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Running head: NURSE-DRIVEN MOBILITY CRITIQUE 1
Nurse Driven Mobility Protocol Critique
Sue Vansteel, Kara Elkins, Benjamin Kasper
Ferris State University
Running head: NURSE-DRIVEN MOBILITY CRITIQUE 2
Abstract
The critique of research by Padula, Hughes, Baumhover (2009) on: “The impact a nurse driven
protocol on functional decline of hospitalized older adults” was conducted by a group of Ferris
State nursing students. An analysis by the group determined that the overall study was weak.
Despite the weakness it was noted, “findings suggest that early and ongoing ambulating in the
hallways may be an important contributor to maintaining functional mobility” (Padula, Hughes,
Baumhover, 2009, p. 330).
Areas of weakness in the study were evident in the purpose and problem, which lacked clarity
and conciseness. The literature also revealed that opposing views were not included. The Barthel
Index (BI) and a Get up and Go test identify the individual ability to perform self-care, however,
they are subjective with an interrater agreement of r + 0.793 for BI score.
Strengths include the hypothesis which was written as “the independent variable was mobility
protocol; dependent variables were functional status and length of stay” (Padula et al., 2009, p.
327). The quasi research design was a “nonequivalent control group design” (Padula et al., 2009,
p. 327), which appears to be appropriate for the study.
Institutions may implement mobility protocols that are nurse driven despite the weakness of this
study. However additional research is needed to validate the guidelines and outcomes of these
protocols and studies.
Keywords: functional decline, mobility, older hospitalized adults, protocols, critique
Running head: NURSE-DRIVEN MOBILITY CRITIQUE 3
Nurse Driven Mobility Protocol Critique
Nursing research evolved from the days of Florence Nightingale which focused on a “healthy
environment promoting patients’ physical and mental well-being” (Burns & Grove 2011, p. 10)
to the evidenced based clinical research of today. Evidence based nursing research reports the
strongest empirical findings that are significant to understanding health and illness experiences.
Based on the relevance of the study, clinical implication is estimated for therapeutic
interventions in nursing practice.
The purpose is to critique the quantitative research article: Impact of a Nurse-Driven
Mobility Protocol on Functional Decline in Older Adults, published in the Journal of Nursing
Care Quality in October -December issue 2009. Using Burns & Grove (2011) text:
Understanding nursing research: Building an evidence-based practice and the Nieswiadomy
guidelines (2009) provided by Hoisington to evaluate the strengths and weakness of the research.
Padula, Hughes, Baumhover (2009) states “maintaining mobility in acutely and even critically ill
people is a key component in achieving positive outcome” (p. 326). This study addressed the use
of a mobility protocol that would be nurse driven to have an impact functional decline that is
commonly seen in hospitalized older adults.
Purpose
Evidence
Padula, Hughes & Baumhover (2009) state, “the purpose of the study to determine the
impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults (p.
326).
Support
NURSE-DRIVEN MOBILITY CRITIQUE 4
According to Burns & Grove (2011), the purpose should contain clear and concise steps
in-order to reach specified goals or outcomes. The process for identifying the purpose of a study
according to Burns & Grove (2011) may include these elements “identify, describe, or explain a
situation; predict a solution to a situation; or control a situation to produce positive outcome in
practice” (p. 41). The purpose is a descriptive statement which includes a focus or concept to be
studied (Burns & Grove, 2011, p. 148). In addition the variables are outlined such as population
and relationships that may exist among the variables. Differences among the groups or variables
need to be outlined in the purpose statement (Burns & Grove, 2011, p. 148).
Analysis
The purpose statement referenced by researchers Padula et al. (2009) is reflected in the
title and restated in the abstract, as a goal in the first paragraph and also following the literature
review. The purpose statement describes the variables being hospitalized which include older
adults, mobility protocol (independent variable) and functional decline (dependent variable).
This is a strong purpose statement. However, reduction in length of stay was discussed in the
abstract as an outcome and was noted in the area of research during the study but was not
addressed in the purpose statement. The addition of LOS would have increased the strength of
the purpose statement
Problem
Evidence
The problem statement given by the authors in this article is: “Maintaining mobility is
paramount in preserving independence in activities of daily living (ADL) for older adults, yet
research has demonstrated that low mobility and bed rest are common during acute
hospitalization” (Padula et al., 2009, p. 325). Padula et al., (2009) also state that “maintaining
NURSE-DRIVEN MOBILITY CRITIQUE 5
functional status forms the foundation for continued independence and health and encompasses
behaviors necessary to actively engage in daily life,” (p. 325) which is why this study is so
important. The author’s also state 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, and impairment in functional status is a strong predictor of poor outcomes" (Padula et al.,
2009, p. 325).
Support
According to Burns & Grove (2011) a research problem is “the area of concern where
there is a gap in the knowledge base needed for nursing practice” (p. 146). With a research
problem there needs to be a research problem statement which identifies the “specific gap in the
knowledge needed for practice” (Burns & Grove, 2011, p. 146). According to the Nieswiadomy
critique guidelines, the problem statement must be clear and the population should be included.
The reader should be able to see how feasible the study will be as well as the significance of the
study based on the problem statement (Nieswiadomy, 2008).
Analysis
The problem statement in this article seems incomplete. The writer’s also placed the
problem statement in a paragraph meshed together with the purpose of the research, which made
it more difficult to distinguish. The problem statement is weak. The writer’s state a problem that
is both ethical and feasible however they are very broad. Just stating that bedrest is common
during hospital stays may not be seen as a problem for readers who are not in the health care
field. The problem statement would have been stronger with some examples of solutions or
specific problem areas, or by putting the problem statement in a section by itself and expanding
on it. This way it would be better understood by every reader regardless of background. Padula
NURSE-DRIVEN MOBILITY CRITIQUE 6
et al. (2009) state the common problem during hospitalization is low mobility and bed rest (p.
