CRITICAL APPRAISAL FOR RESEARCH
Critical Appraisal for Research
Critical Appraisal for Research
Evidence based healthcare involves “integration of the best available evidence, clinical experience and patient preference when making decisions related to health care” MacInnes & Lamont (2014, p. 10). One of the ways to achieve evidence based healthcare is through utilization of research evidence in healthcare. Conducting critical appraisals is one of the ways to identify best evidence to be utilized in clinical practice. Critical appraisal entails evaluation of different aspects of a research paper in order to examine the value of a research paper, design of study used and overall quality of research. Critical appraisal can be done using different assessment tools. One of the hailed assessment tool is the Critical Skills Appraisal Programme (CASP) (2013) which appraisal checklists for different research methodologies. This critical appraisal will employ the CASP assessment checklist for qualitative research to critically appraisal of Fridman and Frederickson’s (2014) study ‘Oncological nurses and the experience of participation in an evidence-based practice project’.
The study had the objective of illuminating “the experiences of oncology nurses who participated in an evidence-based practice project in an institution with an EBP organizational structure” (Fridman & Frederickson, 2014, p. 382). The paper was published in 2014, a recent publication, which means that there may not be much new evidence since publication. The researchers’ literature review indicated that patients do not reap the full benefits of care because of the gap that exist between what is practiced and what research shows (Institute of Medicine, 2001). According to Wilkinson (2013) healthcare providers call for qualitative inquiry and research approaches that use mixed methods to more fully exploit research in EBP. Nurse leaders have pointed to the importance of having a nursing working environment whose infrastructure support, and is conducive to EBP (Gerrish et al., 2012). This study sought to discover what it meant for nurses working in an established infrastructure for EBP to participate in and the EBP process.
Although the research question was not explicitly stated, it can be inferred from the stated purpose of the study. The authors say that the purpose of the study was to “discover the meaning of participation in the EBP process for nurses working within an established infrastructure for EBP” (Fridman & Frederickson, 2014, p. 383). The research question or focus is relevant especially to EBP in oncology. It is a way of evaluating the importance of EBP and an EBP infrastructure through nurses’ experiences. The researchers’ literature review led to the conclusions that although infrastructures that support EBP have been implemented, there have not been any intervention studies that evaluate the process of the outcomes of these infrastructures that support EBP. Therefore, the authors qualify their study in that, it would disclose the nature of EBP process and the meaning nurses get through participation in an EBP process. It can not only inform current practice, but it can also inform future intervention studies. If calls to implement EBP and infrastructure that support EBP continue to be made, then it is important to know the outcomes of implementing EPB to the nurses. According to MacInnes & Lamount (2014), studies that add value are those that address a relevant or significant problem within healthcare. They offer new and meaningful results.
The study employed the phenomenological qualitative approach. Phenomenology seek to elucidate the subjective experience of the research subjects (Fridman & Frederickson, 2014). This study design was appropriate since the study sought to illuminate or understand the experiences of those who took part in the EBP project. Miller (2010) point to the lack of consensus regarding the best method to evaluate qualitative research. However, there is a general agreement that qualitative research be judged based on the methodology of study (Miller 2010; Sandlelowski & Barroso (2003). In view of the role of qualitative research in EBP, Broeder and Donze (2010) argue that “qualitative evidence supports the personal and experiential knowing critical for practice” (p. 197). Since qualitative research studies present their results in the words and stories of the participants, it is easy to apply the findings to practice. Furthermore, nurses prefer qualitative research since its methods and results in most cases are similar to the art of nursing practice (Broeder & Donze, 2010). Although qualitative research has not always been considered as concrete evidence for practice, researchers, are doing their best to justify the role of qualitative research in EBP. This is so well illustrated in Fridman & Frederickson’s (2014) study.
The study was carried out in the Memorial Sloan Kettering Cancer Center. It had different oncology nursing settings and it is also an oncology-focused oncology hospital. As explained by the authors, this study was conducted in this institution because, first, it was an oncology hospital, and secondly, because it had an EBP infrastructure. The evidence based practice infrastructure in the institution include “the position of a director of nursing research and EBP (filled by a doctoral-prepared nurse researcher), a non-nurse research associate, and a part-time nurse researcher” (Fridman & Frederickson, 2014, p. 383).
Ethical Aspects of the Study
The researchers obtained approval to conduct the study from the Memorial Sloan Kettering Cancer Centre’s institutional review board. In addition, the researchers obtained signed consent from the participants of the study. The researchers were keen on participant confidentiality. They ensured interview confidentiality by using an encrypted website to upload audio recording for transcription. Again, only the researchers or doctoral-prepared colleagues would be allowed to review the interviews. Additionally, the researchers ensured that none of the research staff were working at the same workplace with the participants. Finally, the researchers ensured interview confidentiality by using pseudonyms for each participants while transcription of audio interviews was done for report findings. Participant confidentiality is a very important ethical consideration in this research, especially because the research was being conducted in the institution where the participants worked.
Examining the sample population give an indication to the relevance of the study (MacInnes & Lamont, 2014). The study used purposive sampling with additional snowball sampling to increase the number of participants. The method of sampling for the setting and subjects is clearly indicated. Selection criteria included nurses who had participated in an EBP project in the hospital setting. Participants were requested to identify other nurses who had participated in an EBP project. The participants were recruited through emails requesting them to participate in the study. Although probability sampling is considered to offer the likelihood of obtaining generalizable results (Gillespie et al., 2010), this study required purposive sampling. The participants’ characteristics had to include nurses who had been involved in EPB project within the institution with EBP infrastructure. Purposive sampling is often utilized in situations where proportionality is not the main concern (Gillespie et al., 2010). Snowball sampling could provide participants with the desired characteristics for the study, however, Moule and Goodman (2009) warn that this method has inherent biases since selection of the sample is not independent and the participants are known to each other. MacInnes and Lamont (2014) says that selecting a representative sample is one way of reducing bias in a study. According to (Last, 2001), “the presence of bias does not imply a preconception on the part of the researcher, but rather that the results of the study have deviated from the truth” (Cited in Young & Solomon, 2009, p. 82). Different methodologies are prone to different kinds of bias (Young & Solomon, 2009). The researchers were keen to eliminate the chances of bias.
