Mobility Protocol Article Critique 1

Running head: MOBILITY PROTOCOL ARTICLE CRITIQUE 1

Mobility Protocol Article Critique

Katrina Lampman, Tina Palmer, Shelly Parker, and Carol Zinn

Ferris State University MOBILITY PROTOCOL ARTICLE CRITIQUE 2 NURS 350Abstract

This paper is designed to read and critique the article “Impact of Nurse-Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults” by Padula, Hughes & Baumbover (2009) by using Nieswiadomy’s (2010) book titled “Foundations of Nursing Research” as a guide. This article was broken down into the steps of the nursing research process and critiqued accordingly.

Keywords: mobility, functional decline, protocol, internal validity, external validity MOBILITY PROTOCOL ARTICLE CRITIQUE 3 Mobility Protocol Article Critique

The purpose of this paper is to establish students’ skills at critiquing research work as a group. The article critiqued was “Impact of a Nurse-Driven Mobility Protocol on Functional

Decline in Hospitalized Older Adults” by Padula, Hughes & Baumbover (2009). Nieswiadomy

(2010) was used as a resource for evidence-based practice and critique models.

According to Nieswiadomy (2010), a nursing researcher article should include a purpose and problem statement, review of literature and theoretical framework, a hypothesis or hypotheses, sample and study design, data collection methods and instruments, data analysis, discussion of findings, and conclusions, implications, and recommendations. This paper shows the evidence, support, and analysis of each of these sections of the article critiqued.

Purpose

Evidence

According to Nieswiadomy (2012, p. 34), the purpose of an article can be determined by why the study was done. In this article, the purpose was clearly stated as it had the words “the purpose of the study” in the sentence. Padula, Hughes & Baumbover (2009, p. 326) state “the purpose of the study was to determine the impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults”. In a review of the text book materials, the book described the purpose statement and noted the difference between a purpose and a problem, avoiding any possibility of confusion.

Support

The purpose of the study should be written in the article in such a way that it will leave no doubt to the reader what it is (Nieswiadomy, 2012, p. 300). Before the study even begins, the reasons for the study should be determined. The purpose statement is usually written in the MOBILITY PROTOCOL ARTICLE CRITIQUE 4 abstract and again in the introductory section of the article (Nieswiadomy, 2012, p. 34). The text does also state that the purpose statement should be in the form of a study purpose

(Nieswiadomy, 2012, p. 300). It is also noted that the broad purpose of the study may be more specific in the form of objectives or goals.

Analysis

The purpose of the mobility article is pretty strong in this section as it is well defined and the reader is able to understand what is going to happen, but the conclusion in the article included the length of stay which was not mentioned in the purpose statement. According to

Nieswiadomy (2012, p. 303), the conclusion of the study answers the purpose of the study.

There was no abstract with a purpose statement attached to this article.

Problem Statement

Evidence

The problem statement is not clearly defined in this article; however, it can be found at the end of the introductory paragraph, which is the correct placement according to Nieswiadomy

(2012, p. 300). The writers make the problem statement difficult to single out.

The problem in the article is “the goal of this study was to determine the impact of the mobility protocol on the functional decline in hospitalized patients” (Padula, Hughes, and

Baumhover, 2009, p. 325).

Support

According to Nieswiadomy (2012, pp. 33-34), the reader should be able to identify the problem statement at the beginning of the introductory paragraph. The text indicates that the problem of the study should be clearly identified. It further indicates that early in the report there should be a mention of the broad problem of the study. The more specific statement of the MOBILITY PROTOCOL ARTICLE CRITIQUE 5 problem can be found in the abstract and at the end of the introductory section of the report. The text also states that the problem statement can be in the form of a declarative problem statement, a purpose statement, or a research question. The problem statement should contain the population and major variables and indicate the data may be gathered empirically. The feasibility and significance of the study should be apparent. In many reports the purpose may be more easily identified than the problem (Nieswiadomy, 2012, p. 300).

This research article, “Impact of a Nurse-Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults” (Padula, Hughes & Baumhover, 2009) is of quantitative design.

Therefore, there should be a clear problem statement at the beginning of the article. The goal of this article is feasible so it is capable of being carried out successfully as the costs are low, data can be easily gathered, assessed, and the subjects are easily accessible. This study is also beneficial to healthcare workers, physicians, and patients.

Analysis

Since the reader is unable to clearly define the problem statement at the beginning of the article, it is weak. The reader may have to read the manuscript very closely to identify what the problem is. The purpose statement is clear, however. The study is ethical as the patients were informed by a letter approved by a review board and then gave consent. There was no harm done to the patients. The study was low in costs as it did not require any additional staff or expensive equipment. The subjects were readily available, which enabled the studied to be completed.

There are benefits to all the healthcare professionals and the patients as patient satisfaction and level of functioning improve with this intervention. Although the subjects were carefully screened for functional mobility and cognitive ability prior to the study, there were still MOBILITY PROTOCOL ARTICLE CRITIQUE 6 a lot of variables. For example, the fall risk factors were higher in the control group than the treatment group, meaning that there were already some weaknesses or decreases in mobility.

Further, there was a wide age range and some varying levels of independence as some came from home, some from assisted living, and some from a nursing home. It is not clear how the data was gathered or exactly what the data is, therefore the reader is not sure how the authors support their conclusion.

Review of Literature

Evidence

The beginning of the review of literature (ROL) is at the end of the first paragraph in the article after the problem statement. The article goes right from its introduction into the ROL. It cites several articles with statistics to indicate there is an ongoing problem with functional decline in activities of daily living (ADL’s) and ambulation in hospitalized patients. It goes on to discuss how this decline is associated with poor outcomes and prolonged length of stay.

The article then presents its findings associated with increased mobility while hospitalized and how this increased mobility yielded positive outcomes for the patients. The article then concludes its ROL with a short statement regarding maintenance of mobility in critically ill people and how this is crucial in the achievement of positive outcomes. There was some critiquing of the articles, but nothing substantial.

Support

Nieswiadomy indicates in the text that the ROL should be all-inclusive and to the point.