325). The problem is older adults are unable to maintain their independence to manage daily
activities of living (Padula et al, 2009, p. 325). The point of this study seems feasible with the
support of trained professionals a hospital setting to help mobilize the patients. Patient mobility
is important in for positive patient outcomes.
Review of Literature
Evidence
A literature review section is not identified in this article. However, in the introduction
section, this article has nineteen sources which were cited. There was minimal critique of the
literature review cited in the article. The sources were paraphrased with no direct quotations. The
reference section of this paper does contain all listed citations with source dates ranging from
1986 to 2008.
Support
According to Burns & Grove, “A review of literature provides you with the current
theoretical and scientific knowledge about a particular problem, enabling you to synthesize what
is known and not known” (Burns & Grove, 2011, p. 189). Nieswiadomy outlines a guideline for
critiquing the literature review of a research article. The guideline includes the following
questions to ask while doing a review of literature. The group of questions is as follows: is the
literature review comprehensive and concise? Does the review flow logically from the purpose(s)
of the study? Are all sources relevant to the study topic, are the sources critically appraised, are
both classic and current sources included? Are paraphrases or direct quotes used most often, are
both supporting and opposing theory and research presented? Are most of the references primary
sources, can a determination be made if sources are primary or secondary? Are all sources that
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are cited in the article found on the reference list and do the references appear free of citation
errors? (Nieswiadomy, 2011).
Analysis
The literature review by Padula et al. (2009) is a section that is untitled; however, the
author’s covered nineteen sources and gave many examples of studies in their introduction. The
included sources and subsequent review of citation of these sources appear to be comprehensive
supporting the author’s study. Nevertheless, the author’s appear to be lacking information
opposing their study. The literature review in this article is rather brief and it is not concise. To
be concise, there needs to be a lot of information conveyed in a brief yet comprehensive section.
“The purpose of the study was to determine the impact of a nurse-driven mobility
protocol on functional decline in hospitalized older adults” (Padula et al., 2009, p. 326). The
literature flows logically from the purpose; the review of literature was conducted on older
adults. Information included by the author’s was lacking in regards to the age of the population
of study participants in previous studies. The literature review which was done by the author’s
flows nicely into the fact that little research was found specific to mobility and changes to
mobility during hospitalization (Padula et al., 2009, p. 326, para. 3).
While it appears that some possible sources have been excluded, all of the sources used in
the literature review are relevant to the topic and based on functional decline in the hospitalized
older adult population. It does not appear that the authors have critically appraised their sources
and there is a lack of critique. According to Burns & Grove (2011), “a critical appraisal of
research involves careful examination of all aspects of a study to judge its strengths, limitations,
meaning, and significance” (p. 28).
NURSE-DRIVEN MOBILITY CRITIQUE 8
It appears that the authors did include current and classic sources. However, due to lack
of familiarity with this topic; appraisal of sources can be quite difficult. According to Burns &
Grove (2011), “Sources should be current up to the date the paper was accepted for publication”
(p. 194). Current sources should be published within five years of the authors study. Based upon
the five year criteria, there are many sources included in the study published within five years
and many in the years previous to that. In a search on CINAHL using the keywords of acute
hospitalization and functional decline, forty related articles where found between the years 1998
-2009.
Padula et al. (2009) did not use any direct quotations in their review of literature. It
appears that paraphrases were used by the authors with the possibility of synthesis of sources
being used. “Synthesis of sources involves compiling the findings from all of the selected
studies and analyzing and interpreting those findings” (Burns & Grove, 2011, p. 220). The
authors presented many supporting theories and research studies for their article. Conversely,
there does not appear to be any opposing research present in the literature review. A search of
CINAHL found articles demonstrating oppositional research.
Academic Journal
Exercise program implementation proves not feasible during acute care hospitalization.
Full Text Available (includes abstract); Brown CJ; Peel C; Bamman MM; Allman RM;
Journal of Rehabilitation Research & Development, 2006 Nov-Dec; 43 (7): 939-46
(journal article - clinical trial, research, tables/charts) ISSN: 0748-7711 PMID:
17436179
Subjects: Frail Elderly; Home Physical Therapy; Therapeutic Exercise; Aged: 65+
years; Female; Male
NURSE-DRIVEN MOBILITY CRITIQUE 9
Database: CINAHL
Theoretical/Conceptual Model
Evidence
The authors mention functional status, baseline functional status, mobility, activities of
daily living, self-care, and cognitive function as components of various theories of nursing and
conceptual frameworks. For the research study a Geriatric Friendly Environment through
Evaluation and Specific Interventions for Successful Healing (GENESIS) program was utilized
as a model of nursing care delivery for geriatric patients (Padula et al., 2009, p.328).
Incorporated into this mode of care is a nurse-driven mobility protocol. Features of the mobility
protocol require the nurse to evaluate and eliminate barriers to ambulation. This includes
addressing orders for bed rest, necessity of catheters, drains and intravenous therapy. Mobility
of a patient includes ambulation three to four times per day, up in chair for meals and bathroom
or bedside commode encouraged (Padula et al., 2009, p.328).
Support
According to Burns & Grove (2011), “conceptual models are similar to theories but are
more abstract than theories” (p. 228). A conceptual model assists the researcher to provide
details about the phenomena articulate any assumptions and reveal any philosophical positions
(Burns & Grove 2011, p. 228). To provide clarity and consistency for the direction of the
research, it is important to identify the theory and theorist framework. An accurate understanding
the concept and the theorist’s definition of the concept is often clarified in the study. Concepts
may be an idea, word or object in which the meaning is defined by the theorist (Burns & Grove,
2011, p. 228). Concepts have more implication than a dictionary definition and need to be
understood so they can be linked to the method of measurements and implementation in nursing
NURSE-DRIVEN MOBILITY CRITIQUE 10
practice (Burns & Grove, 2011, p. 228). Connecting the concept to the theory provides a
foundation for how the findings will be used in a practice setting.
