CRITIQUE OF THE NURSE-DRIVEN MOBILITY PROTOCOLRESEARCH STUDY

Research Critique of the Nurse Driven Mobility Protocol Research Study Sandra Gilman, Elizabeth McManus Ferris State University

ANALYSIS OF AN ARTICLE Abstract

Throughout this paper you will find an analysis of the article, Nurse Driven Mobility Protocol Research Study written by Cynthia A. Padula, Cynthia Hughes and Lisa Baumhover. The purpose of this paper is to indicate whether or not the article followed the guidelines needed to strongly support evidence based nursing practice. In other words was the article valid in its research and did it prove its hypotheses? The support used to prove the articles strengths came from Understanding Nursing Research, Burns and Grove and Foundations of Nursing Research, Nieswiadomy. The purpose of the article being analyzed was to indicate whether or not older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge and if older adults who participate in a mobility protocol have a reduced length of stay. (Padula, et al., 2009, p. 327) Evidence of this article is laid out indicating the support or lack of support as required for a critical appraisal from the two texts mentioned above. The strength of the articles evidence is outlined in the analysis of each guideline. The guidelines for this analysis are: problem statement, literature review, study framework hypotheses and research questions, research designs, sampling procedure, data collection procedure and methods, descriptive and inferential statistics, presentation of study findings, discussion, limitations and conclusion. Keywords: place keywords here

ANALYSIS OF AN ARTICLE Analysis of an Article Using guidelines we analyzed the strength of the article; Impact of a Nurse-Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults, as a critical appraisal of evidenced based practice for use in nursing practice. This paper is a critique of the research

documented in the article to determine the strength of the evidence indicated. The critique of the evidence points out weaknesses and strengths in the support and analysis as use of the guidelines written by Niewiadomy and Burns and Grove. Purpose and Problem Evidence The researchers discovered a gap in the knowledge surrounding mobility status of hospitalized adults. The problem statement of this articles is stated as maintaining mobility is paramount in preserving independence in activities of daily living (ADL), yet research has demonstrated that low mobility and bed rest are common during hospitalization (Padula, et al., 2009, p. 325). Previous research has indicated that 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, et al., p. 325). When complications occur it leads to an increased length of stay. Many past studies have been completed which have identified a significant decline in the mobility of hospitalized adults. One study found that 35% of patients had worse ADL function at discharge as compared with preadmission baseline (Padula, et al., p. 326). Lastly, previous research also identified that older people who develop new functional deficits during hospitalization are also less likely to recover lost function (Padula, et al., p. 326). In addition there was a study that concluded that patients over the age of 70 who were bed rest or had low mobility in the hospital lead to adverse outcomes leading to functional decline. Due to

ANALYSIS OF AN ARTICLE the fact that a majority of hospitalized adults are older than 65 years; this is a problem of great significance (Padula, et al., p. 325). Support Most areas of research begin with a research problem. The research problem is an area of concern in which there is a gap in the knowledge base needed for nursing practice (Burns & Grove, 2011, p. 146). When there is a gap in knowledge it gives researchers the ability to determine what is needed to decrease or diminish that gap. The problem or area of concern provides the basis for developing the research purpose (Burns & Grove, p. 145), the research purpose is an explanation of the goal of the study (Burns & Grove, p. 146). After determining the research problem, it is important to discuss the significance of the research problem, which indicates the importance of the problem to nursing and health care and to the health of individuals, families and communities (Burns & Grove, p. 146). In order fully evaluate the

research problem; the researchers must evaluate the background of the problem, which is what is known about the research problem. (Burns & Grove, p. 146) Analysis The purpose and problem statement were clearly identifiable and included all necessary components of significance, background and problem statement. The background information of the research problem is stated in the beginning of the article and provides information which proves the significance of the problem being studied. The knowledge that is obtained from this study is significant due to the overwhelming cost of healthcare and the push to have lower length of stays. The purpose expressed the goal of the study clearly stated and was to evaluate the outcome the mobility protocol would have on adult patients greater than 65 years old. Concepts and population is presented in the problem statement, although the population is only described

ANALYSIS OF AN ARTICLE as older adults, it is more specific further in the article as adults over 65 years old. Also, the variables are not clearly expressed in the actual problem statement, it isnt until further in the study that the dependent and independent variables are discussed. Overall this section is strong in most areas and provides a good representation of the research study.

Literature Review Evidence The focus of the present study in the article Impact of a Nurse Driven Mobility Protocol on Functional decline in Hospitalized Older Adults is to compare a control group in the hospital to a group who is encouraged to get out of bed more often while in the hospital to determine the effects of activity on their LOS and outcome. The article is comprehensive, but I feel that without the knowledge of background could become confusing, for an example, within the article statistics of the research were given- the sample consisted of 23 men and 27 women; the mean are was 80.4 years, with a range of 62 to 97 years. The mean number of diagnoses was 6.7. Forty (80%) patients were admitted from home, 7 from assisted living and 3 from a nursing home. (Padula, et al., p. 329) This may only be comprehensive to someone who has been educated in statistics. I felt that the article was very concise as noted in the last paragraph, although the details of the subject being researched were not thoroughly explained. Comparisons to prior research such as Siebens et al developing an exercise program to improve outcomes in hospitalized adults and that the results of the program did not decrease the Length Of Stay (LOS), but improvement of functional outcome were often used. (Padula, et al., p.328) What is known is, there is an increase in length of stay and a decrease in functional outcome in patient who are hospitalized, what is not known is if activity will improve the