It should have a nice flow and be easy to understand. All sources should be relevant to the study topic and should be critically appraised. The research should be critiqued in the article such that the reader knows if the findings are weak or strong (Nieswiadomy 2012, pp. 78-79). MOBILITY PROTOCOL ARTICLE CRITIQUE 7 ROL should include classic sources as well as current sources. Most references should not be more than 5 years old. The ROL should be mostly paraphrases and not direct quotes, but both should be cited when referencing the writings of others. One should be able to determine if the researcher is using primary sources or secondary sources (Nieswiadomy 2012, p. 71).

However, this is not always clear in the writings. To distinguish between the two it may be necessary to look at the reference list for hints. It is to be expected that research journals are primary sources, while secondary sources are items like book chapters and literature reviews.

The only way to know for certain would be to review each reference personally but this is unlikely to be an option. Supporting and opposing theory and research should be presented in the ROL section.

All sources should be cited on the reference list and should be without errors

(Nieswiadomy, 2012, pp. 78-79). The ROL can be found toward the beginning of the article or toward the end of the article, depending on the design. The ROL should “provide an adequate summary of the existing body of knowledge on the phenomenon of interest” (Nieswiadomy,

2012, p. 306). The ROL should end “with a sentence or two that indicates how the present study will contribute to the existing body of knowledge in that subject area” (Nieswiadomy 2012, p.

Analysis

The ROL is not clearly marked but it is distinguishable because it flowed from the purpose statement as indicated it should according to (Nieswiadomy, 2012, p. 79). It is easy to tell when the article moves into discussing the ROL as it starts to give statistics and cites where these statistics come from. The information is to the point, but not convincing that it is all- inclusive and the flow of the information seemed a little off. It is not clear by reading the article MOBILITY PROTOCOL ARTICLE CRITIQUE 8 whether the sources used are primary or secondary. When reviewing the citations at the end of the article, it is apparent that they are mostly primary sources, but some of them were difficult to determine. There are some book references which could be secondary sources as these could be considered classic sources and the articles as current sources. Some of the resources used in the article were more than five years old so the ROL is a weak section. While the article does not indicate direct quotes, specific statistics cannot be paraphrased which is what Nieswiadomy states should be (Nieswiadomy, 2012, p. 300). The researchers also did not critique the articles that they used to determine if the resources are appropriate. According to Nieswiadomy (2012, pp. 78-79), this is part of the ROL process.

This ROL is at the beginning of the article as Nieswiadomy indicates it should be. The article does provide some opposing information but not much. Nieswiadomy (2010, p. 79) states that both supporting and opposing theory should be represented, which makes this section of the article weak as well.

Theoretical Framework

Evidence

Under the Intervention heading, the researcher does mention that education had been provided to nurses on the GENESIS model (Geriatric Friendly Environment through Nursing

Evaluation and Specific Interventions for Successful Healing) (Padula, Hughes & Baumbover,

2009, pp. 327-328). However, there was no information provided on the theories of the

GENESIS program. It would be more beneficial to the readers of this study to know what

GENESIS is. The framework is not clearly defined in this article. MOBILITY PROTOCOL ARTICLE CRITIQUE 9 Support

The theoretical framework provides a general explanation of the relationships between concepts of interest in the study, and is based on one existing theory. The conceptual framework explains the relationships between concepts and can link the concepts from several theories. The theories are based on previous results or from the experience of the researcher. The concepts should flow in a logical manner and are less well developed than a theoretical framework

(Nieswiadomy, 2012, p. 88).

Conceptual frameworks can act like maps. According to Nieswiadomy, theoretical or conceptual framework assists in the selection of the study variables and in defining them. The conceptual framework should define the terms, propositions, and assumptions of the researchers

(Nieswiadomy, 2012, pp. 87-88). The framework also directs the hypothesis and the interpretation of the findings (Nieswiadomy, 2012, p. 35).

Analysis

The article is weak in showing the conceptual framework clearly. The framework is not clearly defined and there is no conceptual framework heading to point the reader in locating the information. There is reference to the educational program provided to the nursing staff called

GENESIS, but there is not much information about what GENESIS is, or the theories related to the program.

The researcher attempted to provide definitions of the variables, especially as noted in describing the instruments used. However, when the researcher used the term functional status, the term was not clearly defined which made it difficult to determine that functional status had actually improved. Finally, the type of hospital used for the research study was not clearly defined. MOBILITY PROTOCOL ARTICLE CRITIQUE 10 Hypothesis

Evidence

According to the article by Padula, Hughes & Baumhover (2009, p. 327), there are two hypotheses stated. The first hypothesis states “older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge” (Padula, Hughes &

Baumhover, 2009, p. 327). This means that the research will prove that elderly patients, that are part of the mobility study, will improve their functional level of mobility or at least maintain it.

The other hypothesis states “older adults who participate in a mobility protocol will have a reduced LOS” (Padula, Hughes & Baumhover, 2009, p. 327). This means that the length of stay will be decreased for those who participate in the mobility exercise. The independent variable, or cause, is the mobility protocol. There are two dependent variables, or effects, and they are the functional status and length of stay. The population in this study is elderly adults and it was plainly identified that the elderly patients were over the age of 60 (Padula, Hughes &

Baumhover, 2009, p. 327).

Support

According to Nieswiadomy (2012, p. 36), a hypothesis should be written in the present tense. The goal of the hypothesis is to be specific in identifying the part of the theory being tested. The hypothesis should answer the research question. The knowledge that is gained through the study is used to either support or reject the hypothesis or theory. Both positive and negative findings are important to the research. The hypothesis predicts the relationship between one or more variables. A variable is something that is different among the population being studied (Nieswiadomy, 2012, pp. 36, 41, 100). MOBILITY PROTOCOL ARTICLE CRITIQUE 11 In the text by Nieswiadomy (2012, pp. 101-104), there exist different hypotheses; simple, complex, research, null, directional, and nondirectional. A simple hypothesis looks at the relationship between one independent variable, or cause, and one dependent variable, or effect.

A complex hypothesis looks at the relationship of two or more independent or dependent variables or both. A null hypothesis states that there will be no relationship between the variables. The researcher’s goal is to disprove the null hypothesis. The research hypothesis expects that there will be a relationship between the variables. Hopefully, the outcome of the research supports the research hypothesis and rejects the null hypothesis. A nondirectional hypothesis is one where a research predicts that there is a relationship between the variables.