Maps or models can be used to graphically display the correlation between a concept and
a relationship statement (Burns & Grove, 2011, p. 233). When maps and models are utilized as a
framework the theorist must include references as support (Burns & Grove, 2011, p. 233). Most
important concepts in a theory or study framework are often expressed in a graphic manner and
assist with identifying the gaps in the theory (Burns & Grove, 2011, p. 233)
According to Burns & Grove (2011) frameworks are the guide by which a research study
is developed (p. 238). The framework provides a reasonable method for collecting and
organizing data, information or problems being investigated. It is through this framework the
researcher is able to examine the result of the study and link them to an existing body of
knowledge. Research uses study frameworks to explain the theory that is being examined. Often
the term conceptual framework or theoretical framework are used to identify the framework and
may be used interchangeably in the context of a research study (Burns & Grove, 2011, 239).
Some frameworks are not always clear and expressed in a manner which is difficult for
the reader to locate. Burns & Grove (2011) describe these frameworks as rudimentary ideas that
are explained through literature review or in the introduction. Often the ideas are not developed
but rather implied from the readings. These are considered to be implicit frameworks (Burns &
Grove, 2011, p. 239).
Analysis
Padula et al. (2009) do not clearly identify a theory or theorist within the context of the
study. The review of the literature speaks to several previous studies which mention functional
status, self-care, and mobility but they are not specifically identified as concepts. These words or
NURSE-DRIVEN MOBILITY CRITIQUE 11
ideas are found in the introduction but they lack definition, clarity and are not linked to a theory.
The reader lumps together many components that tie into functional status to older adult health
and quality of life, but these components also lack clarity or reference to a theory. An example
would be the introduction of the article which states “Functional status, the ability to perform
basic self-care activities, in a significant component of older adults’’ health status and quality of
life” (Padula et al., 2009, p. 325). For clarity, a reference to Orem’s self-care theory would
provide a specific framework in which to base the study. The study variables were identified as
mobility protocol, functional status and length of stay (Padula et al., 2009, p. 325) but explicit
definitions and or framework were not defined.
Padula et al. (2009) use the literature reviews as the method for making relationship
statements that link mobility to functional status and length of stay. Several references are used
to demonstrate that lack of mobility resulted in functional decline (Padula et al., 2009, p. 325).
Other references demonstrate that mobility and frequent ambulation improve functional
outcomes for many patients (Padula et al., 2009, p.326). It is therefore implied that there is a
relationship between mobility and functional decline through various literature reviews.
However, this relationship is vague because the definitions for mobility and functional status are
not provided. Functional and cognitive status instruments are identified for their research.
Without a specified conceptual framework, map or model identified there is a lack of context for
the study. This makes the study weak but still feasible.
Hypothesis and Research Questions
Evidence
In this study, two hypotheses were clearly stated. The first hypothesis given is “older
adults who participate in a mobility protocol will maintain or improve functional status from
NURSE-DRIVEN MOBILITY CRITIQUE 12
admission to discharge” Padula et al., 2009, p. 327). The second hypothesis given is “older adults
who participate in a mobility protocol will have a reduced length of stay (LOS)” (Padula et al.
2009, p. 327). Both hypotheses identify the population, which in this case is older adults, and the
dependent and independent variables. The independent variable in each of the hypotheses is the
mobility protocol. The dependent variable in the first hypothesis is functional status, and in the
second is length of stay (Padula et al. 2009, p. 327).
Support
According to Burns & Grove (2011) “a hypothesis is a formal statement of the expected
relationship between two or more variables in a specified population” (p.167). A hypothesis is
the researchers “educated guess” on what they believe will be the outcomes of the study.
Hypotheses are valuable components of research because they influence the study design,
sampling method, data collection and analysis process, and the interpretation of the findings by
the author (Burns & Grove, 2011, p. 167). A hypothesis guides the entire research process.
A well-written hypothesis should include the variables that are to be measured, as well as
the population that is to be studied, and the proposed outcomes (Burns & Grove, 2011, p. 167).
There are a few different types of hypotheses that are used in research, and they are described in
four different categories. 1) associative versus causal, 2) simple versus complex, 3) non-
directional versus directional, and 4) null versus research (Burns & Grove, 2011, p.167). A
hypothesis can be associative or causal based on the relationship among the variables being
studied. “Associative hypotheses identify relationships among variables in a study but do not
indicate that one variable causes an effect on another variable” (Burns & Grove, 2011, p. 167-
170). A causal hypothesis “proposes a cause-and-effect interaction between two or more
variables” (Burns & Grove, 2011, p. 167-170).
NURSE-DRIVEN MOBILITY CRITIQUE 13
The difference between a simple and complex hypothesis is how many variables are
being used in the study. A simple hypothesis has two variables, whereas a complex hypothesis
has three or more variables being measured (Burns & Grove, 2011, p. 172). Non-directional
hypotheses state a relationship between the variables, but does not predict the exact nature of the
relationship, and this is different than a directional hypothesis because in a directional hypothesis
there is a relationship stated along with the nature of the relationship using terms such as
positive, negative, increase, decrease, etc. (Burns & Grove, 2011, p. 174). The last category of
hypotheses is null verses research. “A null hypothesis is used for statistical testing and for
interpreting statistical outcomes,” and “this type of hypothesis is used when a researcher believes
there is no relationship between two variables and when information is inadequate to state a
research hypothesis” (Burns & Grove, 2011, p. 174). A research hypothesis actually states the
relationships and provides adequate information (Burns & Grove, 2011, p.175).