ANALYSIS OF AN ARTICLE outcome and decrease the LOS of hospitalized patients, and what amount of activity will be needed to see results. ( Padula, et al., p. 325) The purpose of the study was to evaluate the

improvement of outcome of hospitalized patient with an increase in mobility while hospitalized; the flow was logically throughout the literary review, but the plan of the path to be followed was not clear. While displaying the steps of the experiment the article flows in and out of multiple pieces of literature in use of comparison to strengthen the evidence. The sources cited seem to be relevant to the study topic as they are compared to the results of the study as well as the contrasting outcomes of the literature including LOS, but the details of relevance were absent. The tests that are used in the study are compared to a Get up and go test written about in prior literature. Sources are critically appraised by comparison and contrast of the study results with prior literature often illustrated throughout the article. (Padula, et al., p.328) Support This section is used to describe relevant studies, current knowledge and how they are used throughout the article to prove the strength of the Evidence based practice. The studies and research includes evidence to support the outcome. Through the literature review I feel the Evidence in the article does support the problem in question. What is unknown is challenged by comparing what is known by prior research or what is known to the new research to come to a conclusion that will provide the best of evidence based practice. The information supports the need to increase mobility of hospitalized patients to increase the function of outcome. The evidence used in the research is well supported by the comparison of literature to the new information being studied. In the text, Understanding Research, it is stated that prior literature review can be used to clarify evidence for best practices through literature reviews. (Burns and Grove, p.189) Comparing the prior evidence to the new research strengthens the methodology of

ANALYSIS OF AN ARTICLE the evidence based practice, this case shows the improvement of patient outcome by using

increased mobility while hospitalized by use of a new study and literature review on exercise test and Get up and Go testing. (Burns and Grove, p.220) In this article the critical appraisal does not follow the traditional literary review as done in a quantitative study, rather results from the new experiment are compared with literature review done on prior study findings. (Burns and Grove, p. 203) Current theoretical and scientific knowledge about the particular problem is displayed in this article and synthesizing is accomplished to prove the outcome of the research as stated in Understanding Nursing Research, Burns and Grove, p. 189. The synthesis of sources is successful in the article as stated earlier by use of multiple findings of the subject at hand. Interpretation and analysis of a subject is used in a cluster and compared in a table on page 221 in Understanding Research, but if research is not available protocol and clinical findings are used to provide the best outcome. (Burns and Grove, p.220) Sources that are cited in the article are found on the reference list, the use of electronic sources is present as well as the use of literature review and text. The sources are current, but they do not all have reference to the full text. (Burns and Grove, p. 213) Analysis The article missed some of the criteria required of literary review as stated by Understanding Nursing Research. I feel that the evidence in the article is not strongly supported because the requirements were missing, causing the reader to question its validity. There was nothing stated about the research information used was primary or secondary sources. The weak Literary review causes a question in the direction that the article and if there is bias formed by the writer excluding information that would be needed in a strongly supported Literary review. Theoretical/ Conceptual Model

ANALYSIS OF AN ARTICLE

Evidence In this study the framework is slightly difficult to identify. The identifiable piece of the framework is that this study used a nonequivalent control group design, the independent variable was the mobility protocol; dependent variables were functional status and length of stay (Padula, et al., p. 327). The researchers expect that the variable of the mobility protocol will cause increased functional status at discharge and decreased length of stay in the hospital. The concept of the mobility protocol is clearly defined in the research article. Ideas of the framework are discussed in the introduction when stating that: Maintaining mobility is paramount in preserving independence in activities of daily living yet research has demonstrated that low mobility and bed rest are common during acute hospitalization. The goal of this study was to determine the impact of the mobility protocol on functional decline in hospitalized patients. (Padula, et al., p. 325) There is discussion throughout the introduction which link variables to mobility outcomes in previous studies. Support A theoretical framework is an abstract, logical structure of meaning, such as a portion of a theory, which guides the development of the study and enables the researcher to link the finding to nursings body of knowledge (Burns & Grove, p. 238). Implicit frameworks are when ideas for the framework are expressed in the introduction or literature review in which linkages among variables found in previous studies are discussed, but then the researcher stops without fully developing the ideas as a framework (Burns & Grove, p. 239). When implicit frameworks are used they are more difficult to find however a careful reader can extract an

ANALYSIS OF AN ARTICLE

implicit framework from the text (Burns & Grove, p. 239). The researchers did accurately use a concept which is a term that abstractly describes and names an object (Burns & Grove, p. 230). Analysis Overall, compared to other areas of the research articles, the framework was difficult to identify, making this section rather weak. The best category I could place the framework in was that of implicit framework. There was an area of the article under discussion that looked as if it could be the framework, however it isnt clear, so again this is a weak section of this article. It was discussed that this was nonequivalent control group design, but a specific theory or theorist is not identified. Concepts were used throughout the study and clearly identified as the mobility protocol, and each variable and concept is conceptually defined. Lastly, the study findings are able to be linked back to what is believed to be the framework of the study.