The expectation of the researcher may not be clear. In a directional hypothesis the relationship between the variables is clear, as are the expectations of the study (Nieswiadomy, 2012, pp. 101-

A hypothesis is used in a quantitative research design because it contains the researcher’s expectation about the results of the research. A hypothesis must also predict the answer to the research question, contain the population, variables, and be able to be tested in an empirical fashion, which means one should be able to validate the findings of the research by realistic means such as using the senses (Nieswiadomy, 2012, pp. 105-106).

Analysis

This article did contain two clearly stated hypotheses which are written in the present tense. The dependent variable, the functional status, and length of stay are clearly stated as well as the independent variable, and the mobility protocol. The hypothesis is a directional hypothesis as the relationship between the variables is clear. It uses two dependent variables, and one independent variable; the results of the study support the research hypothesis. The null MOBILITY PROTOCOL ARTICLE CRITIQUE 12 hypothesis is not clearly defined, but may be assumed in this study. The population is addressed in the hypothesis, and it can be empirically tested. One can see the results and hear about the results.

More positive findings were addressed in the study than negative. There was a direct correlation between the research question and the hypothesis. The article is strong in clearly stating what the hypotheses are and that the LOS decreased and that mobility had increased and the hypothesis are easily identified within the article. The article was weak in stating what the null hypothesis is.

Research Design

Evidence

In the article by Padula, Hughes & Baumbover (2009, p. 327), they clearly state that the study used the “nonequivalent control group design”. It is clearly stated under the headings

“Research Methods” and “Design” what control group design was used as their research method.

In addition, it is clearly stated under this heading what the independent and dependent variables are. The independent variable is “mobility protocol” and the dependent variables are “functional status and LOS” (Padula, Hughes & Baumbover, 2009, p. 327).

Support

“The research design is the plan for how the study will be conducted” (Nieswiadomy,

2012, p. 37). There are several kinds of research designs. One example is Quantitative designs which consist of experimental and non-experimental research. The experimental research focuses on the cause and effect relationship of the research which means that one happening causes another. Experimental studies involve exploiting the independent variable which is the cause and then measuring the dependent variable which is the effect (Nieswiadomy, 2012, p. MOBILITY PROTOCOL ARTICLE CRITIQUE 13 114). Experimental design is then broken down further into three sub groups. These include true experimental designs, quasi-experimental designs, and pre-experimental designs. True experimental designs are designs where the researcher has a vast amount of control over the research. In order to create a true experimental design the researcher must have manipulation of the independent variable, a control group, and a random assignment of study participants

(Nieswiadomy, 2012, pp. 118-119).

Three types of true experimental design discussed in the text are the pretest-posttest control group design, the posttest-only control group design, and the Solomon four-group design.

The pretest-posttest control group design is the most used research design. It consists of random selection of groups, one control, and one who receives the experimental treatment. Both groups are given a test before and after treatment or perceived treatment. Equality of groups is able to be determined prior to initiation of treatment. The posttest-only control group design is the same as the pre and posttest control group except there is no pretesting. The Solomon four-group design is made up of two control groups and two experimental groups with randomly assigned participants. While only two of the groups are pretested, all of the groups are post tested

(Nieswiadomy, 2012, pp. 119-121).

The Quasi-experimental designs are those designs where there is neither a control group nor where the study participants are not randomly assigned. When using this type of research design the researcher uses pre-established groups for the experimental and control groups. The nonequivalent control group design is a sub category of the quasi-experimental design group.

The nonequivalent control group design is the same as the pre and posttest design group; however, there are no random assignments of participants to the groups (Nieswiadomy, 2012, pp. MOBILITY PROTOCOL ARTICLE CRITIQUE 14 121-122). Non-experimental research is descriptive and does not involve manipulation of the research (Nieswiadomy, 2012, p. 123).

Internal and external validity is associated with experimental studies. Internal validity refers to the degree in which changes in the effect can be credited to the cause. External validity refers to the level at which study results can be influenced by outside items (Nieswiadomy, 2012, pp. 115, 117). Examples of things that can affect the internal validity of a study are selection bias, history, maturation, testing, instrument changes, and mortality or attrition. Examples of things that can affect the external validity include the Hawthorne, the experimenter effects, or reactive effects of the pretest. A control group is needed so that the effects of the experimental group can be tested. Without a control group, you cannot get a good idea of what the research is trying to show (Nieswiadomy, 2012, pp. 115-117).

Analysis

The research design of the nonequivalent control group design in the mobility article is weak due to the threat of internal and external validity. The internal validity is decreased due to the groups not being equal. The external validity is decreased as well because the groups cannot be replicated. The two groups in the study are not equal and the results may be a result from sampling bias.

What is concerning about the groups is the Mini Mental State Exam (MMSE). This part of the study requirement can be confusing as in one area it states that participants were used only if the MMSE was 24 or more. However, in another area it reports that those with MMSE lower than 24, the significant other’s perception of the patient’s abilities was taken into consideration

(Padula, Hughes & Baumbover, 2009, p. 329). This can skew the groups and because of this it makes the research design of the article weak. The article is strong in that the research design is MOBILITY PROTOCOL ARTICLE CRITIQUE 15 clearly identified. There is a decrease in internal validity because the groups are not equal, and a decrease in the external validity because you are not able to externalize the results of this study to the outside population.

Sample and Study Design

Evidence

The article begins by clearly stating the study is geared toward older hospitalized adult’s population. The article also reveals a "sample" heading to locate the sample selected for this study which was of adults 60 years or older admitted with medical diagnoses to one of two nursing units (Padula, Hughes & Baumbover, 2009, p. 327). The population was picked from medical patients versus surgical patients. The sample size was also clearly stated in this section as 50 or 25 in each unit. The sample also had a length of stay 3 or greater days, was able to speak English, and did not have physical abilities that would limit the ability to be mobile. The sample were also cognitively able to participate or had a significant other would could participate. This was determined through the use of a mini mental exam with a score of 24 or better. In order to select the sample, a research nurse screened 453 eligible patients and came up with a sample size of 84 and then eliminated patients for various reasons until 50 were selected

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

Support

According to Nieswiadomy (2012, p. 146), a population is a complete set of persons or objects that possess some common characteristic of interest to the researcher. The goal of sampling in a quantitative research is to be able to make generalizations about the population from which the sample was drawn (Nieswiadomy, 2012, p. 146). MOBILITY PROTOCOL ARTICLE CRITIQUE 16 The population consists of a target and accessible population. The target population is people or things who have the same set of criteria for the researcher to study. It can be a challenge to obtain a population with the same set of criteria, so the researcher may use accessible population or study population to obtain a sample that allows the researcher to report conclusions about the generalities of the study findings (Nieswiadomy, 2012, p. 146).

