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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


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


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


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


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


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).


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

http://0-web.ebscohost.com.libcat.ferris.edu/ehost/viewarticle?data=dGJyMPPp44rp2%2FdV0%2Bnjisfk5Ie46bZRt6uvULOk63nn5Kx95uXxjL6srUmvpbBIr6ieT7iqrlKzq55oy5zyit%2Fk8Xnh6ueH7N%2FiVauttU23prVPsqukhN%2Fk5VXj5KR84LPhgeyorj7y1%2BVVv8SkeeyzsEiur7NNsKe3SaTc7Yrr1%2FJV5OvqhPLb9owA&hid=17


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


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


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


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).


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.


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


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


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


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


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).


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


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


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


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).


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


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


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).


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).


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,


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


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,


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


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


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.


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.


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).


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


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


Your paper should end with a brief conclusion of your

critique 10

PAPER POINTS 100

Deductions for APA, grammar and Spelling

Final GRADE

Documents

Headings - Weeblybenjaminkasperportfolio.weebly.com/.../6/11764927/ebp_… · Web viewDespite the weakness it was noted, “findings suggest that early and ongoing ambulating in