Hypothesis Evidence In this article the hypothesis seems to be clearly identifiable and formally stated. The variable being evaluated is the mobility protocol. The relationship being evaluated is the relationship of increased mobility and how that will affect the functional decline of hospitalized patients. The goal of this study was to determine the impact of a mobility protocol on functional decline in hospitalized patients, (Padula, et al., p. 325) this would be an example of a simple causal hypotheses. The casual hypotheses in this article 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 length of stay (Padula, et al., p. 327). The hypotheses in this article clearly predicted the outcome of

ANALYSIS OF AN ARTICLE 10 this study and is clearly stated as hypothesis 1 that older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge was supported (Padula, et al., p. 330). As well as hypothesis 2, older adults who participate in a mobility program will have a reduced length of stay, was also supported (Padula, et al., p. 330). By stating that adults will maintain or improve function and have a reduced length of stay there is confirmation this is an example of directional hypothesis. Support The hypotheses may be looked at as the predicted outcome of a study. 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 (Burns & Grove, p. 167). A well-organized easy identifiable hypothesis will include the variable that is being measure, the population that is involved as well as the predicted outcomes of the study (Burns & Grove, p. 167). There are 4 different types of hypothesis that can be developed depending on the purpose of the study; these include (1) associative versus causal, (2) simple versus complex, (3) nondirectional versus directional and (4) null versus research (Burns & Grove, p. 167). A causal hypothesis proposes a cause-and-effect interaction between two or more variables, which are referred to as independent and dependent variables (Burns & Grove, p. 170). When communicating the relationship amongst 3 or more variables the hypothesis is said to be complex, however when only stating the relationship between two variables, the hypothesis is said to be simple. (Burns & Grove, p. 172) Analysis This research design was appropriate for this study to accurately determine the outcome of the hypotheses developed for evaluation of the mobility protocol. The purpose of this study

ANALYSIS OF AN ARTICLE 11 was to prove that inpatients who received early mobility will have a higher incidence of being at or above pre-hospitalization function. The effect of early mobility will have an outcome of increased discharge mobility as compared to a population of inpatients who do not receive early mobilization in the hospital. Therefore it is identified that a quasi-experimental study was conducted with independent variable being the mobility protocol and the dependent variable being functional status. The experimental group was exposed to the mobility protocol and the control group was on the only hospital unit that was not trained with the mobility protocol and therefore received standard treatment. The researchers formally stated the hypotheses; however there is no mention of which type of study is needed to correct. The relationships among the variables of the study were identified and the outcome of the study had positive evidence to state that a prediction of the outcomes is within the hypotheses. Research design Evidence

This study best meets the criteria of a randomized clinical trial because there is a group that received treatment and a group that didnt receive treatment. Subjects for the study were selected using clearly defined criteria including, Inclusion criteria included a length of stay 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, et al., p. 327). The article utilized a randomized experimental design with a pretest and posttest, this is evident in the use of the Barthel Index (BI) and the Get up and Go tests and within the treatment and control group. The BI pretest and posttest was administered at the time of admission and again at the time of discharge to assess self perceived level of function. (Padula, et al., p. 328) To minimize the variation of the control group treatment and

ANALYSIS OF AN ARTICLE 12 ethically perform the study; standard care was given by predominantly registered nurses and certified nurse assistants. The nurses on the treatment unit were given special training in the Nurse Driven Mobility Protocol which served as the intervention for this research; the control unit did not implement this program. Special measures like nurses not floating between units were taken to minimize the chance of the intervention affecting the control unit. The article states that the differences between the treatment and control group on the dependent variables were calculated using inferential statistics. (Padula, et al., p. 329) The article states that the study used a nonequivalent control group design, qualitative methods related to mobility decline in hospitalized older adults. I did not find this to be true as stated above. In addition to the above, the researcher clearly describe how participants were selected, stating that the amount of variable used in the sample size was quickly decreased with the screening process leaving 84, although 34 withdrew for a variety of reasons including discharge before data could be collected or before the 3 day criteria was met. The article also stated that, Sample size statistics were conducted to determine adequate power and supported a total number of 50. (Padula, et al., p.327) Sample size statistics were calculated prior to data collection to ensure adequate power to detect differences between the groups. (Padula, et al., p.329) There was a lower fall risk score for the control group as well as the treatment group keeping the initial population similar; in the end the Barthel scores were better in the treatment group than in the control group. (Padula, et al., p.329) Limitations of the study include the recognition that the lower functional level of the control group, though not significant, could have contributed to increased LOS and or later ambulation. (Padula, et al., p.330) The control placed on the design was moderate to strong however the study could have used a control on the length of stay in the hospital. For example a length of stay between 3 and 10 days, with the criteria mentioned a person with 3 days in the

ANALYSIS OF AN ARTICLE 13 hospital could be compared to someone in the hospital for 15 days. It states that the treatment group had a significantly shorter length of stay but how can one be sure this is related to the protocol and not the initial diagnosis of the patient.

Support

An experimental design focuses on examining causality; a combination of characteristics of more than one design may be used by the researcher to meet the need of the study. Commonly used experimental studies use the pre and post test design with experimental and control groups. (Burns and Grove, p.276) To narrow the design use further, a randomized experimental group uses subjects to test the effects of a treatment and compare the results with those of a control group that has not received the treatment, sometimes costing more than nursing studies can afford. Starting with a reference population with clearly defined criteria subjects are assigned randomly to treatment or control groups. It is important that both groups are comparable and the treatment within the group is consistently applied and outcomes are measured consistently. The use of this design has potential to greatly improve the scientific base for nursing practice. (Burns and Grove, p. 280) During an experimental design an intervention is developed to show a change from pretest to posttest results. The goal is to maximize the difference between the control group and the experimental group. Traditionally any intervention would be eliminated but for ethical reasons standard nursing is continued for the comparison group intervention. For adequate appraisal the intervention of standard need to be described in detail to determine the amount of cause and effect they have on a study. There tends to be a high variance in the control group based on the quality of standard of care difference. (Burns and Grove, p.282)

Analysis

ANALYSIS OF AN ARTICLE 14 Based on the statement under design in the article and the use of the variables used in the post testing, I feel that the representation of the design was weak to moderate. The experiments were present, but not thorough in the evidence need to support a strong research design.