An entire population is not generally used in a research study because it is not possible to gain access to the entire population, so a sample is used instead. Samples are chosen through two types of sampling: probability and nonprobability (Nieswiadomy, 2012, p. 147). Probability or random sampling involves taking random samples in a systematic, scientific process, to obtain a representative sample of a population (Nieswiadomy, 2012, p. 147). There is no guarantee in random sampling that the results will be the same as what it would be with a total population, but the hope is the sample selected would mimic that of a total population study.

There are four types of random sampling: simple, stratified, cluster and systematic. In a simple sampling method, each element chosen has an equal chance of being selected. A method of obtaining the sample is identified and examples include drawing a slip of paper out of a hat or using a table of random numbers to choose from. Advantages include that little knowledge of the population is needed, unbiased probability methods, easy to analyze and compute errors, increases probability that the sampling is representative and assures adequate number of cases for subgroups. Disadvantages include that a complete list of the population is necessary and the process is time consuming and expensive (Nieswiadomy, 2012, p. 148).

The stratified sampling method divides populations into a strata format. The advantages are that the method increases the probability that the sample is representative and it assures the adequate number of cases for subgroups. The disadvantages include that the method requires MOBILITY PROTOCOL ARTICLE CRITIQUE 17 accurate knowledge of the population, is costly to prepare the stratified list, and is more complicated (Nieswiadomy, 2012, pp. 148-150). The cluster sample uses groups rather than people to select the population. Advantages include that the method saves time and money, and arrangements made with the small number of sampling units and characteristics of clusters as well as those of population can be estimated. The disadvantages include larger sampling errors than other probability samples, requires assignment of each member of the population uniquely to a cluster, and statistics are more complicated (Nieswiadomy, 2012, pp. 150-151).

Systematic sampling is to obtain listing of the population, determine the sampling side, determine sampling intervals, select random starting point and select every kth element, for example, every 5th, 10th or 15th element. Advantages include that this method is easy to draw the sample, is economic, and is a time saving technique. The disadvantages include that the samples may be biased if order of the population is not random, and population members do not have equal chance of being drawn (Nieswiadomy, 2012, pp. 151-152).

Nonprobability sampling methods select elements from a population in a nonrandom method and are more likely to produce a more biased sample. There is no guarantee that element in a population will be selected, but most nursing research studies use this type of sampling method. The methods used in nonprobability sampling include convenience, quota, and purposive. Convenience sampling uses people or objects that are readily available. Snowball sampling or network sampling is a method of convenience sampling where people give the names of other people they know that fit the qualifications of the study. Quota sampling, like stratified sampling, divides the population into a strata and selects from the strata by means of convenient samples. Purposive or judgmental sampling is handpicking subjects by the researcher or an expert (Nieswiadomy, 2012, pp. 152-154). MOBILITY PROTOCOL ARTICLE CRITIQUE 18 Other important items in sampling include longitudinal studies which include following the subject over a period of time in the future, whereas a cross-sectional study examines the subject at one point in time (Nieswiadomy, 2012, p. 154). Sample error is the difference between data obtained from samples and data that would be obtained if an entire population was studied. Sampling bias occurs when samples are not carefully selected (Nieswiadomy, 2012, p.

Analysis

The researchers in this study did well at explaining the sample size and population used as evidenced by the literature that the population was over the age of 60 and took place in 2 units that are similar within a hospital setting. However, the use of the sampling was weak. The sampling was consistent with the age population and that they were in a hospital setting, had to have the ability to be mobile and were cognitively intact, but there was no comparison to the level of illness and impact on the diseases that impacted the patients, therefore the groups may not be similar at all. There was not enough information about the groups and how they were assigned.

There was also involvement by the significant other if the patient did not score greater than 24 on a mini mental exam; however, there was no discussion of the support systems involved that may have improved the chances of mobility for the patients involved in the study.

The sample group of the patients selected was rather small, but maybe not. There was no description of the amount of admissions each unit actually received and if this was or was not an adequate sample size as compared to the patient turnover. There could be many other factors that could have attributed to increasing the mobility of the patients involved in the study. MOBILITY PROTOCOL ARTICLE CRITIQUE 19 The internal and external validity were again decreased in this section of the mobility article. For the internal validity, the groups are not equal even though the researchers tried to do internal and external conclusion. The external validity was decreased because there was no demographic data provided about the population to know if these groups were even similar.

Data Collection Methods

Evidence

A research nurse screened 453 patient records for study eligibility. In this screening she was able to register 84 patients for the study. There were, however, 34 of those 84 that had either withdrawn or been disqualified due to not meeting criteria which left a total of 50 participants (Padula, Hughes & Baumhover, 2009, p. 327). An advanced practice nurse with expertise in gerontology and geriatrics actually collected the data from the screened and approved participants. The nurse was trained by the geriatric clinical nurse specialist and the principal investigator. The nurse collected data and tracked the data on a spreadsheet. The spreadsheet included several items including gender, diagnosis, use of assistive devices, fall risk assessments, mobility restrictions, use of therapies, length of stay, first and number of times out of bed, and type of out of bed activity. This information was gathered via chart review, and discussions with nursing staff and the patients themselves.

The Barthel Index (BI) and the Get Up and Go test were also tools that were utilized for data collection. The BI measures the ability of one to complete self-activities of daily living.

The BI in this case was used to measure self-perceived levels of function at admission, 2 weeks prior to admission, and at discharge. The Get Up and Go test was used to determine patient’s abilities to stand from a chair, ambulate 3 m, turn around, ambulate back and then return to sitting in a chair (Padula, Hughes & Baumhover, 2009, p. 328). This was completed on MOBILITY PROTOCOL ARTICLE CRITIQUE 20 admission and at discharge. Cognitive status of the study sample was also tested via the Mini

Mental State Exam (MMSE). For those with MMSE scores below 24 the subject’s significant other was utilized for information (Padula, Hughes & Baumhover, 2009, p. 329). The researchers conducted their study at a private, not for profit 247 bed acute care facility in

Providence, Rhode Island. Two nursing units similar in size and patient type were used for this study.