Analysis
Padula et al. (2009) clearly worded their hypotheses. The population, dependent and
independent variables are clearly stated. This information helps to fully understand the author’s
opinions and the outcomes of the study. Both hypotheses stated are simple in that they compare
two variables. They are both research hypotheses in that there is a relationship stated in each.
The first hypothesis which states that “older adults participating in the mobility protocol will
improve functional status, and in the second hypothesis they state that older adults participating
in the mobility protocol will have reduced length of stay” (Padula et al., 2009, p. 327). Because
of the use of the terms to describe the nature of the relationship, they are both considered
directional hypotheses. This section of the research article is strong and the hypotheses directly
relate to the purpose of the study.
NURSE-DRIVEN MOBILITY CRITIQUE 14
Research (Study) Design
Evidence
In the research methods section, Padula et al., state what the research design for their
study will be, “this study used a nonequivalent control group design” (Padula et al., 2009, p.
327).
Support
Burns & Grove (2011) define a research design as a blueprint for conducting a study (p.
253). Research design comprises the type of data that will be collected and what resources will
be used to obtain the data. The researcher must also decide if their goal is to determine causative
factors, explore associations between variables or study historical data from previous research.
A research design must be appropriate to test the hypothesis or answer the research questions.
“Quasi-experimental design facilitates the search for knowledge and examination of causality in
situations in which complete control is not possible” (Burns & Grove, 2011, p. 270). Quasi-
experimental study designs vary widely, according to Burns & Grove, “the most frequently used
design in social science research is the untreated comparison group design with pretest and
posttest” (Burns & Grove, 2011, p. 271).
Experimental designs are very similar to the quasi-experimental design with the exception of the
control groups and the test groups which are randomized. Non experimental groups like
descriptive and comparative designs are used to examine relationships between variables or
examine a single unit in the context of real like environments (Burns & Grove, 2011, p. 262-
264).
Nieswiadomy has set forth guidelines for critiquing quantitative research designs, they
are as follows. Is the design clearly identified in the research paper and is the design appropriate
NURSE-DRIVEN MOBILITY CRITIQUE 15
to test the study hypothesis or answer the research question. If the study used an experimental
design, was the most appropriate type of experimental design used and what means were used to
control for threats to internal and external validity. Does the research design allow the researcher
to draw cause-and-effect relationship between variables? If the design was non-experimental,
would an experimental design have been more appropriate and what means were used to control
for extraneous variables, such as subject characteristics if a non-experimental design was used
(Nieswiadomy, 2008).
Analysis
The research design is clearly stated in the research report. The researcher’s state that
their research study is a “nonequivalent control group design” (Padula et al., 2009, p. 327). This
type of research design is considered a form of quasi-experimental.
The research design that has been chosen appears to be appropriate for the study. The
researchers used a convenience sample which can lead to internal validity problems. By using a
convenience group, it is difficult to make certain that the control group and treatment groups
begin at the same level. The researchers describe their use of a pretest and posttest called Barthel
Index to measure the groups beginning, middle and ending statistics. With the use of a pretest
the hope is that the researchers could tell if the groups were equal before the treatment was
administered. It does appear that this research design is appropriate for this study.
Attempts to control validity were poorly made with this study and in addition it does not
appear that the attempts were strong enough to prevent bias. According to Padula et al. (2009)
criteria used to create groups were ability to understand English, no physical impairment to limit
mobility, and cognitively intact. A research nurse screened potential patients and enrolled
NURSE-DRIVEN MOBILITY CRITIQUE 16
subjects. There was no discussion of the qualifications of the research nurse, which could lead to
bias in which group a patient was placed (control or treatment) (p. 327). There was also mention
of an advanced practice nurse employed on the control unit, with no mention of what, if anything
was done to prevent internal validity concerns. There was no discussion on how the researchers
controlled external validity such as the Hawthorne effect, reactive effects, and experimenter
effect.
The researchers were able to demonstrate by the use of Barthel scoring that there was a
significant increase in the scores for the treatment group, in fact, according to Padula et al.
(2009) the treatment group improved from baseline by +11.5 with the control group improving
by 6.9 which was deemed ‘not significant’ by the researchers. The researchers also used an Up
and Go test which showed scores which were of no significance to their study (p. 329).
In summary, the research design which was selected seems to be appropriate to test the
hypothesis and answer the research questions. The nonequivalent control group design which
was chosen (pretest and posttest control group design) seems to be appropriate for this study. An
area of weakness in this study was mainly the lack of controls for internal and external validity.
The researchers did not discuss or identify how they could control internal and external validity.
Sample and Sampling Methods
Evidence
For this study, “the researchers used a convenience sample of fifty adults (N=50) ages 60
and older, who were admitted with medical diagnoses to 1 of 2 nursing units” (Padula et al.
2009, p. 327). They took 25 patients from each unit being studied. Other criteria that was
included when choosing the population for this study was a length of stay that was at least three
NURSE-DRIVEN MOBILITY CRITIQUE 17
days, English speaking, no prior physical impairment that would greatly limit mobilization, and
those who were cognitively intact. Patients completed a Mini-Mental exam prior to the study
and needed a score of 24 or more to qualify (Padula et al., 2009, p. 327).
Before choosing the sample, a “research nurse screened 453 patients for eligibility, from
those 84 subjects were enrolled, and from those patients 34 were withdrawn from the study for
various reasons” (Padula et al., 2009, p. 327).
The study took place in a private hospital with 247 beds. Two nursing units in this
hospital were a part of the study. The two units that were used were both “equal in size, cared
for similar patient populations, and were characterized by similar nursing staff composition.
They were both predominantly registered nurses and certified nursing assistants” (Padula et al.,
2009, p. 327).
