts provide the audience with the big picture, an overall basis for the
theory, thus a stronger concept will provide a stronger theory. While it is possible to use
the terms construct to give an overall view, the term variable is used to strengthen the
validity of the research due to its narrow definition (Burns & Grove, 2011, p. 230).
Analysis
While some may view this section as a strong, others will not. It is clear that the
background of the audience is needed to validate the strength of this research article.
While it is clearly stated that the GENESIS model is used as a framework for this study,
some audience members may not have heard of this model. BI scores are compared to
Frail Elderly Functional Assessment, and while this is meaningful in the study, the scores
are subjective, and thus could be dependent on other factors not considered in the study.
The Mini-Mental State Examination measures the significant other’s perception; again,
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this is not a clear-cut assessment tool. Outside factors such as optimism, faith and
expectations play into the measurements. Scores for the Up and Go test are defined and
measurable and can be reproduced in future studies, making this a strong assessment tool.
Audience members who are unfamiliar to any of these measurement tools will have
difficulty understanding the importance of their use in this study. While all of these tools
are clearly operational, since they are associated with numbers, the lack of understanding
how these numbers are achieved provides additional frustration to the audience. Thus
leading to confusion and lack of clarity as to why the researcher chose these particular
instruments and this model as a part of the framework.
The goal of this article is to provide information that can be used to validate
current practice, or to review existing protocols and make adjustments to ensure the best
outcomes for our patients. As an audience member, the pure effort needed to examine the
term GENESIS, would leave questions regarding other possible terms used that would
need to be researched. The purpose of a study is to help the audience comprehend the
information provided, not to cause additional work. While the intent of the researcher is
positive, the lack of background information of the research tools leaves a negative tone
to the audience. Therefore, this area of the article must be viewed as a weak area. If the
audience is lost, the results are meaningless.
Hypotheses
Evidence
The article states two hypotheses, “older adults who participate in a mobility
protocol will maintain or improve functional status from admission to discharge and,
older adults who participate in a mobility protocol will have a reduced LOS” (Padula, et
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al., 2009, p. 327). The variables listed being, “the independent variable was mobility
protocol and dependent variables were functional status and LOS” (p.327).
Support:
According to Burns and Grove (2011) the “hypothesis is a formal statement of the
expected relationship(s) between two or more variables in a specified population” (p.
167). A study can have any number of hypotheses that “translate the research problem
and purpose into a clear explanation or prediction of the expected results” (p.167).
Hypotheses are used to predict the outcome of the study; therefore, the purpose of the
study dictates the type of hypotheses used. There are four categories of hypotheses,
“associative verses casual, simple versus complex, non-directional versus directional and,
null versus research” (p. 167). An associative hypothesis “proposes a relationship among
variables that occur or exist together in the real world”, but do not state that “one variable
causes an effect on another variable” (p. 167). However, casual hypotheses do “propose a
cause-and-effect interaction between two or more variables” (p.170). The difference
between simple and complex hypotheses are the number of variables present in the study,
two variables means the hypothesis is simple, three or more means it is complex (p. 172).
A non-directional hypothesis is defined as one that “states that a relationship
exists but does not predict the nature of the relationship” (p. 173), where as a directional
hypothesis does predict the nature of the “interaction between two or more variables” as
either positive or negative (p. 174). Finally, a null hypothesis is “used for statistical
testing and for interpreting statistical outcomes”, it essentially states that the researchers
expect “no relationship between two variables” (p. 174). The opposite of the null
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hypothesis is the research hypothesis, which will “state that a relationship does exist
between two or more variables” (p. 175).
Analysis:
This study clearly identifies two hypotheses immediately following the purpose
statement. Both statements are clear, concise, and declarative as evidenced by including
the word “will” (Padula et al., 2009, p. 327). The group believed that the problem
statement section of this study was not strong, however, the key identified or assumed
variables to the problem were lack of mobility protocols, decreasing functional status in
patients, and longer lengths of stay resulting from decreased functional status. Therefore,
the group agrees that these stated hypotheses are directly tied to the study problem.
As also identified by the group, the framework for this study the GENESIS
program for geriatrics, contains an age-specific mobility protocol and set of interventions,
therefore with the framework being a mobility protocol it can be said that both
hypotheses are derived from the framework. Both of the hypotheses included the
population to be “older adults”, however, should have included the exact parameters of
older adults that was not directly indicated until discussion about the sample. Further,
neither of the hypotheses indicated directly the independent or dependent variables until
research design section following the stated hypothesis. It can be assumed the variables
by the reader in the hypotheses statements, however, if you are going to directly label
them why not do so with the hypotheses themselves.