Sampling and Sampling Methods Evidence

The target population is identified as the older adults who were 60 years or older admitted with a medical diagnosis. The criteria also included a 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, et al., p.327) The accessible population is identified as medical patients who were admitted to 1of 2 medical nursing units in Miriam Hospital, a private 247 bed, not for profit, acute care teaching hospital in Providence, Rhode Island. Non-probability sampling method was used when the researchers screened the target population and purposefully selected subjects without physical impairment and cognitive limitation. A specific sampling method was named as a convenience sample of older adults, described further as stated above. The sample size was met after a screening of 453 patients, 84 eligible subjects were enrolled, 34 withdrew leaving the sample at 50 subjects, 25 on each of the two units. (Padula, et al., p.327) I feel that the nonprobability sampling method is appropriate for the study because of the convenience and accessible population of the hospitalized patient. Demographic data collection sheets were developed specifically for this research and included the information stated in the criteria above and more. Out of bed activity were obtained by chart reviews, discussion with nursing staff and patients. Other test used for functional status were the Barthel Index and the Up and Go tests.

ANALYSIS OF AN ARTICLE 15 (Padula, et al., p.328) With the amount of variable used the sample sized was quickly decreased with the screening process leaving 84, although 34 withdrew for multiple reasons including discharge before data could be collected or before the 3 day criteria was met. The article also stated that, Sample size statistics were conducted to determine adequate power and supported a total number of 50 (Padula, et al., p.327) The population is stated as being representative of the population, including 23 men and 27 women with the mean age of 80.4 years old who were admitted from home and assisted living, this leaving no significant differences between the two groups. (Padula, et al., p.329) A potential sampling biases was not identified rather, the article stated that data analysis showed the sample size statistics were calculated prior to data collection to ensure adequate power to detect differences between the groups. Descriptive statistics were completed for study variables and comparisons between the groups on base line characteristics were examined. Differences between the treatment and control group on the dependent variables were calculated using inferential statistics. (Padula, et al., p.329) Subject dropouts were discussed and were based on the eligibility screenings, discharged early, disqualifying procedure or condition procedure, and one because of anxiety. (Padula, et al., p.327)

Support The accessible population includes the portion of the target population with reasonable access. (Burns and Grove, p.290) Probability occurs when the sample is obtained randomly, nonprobability is achieved when the researcher decides that a subject is too sick or not sick enough. (Burns and Grove, p.299) The biases of the convenience sampling are easily noticed as the patients happened to be there in the hospital on that unit with the appropriate assessment. Subjects are added to the study until the desired sample size is reached.(Burns and Grove, p.305)

ANALYSIS OF AN ARTICLE 16 The demographic variables are attributes of the subjects collected including variables like age, gender and medical admission, these characteristics are used to describe the sample. (Burns and Grove, p.182) In the text Understanding Nursing Research it is stated that the sample size needed may increase based on the type and amount of variable used to detect differences between groups. (Burns and Grove, p.310) Representativeness according to Burns and Grove means that the sample, the accessible population, and the target population are alike in as many ways as possible and that the sample must be representative in terms of characteristics like age, and gender which also influence study variables. (Burns and Grove, p.294) Burns and Grove stated on page 295 As the number of subjects declining participation increases, the possibility of a systematic bias in the study becomes greater. (Burns and Grove, p.295)

Analysis The information given in the article based on sampling was strong as an indication of the critical appraisal guidelines shown in Understanding Nursing Research text, on page 311. (Burns and Grove, p.311) The use of the demographic data collection sheets developed specifically for this research indicated extreme strength in the support of the demographic variables needed in choosing a reliable sample. Although using a convenience sample can cause bias, the article showed strength in the initial sample size and screen to avoid the bias to an excessive amount.

Measurement and Data Collection Evidence In this study, an advanced practice nurse with expertise in gerontology and geriatrics was hired to collect data and was trained by the geriatric clinical nurse specialist and the principal investigator (Padula, et at., p. 328). The training provided to the advanced practice

ANALYSIS OF AN ARTICLE 17 nurse included human subjects protection and achievement of high level proficiency with the protocol and data collection instruments (Padula, et al., p. 329). The screening process and scoring process by use of the study instruments was practiced until adequate reliability was achieved, this process was reevaluated occasionally to ensure accuracy. There were two units involved with this study, the staff of these units we not pulled to the other unit to be sure appropriate care was delivered and to obtain the best collection of data. The sample size statistics were calculated prior to data collection to ensure adequate power and to detect differences between the groups. (Padula, et al., p. 329) In addition a demographic data collection sheet was developed specifically for this research (Padula, et al., p. 328). The demographic data questionnaire, evaluated age, gender, primary diagnosis, use of assisted devices, fall risk assessment, presence of any restrictions to mobility, use of occupational of physical therapy, length of stay, first and amount of times out of bed and amount of time out of bed (Padula, et al., p. 328). In order to obtain research subjects, the researchers recruited a convenience sample of adults 60 years and older who were admitted with medical diagnoses to 1 of 2 nursing units (Padula, et al., p. 327), the first unit was the treatment unit and the second was the control unit. Nurses from the treatment unit were specially trained in a model that included a nurse driven mobility protocol. Patients that were included in the research study were evaluated at admission and at discharge using an ordinal scale measurement tool called the Get up and Go test which 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 (Padula, et al., p. 328). This test consists of a 1 to 4 point scale, 1 being able rise in a single movement and 4 being unable to rise without assistance (Padula, et al., p. 329). In addition the Barthel Index was used which is a subjective assessment to determine the patients perception of their level of dependence with