Support
Sampling is defined by Burns & Grove (2011) as “selecting a group of people, events,
behaviors, or other elements with which to conduct a study” (p. 290). Padula et al. was very
precise when choosing the population they would study. A criterion was established to screen the
patients, and also made sure the population was accessible to them. An accessible population is
very important for a research study, and is the portion of the target population (or entire set of
individuals that meet the criteria of the study) that the researcher has reasonable access to (Burns
& Grove, 2011, p. 290).
Padula et al. (2009) used a convenience sample for their research study. Burns & Grove
define a convenience sample as “a sample where subjects are included in the study merely
because they happen to be in the right place at the right time” (Burns & Grove, 2011, p. 305).
This way of sampling has been known as being a weak approach, only because there isn’t as
NURSE-DRIVEN MOBILITY CRITIQUE 18
much opportunity to control bias (Burns & Grove, 2011, p. 305). Researchers are not able to be
as meticulous when choosing their subjects.
On the positive side of using convenience sampling, “it is inexpensive, accessible, and
usually less time consuming to obtain the samples” (Burns & Grove, 2011, p. 305). This type of
sampling is very common in healthcare research. This is because the sampling frames that meet
specific criteria are not always available and the researcher has to use what is available at the
time or area where they are conducting their research study. The more criteria set when
choosing the sample, the better the power and validity of the study. Power is “the capacity of the
study to detect differences or relationships that actually exist in the population. The minimal
acceptable level for power in a study is 80%” (Burns & Grove, 2011, p. 308). This means that
the study has reasonable findings that can be used in the future.
Analysis
The sampling procedures that were used by the researchers in this study were very well
thought out. They used a convenience sample, but had very specific criteria that gave the study
the validity it needed. The researchers chose to use only medical patients in this study because
then they were able to avoid potential limitations that are associated with post- surgical patients
(Padula et al., 2009, p. 327). Along with this, there were several other criteria that made the
sampling portion of the study very strong and valid. They had a very specific target population,
and then took the initial 453 people and eventually narrowed them down to the final 84 patients
that would take part in the study (Padula et al., 2009, p. 327). From the 84 patients chosen, 34
were withdrawn for many reasons which included discharge, transfer from the units being
studied, having disqualifying procedures, or personal reasons (Padula et al., 2009, p. 327).
NURSE-DRIVEN MOBILITY CRITIQUE 19
The researchers did an excellent job choosing their sample group. They clearly identified
their target population, and had great criteria to narrow the population size. Because of the
smaller location and sample of the study, a comparison study may need to be done in other
hospitals with a similar population to prove the validity of this particular study. This study,
however, will provide enough information to either prove or disprove the hypothesis that “older
adults who participate in a mobility protocol will maintain or improve functional status from
admission to discharge” (Padula et al., 2009, p. 327).
Data Collection Methods
Evidence
Data was collected by
“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. Training included human subjects’ protection and achievement of high level
proficiency with the protocol and data collection instrument (Padula et al., 2009, p. 328)’
The data was collected at Miriam Hospital in Providence, Rhode Island. This facility has 247
beds and 2 nursing units were assigned to the study. These units were of “equal size, cared for
similar patient populations and were characterized by similar nursing staff composition” (Padula
et al., 2009, p. 327). Nurses on the treatment unit had been trained and supported a geriatric
program called Geriatric Friendly Environment through Nursing Evaluation and Specific
Intervention for Successful Healing (GENESIS). Incorporated into this model is a nurse driven
mobility protocol (Padula et al., 2009, p. 328). The control unit had not implemented the geriatric
NURSE-DRIVEN MOBILITY CRITIQUE 20
program and the nurses did not receive the training. The nurses did not float between these two
units.
These data points focus on key elements that help to determine current health status and
future results of the mobility protocol. The data was collected to determine if the implementation
of a mobility protocol would “maintain or improve an older patient’s functional status from
admission to discharge” (Padula et al., 2009, p. 326).
A demographic data collection sheet was developed specifically for this research.
Eligible subjects for the study were screened by the research nurse and the data was collected
within 48 hours of admission.
A ratio-scale was used to measure the nursing staff characteristic by unit for the study
period. The elements of this data included RN hours per patient day, unlicensed assistive
personnel hours per patient day, total nursing hours per patient day, % total nursing hours by RN,
and % total nursing hours by unlicensed assistive personnel.
Key demographic data was collected on the eligible subject for the study. The level of
measurement used for this information is a nominal-scale. Information obtained included “age;
gender; primary diagnosis; use of assistive devices; fall risk assessment; presence of any
restriction to mobility; use of occupational or physical therapy; LOS; first and number of times
out of bed” ( Padula et al., 2009, p. 328). However, the fall risk assessment uses an ordinal-scale
measurement.
The modified Barthel Index, level of independence and the get up and go test are
examples of ordinal-scale measurement. Each of the scales is described below.
According to Padula et al. (2009) data was collected from the patient’s perception of their
functional mobility 2 weeks before admission and at admission. The data was collected using a
NURSE-DRIVEN MOBILITY CRITIQUE 21
modified Barthel Index (BI). It measured 10 items with a 5 point rating scale to enhance the
sensitivity (p. 328).
The level of dependence was measured using a numeric scale 0 (totally dependent) to 100 totally
independent.
A get up and go test with specific criteria measured the ability to stand, walk and return
to sitting (Padula et al., 2009, p. 329). Data for this study was collect at “admission and at
discharge on a 1 to 4 scale, 1 being able to rise in a single movement and to 4 being unable”
(Padula et al., 2009, p. 329).
Measurement of cognitive status was conducted routinely using a mini-mental state
examination score. The rating of this test was not provided. Charts were reviewed to collect the
data for ambulation, number of times in the chair and other activities.
Support
In 1946 Steven “organized the rules for assigning numbers to objects so that hierarchy in
measurement was established” (Burns & Grove, 2011, p. 329). These levels describe as being
nominal, ordinal, interval and ratio.
