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Running head: CRITICAL APPRAISAL: IMPACT OF NURSE-DRIVEN MOBILITY 1

CRITICAL APPRAISAL: IMPACT OF NURSE-DRIVEN MOBILITY PROTOCOL ON

FUNCTIONAL DECLINE IN HOSPITALIZED OLDER ADULTS

Andrea Bengston, Kelli Erb, and Dawn Platt

Ferris State University

CRITICAL APPRAISAL: IMPACT OF NURSE-DRIVEN MOBILITY 2

Abstract

This manuscript is written to analyze, study, and critique the difference aspects of a specific

article as well as increase knowledge about reading and understanding nursing research articles.

The authors will go through the studied article and give evidence, support, and analysis of each

section. The sections that are critiqued are the purpose and problem statement, the review of

literature and conceptual framework, the hypotheses and research design, the population sample,

the data collection and instruments used, the descriptive and inferential statistics, and the study

findings, limitations, and conclusions. The authors used information from a textbook as well as

the article being researched. The purpose of this paper is to increase the author’s knowledge and

understanding of the important pieces of a research article and to enable the authors to critique

nursing research articles in the future.

Keywords: Nursing research, critique of nursing research


Critical Appraisal: Impact of Nurse-Driven Mobility Protocol on Functional Decline in

Hospitalized Older Adults

Research is a very important aspect of nursing. Evidence-based practices guide nurses in

providing the highest quality, safest care to patients; therefore, nurses must continually utilize

research to enhance their knowledge to stay abreast of knew evidence-based practices. The

ability to critically appraise research is an indispensable quality for nurses as nurses must be able

to differentiate between strong and weak research. The object of this paper is to utilize the

process of critical appraisal provided by the book “Understanding Nursing Research: Building an

Evidence-Based Practice” by Nancy Burns and Susan Grove in critiquing the article “Impact of a

Nurse-Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults.”

Purpose

Evidence

The purpose of the study is clearly stated in the article. “The purpose of this study was to

determine the impact of a nurse-driven mobility protocol on functional decline in hospitalized

older adults” (Padula, Hughes, & Baumhover, 2009, p. 326).

Support

According to Burns & Grove (2011), the purpose is a statement that tells the reader what

the researchers plan to accomplish with the study. The information in a purpose statement is

clear, concise, and specific. Variables, population, and sometimes the setting should be included

in the purpose. The purpose statement encompasses the entire research into one single statement

of great impact.

Analysis


Based on the support information, I think the purpose statement is strong. It includes the

variable, which is the functional decline; it includes the population, which is older adults; and it

includes the setting, which is the hospital. It is a simple, solid statement that is clear, concise,

and specific and gives the reader enough information to understand the goal of the research. It

also gives the reader enough information to determine whether or not this article is relevant to

read.

Problem

Evidence

The problem statement was found on the first page of this article in the second paragraph.

“A stay in the hospital often results in complications that lead to functional decline in older

adults, which occurs in 34% to 50% of hospitalized older adults” (Padula, Hughes, &

Baumhover, 2009, p. 325). This is the area of concern for the adult population. The significance

of the problem is that this occurs in “34-50% of hospitalized older adults” (Padula, Hughes, &

Baumhover, 2009, p. 325).

Support

A problem statement describes a situation that has caused concern and shows an area

where nursing needs to make a change (Burns & Grove, 2011). The research problem should

“(1) [identify] an area of concern for a particular population, (2) [indicate] the significance of the

problem, (3) [provide] a background for the problem, and (4) [outline] the need for additional

study in a problem statement” (Burns & Grove, 2011, p. 146).

Analysis

The problem statement is weak. The problem was difficult to find in this article. There

is no section that solely identifies the problem statement, and it seems to be buried in the paper.


It is hard to identify the four items that should be in a problem statement. Because the problem

statement is missing the four elements, it is difficult to see the importance of the paper. The

problem statement is weak, but the study is feasible and ethical.

Review of Literature

Evidence

The abstract clearly states that the article is a study. The key words used are “acute

hospitalization, functional decline, mobility, older adults, [and] protocols” [emphasis omitted]

(Padula, Hughes, & Baumhover, 2009, p. 325). Within the first section of the article the authors

make reference to information from 19 different sources of literature. Of these 19 sources, only

13 of them refer to actual studies that were performed to support the theory of the study. The

information provided in the article from the literature is biased and does not offer any opposing

theories or research. There is some reference to literature review in the discussion at the end of

the article which again provides biased information only in support of the theory that was

studied. The following is a list of the references used for the article. Below the list of references

indicates the type of reference and if it is a primary or secondary source.

Meiner, S. E. & Lueckenotte, A. G. (2006). Gerontologic nursing, (3rd ed.). St. Louis, MO:

Mosby.

This is a book. This is a primary source.

Inouye, S., Peduzzi, P., Robison, J., Hughes, J., Horwitz, R., & Concato, J. (1998). Importance of

functional measures in predicting mortality among older hospitalized patients. JAMA:

Journal Of The American Medical Association, 279(15), 1187-1193.

The publication classifies this as research. This is a primary source.


Siebens, H., Aronow, H., Edwards, D., & Ghasemi, Z. (2000). A randomized controlled trial of

exercise to improve outcomes of acute hospitalization in older adults. Journal Of The

American Geriatrics Society, 48(12), 1545-1552.

The publication classifies this as a clinical trial, and the abstract indicates it as a randomized

controlled trial. This is a primary source.

Torres, O., Muñoz, J., Ruiz, D., Ris, J., Gich, I., Coma, E., & ... Vázquez, G. (2004). Outcome

predictors of pneumonia in elderly patients: importance of functional assessment. Journal

Of The American Geriatrics Society, 52(10), 1603-1609. doi:10.1111/j.1532-

5415.2004.52492.x

The publication classifies this as research, and the abstract indicates it is a prospective

observational study. This is a primary source.

Brown, C., Friedkin, R., & Inouye, S. (2004). Prevalence and outcomes of low mobility in

hospitalized older patients. Journal Of The American Geriatrics Society, 52(8), 1263-

1270. doi:10.1111/j.1532-5415.2004.52354.x

The publication classifies this as research, and abstract indicates it is a prospective cohort study.