ANALYSIS OF AN ARTICLE 18 ADLs. a rating of 0 on the scale was totally dependent whereas a score of 100 was completely independent with ADLs. (Padula, et. al., p. 328) Support Reliability of a test instrument is achieved when results are consistent each time it is utilized in a short period of time (Burns & Grove, p. 332). When measuring the research outcomes it is important to determine if the study is using direct or indirect measurements. The process of direct measures involves determining the value of concrete things (Burns & Grove, p. 328), whereas indirect measures is a means to capture elements of an abstract idea (Burns & Grove, p. 328). There are several different types of levels of measurement so another factor to consider is whether a nominal-scale measurement, ordinal-scale measurement, interval-scale measurement, or a ratio-scale measurement is used. A nominal-scale measurement is used when data can be organized into categories of a defined property but the categories cannot be rank ordered (Burns & Grove, p. 329). In contrast with ordinal- scale measurement data are assigned to categories that can be ranked (Burns & Grove, p. 330). Although ordinal-scale measurement is often used for nursing research interval-scale measurement and ratio-scale measurement are the highest forms of measurement. Interval-scale measurement uses interval scales, which have equal numerical distances between intervals. These scales follow the rules of mutually exclusive categories, exhaustive categories, and rank ordering. (Burns & Grove, p. 330) In comparison, ratio-scale measurement meets all of the rules of measurement including mutually exclusive categories, exhaustive categories, ordered ranks, equally spaced intervals and a continuum of values (Burns & Grove, p. 330). The process of data collection includes selecting subjects, collecting data in a consistent way, maintaining researcher controls as

ANALYSIS OF AN ARTICLE 19 indicated in the research design, protecting the integrity (or validity) of the study and solving problems that threaten to disrupt the study (Burns & Grove, p. 362). Analysis This section of the review of this article in my opinion is strong, the reliability of this article was maintained as evidence by the advanced practice nurse and the research nurse practicing scoring and screening of subjects until adequate reliability was achieved. Subject were selected in a consistent manner, the research nurse screened a total of 453 patient records for eligibility, of those 84 eligible subjects were enrolled (Padula, et al., p. 327). The collection of the data was done within 48 hours of admit and again at discharge, which was consistent with all subjects enrolled in the study. Although ordinal-scale measurement is not the highest form of measurement I still feel it was appropriate to use this level of measurement with the Barthel Index and the Up and Go test. The Barthel index reliability, researchers have determined the Barthel Index was the standard for researchers to use. Lastly, the researchers proved to solve problems that may cause a threat or disrupt the study by ensuring that nurses did not get pulled between the control and treatment units.

Data collection and Instrument Evidence General Criteria The data collection methods were described thoroughly in the instrument section of the article on page 328. The instruments included a demographic data collection sheet that was developed specifically for the research in this article. The data for the sheets was derived from

ANALYSIS OF AN ARTICLE 20 charts, corroborated discussion with nurses and the individual patient. Other instruments used were the Barthel Index (BI) which is a subjective test and The Get Up and Go test which is an objective assessment test. (Padula, et al., p.328) The data collection methods used in the article were appropriate for proving the hypotheses. The article states: The hypothesis that older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge was supported (Padula, et al., p.330). Three of the six instruments used are listed above, the other three include the interview and recruitment of the convenience sample, and the mini-mental state examination. (Padula, et al., p.329) Questionnaires A questionnaire was not used in the article for data collection rather; a screening was performed of the patient and their information. Sampling biases were not discussed in this article, the researcher recruited a convenience sample of adults 60 years or older admitted with a medical diagnosis (Padula, et al., p.327). There was no mention of anonymity or confidentiality although the eligible patients were provided an informational letter that was approved by the Lifespan Institutional Review Board that may have included that information. (Padula, et al., p.328) Interviews The article did not indicate use of an interview throughout the research other than the demographic data collection sheet information that was collected from chart reviews, nursing staff and the patients. The only indication of confidentiality assurance was in training of the clinical nurse to include human subject protection, but no mention of the time that an interview may have taken. Other information provided about training for the interviewer included an advanced practice nurse with expertise in gerontology and geriatrics was hired to

ANALYSIS OF AN ARTICLE 21 collect data and was trained by the geriatric clinical nurse specialist and the principal investigator (Padula, et al., p.328). Other Methods The use of other methods included: screening, a demographic data collection sheet, a functional status test including the Barthel Index (BI) and the get up and go test, and a mini mental state examination. The rationale for use of the demographic data collection sheet allowed no significant differences between the two groups, but rationale of the method of data collection used within the data collection sheet was not mentioned. The rational of the BI test as stated above is a subjective functional status test that measures the capacity of an individual to perform identified ADL, researchers have proposed the BI as the standard for clinical and research purposes. A test called The Get Up and Go test was also used, this test measures the ability to stand, walk, return and sit back down. (Padula, et al., p.328) The rationale for use of the mini mental exam was to evaluate cognitive status and the perception of the patients abilities. Scoring for the methods were discussed for BI which included a 5 point rating scale for each item to improve sensitivity to detecting change, a four point scale which measured the ability to rise without assistance was used for the get up and go test. Details about the mental exam scoring only indicated a score of less than 24, but nothing more, and the information about scoring of the demographic data collection sheet included was not elaborate but the results were useful in breaking up the groups evenly. (Padula, et al., p. 329) Support General Criteria Collecting data and acquiring subjects is considered the process of data collection. As in this article the steps of collecting the data are specific to each study and depend on the