Nominal-scale measurement is the lowest in which data is organized in categories of
defined property but they cannot be ranked in any kind of order. There are several rules to this
measurement in that there is no order to the categories, they are exclusive and exhaustive (Burns
& Grove, 2011, p. 329).
Ordinal-Scale measurements are the level most used in nursing assessment. The data
“are assigned to categories that can be ranked” (Burns & Grove, 2011, p. 330) with rules
governing how the data is ranked. These rules indicated an equal distance does not exist between
the rankings and the categories must be exclusive and exhaustive (Burns & Grove, 2011, p. 330).
NURSE-DRIVEN MOBILITY CRITIQUE 22
The third level is an interval-scale measurement in which there is “equal numerical
distance between the intervals” (Burns & Grove, 2011, p. 329). According to Burns & Grove
(2009) these scales follow the rules of mutually exclusive and exhaustive categories and ranking
ordering are assumed to represent a continuum of value” (p. 330).
The last and highest level of measurement is the ratio-scale. This measurement has
categories that are mutually exclusive, exhaustive, order ranked, equally spaced intervals and a
continuum of values (Burns & Grove, 2011, p. 329).
The type of test can pose a threat to internal validity. This is especially true with pretest and
posttest with the same questions. The threat comes from a subject already knowing the questions
(Hoisington, 2012, Cycle 3). External Validity may be threatened by the subject answering the in
a manner that could sway results.
Analysis
The author’s give a good description, comparison and reason for the selection of these
two nursing units. The data collection was completed by hired trained professionals which
decreases the possibility for error and strengthens the measurement process. However the
author’s do not provide information if others were involved in data collection. A vast amount of
data is collected at admission and discharge using the different assessment scaled. The article
does not explain when other data is collected and how it is collected. In addition the author’s rely
on information being documented in a chart. One cannot be sure if all elements of the data
collection were documented in the chart.
The research goal was to provide data that would demonstrate a nurse driven protocol
would have an impact on a patient’s functional decline in a hospital setting. The modified BI tool
to measure functional status is standard in the clinical and research setting with demonstrated
NURSE-DRIVEN MOBILITY CRITIQUE 23
inter-rater agreement. This strengthens the reliability of the results. The get up and go test also
has been tested for reliability which also strengthen the validity. These were weak in that the test
were subjective and based on patients or significant other perception. The threat to internal
validity is high because the subjects were asked the same question at the start of the study and at
discharge. Despite the weakness of the tool the results appear to be promising and may warrant a
more in-depth follow up study.
Instrument
Evidence
Padula et al. (2009) discussed four instruments which were used in their research. The
instruments used are as follows, demographic data collection sheet, functional status via Barthel
Index, Get Up and Go test, and Mini-Mental State Examination (MMSE) (Padula et al., 2009, p.
328). The demographic data collection sheet falls under a nominal-scale measurement, no
reliability or validity information was provided. The Barthel Index (BI) falls under an ordinal-
scale measurement, the authors state that, “researchers have proposed the BI as the standard for
clinical research purposes” (Padula et al., 2009, p. 328), and provided an interrater agreement of
r = 0.793. The Get Up and Go test is also an ordinal-scale measurement, which according to the
authors has been reported to be reliable and valid with a correlation rating of r = -0.78 in
comparison to the BI (Padula et al., 2009 p.328). The MMSE also falls under ordinal-scale,
however, no reliability or validity measures were included by the authors.
Support
Reliability of an instrument is of great importance to a study. According to Burns &
Grove (2011) “reliability is concerned with the consistency of the measurement method” (p.
332). If an instrument is not reliable, researchers cannot know what it is really measuring or if it
NURSE-DRIVEN MOBILITY CRITIQUE 24
is really measuring what they want it to measure. Reliability testing measures the extent of
random error in the measurement method (Burns & Grove, 2011, p. 333). There are three types
of reliability testing, which according to Burns & Grove are stability, equivalence, and
homogeneity.
Stability is described as a “concern with the consistency of repeated measures of the same
attribute with the use of the same scale or instrument” (Burns & Grove, 2011, p. 333). Stability
is also known as the test-retest reliability. Equivalence is also used as a form of reliability
testing, according to Burns & Grove equivalence, “involves the comparison of two versions of
the same paper-and-pencil instrument or of two observers measuring the same event” (Burns &
Grove, 2011, p. 333). Also mentioned by Burns & Grove is interrater reliability which is a
comparison of two observers of two judges in a study (Burns & Grove, 2011, p. 333).
Homogeneity is the third form of reliability testing described by Burns & Grove. This
type of testing is used primarily with paper-and-pencil instruments or scales which addresses the
correlation of each question to the other questions within the instrument (Burns & Grove, 2011,
p. 334).
Validity of an instrument according to Burns & Grove is a, “determination of how well
the instrument reflects the abstract concept being examined” (Burns & Grove, 2011, p. 334). An
instrument may be valid for one study and that same instrument may not be valid for another.
Researchers need to know if the instruments they are using are valid for what they are
measuring, or their study may be in jeopardy. According to Burns & Grove, there are three types
of validity, which are contrasting groups, convergence, and divergence (Burns & Grove, 2011, p.
335).
NURSE-DRIVEN MOBILITY CRITIQUE 25
Validity from contrasting groups can be determined by, “identifying groups that are
expected (or known) to have contrasting scores on the instrument” (Burns & Grove, 2011, p.
335). Validity from convergence is determined, “when a relatively new instrument is compared
with an existing instrument(s) that measure the same construct” (Burns & Grove, 2011, p. 335).