Both of the stated hypotheses are casual, complex, and directional. They both
state a “cause-and-effect relationship between two or more variables” (Burns & Grove,
2011, p. 170), contains a total of three variables, and also they both state the exact nature
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of the relationship (p. 174). The hypotheses are research hypotheses, therefore, the null
hypothesis is implied to be the exact opposite of the hypotheses, thus that mobility
protocols do not have any effect on functional status or length of stay in older adults.
Finally, both hypotheses are testable which is discussed in the next section of research
design.
Research Design
Evidence
The authors of this article describe the research design as a nonequivalent control
group design. The authors also list the independent variable as the mobility protocol and
two dependent variables functional status and length of stay (Padula et al., 2009, p. 327).
Support
According to Padula et al. (2009), “a research design is a blueprint for conducting
a study” (p. 253), which help control items that would impede validity. The more control
a researcher has over the study the more valid the study becomes and research designs
help to provide control over the study. Further, controlling variables and studies helps
reduce biases (p. 253).
There are many different types of experimental designs. A few examples of
research designs are: quasi-experimental design, experimental, and non-experimental
research design. Quasi-experimental design is a study design about cause and effect. This
design “facilitates the search for knowledge and examination of causality in situations in
which complete control is not possible” (Padula et al., 2009, p. 270). Comparison groups
are used in this design and participants are randomly assigned to the experimental or
comparison group. Experimental research designs can vary but all focus on casualty or
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cause and effect. Non-experimental research designs do not control variables, subjects, or
conditions.
Nonequivalent control group design is a form of quasi-experimental research
design. This design uses pretest and protest where one group receives a specific treatment
and the comparison group does not receive the specific treatment, however, the
comparison group does receive a standard of care. Subjects are chosen from the same
group of possible subjects and then choose whether to receive treatment or not to receive
treatment. This research design does not randomly select the comparison group. “These
groups cannot be considered equivalent, however, because the subjects in the comparison
group usually differ in important ways from those in the treatment group” (Padula et al.,
2009, p. 271).
Analysis
The authors did have a designated section with a heading for the research design
method; however, this section was weak. The author used a nonequivalent control group
design which means the experimental group and the comparison groups were not equal.
Internal validity is threatened in this study because the groups were not equal. The
authors believed that participants that followed the mobility protocol would have
improved functional status and length of stay in the hospital. If the groups were not equal,
other factors may have contributed to the outcome of the study. The author did
acknowledge that other factors may have influenced the outcome. If the groups were not
equal, then the audience may have doubts that the mobility protocol affected the length of
stay and the functional status results. Also, the audience may question whether the same
results would occur in a similar study.
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Sample
Evidence
The article clearly identifies the target population under the sample section, as
adults “age 60 and older, and admitted with a medical diagnosis to one of two nursing
units (n=25 each)” (Padula et al., 2009, p. 327). While the hospital population is
obviously much larger, the researcher chose to use a convenience sample from within
these two units as subjects for the study. As with any reliable study the researcher
described the sampling method used to select participants. Functional status, “LOS,
ability to understand English, no physical impairment, and cognitive function all were
part of the inclusion criteria” (Padula et al., 2009, p.327). The exclusion of subjects was
based on a score below 24 on the Mini Mental Status Examination, transfer from the unit
prior to the end of the study, and a LOS under three days (Padula et al., 2009, p. 327).
A total of 84 subjects were enrolled into the study for those that were eligible; 34
withdrew for a variety of reasons. The attribution rate for the study was 17% and the
retention rate was 100%. “Sample size statistics were conducted to determine adequate
power and supported a total number of 50” (Padula et al., 2009, p. 327). The researcher
utilized two homogeneous units related to “size, patient population, and unit staff
composition” (Padula et al., 2009, p. 327).
Support
A researcher would find it nearly impossible to study all individuals in order to
create a theory. Instead, the researcher will select a sample; “sampling involves selecting
a group of people, events, behaviors, or other elements with which to conduct a study”
(Burns & Grove, 2011, p.290). By using specific criteria the researcher will be able to
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focus on the individuals that will provide evidence that the theory is correct, or prove that
not enough sufficient evidence exists to confirm the hypothesis of the theory. “If a study
is of high quality with finding that are consistent with previous research, then the
researchers can be confident in generalizing their finding to the target population” (Burns
& Grove, 2011, p.291).
Many steps are necessary to ensure that the sample is representative of the
population. To start, we can use the example in Burns and Grove (2011) regarding
diabetes; the target population would consist of all diabetics (p. 290). With the target
population identified it now is necessary to determine who “the portion of the target
population to which the researcher has reasonable access” (Burns & Grove, 2011, p.290).