ANALYSIS OF AN ARTICLE 22 research design and measurement techniques (Burns & Grove, p361). Physiological measures are measurement methods used to quantify the level of functioning of living beings. The precision, accuracy, and error of physiological and biochemical measures tend not to be reported or are minimally covered in published studies (Burns & Grove, p.338). The five tasks used by the investigator in either qualitative or quantitative research are: selecting subjects, collecting data in a consistent way, maintaining research controls as indicated in the study design, protecting the integrity or validity of the study, solving problems that threaten to disrupt the study and all of these were used in the article (Burns & Grove, p362). Questionnaires Although a questionnaire was not used for recruitment, a screening was. A questionnaire is a printed self report form designed to elicit information through written or verbal responses of the subject. The information obtained from a questionnaire is similar to that obtained by an interview, but bias is less in a questionnaire (Burns & Grove, p. 353). Recruitment of subjects needs to be done at the initiation and throughout the data collection. The number of subjects planned is critical in having an adequate sample size and there search report needs to describe the subject recruitment process (Burns & Grove, p. 362) Interviews Quantitative and qualitative research use interviews, these interviews can be structured or unstructured. In an unstructured interview the questions are broader, but in a structured interview the questions are used to control the content of the interview (Burns & Grove, p.350). The specifics of an interview were not mentioned in the article but the use of the collection sheet information included such as age gender primary diagnosis indicate a more structured way of obtaining information.

ANALYSIS OF AN ARTICLE 23 Other Methods The methods used were observational measurement where the observer or the researcher collects data by way of qualitative research. The observer watches the study participant perform in a specific setting. Structured observational measures allow the researcher to carefully define what he or she will observe and how the observations are to be made, recorded and coded (Burns & Grove, p.348). Analysis Data collection and instruments were of average support in this article. Some of the instruments used were described in detail proving to be strong. Although the weak were lacking in content, including: exactly how the screening for recruitment, how data was obtained, how the information for the demographic data collection in regards to individual patient was gathered, and the details about examination routinely conducted to evaluate cognitive status in the minimental state exam. Some of the details were left out as described above, but the uses of instrument in data collection were appropriate to prove the hypotheses.

Data Analysis Descriptive Statistics

Evidence

The researchers use ungrouped frequency when discussing the study subjects who were withdrawn from the study for various reasons.

ANALYSIS OF AN ARTICLE 24 34 subjects were withdrawn from the study for a variety of reasons including discharge before discharge data could be collected (n = 11) or before 3 days (n = 9), transfer off study unit (n = 8), occurrence of a disqualifying procedure or condition procedure (n = 5), and personal reasons (1 client voluntarily withdrew because of illness-associated anxiety). (Padula et al., p. 327)

Throughout the study the Mean was the most often used measurement of central tendency. Of the selected sample used for the study the mean age was 80.4 yearsthe mean number of diagnoses was 6.7 ( Padula, et al., p. 329). The mode was also used when stating the majority (n = 3, 62%) acknowledged using some type of assistive device prior to admission ( Padula, et al., p. 329). The researchers used both Range and Variance in this article. The range was used when discussing the mean age of 80.4 years with a range of 62 to 97 years (Padula, et al., p. 329). Variance was the most often used measure of dispersion. Variance was used when discussing fall risk scorers of the treatment group vs. the control group, the treatment group had a fall risk score of 7.5% vs. the 9.5 % of the control group. (Padula, et al., p. 329) Variance was also used when the overall results of the study were discussed.

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. However, the treatment group ambulated in the hallway earlier (2.7 days treatment vs. 4.9 days control, P = .007) and more often (3.12 times treatment vs. 2.44 times control; NS). The treatment group had significantly shorter length of stays (4.96 days treatment vs. 8.72 days control; P < .001). (Padula, et al., p. 329)

ANALYSIS OF AN ARTICLE 25 The researchers used standardized scores to demonstrate the treatment group had a greater improvement in functional status as measured by the Barthel Index than the control group (P = 0.05) (Padula, et al., p. 330). This reveals that the treatment group had an improvement rate that was 0.05% above the mean.

Support

Descriptive statistics are used in studies where the data is numerical. Descriptive statistics include frequency distributions, measures of central tendency, measures of dispersion, and standardized scores (Burns & Grove, p. 383). Frequency distribution is used to organize the data and is categorized by two different types, ungrouped frequency distributions and group frequency distributions. Ungrouped frequency distribution is used to display all numerical values obtained for a particular value (Burns & Grove, p. 384). Each variable is shown with the amount of subjects representing the variable. The measure of central tendency is used to demonstrate the average of the data. Included in this is the mode, median and the mean. The mode is the number that occurs most frequently whereas the mean is the sum of scores divided by the number of scores being summed (Burns & Grove, p. 387). Range and variance are used as measures of dispersion, which is the differences of the members of the sample (Burns & Grove, p. 387). The range is simply calculated by subtracting the lowest score from the highest score (Burns & Grove, p. 387). A more complex measure of dispersion is the variance. The variance is calculated with a mathematical equation and indicates the spread or dispersion of the scores (Burns & Grove, p. 387). Lastly Standardized scores are used as a measure specifically when values are different in various categories. A common standardized score is the Z-Score; it expresses deviations from the mean (Burns & Grove, p. 388). The mean Z-Score is expressed as

ANALYSIS OF AN ARTICLE 26 zero, if a number is above the mean, the z score would be a positive number, if below the mean is would have a negative number.