According to Burns & Grove (2011), the instruments are used concurrently, and then the results
are evaluated using correlational analysis. Measures which are positively correlated strengthen
the validity of the instrument (p. 335). Lastly, validity from divergence can be measured, which
is using an instrument of opposite effect than what is actually being measured. According to
Burns & Grove (2011) “correlational procedures are performed with the measures of the two
concepts. If the divergent measure is negatively correlated with the other instrument, validity for
each of the instruments is strengthened” (p. 335).
Analysis
Padula et al. (2009) provides clear descriptions of the instruments used for data collection
performed in this study. The instruments are described; their purpose and function are included
with how the data was collected. The authors created a demographic data collection sheet for
this study; however, they did not include any form of reliability or validity for this tool.
The function and purpose of the BI and Get Up and Go tests were described by the
authors. The BI was listed as having an interrater score of r = 0.793 which according to Burns &
Grove is a low score for reliability, an interrater score should be greater than 0.80 to avoid
reliability concern (Burns & Grove, 2011, p. 333). The Get Up and Go test was reported to
correlate to the BI with a score of r = -0.78. This score is negative due to the fact that the Get Up
and Go test is a divergent test from the BI. This score also falls below the recommended score
set forth by Burns & Grove of 0.80 (Burns & Grove, 2011, p. 334).
NURSE-DRIVEN MOBILITY CRITIQUE 26
The author’s include excellent information on the instruments. However, they are
deficient in explanation of the suitability of the tools used for their study. There are significant
threats to internal validity of this study. The authors did not identify the possibility of skewed
information, for example, the patients are being given the same test over and over again, and
there is a possibility of repeated testing bias.
Descriptive Analysis
Evidence
Padula et al. (2009) did not use many descriptive statistics in their research presentation.
They have given two tables in their work, one that shows nursing staff characteristics by unit
during the study period in hours between the treatment and control group, and another that shows
Barthel scores (which reflect the subjects’ perception of functioning) preadmission, admission,
and discharge between the treatment and control groups (p. 327 and 329).
Support
Burns & Grove (2011) defines descriptive statistics as “statistics that allow the researcher
to organize the data in ways that give meaning and facilitate insight; such as frequency
distributions and measures of central tendency and dispersion” (p. 536). Ways that this
information can be given in a research article are in tables, charts, and graphs. There are many
types of charts and graphs that can be used. The goal of descriptive statistics is to show the
reader different examples of how the variables reflect and relate to each other (Burns & Grove,
2011, p. 389).
Frequency distribution, a type of descriptive statistics, is “used to organize the data for
examination. In this case tables are developed to display the values” (Burns & Grove, 2011, p.
384). Measures of control tendency, the average of the data, consist of the values for mode,
NURSE-DRIVEN MOBILITY CRITIQUE 27
median, mean, and midpoint (Burns & Grove, 2011, p. 385-387). Measures of dispersion,
measures of individual differences of the members of the sample, include the variance, range,
and standard deviation, which are usually shown in graphs (Burns & Grove, 2011, p. 388). “The
purpose of this analysis is not to define causality, but to describe the difference in the variables
and groups being studied” (Burns & Grove, 2011, p. 389).
Analysis
Padula et al. (2009) presented their data using limited descriptive statistics. As
mentioned previously only two tables were used, the inclusion of additional graphs would have
been more helpful to the reader and made it easier to understand their data and findings. This
was a very weak section in their analysis.
Inferential Statistics
Evidence
“Inferential statistics were used in this study to calculate the probability theory and the
differences between the treatment and control group on the dependent variables” (Padula et al.,
2009, p. 329). The majority of their probability testing gave results that were “non-significant”.
The researchers calculated probability between the treatment and control groups on fall risk
scores on admission. “The p score, or probability score, was documented as P=.07 (about 7%),
and the treatment group did have slightly lower scores than the control” (Padula et al., 2009, p.
329).
Barthel scores were also calculated for probability. “Discharge scores improved for the
treatment group from admission to discharge (P=.05), while the control group numbers were
insignificant and actually had a slight increase by P=.006” (Padula et al., 2009, p. 329). “The
treatment group did have a shorter length of stay on average than those in the control group with
NURSE-DRIVEN MOBILITY CRITIQUE 28
a probability score of P<.001” (Padula et al., 2009, p. 329). T scores were not given in this data
analysis.
Support
Inferential statistics are calculations and other ways to show the relationship between the
groups and variables being studied. Many different tests are used in this area. “The probability
test is used to explain the extent of the relationship, and the probability that an event will occur
in a given situation, or can be accurately predicted” (Padula et al., 2009, p. 376). Probability
values are expressed as p and given in decimals to be translated into percentages.
The chi-square test is another example of a statistic that researchers use. “The chi-square
test determines whether two variables are independent or related, and can be used with nominal
or ordinal data” (Padula et al., 2009, p. 401).
“The t test is a very common analyses that tests for significant differences between two
samples” (Padula et al., 2009, p. 404). “This test is used to examine differences in groups when
the variables are measured at the interval or ratio level” (Padula et al., 2009, p. 404).
“ANOVA and ANCOVA are used to help the researcher examine the f statistic and the
effect of a treatment apart from the effect of one or more potentially confounding variables”
(Padula et al., 2009, p.407-408).
Analysis
Padula et al. (2009) only gave probability test results, and did not provide any t tests.
They gave a few different probability values that gave the reader a good picture of the data that
was being presented, but could have offered more testing results to provide additional clarity of
the outcomes. Their use of inferential statistics was greater than their descriptive statistic use,
NURSE-DRIVEN MOBILITY CRITIQUE 29
and therefore was stronger, but they could have used more variety in their testing and
calculations to provide the reader with a broader picture of their data analysis.