Next, is to determine the inclusion, what makes the person part of the population that the
researcher wants to study, or the exclusion criteria, what characteristic does the individual
possess that may pose a threat to the validity of the study. The objective of the researcher
is to acquire homogeneous subjects. The similarity of the subjects will provide a basis for
the study thus allowing the researcher to make a generalization when complete (Burns &
Grove, 2011, p. 290).
The sample must be representative of the population. Researchers conduct studies
using a variety of methods dependent on the goal of the study. “A simple random sample
is the most basic of the probability plans. It is achieved by randomly selecting elements
for the sample frame” (Burns & Grove, 2011, p.299). This process can be thought of as a
raffle, each person eligible is considered to have an equal chance at being selected by
pure chance. Stratified random samples are groups from within a larger group. For
example a high school may contain four levels of students: freshmen, sophomores,
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juniors, and seniors. To make sure each group is appropriately represented, the same
number of subjects will be chosen from each grade level. Cluster sampling uses a macromicro approach; researchers start with the largest group possible and then narrowing the
focus to make a generalization regarding the group (Burns & Grove, 2011, p. 299).
Burns and Grove (2011) also list systematic sampling, quota sampling, and nonprobability sampling as ways to obtain subjects for a study. However, one of the weakest
types of sampling is the convenience sample. Subjects are chosen purely because they are
in the “right place at the right time” (p. 305). Researchers will often use convenience
samples due to low cost and easy accessibly of the subjects. They feel that in the
healthcare field it is often better to use a convenience sample thus increasing the sample
size by including all of the potential subjects who meet the specified criteria (Burns &
Grove, 2011, p. 305).
Sample bias is a major concern with convenience samples. “Bias in a study
distorts the findings from what the results would have been” (Burns & Grove, 2011, p.
254). However, by recognizing this as a potential complication, researchers can design
the study to limit the number biases and therefore create a stronger foundation for the
study. While not all biases are evident, by critically evaluating study methods, treatment,
and tools, the biases can be recognized and reported in the study (Burns & Grove, 2011,
p. 254).
Analysis
The researcher listed the target population for the study and attempted to use
inclusion and exclusion criteria that would make both units as homogeneous as possible.
While this effort did strengthen the overall point of the study, there are multiple variables
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that were not addressed. Criteria that should be reviewed include the random selection of
the patients in the study. How would the results differ if the subjects were randomly
divided into equal groups on each floor instead of having one floor as a treatment group
and the other as no treatment? The sample size (n = 25 each unit) is based from a
convenience sample; the relatively small size can easily cause bias within the results.
Although the adequate power of the study does support the size, in reality, the study
design is still weak due to the convenience sample method.
The mobility of each patient is not only based on the efforts of the health care
staff but also the efforts of the individual patient. The mindset of the individual will aid
the staff to facilitate increased mobility providing an enhanced outcome to the client.
Social factors are not considered within the study framework. Family, friends, neighbors,
groups, and organizations are all key components to be considered. The focus of the
study is on seniors’ age 60 and older, the hospital setting may be the only social contact
for the patient; this lack of social support may decrease the initiative of the patient to
participate with the mobility protocol. Again, we do not know if this was a concern or if
there were equal support systems in place on both units.
Overall health and co-morbidities were not discussed. As an audience we are
unaware if this was addressed, and if so, how similar were the groups? The characteristics
of the nursing staff are provided for each unit yet it fails to mention the experience level
of each unit. While the nurses did not float between floors to work, the opportunity still
existed for staff to share experiences and ideas (Padula et. al, 2009, p. 327). These
questions leave the audience to ponder if the treatment was successful or if other factors
came into play and made the difference between the treatment and control groups.
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Measurement and Data Collection
Evidence
For this study, an advance practice nurse was hired to collect data. The nurse had
experience in the geriatric field and was also trained by the investigator and a geriatric
clinical nurse. Padula et al. (2009) state that, “training included human subjects’
protection and achievement of high-level proficiency with the protocol and data
collection instruments” (p. 328). The research nurse screened all patients using the study
instrument, which was tested for reliability prior to this study until an acceptable level
was reached. If patients met eligibility requirements, they received an information letter
regarding the study (p. 328).
A data collection sheet was used to collect data for this study. The tool was used
to gather data such as: “age, gender, primary diagnosis, use of assistive devices, fall risk
assessment, presence of any restrictions to mobility (eg. bed rest order, foley, oxygen use,
restraints), use of occupational or physical therapy, LOS, first and number of times out of
bed, and type of bed activity” (Padula et al., 2009, p. 328). The other tools used in this
study were the Get Up and Go test and the BI. These tools will be described in further
detail in the instrument section below. The data was collected at Miriam Hospital, an
acute care hospital, on two separate but similar units in size, patient population, and
nursing staff. The collection process occurred within 48 hours of admission; however, for
the BI instrument, self-perception of functional status was measured at two weeks before
admission, at admission, then at discharge (Padula et al., 2009, p. 328).