This is a primary source.

Callen, B., Mahoney, J., Wells, T., Enloe, M., & Hughes, S. (2004). Admission and discharge

mobility of frail hospitalized older adults. MEDSURG Nursing, 13(3), 156-164.

This is a journal article for continuing education credits. This is a primary source.

Inouye, S., Bogardus, S. r., Baker, D., Leo-Summers, L., & Cooney, L. r. (2000). The Hospital

Elder Life Program: a model of care to prevent cognitive and functional decline in older

hospitalized patients. Journal Of The American Geriatrics Society, 48(12), 1697-1706.


The publication classifies this as a clinical trial. This is a primary source.

Lang, P., Heitz, D., Hédelin, G., Dramé, M., Jovenin, N., Ankri, J., & ... Blanchard, F. (2006).

Early markers of prolonged hospital stays in older people: a prospective, multicenter

study of 908 inpatients in French acute hospitals [corrected] [published erratum appears

in J AM GERIATR SOC 2006 Sep;54(9):1479-80]. Journal Of The American Geriatrics

Society, 54(7), 1031-1039.

The publication classifies this as research, and the abstract indicates this is a prospective

multicenter study. This is a primary source.

Boyd, C. M., Xue, Q. L., Simpson, C. F., Guralnik, J. M., & Fried, L. P. (2005). Frailty,

hospitalization, and progression of disability in a cohort of disable older women.

American Journal of Medicine, 4(12), 1225-1231.


Rozzini, R., Sabatini, T., Cassinadri,. A, et al. (2005). Relationship between functional loss

before hospital admission and mortality in elderly persons with medical illness. Journal

of Gerontology: Medical Science, 60(9), 1180-1183.

The publication classifies this as a comparative study. This is a primary source.

Covinsky, K., Palmer, R., Fortinsky, R., Counsell, S., Stewart, A., Kresevic, D., & ... Landefeld,

C. (2003). Loss of independence in activities of daily living in older adults hospitalized

with medical illnesses: increased vulnerability with age. Journal Of The American

Geriatrics Society, 51(4), 451-458. doi:10.1046/j.1532-5415.2003.51152.x

The publication classifies this as research, and the abstract indicates this is a prospective

observational study. This is a primary source.


Lindenberger, E., Landefeld, C., Sands, L., Counsell, S., Fortinsky, R., Palmer, R., & ...

Covinsky, K. (2003). Unsteadiness reported by older hospitalized patients predicts

functional decline. Journal Of The American Geriatrics Society, 51(5), 621-626.

doi:10.1034/j.1600-0579.2003.00205.x

The publication classifies this as research, and the abstract indicates this is a prospective cohort

study. This is a primary source.

Sager, M. A., Franke, T., Inouye, S. K., et al. (1996). Functional outcomes of acute medical

illness and hospitalization in older persons. Archives of Internal Medicine, 156(6), 645-

652.

The publication classifies this as a multicenter study. This is a primary source.

Inouye, S., Wagner, D., Acampora, D., Horwitz, R., Cooney, L. r., & Tinetti, M. (1993). A

controlled trial of a nursing-centered intervention in hospitalized elderly medical patients:

the Yale Geriatric Care Program. Journal Of The American Geriatrics Society, 41(12),

1353-1360.

The publication classifies this as a clinical trial. This is a primary source.

Counsell, S., Holder, C., Liebenauer, L., Palmer, R., Fortinsky, R., Kresevic, D., & ... Landefeld,

C. (2000). Effects of a multicomponent intervention on functional outcomes and process

of care in hospitalized older patients: a randomized controlled trial of acute care for

elders (ACE) in a community hospital. Journal Of The American Geriatrics Society,

48(12), 1572-1581.

The publication classifies this as a clinical trial, and the abstract indicates that it is a randomized

controlled trial. This is a primary source.


Tucker, D., Molsberger, S., & Clark, A. (2004). NGNA. Walking for wellness: a collaborative

program to maintain mobility in hospitalized older adults. Geriatric Nursing, 25(4), 242-

245.

The publication classifies this as a journal article. This is a primary source.

Brown, C. J., Roth, D. L., Peel, C., & Allman, R. M. (2006). Predictors of regaining ambulatory

ability during hospitalization. Journal of Hospital Medicine, 1(5), 277-284.

The publication classifies this as a comparative study, and the abstract indicates this as a

prospective cohort study. This is a primary source.

Bailey, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., & ... Hopkins, R.

(2007). Early activity is feasible and safe in respiratory failure patients. Critical Care

Medicine, 35(1), 139-145.

The publication classifies this as a journal article, and the abstract indicates this as a prospective

cohort study. This is a primary source.

Thomsen, G., Snow, G., Rodriguez, L., & Hopkins, R. (2008). Patients with respiratory failure

increase ambulation after transfer to an intensive care unit where early activity is a

priority. Critical Care Medicine, 36(4), 1119-1124.

The publication classifies this as research, and the abstract indicates this is a pre-post cohort

study. This is a primary source.

Shah, S., Vanclay, F., & Cooper, B. (1989). Improving sensitivity of the Barthel index for stroke

rehabilitation. Journal of Clinical Epidemiology, 42(8), 703-709.


Mathias, S., Nayak, U. S., & Isaac, B. (1986). Balance in the elderly patient: the “get-up and go”

test. Archives of Physical Medicine and Rehabilitation, 67(6), 387-389.


The publication classifies this as comparative terms. This is a primary source.

Wade, D. & Collins, C. (1986). The Barthel ADL index: A standard measure of physical

disability? International Disability Studies, 10(2), 64-67.

The publication classifies this as a review. This is a secondary source.

Gloth, F., Walston, J., Meyer, J., & Pearson, J. (1995). Reliability and validity of the Frail

Elderly Functional Assessment Questionnaire. American Journal Of Physical Medicine &

Rehabilitation, 74(1), 45-53.

The publication classifies this as a questionnaire, and the abstract indicates that it is a study.

This is a primary source.

Formiga, F., Mascaro, J., & Pufol, R. (2005). Inter-rate reliability of the Barthel index. Age

Ageing, 34(6), 655-656.