Study Findings
Evidence
The research study by Padula et al. (2009) contains a discussion section in which the
study findings are also presented. In the discussion section, Padula et al. (2009) presents their
two hypotheses and relates their findings accordingly. The discussion section contains statistical
data to support their findings. Padula et al., discussed that their first 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., 2009, p. 330). Also stated by the
researchers was that their second hypothesis, “older adults who participate in a mobility protocol
will have a reduced LOS, was also supported” (Padula et al., 2009, p. 330). The researchers
came to the determination that their study showed a significant decline in functioning between
preadmission and admission and that prolonged immobility is a contributor to functional decline.
Padula et al. (2009) also included a conclusion section in which they tied together their findings
in one short paragraph.
Support
This section contains support for study findings, study discussion and study conclusion.
According to Burns & Grove (2011) the findings section of a study contains results which are,
“translated and interpreted to become study findings, which are a consequence of evaluating
evidence from study” (Burns & Grove, 2011, p. 410). Next is the discussion section, according
to Burns & grove (2011), “The discussion section ties together the other sections of the research
report and gives them meaning” (Burns & Grove, 2011, p. 59). The discussion section should
NURSE-DRIVEN MOBILITY CRITIQUE 30
contain items such as, “major findings, limitations of the study, conclusions drawn from the
findings, implications of the findings for nursing, and recommendations for further research”
(Burns & Grove, 2011, p. 59). Limitations should be discussed so the reader will understand
what restrictions were encountered during the study so a determination can be made about the
credibility of the findings (Burns & Grove, 2011, p. 48). The last section is the study conclusion
section which should include a “synthesis of the findings” (Burns & Grove, 2011, p. 412).
Analysis
While Padula et al. (2009) presented their findings, the researchers placed their findings
and discussion into the same section which makes it difficult for the reader to separate between
the two at times. The researchers did not include information on where the study results could be
used in actual nursing practice, nor did they accentuate how this study makes an important
difference in the lives of people. The researchers did give limitations and mentioned that
“further study with quantification of the impact of diseases is indicated” (Padula et al., 2009, p.
330). The researchers also made mention that the control group and treatment groups had
identical out of bed times during the study, which indicates that even on the non-trained
GENESIS unit that the patients were getting similar care.
Padula et al. (2009) discusses in their conclusion that their findings suggest that “early
and ongoing ambulation in the hallway may be an important contributor to maintaining
functional status during hospitalization and to shortening LOS” and that “ambulation should be
viewed as a priority and as a vital component of quality nursing care” (Padula et al., 2009, p.
330). The researchers seem to be making an all-inclusive statement that all patients will benefit
from their study, when in fact they did not include all patients in their study. They also do not
make any suggestions for further research in this area with different design or samples.
NURSE-DRIVEN MOBILITY CRITIQUE 31
Conclusion
Padula et al. (2009), made a great case for the need of a mobility protocol. They had a
strong hypothesis that clearly stated the variables, and gave strong support for why they felt a
mobility protocol was needed, but unfortunately, their research was weak. They only did their
research in one facility, using one unit as a control, and another as a treatment group which made
their sample very small. “The research nurse screened a total of 453 patient records for
eligibility; of those, 84 eligible subjects were enrolled, but 34 were then withdrawn from the
study (Padula et al., 2009, p. 327). They used specific criteria to screen the patients which
allowed for less bias and more validity in their research, but they did not recognize the external
validities of the certain diseases and acuity of the patient participating in the treatment, and
therefore, did not take into account these factors and how they may have themselves contributed
to the LOS.
“Prolonged immobility is clearly demonstrated to be an important contributor to
functional decline, and ambulation is a priority and a vital component of quality nursing care”
(Padula et. al., 2009, p. 330). These researchers have proven that a mobility protocol of some
sort is needed, and does help in reducing length of stay, but further research must be done in this
area with a bigger sample to compare results. Only older adults over 70 were used in this study,
and the research could be used to assist all ages in reducing LOS in all types of units. Overall,
this research was weak, but with a little more detail and larger and broader samples, this research
could be used to change practice all over the world.
NURSE-DRIVEN MOBILITY CRITIQUE 32
References
Burns, N. & Grove S. K. (2011) Understanding nursing research: Building an evidence-based.
Maryland Heights, MO: Elsevier
Nieswiadomy, R. M. (2008). Nursing Research guidelines provided in class.
Padula, C.A., Hughes, C., & Baumhover, L.(2009). Impact of a nurse-driven mobility protocol
on functional decline in hospitalized older adults. Journal of Nursing Care Quality. 24(4).
NURSE-DRIVEN MOBILITY CRITIQUE 33
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
PointsEarned
Comments
Abstract andIntroduction: No heading
for intro, but there should be a introduction of the study and what your paper will address, why you are doing the critique
10
Purpose & Problem Statement (Identify the
problem & purpose and analyze whether they are clear to the reader. Are there clear objectives & goals? Analyze whether you can determine
feasibility and significance of the study)
10
Review of the Literature and Theoretical
Framework (Analyze relevance of the sources; Identify a theoretical or
conceptual framework & appropriateness for study)
10
NURSE-DRIVEN MOBILITY CRITIQUE 34
Hypothesis(es) or Research Question(s)
(Analyze whether clearly and concisely stated; discuss
whether directional, null, or nondirectional hypothesis[es])
10
Sample & Study Design (Describe sample & sampling method & appropriateness for study; analyze appropriateness of design; discuss how ethical
issues addressed)
10
Data Collection Methods & Instruments (Describe & analyze the appropriateness of the what, how, who, where and
when; describe & analyze reliability and validity of
instrument)
10
Data Analysis (Describe descriptive & inferential
statistics & analyze whether results are presented accurately
& completely)
10
Discussion of Findings (Analyze whether results are
presented objectively & bound to the data, whether there is a
comparison to previous studies and whether new literature is
introduced that was not included in the Literature
Review
10
Conclusions, Implications, &
Recommendations (Analyze whether the
conclusions are based on the data, whether hypotheses were
supported or not supported, whether implications are a result of the findings, and recommendations consider
limitations
10