GROUP CRITIQUE
Support
According to Burns and Grove (2011), “data collection is the process of acquiring
the subjects and collecting the data for the study” (p. 361). The data collection process
should be detailed in the research study and the steps should be clear, although different
with each study depending on the design and measurement techniques. The steps or
process of data collection consists of five tasks completed simultaneously: “selecting
subjects, collecting data in a consistent way, maintaining controls, protecting the studies
integrity, and solving problems that threaten the study” (Burns & Grove, 2011, p. 362).
The process of selecting subjects that meet criteria, descriptions of those that decline
participation, measurements, and time and setting of measurement should be included in
the report as well (Burns & Grove, 2011, p. 362).
“Measurement is the process of assigning numbers or values to individuals’ health
status, objects, events, or situations using a set of rules” (Burns & Grove, 2011, p. 327).
There are four different levels of measurement: nominal, ordinals, interval, and ratio.
Each level of measurement has a statistical test that is used. According to Burns and
Grove (2011), nominal-scale measurement is used when subjects or objects will be
placed “into categories of a defined property”, such as gallbladder stone and cellulitis (p.
329). Three rules exist for categories in nominal measurement; they must be exclusive,
exhaustive, and not orderable (Burns & Grove, 2011, p. 329).
Ordinal-scale measurement must also be exclusive and exhaustive; however, the
categories can be ranked (Burns & Grove, 2011, p. 328). The category intervals are
unequal, meaning there may be a difference between the rankings. The interval-scale
measurement has numerically equal intervals (Burns & Grove, 2011, p. 329). The
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GROUP CRITIQUE
categories in this scale are exclusive, exhaustive, and orderable. This scale lacks a zero
point and represents a range of values.
The ratio-scale measurement “meets all of the rules of other forms of
measurement: mutually exclusive categories, exhaustive categories, ordered ranks,
equally spaced intervals, and a continuum of values” (Burns & Grove, 2011, p. 330). This
is considered the highest level of measurement and has a zero point. Ratios help
determine the differences among groups and determine the strength of relationship
between the groups.
Two items that may affect data collection are Hawthorne effect and researcher
effect. The Hawthorne effect occurs when subjects act in a certain way because they
know they are in a study. This effect may cause unintended outcomes to studies or
experiments. The researcher effect occurs when the researcher is bias or influences
certain behaviors of subjects in the study creating conditions that are not equal or
identical. Avoiding these effects allows for increased validity of the study.
Analysis
The data collection section was not detailed thoroughly by the authors, making
this section weak. The information regarding data collection was spread throughout the
article and not confined to its own section. The data collection is suppose to answer the:
who, what, where, when, and why of a study. In this study the authors did not include the
length of time it took to collect the data for all participants. The article did state that data
was collected within 48 hours of admission and a time frame for the BI instrument was
provided (Padula et al., 2009). The authors stated who collected the data, the advance
practice nurse, and described some of her background to let the audience know the
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GROUP CRITIQUE
25
collector had experience with geriatrics. The data was collected on two units but the
authors did not describe what type of units they were and the type of unit could
potentially affect the outcome; however, the authors did state the two units were similar.
The authors did not discuss why the data they collected was collected; however, a
description of what data was collected was listed as described above such as fall risk
assessment.
The level of measurement was not provided the audience, leaving questions
regarding the statistical analysis of this study. By not providing the audience with the
measures, the audience does not know if the study is using the correct statistical tests.
This is a threat to internal validity. Also, the audience does not know if Hawthorne or
researchers effects affected the data collection in this study, which would be a threat to
external validity. In return, the audience is left to question whether the outcome is
affected by Mobility Protocol or the how the data was collected.
Instruments
Evidence
The authors began by using a data collection sheet,
developed specifically for this research and included such
information as age; gender; primary diagnosis; use of
assistive devices; fall risk assessment; presence of any
restrictions to use of occupational or physical therapy;
LOS; first and number of times out of bed; and type of outof-bed activity (Padula et al., 2009, p. 328).