The publication classifies this as a commentary. This is a secondary source.

Thrane, G., Joakimsen, R., & Thornquist, E. (2007). The association between timed up and go

test and history of falls: the Tromsø study. BMC Geriatrics, 12(7), 1.

The publication classifies this as research support. This is a primary source.

Whitney, S., Wrisley, D., Marchetti, G., Gee, M., Redfern, M., & Furman, J. (2005). Clinical

measurement of sit-to-stand performance in people with balance disorders: validity of

data for the Five-Times-Sit-to-Stand Test. Physical Therapy, 85(10), 1034-1045

The publication classifies this as research, and the abstract indicates that it is a study. This is a

primary source.

Brown, C. J., Roth, D. L., Peel, C., & Allman, R. M. (2006). Predictors of regaining ambulatory

ability during hospitalization. Journal of Hospital Medicine, 1(5), 277-284.


The publication classifies this as a comparative study, and the abstract indicates it is a

prospective cohort study. This is a primary source.

MacCulloch, P., Gardner, T., & Bonner, A. (2007). Comprehensive fall prevention programs

across settings: a review of the literature. Geriatric Nursing, 28(5), 306-311.

The publication classifies this as a review. This is a secondary source.

Support

The authors of this article included information from 28 different sources to support their

evidence for the study. Twenty-five of the 28 sources are considered primary sources which are

“written by the person who originated or is responsible for generating the ideas published”

(Burns & Grove, 2011, p. 191). The rest are considered secondary sources which “[summarize]

or [quote] content from primary sources. Thus, authors of secondary sources paraphrase the

works of researchers and theorists” (Burns & Grove, 2011, p. 192). Of the 28 sources used for

this article, 16 of them are current, which “are those published within 5 years before acceptance

of the manuscript for publication” (Burns & Grove, 2011, p. 190). The date of acceptance for

publication for this article is February 24, 2009. All of the sources used are relevant to the topic

of the article, but the information provided from the articles is biased and only offers support for

the study performed.

Analysis

The review of literature is very weak for this article. The authors did not critique the

literature nor did they offer contrary information to the topic. The review of literature is not

clear-cut nor is it truly distinctive from other sections in the article. The research provided in the

article appears to be bits and pieces of literature put together in an attempt to solidify support for

the topic which led to the study. In addition, several pieces of the literature had very little


relevance to topic. The authors did include some very good literature to support they topic;

however, the overall quality of the literature was moderate to poor due to the number of

irrelevant, outdated sources. Furthermore, the information from the sources that the authors tried

to use for support was not solid, concrete, compounding evidence. There were a few statements

here and there regarding results of studies performed but nothing that would make a huge impact

on the reader.

Theoretical/ Conceptual Model

Evidence

The “sample included 50 adults 60 years or older who were admitted with medical

diagnoses in an acute care teaching hospital” (Padula, Hughes, & Baumhover, 2009, p. 327).

Twenty-five people went on one floor (the treatment floor), and 25 people went on the other

floor (the control floor). Both floors were similar in size and had primarily Registered Nurses

and Certified Nurse Assistants. “Inclusion criteria included [length of stay (LOS)] of 3 or more

days, ability to understand English, without a physical impairment that would significantly limit

ability to mobilize, and cognitively intact or with a significant other able to participate” (Padula,

Hughes, & Baumhover, 2009, p. 327). The treatment floor used an intervention called the

Geriatric Friendly Environment through Nursing Evaluation and Specific Interventions for

Successful Healing (GENESIS). “The registered nurse is directed to question orders for bed rest

as well as to routinely evaluate the necessity of obstacles to mobility” (Padula, Hughes, &

Baumhover, 2009, p. 328). “It is a priority of certified nurse assistants to walk GENESIS

patients 3 to 4 times per day and also to assist patients to the chair for meals and the bathroom or

commode for toileting” (Padula, Hughes, & Baumhover, 2009, p. 326).

Support


“A phenomenon is an occurrence or a circumstance that is observed, something that

impresses the observer as extraordinary, or a thing that appears to and is constructed by the

mind” (Burns, N & Grove S., 2011, p. 228). “Assumptions are statements that are taken for

granted or considered true, even though they have not been scientifically tested” (Burns, N &

Grove S., 2011, p. 228). “A philosophical stance is a specific philosophical view held by a

person or group of people” (Burns, N & Grove S., 2011, p. 228). “The independent variable was

mobility protocol and dependent variables were functional status and length of stay” (Padula,

Hughes, & Baumhover, 2009, p. 325). The findings of the study included “older adults who

participated in a mobility protocol maintained or improved functional status and had a reduced

length of stay” (Padula, Hughes, & Baumhover, 2009, p. 325). The framework includes what the

author believes will happen. The authors state the following two hypotheses: “Hypothesis 1 that

older adults who participate in a mobility protocol will maintain or improve functional status

from admission to discharge. . . . [and ] hypothesis 2, older adults who participate in a mobility

protocol will have a reduced LOS” (Padula, Hughes, & Baumhover, 2009, p. 330).

Analysis

The critical framework in this article is weak. It is hard to distinguish what the actual

framework is. The variables, assumptions, phenomenon, philosophical stance, and hypothesis

are hard to extricate, and they do not go into detail. GENESIS and the objectives of what the

author is testing are not easily defined. Definitions are not written out as to what they are

measuring.

Hypothesis

Evidence


There are two hypotheses. They are “(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, Hughes, &

Baumhover, 2009, p. 327). The variables were stated as, “the independent variable was mobility

protocol; dependent variables were functional status and LOS” (Padula, Hughes, & Baumhover,

2009, p. 327). The population intended for this study was a:

Convenience sample of adults 60 years or older, who were admitted with medical

diagnoses to 1 or 2 nursing units. Inclusion criteria included an LOS of 3 or more days,

ability to understand English, without a physical impairment that would significantly

limit ability to mobilize, and cognitively intact or with a significant other able to

participate. (Padula, Hughes, & Baumhover, 2009, p.327)

Support

According to Burns & Grove (2011):

A hypothesis is a formal statement of the expected relationship(s) between two or more

variables in a specified population. The hypothesis translates the research problem and

purpose into a clear explanation or prediction of the expected results or outcomes of

selected quantitative and outcome studies. (p.167)

The hypothesis should contain variables that will be measured or changed, should identify the

population to be studied, and should include the predicted outcomes (Burns & Grove, 2011).