Support

According to Nieswiadomy (2012, p. 165), there are four levels of measurement. These levels include nominal, ordinal, interval, and ratio. Nominal levels of measurement include the naming or categorizing of the events. These categories are distinct from one another and are called mutually exclusive categories. Additionally, these categories include all of the possible ways of categorizing the data which is referred to as exhaustive categories. The number of categories can range from two to several. This type of data is acquired via counting the rate or percentage of incidents in each category. Some examples of nominal data include gender or marital status. Nominal data is the least precise of the level of measurement methods

(Nieswiadomy, 2012, pp. 164-165).

The next level of measurement is called ordinal level of measurement. Ordinal level of measurement is data that can be rank ordered and placed into categories. Differences between the ranks cannot be distinguished. Data represents an order instead of an amount (Nieswiadomy,

2012, p.165). Interval level of measurement consists of real number data such as ages of participants. This data can be ranked and placed into categories and the distance between the ranks can be determined (Nieswiadomy, 2012, p. 165). The last level of measurement is the ratio level of measurement. This is the most precise level of measurement because the data can be MOBILITY PROTOCOL ARTICLE CRITIQUE 21 ranked, placed into categories, the distance between ranks can be determined, and a natural zero point can be determined (Nieswiadomy, 2012, p. 165).

In the text, Nieswiadomy indicates that there are several ways in which to collect the data. These include interviews, attitude scales, Delphi techniques, observational methods, physiological measures, preexisting data, psychological tests, Q-sort, questionnaires, and visual analogue scale (Nieswiadomy, 2012, pp. 328-329). Attitude scales are “self-reported data collection instruments that ask respondents to report their attitudes or feelings on a continuum”

(Nieswiadomy, 2012, p. 316). The Delphi technique “uses several rounds of questions to seek a consensus on a particular topic from a group of experts on that topic” (Nieswiadomy, 2012, p.

318). Pre-existing data is data that has been previously obtained but not used for research purposes (Nieswiadomy, 2012, p. 323). Q sort or Q methodology is where “subjects are asked to sort statements into categories according to their attitudes toward, or rating of, the statements”

Finally, the visual analogue scale is where “subjects are presented with a straight line anchored on each end with words or phrases that represent the extremes of some phenomenon”

(Nieswiadomy, 2012, p. 326). For example, the 0-10 pain scale that we use to determine pain levels. The researcher effect or experimenter effect is when the person conducting the research skews the data by influencing the subject’s behaviors with their own behaviors and attitudes

Another thing that can skew the data results is the Hawthorne effect. This occurs when the study participants are aware they are being monitored and their behaviors are influenced because of this (Nieswiadomy, 2012, p. 117). It would be difficult as a nurse not to affect your MOBILITY PROTOCOL ARTICLE CRITIQUE 22 patient’s behavior. The patients knew about the study because they had to be in agreement to participate, so there would have to be some behavior modifications.

According to Nieswiadomy (2012, p. 166), what is important for data collection is to ask these five questions: Who? What? Where? When? How? You need to know who will be collecting the data, what type of data is going to be collected, where will the collection of data occur, when will it be collected, and how will it be collected (Nieswiadomy, 2012, pp. 166-167).

Analysis

The authors did a good job in describing the who, what, where, and when of the data collection; however, they did a poor job of explaining the why. The information was jumbled together and not clear cut. It was hard to determine which levels of measurements they were using for this study. It feels as if the way in which they chose to conduct this study made it very difficult to really get good accurate results from each patient

The Hawthorne effect, as well as the researcher effect, could be a factor in this study as participants were aware of the study being conducted and were asked questions based on their perception. The author should have just stuck to concrete facts and not used perception as this can be highly interpretational. It also feels as though this particular study was not very well thought out and that there are just too many variables in this situation. There are a lot of variables so it is difficult to know how valid the study is.

This section is weak as there were not enough specifics as to how the data was collected.

The internal validity is decreased due to there not being enough specific detail as to how the data was collected. The external validity is also decreased because the Hawthorne and researcher effects may have contributed to the study results. MOBILITY PROTOCOL ARTICLE CRITIQUE 23 Instruments

Evidence

The instruments used and how they were used are listed under the levels of measurement.

The data collected by the nurse for the spread sheet is an example of nominal data and interval data, whereas the Barthel Index (BI) and the Get Up and GO instruments are examples of ordinal data collection. The researchers were not specific in their descriptions of the reliability and validity of their chosen instruments. The article does indicate that the BI is the standard for clinical research purposes, and that when compared to the Frail Elderly Functional Assessment the BI was reported to be a better tool overall (Padula, Hughes & Baumhover, 2009, p. 328). In regards to the Get Up and Go instrument, the article indicates that the instrument has been shown to be reliable and valid and has been correlated with the BI instrument. Again, there are not any other specifics as to why or how this instrument has been determined to be reliable and valid.

Support

According to Nieswiadomy the practicality, reliability, and validity of the instrument must be considered when choosing data collection methods. Practicality of the tool must first be determined. In order to determine the practicality of the instrument, one must consider the cost of the instrument and the appropriateness of the instrument to the study population. One must also consider if there are any specialists needed to conduct or interpret the data (Nieswiadomy,

2012, pp. 168-169).

Reliability of the instrument must then be examined. This is measured by the consistency and stability of the instrument. The extent of the reliability is determined by the correlation coefficients. Correlation coefficients are determined by two sets of scores or between the ratings of two judges. The higher the correlation coefficient, the more reliable the instrument is. MOBILITY PROTOCOL ARTICLE CRITIQUE 24 Generally speaking, the more items that the instrument contains the more reliable it is. However, reliability does not always sustain itself over time. It must be continually re-evaluated as it is used throughout the study (Nieswiadomy, 2012, p. 169). The text goes on to indicate that there are three different types of reliability. These are stability, equivalence, and internal consistency.