GROUP CRITIQUE
The authors determined functional status using “the modified BI and the Up and
Go Test” (Padula et al., 2009, p. 328). Compared to the original BI, “the modified version
used, retained the original 10 items but included a 5-point rating scale for each item to
improve sensitivity to detecting change” (Padula et al., 2009, p.328). Individual test
results will range from, “0 (totally dependent) to 100 (totally independent)” (Padula et al.,
2009, p.328). The BI is taking the place of the traditional assessment of Frail Elderly
Functional assessment as “researchers have proposed the BI as the standard for clinical
and research purposes” (Padula et al., 2009, p. 328). The two were shown to exhibit
“correlations of … 0.91…the interrater agreement of r = 0.793 was reported for the
overall BI score” (Padula et al., 2009, p. 328).
The second “objective assessment” tool, was the Up and Go Test. The authors
stated. “the get up and go test has been shown to be reliable and valid and is reported to
correlate with the BI at r = -0.78” (Padula et al., 2009, p. 328). Test scores for the Get Up
and Go Test are given “on a 1 to 4 scale, 1 being “able to rise in a single movement and 4
being unable to rise without assistance” (Padula et al., 2009, p. 328). Finally the authors
measured cognitive status using the “mini-mental state examination” without offering any
information on reliability and validity. Participants who “score[d] less than 24, the
significant other’s perception of the patient’s abilities [were assessed]” (Padula et al.,
2009, p. 328).
Support
According to Burns and Grove (2012), reliability deals with the “consistency of
the measurement method” and reliability testing is the “measure of the amount of random
error in the measurement technique” (p. 332-333). There are three areas that reliability
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GROUP CRITIQUE
testing focus on, “stability, equivalence, and homogeneity” (Burns & Grove, 2012, p.
333). An instruments’ stability or test-retest ability “is concerned with the consistency of
repeated measures, of the same attribute, with the use of the same scale or instrument”
(Burns & Grove, 2012, p. 333). There is also interrater reliability, which measures the
equivalence between “two versions of the same-pencil-and paper instrument or of two
separate observers” (Burns & Grove, 2012, p. 333). There is not a specific value at which
“interrater reliability is unacceptable, however, any value below 0.80 should generate
serious concern about the reliability of the data or of the data gathered” (Burns & Grove,
2012, p. 333). What the interrater value means for a value of 0.80 is that there is 80%
reliability and 20% random error, obviously the less the random error the more reliable
the instrument.
Finally, homogeneity is the final type of reliability testing used “primarily with
paper-and-pencil instruments or scales to address the correlation of each question” with
the others in the instrument (Burns & Grove, 2012, p. 334). Also known as a measure of
the internal consistency, reliability of 0.80 is considered strong for an instrument that has
been used multiple times in the past, however, a new instrument having a reliability of
0.70 is considered acceptable. Again, the higher the reliability, the less chance there is of
random error.
Validity of the instruments is a measurement of how well the instrument “reflects
the abstract concept being examined” (Burns & Grove, 2012, p. 334). According the
Burns and Grove (2012), “no instrument is completely valid…validity will vary from one
sample to another and one situation to another” (p. 334). Evidence of validity are
presented in published studies in three common ways: “contrasting groups, convergence,
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GROUP CRITIQUE
and divergence” (Burns & Grove, 2012, p. 335). Evidence of validity from contrasting
groups is the tested when the same instrument is completed by two separate groups
“known to have contrasting scores” (Burns & Grove, 2012, p.335). Evidence of validity
from convergence deals with a new instrument being compared with an existing
instrument, where as evidence of validity from divergence deals with two instruments
including one that measure the direct opposite of the concept under study (Burns &
Grove, 2012, p. 335). For example: “if the newly developed instrument is a measure of
hope, you could make a search for an instrument that measures despair…if the divergent
measure (despair) is negatively correlated with the other instrument (hope) that validity
of both instruments is strengthened” (Burns & Grove, 2012, p. 335).
Analysis
The instrument section of this published study is clearly labeled, and consists of
three separate instruments: BI, Up and Go Test, and Mini-mental state examination. The
authors clearly described the BI test, how and when it was administered, and that this
instrument measured the self-perceived ADL functional ability of the patient. The authors
mention the Frail Elderly Functional Assessment and provide evidence of validity from
convergence of 0.91, which based on the text increases the validity of the new instrument
of BI. However, the evidence of validity cited in the study is cited from another study,
indicating that the authors themselves did not verify the validity of the BI. Further the BI
and the Frail Elderly Functional Assessment are not equal instruments: as the BI is purely
subjective and the Frail Elderly Functional Assessment is both subjective and objective,
nor did the authors state the test of validity. Further while the BI was mentioned to be the
new standard, the authors neglected to include this in the narration part, and only cited
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GROUP CRITIQUE
their source. The type of reliability testing done for the BI was not concretely stated, it
leaves the readers to assume the authors chose equivalence or interrater reliability which
resulted in a reading of r= 0.793, which is .007 below the unacceptable value.