Hypotheses are used in quantitative research “to test the effectiveness of a treatment or

intervention” (Burns & Grove, 2011, p.167).

There are different types of hypotheses which depend on the hypothesis complexity and

are developed based on the purpose of the study (Burns & Grove, 2011). A simple hypothesis


“states the relationship (associative or causal) between two variables (Burns & Grove, 2011,

p.172). Burns & Grove (2011) explain “a complex hypothesis states the relationships

(associative or causal) among three or more variables” (p. 172). A research hypothesis is defined

as the “the alternative hypothesis to the null hypothesis and states that a relationship exists

between two or more variables” (Burns & Grove, 2011, p. 175). Another type of hypothesis is

the null hypothesis. This is different because it “is used for statistical testing and for interpreting

statistical outcomes. Even if the null hypothesis is not stated, it is implied, because it is the

converse of the research hypothesis” (Burns & Grove, 2011, p. 174). “A nondirectional

hypothesis states that a relationship exists but does not predict the nature of the relationship”

(Burns & Grove, 2011, p. 173). The directional hypothesis “states the nature (positive or

negative) of the interaction between two or more variables” (Burns & Grove, 2011, p. 174).

Analysis

The types of hypotheses stated are complex and research hypotheses. The null is not

stated, but it is assumed the null is older adults who don’t participate in the mobility protocol will

maintain or have decreased functional status from admission to discharge and older adults who

do not participate in a mobility protocol will have the same or increased LOS. The section of

this article is strong. The hypotheses are clearly identified and even if the null hypothesis is

absent from the article, it can be implied.

Research (Study) Design

Evidence

The study used a nonequivalent control group design.

Support


“Experimental design provides the greatest amount of control possible in order to

examine causality more closely” (Burns & Grove, 2011, p. 537). The pretest-posttest design is

an experimental design and is the most common. Experimental and control groups are used and

“each one of multiple experimental groups can receive a variation of the treatment, such as a

different frequency, intensity, or duration of nursing care measures” (Burns & Grove, 2011, p.

276). The other experimental design is the randomized clinical trial. Burns and Grove (2011)

state:

A randomized clinical trial is a carefully designed experimental study that uses large

numbers of subjects to test the effects of a treatment and compare the results with those

of a control group that has not received the treatment (or that has received a traditional

treatment). (p. 280)

The randomized clinical trial is one of the most rigorously controlled randomized studies. A

quasi-experimental design is a study that randomly selects the controls and places them in a no-

treatment category, alternative treatment group, or an experimental treatment. Burns & Grove

state the following regarding quasi-experimental design:

Use of a quasi-experimental design facilitates the search for knowledge and examination

of causality in situations in which complete control is not possible. This type of design

was developed to control as many threats to validity as possible in a situation in which

some of the components of true experimental design are lacking. (p. 270)

“A descriptive design may be used to develop theories, identify problems with current practice,

justify current practice, make judgments, or determine what other nurses in similar situations are

doing” (Burns & Grove, 2011, p. 256). The environment is partially controlled, and there is no

manipulation of variables. “The comparative descriptive design is used to describe variables and


to examine differences in variables in two or more groups that occur natural in a setting” (Burns

& Grove, 2011, p. 260). There needs to be control to reduce bias. “The greater the researcher’s

control over the study situation, the more credible (or valid) the study findings” (Burns & Grove,

2011, p. 255). If randomization does not occur in the study with the subjects or controls in a

nonequivalent study, then the internal validity may be compromised because of the differences

within the group.

Analysis

The research design in this article is weak. It does state that it is a nonequivalent control

group design. The study has many causes that should be addressed separately to really determine

that the length of stay and functional status was impacted by the GENESIS program. There was

bias in the study with the participants simply because they all did not have the same diagnosis,

some were on separate floors, and it was based on convenience. The control was not the same

throughout the study. Different surgeries were done, and different age groups were used.

Sample and Sampling Methods

Evidence

A convenience sample was used to eventually obtain a sample size of 50 participants.

Inclusion criteria for the participants included the following:

[The participant needed to be “60 years or older, . . . admitted with a medical diagnosis to

unit of 1 of 2 nursing units, . . . LOS of 3 or more days, ability to understand English,

without physical impairment that would significantly limit ability to mobilize, and

cognitively intact or with a significant other able to participate. (Padula, Hughes, &

Baumhover, 2009, p. 327)


In order to determine cognitive status of the participants a Mini-Mental Status Examination was

completed, and those with scores of 24 or higher were acceptable participants (Padula, Hughes,

& Baumhover, 2009). In addition, “medical patients were selected to avoid potential limitations

in mobilization frequently associated with the surgical experience” (Padula, Hughes, &


The researchers began with a total of 453 patients who were screened by a research nurse.

Of these 453 patients, 84 participants were originally enrolled for the study and 34 were

eventually withdrawn for several different situations. These different situations included being

“[discharged] before discharge data could be collected . . . or before [three] days . . . , transfer off

study unit . . . , occurrence of a disqualifying procedure or condition procedure . . . , and personal

reasons” (Padula, Hughes, & Baumhover, 2009, p. 327).

Support

There are several different types of sampling that can be used in research. With

probability sampling “every member (element) of the population has a probability higher than

zero of being selected for the sample. To achieve this probability, the sample is obtained

randomly” (Burns & Grove, 2011, p. 298-299). The four different types of probability sampling

are simple random sampling, stratified random sampling, cluster sampling, and systematic

sampling. Simple random sampling is “achieved by randomly selecting elements from the

sampling frame” (Burns & Grove, 2011, p. 299). This can be achieved by placing names on a

piece of paper and inserting them in a container to draw them out or to input the names into a

computer program and have the computer randomly select the participants. “Simple random

sampling is the most basic of the probability sampling plans” (Burns & Grove, 2011, p. 299).

