critique paper for nursing research

Reading and critiquing a research article

Nurses use research to answer questions about their practice, solve problems, improve the quality of patient care, generate new research questions, and shape health policy. Nurses who confront questions about practice and policy need strong, high-quality, evidence-based research. Research articles in peer-reviewed journals typically undergo a rigorous review process to ensure scholarly standards are met. Nonetheless, standards vary among reviewers and journals. This article presents a framework nurses can use to read and critique a research article.

When deciding to read an article, determine if it’s about a question you have an interest in or if it can be of use in your practice. You may want to have a research article available to read and critique as you consider the following questions.

Does the title accurately describe the article?

A good title will pique your interest but typically you will not know until you are done reading the article if the title is an accurate description. An informative title conveys the article’s key concepts, methods, and variables.

Is the abstract representative of the article?

The abstract provides a brief overview of the purpose of the study, research questions, methods, results, and conclusions. This helps you decide if it’s an article you want to read. Some people use the abstract to discuss a study and never read further. This is unwise because the abstract is just a preview of the article and may be misleading.

Does the introduction make the purpose of the article clear?

A good introduction provides the basis for the article. It includes a statement of the problem, a rationale for the study, and the research questions. When a hypothesis is being tested, it should be clearly stated and include the expected results.

Is a theoretical framework described?

When a theoretical framework is used, it should inform the study and provide a rationale. The concepts of the theoretical framework should relate to the topic and serve as a basis for interpreting the results. Some research doesn’t use a theoretical framework, such as health services research, which examines issues such as access to care, healthcare costs, and healthcare delivery. Clinical research such as comparing the effectiveness of two drugs won’t include a theoretical framework.

Is the literature review relevant to the study and comprehensive? Does it include recent research?

The literature review provides a context for the study. It establishes what is, and is not known about the research problem. Publication dates are important but there are caveats. Most literature reviews include articles published within the last 3 to 5 years. It can take more than a year for an article to be reviewed, revised, accepted, and published, causing some references to seem outdated.

Literature reviews may include older studies to demonstrate important changes in knowledge over time. In an area of study where little or no research has been conducted, there may be only a few relevant articles that are a decade or more old. In an emerging area of study there may be no published research, in which case related research should be referenced. If you are familiar with the area of research, review the references to determine if well-known and highly regarded studies are included.

Does the methods section explain how a research question was addressed?

The methods section provides enough information to allow the study to be replicated. Components of this section indicate if the design is appropriate to answer the research question(s).

• Did the researcher select the correct sample to answer the research questions and was the size sufficient to obtain valid results?
• If a data collection instrument was used, how was it created and validated?
• If any materials were used, such as written guides or equipment, were they described?
• How were data collected?
• Was reliability and validity accounted for?
• Were the procedures listed in a step-by-step manner?

Independent and dependent variables should be described and terms defined. For example, if patient falls in the hospital are considered the dependent variable, or outcome, what are the independent variables, or factors, being investigated that may influence the rate at which patient falls occur? In this example, independent variables might include nurse staffing, registered nurse composition (such as education and certification), and hospital Magnet &#174 status.

Is the analytical approach consistent with the study questions and research design?

The analytical approach relates to the study questions and research design. A quantitative study may use descriptive statistics to summarize the data and other tests, such as chi squares, t-tests, or regression analysis, to compare or evaluate the data. A qualitative study may use such approaches as coding, content analysis, or grounded theory analysis. A reader who is unfamiliar with the analytical approach may choose to rely on the expertise of the journal’s peer reviewers who assessed whether the analytical approach was correct.

Are the results presented clearly in the text and in tables and figures?

Results should be clearly summarized in the text, tables, and figures. Tables and figures are only a partial representation of the results and critical information may be only in the text. In a quantitative study, the significance of the statistical tests is important. The presentation of qualitative results should avoid interpretation, which is reserved for the discussion.

Are the limitations presented and their implications discussed?

It is essential that the limitations of the study be presented. These are the factors that explain why the results may need to be carefully interpreted, may only be generalized to certain situations, or may provide less robust results than anticipated. Examples of limitations include a low response rate to a survey, not being able to establish causality when a cross-sectional study design was used, and having key stakeholders refuse to be interviewed.

Does the discussion explain the results in relation to the theoretical framework, research questions, and significance of the study?

The discussion serves as an opportunity to explain the results in respect to the research questions and the theoretical framework. Authors use the discussion to interpret the results and explain the meaning and significance of the study. It’s also important to distinguish the study from others that preceded it and provide recommendations for future research.

Depending on the research, it may be equally important for the investigators to present the clinical and/or practical significance of the results. Relevant policy recommendations are also important. Evaluate if the recommendations are supported by the data or seem to be more of an opinion. A succinct conclusion typically completes the article.

Once you’re done reading the article, how do you decide if the research is something you want to use?