The instrument, Get Up and Go, the authors stated that it was reliable and valid,
however, based on another study’s conclusions, appearing to the reader that the authors
did not test the reliability and validity themselves. According the study cited, the BI and
Get Up and Go test correlate at r = -0.78 (p. 328). The authors did not express the type of
validity completed on the two tests, leaving the reader to individually determine that it
was from divergence, based on the fact the authors described this test as objective.
According to the text having negative correlation strengthens both instruments. Nothing
related to reliability or validity was mentioned about the third instrument used, the minimental state examination, borrowed from another study or completed by the authors
themselves.
There is a huge threat to internal validity in this study based on instrumentation.
First, the levels of reliability and validity of both the BI, and Get Up and Go test were
cited from another study, no information was given to conclude that it was even
measurement on the same type of sample. Also the BI instrument is a pencil and paper
instrument given at admission inquiring about two weeks prior to admission, at admission
for present level of mobility, and again at discharge. Therefore, the answers achieved are
in question, and results invalid because the question arises as to whether taking the same
test more than once produces real results or results based on seeing the same questions
before.
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30
Data Analysis (Descriptive Statistics)
Evidence
The article includes frequency data regarding the research. Ungrouped frequency
revealed the use of 23 men and 27 women in the study, and also the number of
participants that used assistive devices prior to admission. Occupational and physical
therapy participation is noted along with use of restraints. Grouped frequencies list where
the patients were living prior to admission. Measures of central tendency include the
mean age of 80.4 and 6.7 as the mean number of diagnoses. Measurements of dispersion
utilize the age range of 62 to 97 years old. Standardized scores were not utilized in this
study as the groups were evenly divided between the treatment and the control group
(Padula et al., 2009). Table one provides various information regarding the two units that
were used for the study.
Support
Researchers need to help the target audience understand the population that was
used, and which measurements were utilized to explain variables present in the study.
Four key areas to understand are “frequency distribution, measures of central tendency,
measures of dispersion, and standardized scores” (Burns & Grove, 2011, p. 383).
Frequency distribution is divided into two classifications: grouped and ungrouped.
While ungrouped provides data that is discrete such as sex, gender, ethnicity, ungrouped
distribution is used for continuous information like age, weight, and time (Burns &
Grove, 2011, p. 384). Measures of central tendency include the mode, median, and mean.
While each of these represents a point of information, each does so in its own unique
way. The mode simply is the “numerical value or score that occurs with the greatest
GROUP CRITIQUE
frequency” (Burns & Grove, 2011, p. 385). To find the median the data is placed in
numerical order and the number in the middle is the median. If there are an odd number
of items, then the two numbers in the center are added together and divided by two to
obtain the median. The mean is the “sum of the scores divided by the number of scores
being summed” (Burns & Grove, 2011, p. 387).
Measures of dispersion allow the researchers to provide information that cannot
be obtained from the mode, median, or mean. While the range of a measurement is
simple to figure out, it is sensitive to numbers that are extreme in one direction or
another. A “variance value has no absolute value and can be compared only with data
obtained using similar measures” (Burns & Grove, 2011, p. 388). The standard deviation
is used to help understand the relationship of the data. In a normal bell shaped curve
“68% of the values will be within one standard deviation above or below the mean, 95%
will be within 1.96 standard deviations above or below the mean, and 99% will be within
2.58” (Burns & Grove, 2011, p. 388).
Standardization of scores is necessary in order to make accurate comparisons.
Raw scores are calculated and given a Z-score. Thus, when comparing two groups that
are unequal in number, the researcher can use a Z-score to measure both the uniqueness
and the similarities of groups (Burns & Grove, 2011, p. 388). A scatterplot is frequently
used to show a graphic view of the data. By placing information in the graph researchers
can look for patters and often reveal “the degree of relationships between the variables”
(Burns & Grove, 2011, p. 389).
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32
Analysis
The article does provide basic information to begin to understand the groups that
were used in this study. However, a table listing each participant’s age, diagnosis, LOS,
BI score, Up and Go score and other variables would provide a better picture for readers
to grasp both the commonalities and the distinct differences between the groups. It is
important that the researcher noted that the groups are comparable, yet to strengthen this
claim a chart would provide additional information at a glance. Slightly over 50% of the
participants had either occupation therapy or physical therapy ordered. Of this group
(which the author again states is approximately equal) how did this effect the overall
outcome for the patient? Was it those who received this therapy that scored the highest
gains in mobility, or those that were assisted only by nursing staff? How is it possible to
compare this group with those not receiving therapy and yet claim that mobility by the
nursing staff increases patient outcomes? Unfortunately, the descriptive statistics leaves
the audience with more questions than answers. The author might consider adding a chart
to future studies to strengthen the information provided for easier understanding of the
audience.