The stability reliability of a study refers to the consistency of the study over time

(Nieswiadomy, 2012, p. 169). The equivalence reliability refers to the level in which two different forms of an instrument achieve the same results. It can also refer to two or more observers using one instrument and achieving the same result (Nieswiadomy, 2012, p. 170).

Lastly, internal consistency reliability refers to the amount of all items on the instrument that measures the same variable. This type of reliability is only used when testing one concept at a time (Nieswiadomy, 2012, p. 171). Finally, the validity of the instrument must be determined.

The validity is determined by the instruments ability to gather the intended data. The subject matter of the instrument is up most important when determining validity of the instrument.

Validity of the instrument is based on a panel of experts or examination of the current literature on the topic.

There are four subgroups to validity: face, content, criterion, and construct

(Nieswiadomy, 2012, p. 171). Face validity is when the instrument shows at first look that it is measuring what it is intended to measure. “Content validity is concerned with the scope or range of items used to measure the variable” (Nieswiadomy, 2012, p. 172). Criterion validity is when the instrument is assessed for determination of participant’s responses now or in the future.

There are again subgroups under criterion validity which are concurrent validity and predictive validity. Concurrent validity refers to the way the instrument compares with another instrument MOBILITY PROTOCOL ARTICLE CRITIQUE 25 that measures the same thing, and predictive validity refers to the ability of the instrument to predict the behavior of the participants in the future.

Lastly, construct validity, which is the hardest to measure, refers to the level of the variable that is not directly observable. It is developed from an underlying theory that is used to explain the variable. Construct validity also has two subgroups which are known-groups procedure and factor analysis. Known-groups procedure refer administration of the instrument in question to two groups who are expected to give different answers, whereas factor analysis refers to the methods used to identify groups of connected objects on the instrument

(Nieswiadomy, 2012, pp. 173-174). Reliability and validity are used together intimately.

Generally reliability is determined first as it is a precursor to validity (Nieswiadomy, 2012, p.

174). Instruments must be reliable and valid so as not to skew the data. If the instrument is not, then the research will not be accurate and the data obtained from the research will not have meaning.

Analysis

There is not enough information on the reliability and validity of the instruments used in this research article. The use of the BI instrument in this particular case is based on patient perception. The purpose of this study was to determine if the nurse-driven mobility protocol had an impact on functional decline in the hospitalized patient. To do this, concrete data should be used and not the perception of the patient because the patient perception is not always reality.

One patient’s perception is much different than another’s. It is not known for sure that these instruments really measured accurately what the researches intended. The perception of the patient is not a reliable source of information as so much can skew this. This study would have MOBILITY PROTOCOL ARTICLE CRITIQUE 26 been better served using instruments such as the Tenetti balance scale or comparing ambulation distances at admission and at discharge.

There is just not enough information to assure validity of the instruments or the results of the research so this section is weak. The researchers do not explain to the reader the instruments used. There is again a decrease in the internal and external validity because the article does not state the reliability and validity of the instruments.

Data Analysis

Descriptive statistics

Evidence. In the mobility article, descriptive statistics were done for the study variables and to compare the two groups on the baseline characteristics that were examined (Padula,

Hughes & Baumbover, 2009, p. 329). Two contingency type tables were used in the article.

One showed the characteristics of the nursing staff for the treatment and control groups. The other table showed the Barthel scores for the treatment and control groups. Measures of central tendency stats were used as they used the mean to describe the average age and diagnoses of the sample groups. The mean age was 80.4 and mean diagnosis 6.7 (Padula, Hughes, & Baumbover, p. 329).

Support. Descriptive statistics are “statistics that organize and summarize numerical data gathered from samples” (Nieswiadomy, 2012, p. 205). There are several ways that descriptive statistics can be categorized. Nieswiadomy categorizes them into four different groups. They are as follows: measures to condense data, measures of central tendency, measures of variability, and measures of relationships.

First, measures to condense data are statistics that summarize and condense the data, which involves frequency distributions, percentages, and graphic presentations. Frequency MOBILITY PROTOCOL ARTICLE CRITIQUE 27 distributions are used to report the numerical values from the data which are listed from the lowest to highest or vice versa. Percentages are used to represent the proportion of a subgroup to compare it to the total group (Nieswiadomy, 2012, p. 210). The percentage will be the most useful and valid if the size of the total group is at least 20. Graphic presentation involves putting the data into a graph such as a bar graph, histogram, or a frequency polygon (Nieswiadomy, pp.

208-210).

Second, measures of central tendency are “statistics that describe the average, typical, or most common value for a group of data” (Nieswiadomy, 2012, p. 211). Measures of central tendency include mode, median, and mean. The mode is the value that occurs the most often in the group of data, the median is the middle value of the data, and the mean is the average sum of the data of the group.

Third, measures of variability statistics describe how the values spread out in the distribution of values. The range, percentile, standard deviation, variance, and z scores are used in variability statistics. The range is the distance between lowest and highest value in the group of scores, and a percentile is the data point below that puts a certain percentage of the values in a frequency distribution. A standard deviation is a statistic that shows the average variation of all the values from the mean in a set of data, the variance is the square of the standard deviation, and the z score indicates how many standard deviations that a value is from the mean of the set of values (Nieswiadomy, 2012, pp. 213-214).

Lastly, measures of relationships are concerned with the correlation between the variables. Measures of relationship include correlation of coefficients, scatter plots, and contingency tables. Correlation coefficients are statistics that present “the magnitude and direction of a relationship between two variables” (Nieswiadomy, 2012, p. 215). Correlation MOBILITY PROTOCOL ARTICLE CRITIQUE 28 coefficients are symbolized by the letter r. These vary between -1.00 and +1.00. A correlation coefficient of -1.00 shows a perfect negative relationship whereas a +1.00 shows a perfect positive relationship. If the correlation coefficient is 0, then there is no relationship in the variables. A scatter plot shows the relationship of the two variables by placing the variables on an X and Y axis on a graph, and a contingency table is a table that shows the relationship between the sets of nominal data in a visual sense.

Analysis. The article stated that descriptive statistics were used, but was not clear as to which types they used. Only two contingency type tables were used and the information used in the tables was not helpful with what the research article was about. It would have been more beneficial to have tables or graphs to show the results of the study hypothesis that were presented in the article. Only one descriptive statistics was used, which was the age of the participants, so this section of the article is weak. Both the internal and external validity were decreased due to not having enough information.