“Stratified random sampling is used in situations in which the research knows some of the


variables in the population that are critical for achieving representativeness. . . . Stratification

ensures that all levels of the identified variables are adequately represented in the sample” (Burns

& Grove, 2011, p. 301). The participants are chosen and separated into appropriate groups based

on the variables such as age, sex, ethnicity, and socioeconomic status. Cluster sampling, also

known as multistage sampling, is when “a researcher develops a sampling frame that includes a

list of all states, cities, institutions, or organizations with which elements of the identified

population can be linked” (Burns & Grove, 2011, p. 302). “Systematic sampling is used when an

ordered list of all members of the population is available. The process involves selecting every

kth individual on the list using a starting point selected randomly” (Burns & Grove, 2011, p.

303). To determine “k” the following equation is used: “k = population / the desired sample

size” (Burns & Grove, 2011, p. 303).

The other types of sampling are nonprobability sampling where “not every element of the

population has an opportunity for selection to be included in the sample” (Burns & Grove, 2011,

p. 305). The five different types of nonprobability samplings are convenience sampling, quota

sampling, purposeful or purpose sampling, network or snowball sampling, and theoretical

sampling. “Convenience sampling, also called ‘accidental sampling,’ is a weak approach

because it provides little opportunity to control for biases; subjects are included in the study

merely because they happen to be in the right place at the right time” (Burns & Grove, 2011, p.

305). Convenience sampling is a very easy way to obtain a large amount of participants in a

short period of time. The researcher can simply enter an establishment and ask individuals to

participate in the research. Convenience sampling is commonly used for surveys and interviews.

“Convenience sampling method is commonly used in healthcare studies because most

researchers have limited access to patients who meet study sample criteria” (Burns & Grove,


2011, p. 305). Within the convenience sampling, the participants can be randomly assigned to

groups based on variables. According to Burns & Grove (2011), “this random assignment to

groups, which is not a sampling method but a design strategy, does not alter the risk of biases

resulting from convenience sampling but does strengthen the equivalence of the study groups”

(p. 305). “Quota sampling uses a convenience sampling technique with an added feature—a

strategy to ensure the inclusion of subject types likely to be underrepresented in the convenience

sample” (Burns & Grove, 2011, p. 307).

The other three types of nonprobability sampling are used in qualitative studies. “With

purposeful sampling . . . the researcher consciously selects certain participants, elements, events,

or incidents to include in the study” (Burns & Grove, 2011, p. 313). “Network sampling takes

advantage of social networks and the fact that friends tend to have characteristics in common.

This strategy also is particularly useful for finding subjects in socially devalued populations”

(Burns & Grove, 2011, p. 315). In theoretical sampling “the researcher gathers data from any

person or group able to provide relevant, varied, and rich information for theory generations”

(Burns & Grove, 2011, p. 316).

Analysis

Because the researchers used a convenience sampling type without using random

assignment, this area of the study is very weak. There are so many variables that were not

accounted for that could have changed the outcome of the study. There is no way to tell if the

two groups selected were similar enough that extraneous variables did not alter the results in any

way. The internal and external validity are extremely threatened in this study due to the

weakness of the style of sampling the researchers chose. Even though the researchers included

some exclusions and inclusions utilized in their sampling, strong variables such as cultural


differences can have a very strong effect on the results of the study. Therefore, the sampling

technique used for this study was very weak and did not lay a solid foundation for strong results.

Data Collection Methods

Evidence

According to Padula, Hughes, and Baumhover (2009):

A demographic data collection sheet was 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 mobility; use of occupational or

physical therapy; LOS; first and number of times out of bed; and type of out-of-bed

activity. (p. 328)

The authors also used the modified Barthel Index (BI) and the Up and Go test. The modified BI

"used and retained the original 10 items but included a 5-point rating scale from each item to

improve sensitivity to detecting change. A quantitative estimate of level of dependence was

obtained, ranging from 0 (totally dependent) to 100 (totally independent)" (Padula, Hughes, &

Baumhover, 2009, p. 328). The Up and Go test was also used.

Various methods have been used to determine how well people can rise from a chair; for

this study, subjects were rated at admission and at discharge on a 1 to 4 scale, 1 being

‘able to rise in a single movement’ and 4 being unable ‘to rise without assistance.’

(Padula, Hughes, & Baumhover, 2009, p. 328)

The last instrument used that included measurement was the Mini-Mental State Examination.

"For subjects with a Mini-Mental State Examination score of less than 24, the significant other's

perception of the patient's abilities was assessed" (Padula, Hughes, & Baumhover, 2009, p. 329).

Support


Nominal-scale measurement “is used when data can be organized into categories of a

defined property but the categories cannot be rank order” (Burns & Grove, 2011, p. 329). This

type of measurement is exhaustive, exclusive, and cannot be ranked. “Data such as gender,

ethnicity, marital status, and diagnoses are examples of nominal data” (Burns & Grove, 2011, p.

330). Ordinal-scale measurement is ranked, exclusive, and exhaustive. “With ordinal-scale

measurement, data are assigned to categories that can be ranked. To rank data, one category is

judged to be (or is ranked) higher or lower, or better or worse, than another category” (Burns &

Grove, 2011, p. 330). The quantity can be identified with this type of measurement. In ordinal-

scale measurement “you cannot know certainty that the intervals between the ranked categories

are equal” (Burns & Grove, 2011, p. 330). “Ordinal data are considered to have unequal

intervals” (Burns & Grove, 2011, p. 330). Examples of ordinal-scale measurements include

“degrees of coping, levels of mobility, ability to provide self-care, or levels of dyspnea” (Burns

& Grove, 2011, p. 330). Another type of measurement is the interval scale. “These scales

follow the rules of mutually exclusive categories, exhaustive categories, and rank ordering and

are assumed to represent a continuum of values” (Burns & Grove, 2011, p. 330). They have

equal space between intervals. There is not a zero point in the interval-scale. “Temperature is

the most commonly used example of an interval scale” (Burns & Grove, 2011, p. 330). “Ratio-

scale measurement is the highest form of measurement and 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). Ratio-scale does

have a zero point. “Weight, length, and volume are commonly used examples of ratio scales”

(Burns & Grove, 2011, p. 331). “During the data collection period, the researcher focuses on

obtaining subjects, training data collectors, collecting data in a consistent way, maintaining


research controls, protecting the integrity (or validity) of the study, and solving problems that

threaten to disrupt the study” (Burns & Grove, 2011, p. 361). The researcher needs to ensure

that they have gathered the right number of subjects to ensure that they have a sufficient sample

size for the study. To maintain consistency, the researcher needs to use the same patterns

throughout the study and to ensure that if deviations have occurred that they are documented in

the study. The researcher needs to ensure that they maintain the internal and extraneous variables

to ensure that they have control over the study. If they do not, then the validity can be

jeopardized. The Hawthorne effect can effect data collection due to the subjects changing their

behavior because they are being observed. They try to do what the researcher wants them to do,

not what they would naturally be doing. The researcher effect is when the researcher somehow

influences the subjects placing a bias and threating the internal validity of the study. This would

give inaccurate data collection during the study.