Data Analysis (Inferential Statistics)
Evidence
Fall risk scores for subjects prior to admission was scored at P=.07. Table two
uses Barthel scores for preadmission, admission, and discharge. Improvement in
discharge scores from preadmissions, P=.05 and decrease in discharge scores from
preadmission, P=.006. Other scores include out of bed to chair, P=.05; ambulation in the
hallway, P=.007; LOS P<0.001 (Padula et al., 2009, p. 329).
GROUP CRITIQUE
Support
The goal of the researcher when selecting a population is to gain as much
information as possible to support the given claim. From there “an inference is made
from the study findings obtained from a specific sample and applied to a more general
public” (Burns & Grove, 2011, p. 378).
A t-test is used to “test for significant differences between two samples” (Burns &
Grove, 2011, p. 404). While it is possible to encounter a type I error if this test is used
incorrectly, the t-test remains general accepted unit of measurement. A t-score can be
used for relatively small sample sizes and provides a slightly wider confidence interval
than a z-score.
Analysis
The author does not do a very good job of presenting the information here. There
is very limited statistical information to make inferences. These few statistics provided
are meant to assist us in deciding if there is enough evidence to pursue further research in
this area, or if there is not enough evidence to support the claim. The limited size of the
study (n=25) in each unit, along with the P-value leave room for errors in the study. An
alpha score should be utilized in this study as this article pertains to nursing which tends
to operate on an alpha = 0.05. While it is not useful to make the criteria extremely
limited, the author does not place enough information in here to fully appreciate the
potential for increasing mobility to provide better functioning. More testing and
measurements need to be evaluated in order to consider this study truly helpful.
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34
Study Findings
Evidence
The study was to research two separate hypotheses. First, “older adults who
participate in a mobility protocol will maintain or improve functional status from
admission to discharge” (Padula et al., 2009, p. 327). The authors indicate that this was
supported through their results. The researchers present results indicating the BI score of
the treatment group had greater improvements over the control group (P=0.05).
Hypothesis two states “older adults who participate in a mobility protocol will have a
reduced LOS” (Padula et al., 2009, p. 327). This hypothesis is also supported (P <.001)
according to the authors.
Support
Findings from a study represent the information gained by researchers through
testing. As evidence is evaluated, the researchers begin the process of exploring the
significance of the findings. “Significance may be associated with the amount of variance
explained, the degree of control in the study design to eliminate unexplained variance, or
the ability to detect statistically significant differences” (Burns & Grove, 2011, p. 410).
Some studies are clearly more important than others, and several may not be important
for years. “The strongest findings of a study are those that have both statistical
significance and clinical importance” (Burns & Grove, 2011, p. 410).
Nursing research seeks to find meaning form the study. “Implications are based
on but more specific than conclusions, and they provide specific suggestions for
implementing the findings in nursing” (Burns & Grove, 2011, p. 414). Nurses, as well as
the entire medical community, are constantly striving to improve current practices with
GROUP CRITIQUE
35
the best evidence available. It is important to stay current and continue to develop
research to best serve patients and the community.
Analysis
This section is quite confusing to the audience. Common sense would have
validated the same results. If a patient is mobilized they will have better functional
ability; a patient that is active will have a shorted LOS. This is basic information that the
audience already knows. The researchers fail to explain why this information is important
and what difference it will make in current treatment plans. As health care providers
basic goals are not changed due to these statistics. Members of the treatment team will
still assist patients in mobilization as it is good practice. This section is weak. Other than
providing information that should already be practiced, nothing is new to the audience.
Study Discussion
Evidence
According to Padula et al., (2011) “A significant decline in function between
preadmission and admission was detected in both groups, a finding with important
implications for both lay and professional care providers” (p. 330). Limitations of the
study include that groups were unequal at the start and other factors may have come into
play that are not reported. The researchers’ so suggest that additional studies “with
quantification of the impact of diseases is indicated, especially because participants in the
study experienced on average, about seven comorbid conditions” (Padula et al., 2011, p.
330).
GROUP CRITIQUE
Support
This area of the research is where evidence is pulled together to give them
significance. “This section includes major findings, limitations of the study, conclusions
drawn from the findings, implications of the findings for nursing, and recommendations
for further research” (Burns & Grove, 2011, p. 59). Limitations need to be reviewed so
the audience can fully understand the importance of the information provided.
“Limitations are restrictions in a study that may decrease the credibility and
generalizability of the findings” (Burns & Grove, 2011, p. 48). By relating the findings to
the framework provided in the study, researchers will validate the findings and increase
the validity of the research.