Inferential Statistics

Evidence. In the article by Padula, Hughes & Baumbover (2009, p. 329), they used inferential statistics to determine the differences between the control and treatment group on the dependent variables. The inferential statistics are found in the results section of the article.

When a p value is seen in the article, it is known that an inferential statistic was used. Parametric statistical tests are used in this article because population parameters are used.

Subjects in the treatment group showed a decreased fall risk score on admission (P = 0.7)

(Padula, Hughes & Baumbover, 2009, p. 329). The Barthel scores upon discharge for the treatment was higher and the control group was lower in comparison to their admission scores.

The treatment group was P = .05 and the control group was P = .006 (Padula, Hughes & MOBILITY PROTOCOL ARTICLE CRITIQUE 29 Baumbover, 2009, p. 329). For the Up and Go test, both the treatment and control groups score had improvement in p scores. For hypothesis 1 of the study, the treatment group had greater improvement in functional status than the control group at P = .05 (Padula, Hughes &

Baumbover, 2009, p. 330). Hypothesis 2 showed the length of stay at P < .001 (Padula, Hughes

& Baumbover, 2009, p. 330).

Support. According to Nieswiadomy (2012, p. 225), inferential statistics are types of statistics that use the characteristics of the samples or populations, and uses sample data to make an interpretation about the population, and are based on the laws of probability. The purpose of inferential statistics is to estimate the population parameters from the sample data and to test the hypothesis.

The level of significance is the probability of rejecting the null hypothesis when it is true

(Nieswiadomy, 2012, p. 320). The letter p or the Greek letter alpha symbol is used to represent the probability level of the test. In nursing studies, the most common level of significance is p =

.05, which means that the researcher is wrong 5% (5 times out of 100) of the time when rejecting the null hypothesis (Nieswiadomy, 2012, p. 231).

The t test is a test that examines the difference between the mean values of two groups.

This is one of the most popular tests in statistics. The t test is valuable with small sample sizes but can be used with any size sample. The t test is a parametric test, which means that the sample data has been taken from populations that have been normally distributed and have similar variances. There are two forms of t tests. One uses independent variables and the other uses dependent variables. The independent t test is used when there is no relationship between the two sets of scores being compared, whereas the dependent t test is used when one set of scores is dependent on the other set of scores (Nieswiadomy, 2012, p. 235). MOBILITY PROTOCOL ARTICLE CRITIQUE 30 In Nieswiadomy’s book, this chapter is confusing, but did find it helpful in using the term

“chance” (Nieswiadomy, 2012, p. 225) to better understand the meaning of inferential statistics.

It is also noted that the terms sampling error and random error are used interchangeably.

Additionally, it made more sense in understanding that the larger the difference found between the groups, the lower the probability that the difference occurred by chance (Nieswiadomy, 2012, p. 225).

Analysis. The article provides a large amount of statistical data which is somewhat confusing to understand. Having the statistics comparing the findings of the treatment and control groups placed in a graph or table would make it easier to follow. The information submitted in the article was really neither weak nor strong. It does state in the article that the differences in the fall risk scores were not significant, but overall the article could have done a better job on providing more detail for this information. There was no impact of internal and external validity in this section.

Study Findings

Evidence

The findings that the researchers in the mobility article present are that the subjects in the treatment group had shorter lengths of stay and ambulated in the hallway earlier than those in the control group, which supports the hypothesis that “older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge” (Padula,

Hughes & Baumhover, 2009, p. 327). The findings supported that the treatment group showed greater improvement using the Barthel Index instrument than the control group as well. The

Barthel Index measures the individual’s capacity to perform certain ADL’s. The hypothesis that the treatment group will show a reduction in length of stay as compared to the control group was MOBILITY PROTOCOL ARTICLE CRITIQUE 31 also supported. Since there were some significant limitations due to variables between the groups, it is hard to determine how strong the support of the findings really is.

Support

According to (Nieswiadomy, 2012, p. 247), the study findings are the final phase of the research where the findings are presented with empirical data and facts and then discussed. At the end of the research, implications and conclusions should be pulled together.

Recommendations should be given according to data collected and the findings. The study findings should state what has been learned and also make recommendations about what should be studied in the future. This should all be placed under separate headings at the end of the report such as: conclusions, implications, recommendations, findings, and discussion of findings.

In a quantitative study such as this the results should be presented as facts or empirical data, meaning it can be seen or heard. The opinions or reactions of the study should not be personalized. The findings need to be presented in past tense. Data should be collected and analyzed before the research report is written.

Descriptive statistics should be used to describe the sample and present the findings.

Inferential statistics, which are used to make inferences or decisions about a population, should be used when presenting the findings. These statistics are usually presented in narrative form or in tables. If the findings are presented in narrative form, they must be clear and succinct. The narrative form usually contains direct quotes from the participants. In a quantitative study the hypotheses are tested and the report should present the data that supports or fails to support the hypotheses. In a study finding there is information that should always be included, such as degrees of freedom and probability value. Tables should be used to organize data, according to

(Nieswiadomy, 2012, pp. 247-250). MOBILITY PROTOCOL ARTICLE CRITIQUE 32 Analysis

The findings should be under different headings, but this article goes from the results, into the discussion, and then the conclusion without separate headings for the findings, implications, and recommendations. The findings were at the final phase of the report as they should be; however, the report does not state what has been learned or make references to possible future study. It does make the recommendation that early ambulation and ongoing ambulation help improve functional status and shorten length of stay.

The report was presented in the past tense. The data was gathered and analyzed prior to writing the report, so it is not known how clearly and concisely the findings were presented.

Statistics were given in table and in narrative form. Once again, the findings are weak as there were many limitations in the study as well as several variables that can skew the findings. The study was not well thought out and the groups were distributed evenly to get a good picture of what results they were looking for. As far as the internal and external validity goes, there was no impact.

Discussion of Findings

Evidence

In the mobility article by Padula, Hughes & Baumhover (2009, p. 330), both hypotheses were supported with the improvement in the functional status of the treatment group, and the reduction in length of stay in the treatment group as compared to the control group. In the research the probability, limitations, and instruments used were discussed.