Analysis

The researchers had strong evidence in each category of the study and represented the findings according to the critique guidelines of Nieswiadomy. Included in this research report were ungrouped frequency distributions, which adequately described the cause of participants withdrawal from the study. The measures of central tendencies used in this article included both the mode and the mean. The mode of 62% accurately demonstrated that the majority of subject in the study used some type of assistive equipment prior to admission. The mean age and diagnoses provided a clear picture of the average age and amount of varying diagnoses. In different areas of the study both range and variance were utilized to express measurement of dispersion. Both the range is the simplest for and served the purpose of expressing the range of the age group. The variance used to express the results of the study provided a clear explanation of the findings. Standardized scores were used to demonstrate the average above the mean for the treatment vs. control groups and provided a good understanding. I do feel that the levels of measurement were appropriate given the variable being measured. The Central tendencies and variability was thoroughly explained when giving the overall results of the study as evidence by stating that the mean age was 80.4 with a range of 62-97 years (Padula, et al., p. 329). The demographic characteristics of the subjects was clearly explained as evidence by age range as well as explaining that forty (80%) patients were admitted from home 7 from assisted living and 3 from a nursing home. Four (8%) had a documented diagnosis of dementia on admission (Padula, et al., p. 329). Tables and graphs were used throughout the research articles to

ANALYSIS OF AN ARTICLE 27 demonstrate the nursing staff characteristics as well as Barthel Index scores by group which was consistent with the information found in the text. Overall this is a very strong section of the research article.

Data Analysis Inferential Statistics Evidence Inferential statistics are used in the article Impact of a Nurse Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults as stated on page 329. Differences between the treatment and control group on the dependent variables were calculated using inferential statistics. The research determines that the control group did get out of bed everyday which is not representative of the population of hospital patients who normally do not get out of bed this may have influenced the mobility outcome for the control group. (Padula, et al., p. 330) The pretest and posttest indicated on page 328 and the results on 329 are a determination of an appropriate test used in inferential testing although this was the only test indicated. The inferential statistic of the calculated value for each hypothesis was presented in the text and the level of significance was stated on page 330. The p values that were stated on page 329 of the article indicated the individual test values as well. The degree of freedom was not indicated throughout the description of the test values. The pretest and posttest explained in the instrument section of the article was an appropriate test choose for inferential statistics, the level of measurement of strength and mobility of the patients on admission and discharge being assessed. (Padula, et al., p. 328) Are inferential statistics presented for each hypothesis that was stated in the study? The pretest and posttest of the get up and go and BI were the inferential statistics that were used for both hypothesis one; older adults who participate in a mobility protocol will

ANALYSIS OF AN ARTICLE 28 maintain or improve functional status from admission to discharge and hypothesis two; older adults who participate in a mobility protocol will have a reduced LOS. (Padula et al., p. 327) The results of the hypothesis are present in the text, but they are not present in a table form. The text states that hypothesis 1 proves the treatment group to have better results than the control group (p=.05). Hypothesis 2 was also supported (p= .001) that the length of stay would be reduced when participating in the mobility protocol. (Padula, et al., p. 330) Support Inferential statistics deal with the population, using the sample data to make an inference about a population. To infer is the process of obtaining a strict sound consequence of assumed basis, this can also be referred to as probability. Choosing the appropriate tests is very important there are two basic choices, ones that search for differences in sets of data and the ones that search for relationship between sets of data. (Burns and Grove, p. 378) The measurement before and after a specific nursing intervention will be tested, i.e. the pre and posttest indicating the relationship, because the same data is measure both times. The significance is stated by rejecting or failing to reject the null hypothesis. This is the value of how likely it is that a wrong decision has been made when two groups are said to be different or when an independent variable is said to cause the change in the dependent variable. The level of significance is valued at .05 the indication of how many times out of 100 the researcher is willing be to wrong. (Nieswiadomy, 2008, p.302) The degree of freedom indicates the number of values that are not free to vary. In inferential statistics the difference between the experimental group and the control group is a real or a chance difference, because an unrepresentative sample was chosen from the population. When sample data is used to estimate the characteristics of a population, there is a chance the estimate will be inaccurate. To be sure the sample is representative of the population an

ANALYSIS OF AN ARTICLE 29 inferential statistic is used.(Burns and Grove, p. 383) Testing of the hypothesis has become more of an interest to nurses, but estimation of the population and testing hypothesis are both reasons for using inferential statistics. During the testing of a hypothesis steps are followed, they include: state the study hypothesis, choose the appropriate statistic test, decide on a level of statistics, decide if a one or two tailed test will be used, calculate the test statistics using the research data, compare the calculated value to the critical value for that test, reject or fail to reject the null hypothesis, determine support or lack of support for research hypothesis. (Nieswiadomy, p. 300) Analysis The use of only the pretest and posttest to prove the hypotheses indicates weakness of the evidence within the article to support a critical appraisal. Weakness in the appraisal is also indicated in the lack of description of the test values in lieu of the degree of freedom. The support is weak in providing evidence to prove the hypothesis because it lacks more testing or prior valid research. Discussion Evidence In the discussion of this research article the researchers reiterate that both of the hypotheses were proven accurate based on the evidence throughout the study. The major finding number one of the study was that older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge (Padula, et al., p. 330). The major finding number two of the study was older adults who participate in a mobility protocol will have a reduced length of stay (Padula, et al., p. 330). The discussion section touches on