Analysis

This section is weak. The authors did not explain what types of measurement were used,

how they collected the data, where they collected it, and who collected it. The only instruments

that they used were the Barthel Index, Up and Go test, the data sheet, and the Mini-Mental State

Examination. None of the instruments were explained on what they did or how they were used

to collect the data.

Instrument

Evidence

According to Padula, Hughes, & Baumhover (2009), the study used four different

instruments. The authors state the following regarding a data sheet that was developed:


[It was used] 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 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

out of bed activity. (p. 328)

This instrument was “developed specifically for this research” (p. 328). The research does not

speak to this instrument’s reliability of validity.

Two other types of instruments Padula, Hughes, & Baumhover (2009) used were the

Barthel Index (BI) and the Up and Go test. According to Padula, Hughes, & Baumhover (2009),

“the BI is a subjective measure that measures the capacity of an individual to perform identified

ADL (personal hygiene, bathing, feeding, toileting, stair-climbing, dressing, bowel control,

bladder control, ambulation, and chair/bed transfer)” (p. 328). The researchers used a modified

version of the BI, which used “the original 10 items but included a 5-point rating scale for each

item to improve sensitivity to detecting change” (p. 328). This instrument is used to identify

what the patient believes their level of function was before admission, during admission, and at

discharge. This instrument is used frequently for clinical and research projects which proves its

reliability and validity (Padula, Hughes & Baumhover, 2009).

The other instrument used, was The Get Up and Go test. According to Padula, Hughes,

& Baumhover (2009), this test is “an objective assessment that measures subjects’ ability to

stand from an armchair, walk 3 m, turn around, return, and sit down in the chair again” and this

“test has been shown to be reliable and valid and is reported to correlate with the BI at r = -0.78”

(p. 328).


The last instrument used in the study was a Mini-Mental State Examination. “For

subjects with a Mini-Mental State Examination score of less than 24, the significant other’s

perception of the patient’s abilities was assessed” (Padula, Hughes & Baumhover, 2009, p. 329).

For data analysis, the program that was used is called the StigmaStat statistical program.

“Sample size statistics were calculated prior to data collection to ensure adequate power to detect

differences between the groups” (Padula, Hughes, & Baumhover, 2009, p.329).

Support

According to Burns & Grove (2011), “reliability is concerned with the consistency of the

measurement method” (p. 332). A test is considered reliable if a subject receives similar scores

each time it is completed. “Reliability testing is a measure of the amount of random error in the

measurement technique. It takes into account such characteristics as dependability, precision,

stability, consistency, and reproducibility” ( Burns & Grove, 2011, p. 333). Burns & Grove

(2011), also stated “a measurement method must be reliable if it is to be considered a valid

measure for a study variable” (p. 334).

“The validity of an instrument is a determination of how well the instrument reflects the

abstract concept being examined [and] no instrument is completely valid” (Burns & Grove,

2011, p.334). It is possible for the validity of an instrument to differ from “one sample to

another and one situation but not another” (p. 334). There are different types of validity.

According to Burns & Grove (2011), “validity is considered a single broad method of

measurement evaluation that is referred to as construct validity and includes content and

predictive validity” (p. 335). Content-related validity “examines the extent to which the

measurement includes all the major elements relevant to the construct being measured” (p. 335).

Three of the most common types of validity that are present in most studies “include evidence of


validity from: (1) contrasting groups, (2) convergence, and (3) divergence” (p. 335). A

researcher can test an “instrument’s evidence of validity from contrasting groups by identifying

groups that are expected (or known) to have contrasting scores on the instrument” (p. 335). The

next type of validity is evidence of validity from convergence. “Evidence of validity from

convergence is determined when a relatively new instrument is compared with an existing

instrument(s) that measures the same construct. The instruments, the new one and the exisiting

ones, are administered to a sample concurrently” (p. 335). The last type of validity is defined as:

evidence of validity from divergence is “correlational procedures performed with the measures

of two opposite concepts. If the divergent measure is negatively correlational with the other

instrument, validity for each of the instruments is strengthened” (p.335).

Analysis

The instruments used in this study appear to be valid and reliable. The only questionable

item is the first instrument used which is the data collection sheet. This sheet was developed

specifically for this research study. However, it is just a data sheet for information. The results

wouldn’t change regarding the sources demographic situation.

Data Analysis: Descriptive Statistics

Evidence

Padula, Hughes, & Baumhover (2009), use descriptive statistics with their sample. They

used patients over the age of 60, and they also used two tables on pages 327 and 329. The table

on page 327 describes nursing staff characteristics between the treatment and control group, and

the table on page 329 shows Barthel Index scores by group.

Support


According to Burns & Grove (2011), descriptive statistics is when data is numerical.

Some studies “researchers use descriptive statistics primarily to describe the characteristics of the

sample from which the data were collected and to describe values obtained from the

measurement of dependent or research variables” (p. 383). Burns & Grove (2009) also say

descriptive statistics include “frequency distributions, measures of central tendency, measures of

dispersion, and standardized scores” (p.383).

Analysis

This article was extremely weak in this section. They didn’t describe the descriptive

statistics very well. The first table that was used didn’t seem to help the reader understand the

research and the second table showed Barthel Index scores, which was ok.