The sample size is an important consideration as it produces statistically significant results (MacInees & Lamont, 2014). 14 nurses responded to the invitation emails; 12 were picked for the study. The characteristics of the participants include; six staff nurses, six advanced practice nurses, females aged between 27 and 58 years, with nursing experience of 5-39 years, and have participated in an EBP project from the present to the past 5 years. This sample size is somewhat small and may not produce generalizable results.
Data Collection and Analysis
Data was collected through in-depth interviews with each nurse. Open-ended questions were used and asked in a non-leading manner. Data sources and data collection have been described in enough details in the study. To eliminate bias, the researchers identified and documented sources of bias. The researchers also kept a journal which allowed the researchers to bracket personal biases. According to LoBiondo-Wood and Haber (2013), use of a journal in phenomenologic research helps researchers to recognize and set aside personal biases in the process of interviews so that they do not interfere with the interview or analysis of interview data.
Data analysis employed the phenomenologic reduction approach. Data is read out and statements that are repeated over by participants are categorized as emerging themes. Data is then coded into themes and sub-themes and later interpreted. Rigor in data analysis was achieved by application of audability, credibility and fittingness (Fridman & Frederickson, 2014). Credibility was achieved through going back to the participants who reviewed interview transcriptions and confirmed their accuracy. To achieve credibility, the researchers allowed participants to read the descriptions and interpretations of the researchers. Credibility was obtained when the participants agreed with the themes and interpretations of the researchers. Misinterpretations were also corrected. Fittingness, ‘phenomenological nod’, was achieved by having doctoral peer readers into the data analysis process.
Four major themes were identified in this research: support, challenges, evolution and empowerment. 11 sub-themes were also identified which indicated nurses’ personal and professional growth, as well and creation of a culture of EBP in the workplace. In support, the participants pointed to EBP support through organizational context, EBP structures and process and workgroup support. The second theme identified were challenges of EBP where the participants pointed out resistance to change, time and knowledge as the main challenges. Evolution was also a major theme, here the nurses described the experience of participating in an EBP project as a discovery, transformational, expanding boundaries and enabling professional development. Empowerment is the last theme; here the participants described the outcomes they achieved through participating in an EBP project. The nurses stated that their new-found knowledge helped them to challenge the status quo as well as make a difference in patient care. The results of the study are presented in a credible way. For instance, sequences from the original data are presented when presenting the results. Additionally the explanations given are plausible and coherent. The researchers concluded that the participants’ participation in an EBP project within an EBP infrastructure brought transformation in their personal and professional transformation. Thus, their transformation can be used as a foundation for nursing to assume that EBP will transform healthcare. This conclusion is justified by the results
Implications to Clinical Practice and Further Research
Fridman and Frederickson (2014) believe that this is the first study of its kind (qualitative study) to show improved nursing outcomes and nurses’ perception of improved patient outcomes. The researchers clearly identify what the findings of this study add to oncology nursing. Fridman & Frederickson (2014, p. 387) deduced that first, participating in a supported EBP project “empowers oncology nurses and improves perception of patient outcomes”; secondly, “EBP infrastructure gives oncology nurses a workplace culture that supports implementation of EBP projects”; and finally, participant descriptions of nurse and patient outcomes show that implementing EBP infrastructure would be an improvement in the workplace.
The researchers also indicate what the findings of this research mean future research in this area being that, qualitative methodology can be used for future intervention studies by operationalizing nurse outcomes identified as well as the themes that emerged in the study. Additionally, descriptive studies can be performed to examine the prevalence of EBP programs in the workplace. Further, the study can be replicated in different settings to increase understanding of nurses and EBP experience.
Overall Quality of the study
Regardless of the methodological rigor used in any study, if a study does not address a significant question and add to the heath literature already available, it may not be termed as valuable (Mays & Pope, 2000). As such, the first consideration is whether Fridman and Frederickson’s (2014) study addresses an important question, and whether their study contribute to the available literature in this area. This study identified an important gap in literature and adequately addressed it – the actualization of EBP in oncology nursing and capturing oncology nurse experiences of participating in an EPB process within an EBP infrastructure. As mentioned earlier, this study is considered the first of its kind (qualitative study) which demonstrated improved nursing outcomes. Additionally, it demonstrates oncology nurse perceptions of improved patient outcomes after participation in an EBP project. Thus, the study is not only of great value in oncology nursing, but it is also a high quality study that performed the highest methodological rigor.
As MacInnes and Lamont (2014) say, the final stages of critically appraising a paper is examining the relevance of the study’s findings to the profession. This study offers significant information to oncology nursing. First, the value of EBP infrastructure in oncology nursing, and secondly, highlighting nurse experiences by participating in an EBP project. The study has also identified significant implications for future research.
Overall Fridman and Frederickson (2014) performed thorough research rigor in this study. The methodology was the best for meeting the research objective. Sampling was the major limitation in this study especially since purposive and snowball sampling used are prone to bias. Nonetheless, the researchers’ explicit admission to this limitation and that of the workplace setting show objectivity in research.
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