ANALYSIS OF AN ARTICLE 30 previous literature by repeating that immobility contributes to functional decline and also walking difficulties have been identified as an early marker for prolonged hospital stays in older adults (Padula, et al., p. 330). Lastly, the researchers reiterate that in this study, 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 (Padula, et al., p. 330). Support The discussion section is found toward the end of the research article as is used to tie all of the sections of the article together. The discussion 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 (Burns & Grove, p. 59). Analysis The discussion section showed results that offered new information about the target phenomenon (Burns & Grove, p. 446). The new information coupled with the linkage to previous findings and literature makes this section of the research article strong. Limitations Evidence The limitations listed in this research article were found under the Discussion section. The control group was found to have a lower functional level; however it was not significant, but could have contributed to longer length of stay. Also disease burden and patient acuity were not measured in this study. It was suggested that the modified Up and Go test be investigated as it did not detect differences in functional level that were identified by the Barthel Index (Padula et al., p. 330). Lastly, the control unit was the only unit not trained in the Genesis model,

ANALYSIS OF AN ARTICLE 31 however at the time of the study they were the only unit in the hospital that employed a unitbased advanced practice nurse with responsibility for clinical outcomes on the unit (Padula et al., p. 330). The results of this study showed that both the control group and the treatment group were out of bed every day, however anecdotal observations and the literature support that hospitalized patients do not generally get out of bed every day during a hospital stay (Padula et al., p. 330). The conclusion is made that it is possible that the presence of the advanced practice nurse positively affected mobility outcomes (Padula et al., p. 330). Support It is important for the researcher to discuss the limitations of a study and make suggestions for further studies based on those limitations. Limitations are restrictions in a study that may decrease the credibility and the generalization of the findings. (Burns & Grove, p. 48) Analysis Overall the limitations section of the research article was very strong. The researchers clearly listed the limitations and suggested further testing in the areas of the limitation. For example, further investigation of the Up and Go test was recommended as well as the recommendation to build on this study and include quantification of the impact of diseases (Padula et al., p. 330). It is obvious that the researchers critically investigated their study to determine the limitations involved. Conclusion Evidence The researchers concluded that although older adults typically experience functional decline during an acute hospital stay (Padula, et al., p. 330) through early mobilization in the hallway the functional decline can be lessened. The existing literature actually suggests that

ANALYSIS OF AN ARTICLE 32 functional decline starts pre admission. The researchers found that early and ongoing ambulation in the hallway may be an important contributor to maintaining functional status during hospitalization and to shorten length of stay (Padula et al., p. 330). With the research provided ongoing ambulation of patients should be a nursing priority. Support The conclusion of a research article is a synthesis of the findings (Burns & Grove, p. 412). When creating the conclusion the researcher 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, p. 412). The researcher must be careful to not form conclusions that are not warranted by the data (Burns & Grove, p. 412) Analysis The conclusion is a concise summary of the research study. Based on Burns and Groves Critical Appraisal Guidelines found on page 412 of Understanding Nursing Research the conclusion of this research article is strong. The conclusion mentions that it is consistent with previous studies which identifies that functional decline begins at pre admission. The conclusion was appropriate suggesting that early and ongoing ambulation in the hallway may be an important contributor to maintaining functional status during hospitalization (Padula, et al., p. 330). In the conclusion the final suggestion is that ambulation should be viewed as a priority for nurses.

Conclusion

ANALYSIS OF AN ARTICLE 33 A conclusion is a good summary of the Evidence with highlights of the Evidence, recommendations, etc. The evidence in this article has its weak points as in its inability to prove the hypotheses and support the research information given along with its strengths as in the use of descriptive statistics that were used to show the values related to the outcome of the studies that were used. I recommend that the tests that were recommended to further the study be researched and added to the article rather than stating that they are missing. This would help validate the hypotheses that were only tested with pretests and posttest. what would you recommend? More studies need to be done to validate and strengthen the weak sections of the research.

ANALYSIS OF AN ARTICLE 34

References Start first reference here. One double space between lines in a reference and between each reference. Indent line two of each reference. If reference is a journal article, make sure you have the volume and issue number after the article title like this 27(3) followed by the page numbers. Start second reference here. For this paper include all 10 articles you reviewed for this project even if you did not use them in the article. Nieswiadomy, R.M., (2008). Foundation of nursing research (5th ed.). Upper Saddle River, N.J. Pearson Education. Burns, N., Grove, S.K., (2011). Understanding nursing research. building an evidence-based practice. (5th ed.). Maryland Heights, M.O. Elsevier Saunders. Baumhover, L., RN, CNS, BC, Hughes, C., MSN, RN, Padula, C.A., PhD, RN, (2009). Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. Journal Nursing Care Quality, Vol. 24(4) pp. 325-331., Wolters Kluwer Health/ Lippincott Williams & Wilkins.

ANALYSIS OF AN ARTICLE 35 Research Critique Grading 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 Comments

Points
Abstract and Introduction: 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 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) Review of the Literature and Theoretical Framework (Analyze relevance of the sources; Identify a theoretical or conceptual framework & appropriateness for study) Hypothesis(es) or Research Question(s) (Analyze whether clearly and concisely stated; discuss whether directional, null, or nondirectional hypothesis[es]) Sample & Study Design (Describe sample & sampling method & appropriateness for study; analyze appropriateness of design; discuss how ethical issues addressed) Data Collection Methods & Instruments (Describe & analyze the appropriateness of the what, how, who,
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ANALYSIS OF AN ARTICLE 36
where and when; describe & analyze reliability and validity of instrument) Data Analysis (Describe descriptive & inferential statistics & analyze whether results are presented accurately & completely) 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 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 Your paper should end with a brief conclusion of your critique PAPER POINTS Deductions for APA, grammar and Spelling

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