Determine the scientific merit of the study by evaluating the level and quality of the evidence. There are many scales to use, several of which can be found in the Research Toolkit on the American Nurses Association’s website http://www.nursingworld.org/research-toolkit.aspx . Consider what you learned and decide if the study is relevant to your practice or answered your question as well as whether you can implement the findings.

A new skill

A systematic approach to reading and critiquing a research article serves as a foundation for translating evidence into practice and policy. Every nurse can acquire this skill.

Louise Kaplan is director of the nursing program at Saint Martin’s University in Lacey, Washington. At the end of this article is a checklist for evaluating an article.

Selected references

Hudson-Barr D. How to read a research article. J Spec Pediatr Nurs . 2004;9(2):70-2.

King’s College D. Leonard Corgan Library. Reading a research article. http://www.lib.jmu.edu/ilworkshop08/materials/studyguide3.pdf . Accessed September 5, 2012.

Oliver D, Mahon SM. Reading a research article part I: Types of variables. Clin J Oncol Nurs . 2005;9(1):110-12.

Oliver D, Mahon SM. Reading a research article part II: Parametric and nonparametric statistics. Clin J Oncol Nurs . 2005;9(2):238-240.

Oliver D, Mahon SM. Reading a research article part III: The data collection instrument. Clin J Oncol Nurs . 2006;10(3):423-26.

Rumrill P, Fitzgerald S, Ware, M. Guidelines for evaluating research articles. Work . 2000;14(3):257-63.

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A guide to critical appraisal of evidence

Fineout-Overholt, Ellen PhD, RN, FNAP, FAAN

Ellen Fineout-Overholt is the Mary Coulter Dowdy Distinguished Professor of Nursing at the University of Texas at Tyler School of Nursing, Tyler, Tex.

The author has disclosed no financial relationships related to this article.

Critical appraisal is the assessment of research studies' worth to clinical practice. Critical appraisal—the heart of evidence-based practice—involves four phases: rapid critical appraisal, evaluation, synthesis, and recommendation. This article reviews each phase and provides examples, tips, and caveats to help evidence appraisers successfully determine what is known about a clinical issue. Patient outcomes are improved when clinicians apply a body of evidence to daily practice.

How do nurses assess the quality of clinical research? This article outlines a stepwise approach to critical appraisal of research studies' worth to clinical practice: rapid critical appraisal, evaluation, synthesis, and recommendation. When critical care nurses apply a body of valid, reliable, and applicable evidence to daily practice, patient outcomes are improved.

Critical care nurses can best explain the reasoning for their clinical actions when they understand the worth of the research supporting their practices. In c ritical appraisal , clinicians assess the worth of research studies to clinical practice. Given that achieving improved patient outcomes is the reason patients enter the healthcare system, nurses must be confident their care techniques will reliably achieve best outcomes.

Nurses must verify that the information supporting their clinical care is valid, reliable, and applicable. Validity of research refers to the quality of research methods used, or how good of a job researchers did conducting a study. Reliability of research means similar outcomes can be achieved when the care techniques of a study are replicated by clinicians. Applicability of research means it was conducted in a similar sample to the patients for whom the findings will be applied. These three criteria determine a study's worth in clinical practice.

Appraising the worth of research requires a standardized approach. This approach applies to both quantitative research (research that deals with counting things and comparing those counts) and qualitative research (research that describes experiences and perceptions). The word critique has a negative connotation. In the past, some clinicians were taught that studies with flaws should be discarded. Today, it is important to consider all valid and reliable research informative to what we understand as best practice. Therefore, the author developed the critical appraisal methodology that enables clinicians to determine quickly which evidence is worth keeping and which must be discarded because of poor validity, reliability, or applicability.

Evidence-based practice process

The evidence-based practice (EBP) process is a seven-step problem-solving approach that begins with data gathering (see Seven steps to EBP ). During daily practice, clinicians gather data supporting inquiry into a particular clinical issue (Step 0). The description is then framed as an answerable question (Step 1) using the PICOT question format ( P opulation of interest; I ssue of interest or intervention; C omparison to the intervention; desired O utcome; and T ime for the outcome to be achieved). 1 Consistently using the PICOT format helps ensure that all elements of the clinical issue are covered. Next, clinicians conduct a systematic search to gather data answering the PICOT question (Step 2). Using the PICOT framework, clinicians can systematically search multiple databases to find available studies to help determine the best practice to achieve the desired outcome for their patients. When the systematic search is completed, the work of critical appraisal begins (Step 3). The known group of valid and reliable studies that answers the PICOT question is called the body of evidence and is the foundation for the best practice implementation (Step 4). Next, clinicians evaluate integration of best evidence with clinical expertise and patient preferences and values to determine if the outcomes in the studies are realized in practice (Step 5). Because healthcare is a community of practice, it is important that experiences with evidence implementation be shared, whether the outcome is what was expected or not. This enables critical care nurses concerned with similar care issues to better understand what has been successful and what has not (Step 6).