Data Analysis: Inferential Statistics

Evidence

Padula, Hughes, & Baumhover (2009), identified the mean age of the group was “80.4

years with a range of 62 to 97 years. The mean number of diagnoses was 6.7, [and] forty (80%)

patients were admitted from home, 7 from assisted living, and 3 from a nursing home” (p.329).

The P value for the difference between fall-risk scores of the treatment group and control group

was P=.07. “The treatment group fall-risk level also was lower (1.86 treatment vs. 2.4 control;

P=.04) suggesting that the treatment group was at lower fall risk on admission” (Padula, Hughes,

& Baumhover, 2011, p. 329). Padula, Hughes, and Baumhover (2009) also report that

“discharge scores significantly improved from the admission baseline for the treatment group

(P= .05) by +11.5, with control group scores improving by 6.9 (not significant) [and]the control

group demonstrated a statistically significant decrease in function between preadmission to

discharge (P=.006)” (p. 329). Padula, Hughes, & Baumhover (2009) had statistics for patients


being out of bed to the chair. The statistics include “subjects in the treatment group were out of

bed to chair less often (5.9 times treatment vs 8.7 times control; P=.05) and ambulated in the

room less often (5.54 times treatment vs 7.16 times control; NS) than the control group” (p. 329).

The researchers identified the patients in the treatment group walked in the hallways earlier on in

their stay then the control group and more often, “2.7 days treatment vs 4.9 days control, P

= .007” and “3.12 times treatment vs 2.44 times control; NS” (Padula, Hughes, & Baumhover,

2009, p. 329). The last statistic noted in this section was “the treatment group had significantly

shorter LOS (4.96 days treatment vs 8.72 days control; P < .001)” (Padula, Hughes, &


Support

According to Burns & Grove (2011), “inference is a conclusion or judgment based on

evidence. Statistical inferences are made cautiously and with great care” (p. 378). One way to

analyze data is to use a t-test. “One of the most common analyses used to test for significant

differences between two samples” (p. 404) is by using the t-test. “The t-test is used to examine

group differences when the variables are measured at the interval or ratio level of measurement”

(p. 404). According to Burns & Grove (2009), the alpha level, also called the level of statistical

significance, “is the probability level at which the results of statistical analysis are judged to

indicate a statistically significant difference between the groups” (p. 377). Authors and

researchers should be reporting this value.

Analysis

This section of the article was mediocre. The authors included many of the different p

values for the variables they were studying, but it could have been laid out in a way that was

easier for the reader to understand.


Study Findings

Evidence

The first non-significant information the authors mentioned was that “no significant

differences between the groups were found on demographic variables” (Padula, Hughes, &

Baumhover, 2009, p. 329). Prior to this statement the authors described the sample used for the

study in relation to male and female, age, where they were before they were admitted to the

hospital, if they had some type of dementia, and whether or not they received some type of

rehabilitation services prior to admission.

There were several other significant and nonsignificant findings listed from the study.

The significant findings included the following:

Barthel readmission scores, which reflect subjects’ perceptions of functioning 2 weeks

prior to admission, were significantly higher than admission scores for both groups, . . .

discharge scores significantly improved from the admission baseline for the treatment

group, . . . the control group demonstrated a statistically significant decrease in function

between preadmission to discharge, [and] the treatment group had significantly short

LOS. (Padula, Hughes, and Baumhover, 2009, p. 329)

The nonsignificant findings include the “subjects in the treatment group had a lower fall-risk

score on admission than the control group,” (p. 329) that discharge scores for the control group

improved with nonsignificant findings, “treatment group scores [for function] were lower at

discharge than at preadmission, [and] scores for the Up and Go test improved slightly for both

groups” (Padula, Hughes, & Baumhover, 2009, p. 329).

Support


According to Burns and Grove (2009), several different results or findings can be found

from a study. “Significant [and predicted] results agree with those predicted by the researcher

and support the logical links developed by the researcher among the frameworks, questions,

variables, and measurement tools” (Burns & Grove, 2011, p. 409).

Nonsignificant (or inconclusive) results, often referred to as ‘negative’ results, may be a

true reflection of reality. . . . Negative results do not mean that no relationships exist

among the variables. Negative results indicate only that the study failed to find any.

Nonsignificant results provide no evidence of either the truth or the falsity of the

hypothesis. (Burns & Grove, 2011, p. 409)

Burns and Grove also state that “significant and unpredicted results are the opposite of those

predicted by the researcher and indicate that flaws are present in the logic of both the researcher

and the theory being tested” (p. 409). Examples of mixed results would be that “one variable

may uphold predicted characteristics whereas another does not; or two dependent measures of

the same variable may show opposite results” (Burns & Grove, 2011, p. 409-410). The last type

of results is unexpected results which “usually are relationships found between variables that

were not hypothesized and not predicted from the framework being used” (Burns & Grove, 2011,

p. 410). According to Burns & Grove (2011), “results in a study are translated and interpreted to

become study findings, which are consequences of evaluating evidence from a study” (p. 410).

Analysis

Based on what should be included and what actually was included in the findings, the

authors did a decent job providing significant and nonsignificant data. The findings are

explained in terms that can be understood by both laypersons and professionals, which can be

nice. However, the findings are still presented in a biased format. Because the authors only


included significant and nonsignificant findings, one may wonder if other findings were omitted

in an attempt to support the hypothesis.

Discussion of Findings

Evidence

In the discussion the authors reference three studies that support the results of this study.

The first referenced study states that “prolonged immobility is clearly demonstrated in the

literature to be an important contributor to functional decline. Walking difficulties have been

identified as an early marker for prolonged hospital stays in older people” (Padula, Hughes, &

Baumhover, 2009, p. 330). The second reference the authors make states that “mobility that is

lost during hospitalization is often not recovered by discharge” (Padula, Hughes, & Baumhover,

2009, p. 330). The third and final reference made by the authors states that “lower extremity

weakness and balance and gait disorders have been identified as intrinsic fall-risk factors, and

exercises that improve lower body strength and balance have been shown to reduce falls and fall-

related injury” (Padula, Hughes, & Baumhover, 2009, p. 330). Regarding discussion of this

study, Padula, Hughes, and Baumhover (2009) state that “ambulating in the hallway seemed to

be more effective than chair rest and even ambulating in the room. This may be because

ambulation in the hall requires significant strength, balance, and coordination” (p. 330).