Support

According to Nieswiadomy, the discussion of findings should be more subjective than the presentation of findings. In this section, the researcher makes interpretations of the findings. MOBILITY PROTOCOL ARTICLE CRITIQUE 33 Nieswiadomy (2012, p. 249) states “the findings are interpreted in the light of the theoretical framework and within the context of the literature review”. There should not be any literature sources cited here that were not referred to in the literature section of the report, as it would seem that the researcher gathered information after data was already collected to support the study findings.

In this section, the researcher talks about the features of the results that agree or do not agree with the previous research collected. The researcher also discusses study limitations, which are weaknesses in the study, and uncontrolled variables which may affect results.

However, this section is not a place to list all weaknesses and disregard findings based on whether they agree with the theoretical framework, which is based on a theory that there is a relationship between concepts. In this section, interpretations of findings are presented and the strengths and weaknesses of the study should only be mentioned.

Analysis

The relationship between concepts in the mobility article is the relationship between increased mobility on length of stay and functional status. The framework is the study of increased mobility on functional status and length of stay in hospitalized patients. The limitations are some of the variables between the control group and treatment group. The treatment group had a lower fall-risk score than the control group, so this could skew the results as they had some mobility issues to begin with. The article recognized that the functional level of the control group was lower than that of the treatment group, but that did not feel it affected the results significantly. It would seem that this, along with the lower fall-risk score, would have a significant effect on the findings. The researchers stated they calculated the differences in groups using inferential statistics (Padula, Hughes & Baumhover, 2009, p. 329). MOBILITY PROTOCOL ARTICLE CRITIQUE 34 The interpretation of the findings, according to the article, was consistent with the literature, but it was not discussed how the limitations or weakness affected the findings, only that these differences may have affected the findings. The researchers did not generalize the results to all populations. The results were specific to the elderly population in an acute hospital unit. It appears that all sources used in the report were accounted for in the reference section.

There were not any suggestions in the mobility article found to improve upon the research.

This section of the article is weak and there was no threat to the internal and external validity. There was no information provided regarding the socioeconomic status, nutritional status, demographics, income, or insurance information on the participants in the study.

Conclusions, implications, and Recommendations

Evidence

In the mobility article, a conclusion is provided at the end stating that the research does support literature. The conclusion of this article is very short and to the point. It states that the findings are suggestive of functional decline starting prior to admission to the hospital and continues if early ambulation and mobility is not initiated which can in turn be linked to increased length of stays in the hospital.

Support

According to Nieswiadomy, in the study conclusion the researcher summarizes the findings and demonstrates what has been learned by the research. The researcher validates the worth and the meaning of the research study (Nieswiadomy, 2012, p.303). The problem is again referred to as well as the purpose, hypothesis, and theoretical framework. It should be made clear to the reader what the study has revealed in each of these parts. The sample size of the study must be considered when drawing conclusions from the findings. The conclusion should MOBILITY PROTOCOL ARTICLE CRITIQUE 35 not just reinforce the findings, it should go beyond the findings by applying them to similar populations. It is permissible to use the word appears in the conclusion because one cannot prove the findings when research is conducted using people.

Analysis

In the mobility article the conclusion is quite brief. The problem is identified at the beginning of the paragraph and the purpose is clearly stated. The hypothesis is referred to in the section as well. There is not a strong theoretical framework. This conclusion does not clearly apply the findings to populations other than the sample groups, so this is weak. The conclusion could have been more in depth. It does generalize the problem to older adults in the beginning of the conclusion paragraph. The researchers do not try to state that the findings are absolute rather that they may suggest the hypotheses are true, which is in keeping with the criteria for the conclusion. In ending the paragraph, the researchers reinforce the theory of ambulation being an important part of nursing care, but do not state why. There was no effect on the internal and external validity in this section.

Conclusion

The conclusion of this article is that is overall weak. It does not speak to all of the requirements set by Nieswiadomy. It is felt that the research project was a waste of time as isn’t it just common sense that if you don’t get people up and moving while in the hospital they will become weaker? Again, the whole article is weak and not very well thought out or prepared for.

Paper Conclusion

In conclusion, our student group found the article, “Impact of a Nurse-Driven Mobility

Protocol on Functional Decline in Hospitalized Older Adults” by Padula, C. A., Hughes, C., &

Baumbover, L. (2009), weak on many aspects, especially the theoretical framework. The MOBILITY PROTOCOL ARTICLE CRITIQUE 36 theoretical framework is not clear to the reader. The authors discussed the nurses in the control group being educated on the GENESIS program, but did not describe exactly what the GENESIS program is.

The purpose of this study was clearly defined, but the reader finds it difficult to find the problem statement. Another weak feature of this article was that the study groups were not equal due to differences in fall-risk factors, pre-functional, among other variables, so it is difficult to determine the validity of the study. There was not enough information given on the study groups. The reader is aware that the study groups were selected by convenience sampling, but there is not enough information about that population of patients selected, such as the socioeconomic background, insurance coverage, level of education, and demographics to really compare the groups for equality. The statistics were not explained well. There were not many tables or graphs to make the findings clear. The article stated which instruments were used, but were weak on discussing the reliability and validity of the instruments.

Some of the stronger points of the article were the hypotheses. These were made clear to the reader and were supported by the findings. Another stronger section of the article was the discussion of data used. The article gave details as to who gathered the data, what the data was, and the location it was gathered from, but did not really explain why the data was collected. Our group feels that more research needs to be conducted with fewer variables and more details to better apply the findings of the study.

Overall, this study could have been organized better with more headings to differentiate between the sections, explain in more detail what the nursing protocol was between the units studied, and what was done differently with the control group and the treatment group. MOBILITY PROTOCOL ARTICLE CRITIQUE 37 However, we are in agreement that increasing one’s mobility during a hospital stay will decrease complications and maintain function which will ultimately reduce the length of hospital stay. MOBILITY PROTOCOL ARTICLE CRITIQUE 38 References

Nieswiadomy, R. M. (2012). Foundations of nursing research. (6th ed.). Upper Saddle River,

NJ: Pearson.

Padula, C. A., Hughes, C., & Baumhover, L. (2009). Impact of s nurse-driven mobility protocol

on functional decline in hospitalized older adults. Journal of Nursing Care Quality,

24(4), 325-331.