Analysis
While the authors were able to point out limitations of the research, the study is
very weak and leaves the audience to question the validity of the study from the start. The
information studied, mobility on functional decline, is basic nursing 101. Health care
providers already understand anatomy and physiology and the “use it or lose it”
scenarios. The authors fail to make the connection from their research to why it is
important, and what population will benefit from this information. It is best practice to
mobilize patients as soon as possible, this article fails to prove new ground breaking
information. The researchers did suggest that further studies are necessary and suggest
that disease should be studied to see how they affect the results. This is fine, however,
what difference will this make? Knowing that patients need to be mobilized and having
the correct tools in place are two separate topics. Perhaps the next study should indicate
the need for additional staff members that are solely dedicated to helping patients
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GROUP CRITIQUE
ambulate. The extra set of hands on the floor may prove to be more of a asset than
understand the fact that patients need to move.
Study Conclusions, Implications, & Recommendations
Evidence
Padula et al. (2009) concluded that “early and ongoing ambulation in the hallway
may be an important contributor to maintaining functional status during hospitalization
and to shortening LOS” (p. 330). The authors also conclude that “ambulation should be
viewed as a priority and as a vital component of quality nursing care” because research
indicates that “functional decline actually begins in the preadmission period” (Padula et
al., 2009, p. 330).
Support
The conclusion includes a summary of the results or outcomes. In order to form a
conclusion Burns and Grove (2011) states “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 explanations of the data” (p. 412). Risks are involved when the
researcher forms the conclusion that goes outside of what the data states (Burns & Grove,
2009, p. 412). The study data must support the conclusion statements.
Analysis
The conclusion Padula et al. (2009) provided the audience was short and did not
provide a meaningful summary of the study data. Padula et al. (2009) concluded “this
research supports existing literature” but did not recommend any further research or
studies concerning the mobility protocol (p. 330). Although the conclusion affirms that
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38
ambulating in the hallway maintains functional status, the researchers do not provide the
distance or how often a patient needs to ambulate to maintain functional status leaving
the audience with questions (Padula et al., 2009, p. 330). The mobility protocol was not
referenced in the conclusion and the researchers did not provide any other explanation to
the data outcomes in the conclusion.
Critique Conclusion
Nursing research is vital to the nursing profession. Burns and Grove (2011) define
nursing research as “a scientific process that validates and refines existing knowledge and
generates new knowledge that directly and indirectly influences nursing practice” (p. 4).
Nursing research helps develop a solid, evidence-based practice for the professional
nurses and Burns and Grove (2009) believe that “evidence-based practice involves the
use of best research evidence to support clinical decisions in practice” (p. 22).
Overall, Impact of a Nurse-Driven Mobility Protocol on Functional Decline in
Hospitalized Older Adults was a weak research article. Although the outcome results
presented are appealing, there are many factors that may have affected the results and
need to be taken into consideration when reviewing this research study. The only section
found to be strong in this article was the purpose section. The authors clearly defined the
purpose, their goals, and how the mobility protocol would affect those involved.
All other sections in this article were found to be weak for a variety of reasons.
The problem statement lacked statistical information and subject knowledge that may
have drawn the audience to review the research article. The review of literature was
sporadically referenced throughout the article and seven of the articles were found to be
older than five years making the information less meaningful to the current knowledge.
GROUP CRITIQUE
The authors used the GENESIS model for the framework; however, this model
was not detailed enough for the audience to fully grasp why this was chosen and the
importance it had on the research. Use of a nonequivalent control group was an internal
threat to validity because the control group and the comparison groups were not equal.
The authors did not address co morbidities in this study leaving the audience to question
if one group had more co morbidities than the other group. The participant’s previous
condition could have affected the outcome and skewed the results. The sample size was
small with twenty-five participants in each group. The research of the mobility protocol
needs to be further studied on a larger sample size to validate the results. Also, the
audience needs a better explanation of the instruments used in this study such as the
reason for selecting the instruments, if they have been used in past research, and if they
found them to be reliable and valid. Instruments were also found to be an internal threat
to validity.
Mobility of hospitalized patients is an important topic in nursing. It has been
found that many complications arise from prolonged immobility. We recommend that
further research be conducted and reviewed on mobility and mobility protocols in
hospitalized patients.
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40
References
Burns, N., & Grove, S.(2011). Understanding nursing research: Building an evidencebased practice (5th ed), Marilyn Heights, MO: Elsevier Saunders.
Padula, C., Hughes, C., & Baumhover, L. (2009). Impact of a nurse-driven mobility
protocol on functional decline in hospitalized older adults. Journal of Nursing
Care Quality, 24(4), 325-331.