Limitations that the authors clearly recognize include the following:

The lower functional level of the control group . . . could have contributed to increase

LOS and/or later ambulation, [that] although differences between the groups on baseline

characteristics were not detected, it is possible that differences existed and affected the

findings, [and that the] data from the Up and Go test did not detect differences in


functional level that were identified by the BI. (Padula, Hughes, & Baumhover, 2009, p.

330)

The authors also recognized that “it is possible that the presence of the advanced practice nurse

[employed on the control group unit and responsible for clinical outcomes] positively affected

mobility outcomes” (Padula, Hughes, & Baumhover, 2009, p. 330). The authors did state that

“further study with quantification of the impact of diseases is indicated, especially because

participants in this study experienced, on the average, about 7 comorbid conditions” (Padula,

Hughes, & Baumhover, 2009, p. 330).

Support

According to Burns & Grove (2011), the following describes the discussion section of a

research paper:

The Discussion section ties together the other sections of the research report and gives

them meaning. This section includes the major findings, limitations of the study,

conclusions drawn from the findings, implications of the findings for nursing, and

recommendations for further research. (p. 59)

In addition, Burns & Grove (2011) state that “the significance of a study is associated with its

importance in contributing to nursing’s body of knowledge” (p. 410).

Analysis

Even though the discussion included the major findings and the limitations, the authors

do not indicate how the results of this study can influence nursing. In addition, even though the

authors do make recommendations for further studies regarding the impact of diseases and to

investigate the BI measurement tool, they do not give further recommendations in relation to the

end results of this study. There is no mention of recommended further studies. The authors also


did not recognize the limitation of the sample size and how the sample was chosen. Because the

sample size is so small and the fact that they were recruited in a convenience style, the results of

this study cannot be generalized to the entire population. The authors leave the reader with

several unanswered questions.

Study Conclusions, Implications, & Recommendations, Recommendations

Evidence

“This research supports existing literature that identifies that functional decline actually

begins in the preadmission period” (Padula, Hughes, & Baumhover, 2009, p. 330). Padula,

Hughes, and Baumhover (2009) also conclude that “findings suggest 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).

Support

“In forming conclusions, the researcher uses logical reasoning, creates a meaningful

whole from pieces of information obtained through data analysis and findings from previous

studies, remains receptive to subtle clues in the data, and considers alternative explanations of

the data” (Burns & Grove, 2011, p. 412). “One of the risks in developing conclusions is going

beyond the data, or forming conclusions that are not warranted by the data” (Burns & Grove,

2011, p. 412). “Conclusions are a synthesis of the findings” (Burns & Grove, 2011, p. 412).

Analysis

The article conclusion is very small. It is a weak section. It does not state whether there

needs to be more studies or a bigger or smaller sample size. It does not state how they came to

the conclusion that functional status or LOS was affected.

Conclusion


The article was a good learning tool for students to visualize and learn how to write a

research article. The article included both strong and weak sections. The majority of the article,

however, was full of weak sections. The weak sections included the problem statement, critical

framework, review of literature, research design, instruments, data collection, population,

sample, sampling plan, measurement, study findings, discussion of findings, and the conclusion.

What made most of these sections weak was the lack of information provided. The authors did

not go into enough detail to thoroughly explain and prove that functional status and length of

stay were truly affected by the GENESIS program. The population and sample size was not

properly distributed to prove any change occurred. There was a lack of measurement and

instrument information on how it was used, obtained, and if the instruments were valid. The

authors also did not go into enough detail about what their findings were and how they obtained

them. Discussion about the findings was not very thorough. Although the majority of the article

was weak, there were two sections that were strong. These included the purpose statement and

the hypotheses. The purpose statement was straight to the point and was carried out throughout

the article. The purpose never changed. The hypothesis also stayed the same and was straight

forward. Altogether, this article showed that using the GENESIS program needs to be further

researched before it can be introduced into nursing practice. There are far too many weak

sections than there are strong to prove that this is actually evidence based and should be used.


References

Burns, N. & Grove, S. K. (2011). Understanding nursing research: Building an evidence-based

practice (5th ed.). Maryland Heights, MO: Saunders, Elsevier.

Padula, C. A., 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.


Research CritiqueGrading Criteria

APA Format: up to 30 points or 30% can be removed after the paper is graded for Title page, abstract, headers Margins, spacing, and headings, reference page, title page, abstract Sentence structure, spelling, grammar & punctuation.

Headings Possible Points

PointsEarned

Comments

Abstract andIntroduction: No heading

for intro, but there should be a introduction of the study and what your paper will

address, why you are doing the critique

10

Purpose & Problem Statement (Identify the problem & purpose and

analyze whether they are clear to the reader. Are there

clear objectives & goals? Analyze whether you can determine feasibility and significance of the study)

10

Review of the Literature and Theoretical

Framework (Analyze relevance of the sources; Identify a theoretical or

conceptual framework & appropriateness for study)

10

Hypothesis(es) or Research Question(s)

(Analyze whether clearly and concisely stated; discuss

whether directional, null, or nondirectional hypothesis[es])

10

Sample & Study Design (Describe sample & sampling method &

appropriateness for study; analyze appropriateness of design; discuss how ethical

issues addressed)

10

Data Collection Methods & Instruments (Describe & analyze the appropriateness

of the what, how, who, where and when; describe &

10


analyze reliability and validity of instrument)

Data Analysis (Describe descriptive & inferential

statistics & analyze whether results are presented

accurately & completely)

10

Discussion of Findings (Analyze whether results are

presented objectively & bound to the data, whether

there is a comparison to previous studies and

whether new literature is introduced that was not

included in the Literature Review

10

Conclusions, Implications, & Recommendations (Analyze whether the

conclusions are based on the data, whether

hypotheses were supported or not supported, whether implications are a result of

the findings, and recommendations consider

limitations

10

Your paper should end with a brief conclusion of your

critique 10

PAPER POINTS 100

Deductions for APA, grammar and Spelling

Final GRADE

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