Critical appraisal of evidence

The first phase of critical appraisal, rapid critical appraisal, begins with determining which studies will be kept in the body of evidence. All valid, reliable, and applicable studies on the topic should be included. This is accomplished using design-specific checklists with key markers of good research. When clinicians determine a study is one they want to keep (a “keeper” study) and that it belongs in the body of evidence, they move on to phase 2, evaluation. 2

In the evaluation phase, the keeper studies are put together in a table so that they can be compared as a body of evidence, rather than individual studies. This phase of critical appraisal helps clinicians identify what is already known about a clinical issue. In the third phase, synthesis, certain data that provide a snapshot of a particular aspect of the clinical issue are pulled out of the evaluation table to showcase what is known. These snapshots of information underpin clinicians' decision-making and lead to phase 4, recommendation. A recommendation is a specific statement based on the body of evidence indicating what should be done—best practice. Critical appraisal is not complete without a specific recommendation. Each of the phases is explained in more detail below.

Phase 1: Rapid critical appraisal . Rapid critical appraisal involves using two tools that help clinicians determine if a research study is worthy of keeping in the body of evidence. The first tool, General Appraisal Overview for All Studies (GAO), covers the basics of all research studies (see Elements of the General Appraisal Overview for All Studies ). Sometimes, clinicians find gaps in knowledge about certain elements of research studies (for example, sampling or statistics) and need to review some content. Conducting an internet search for resources that explain how to read a research paper, such as an instructional video or step-by-step guide, can be helpful. Finding basic definitions of research methods often helps resolve identified gaps.

To accomplish the GAO, it is best to begin with finding out why the study was conducted and how it answers the PICOT question (for example, does it provide information critical care nurses want to know from the literature). If the study purpose helps answer the PICOT question, then the type of study design is evaluated. The study design is compared with the hierarchy of evidence for the type of PICOT question. The higher the design falls within the hierarchy or levels of evidence, the more confidence nurses can have in its finding, if the study was conducted well. 3,4 Next, find out what the researchers wanted to learn from their study. These are called the research questions or hypotheses. Research questions are just what they imply; insufficient information from theories or the literature are available to guide an educated guess, so a question is asked. Hypotheses are reasonable expectations guided by understanding from theory and other research that predicts what will be found when the research is conducted. The research questions or hypotheses provide the purpose of the study.

Next, the sample size is evaluated. Expectations of sample size are present for every study design. As an example, consider as a rule that quantitative study designs operate best when there is a sample size large enough to establish that relationships do not exist by chance. In general, the more participants in a study, the more confidence in the findings. Qualitative designs operate best with fewer people in the sample because these designs represent a deeper dive into the understanding or experience of each person in the study. 5 It is always important to describe the sample, as clinicians need to know if the study sample resembles their patients. It is equally important to identify the major variables in the study and how they are defined because this helps clinicians best understand what the study is about.

The final step in the GAO is to consider the analyses that answer the study research questions or confirm the study hypothesis. This is another opportunity for clinicians to learn, as learning about statistics in healthcare education has traditionally focused on conducting statistical tests as opposed to interpreting statistical tests. Understanding what the statistics indicate about the study findings is an imperative of critical appraisal of quantitative evidence.

The second tool is one of the variety of rapid critical appraisal checklists that speak to validity, reliability, and applicability of specific study designs, which are available at varying locations (see Critical appraisal resources ). When choosing a checklist to implement with a group of critical care nurses, it is important to verify that the checklist is complete and simple to use. Be sure to check that the checklist has answers to three key questions. The first question is: Are the results of the study valid? Related subquestions should help nurses discern if certain markers of good research design are present within the study. For example, identifying that study participants were randomly assigned to study groups is an essential marker of good research for a randomized controlled trial. Checking these essential markers helps clinicians quickly review a study to check off these important requirements. Clinical judgment is required when the study lacks any of the identified quality markers. Clinicians must discern whether the absence of any of the essential markers negates the usefulness of the study findings. 6-9

The second question is: What are the study results? This is answered by reviewing whether the study found what it was expecting to and if those findings were meaningful to clinical practice. Basic knowledge of how to interpret statistics is important for understanding quantitative studies, and basic knowledge of qualitative analysis greatly facilitates understanding those results. 6-9

The third question is: Are the results applicable to my patients? Answering this question involves consideration of the feasibility of implementing the study findings into the clinicians' environment as well as any contraindication within the clinicians' patient populations. Consider issues such as organizational politics, financial feasibility, and patient preferences. 6-9

When these questions have been answered, clinicians must decide about whether to keep the particular study in the body of evidence. Once the final group of keeper studies is identified, clinicians are ready to move into the phase of critical appraisal. 6-9

Phase 2: Evaluation . The goal of evaluation is to determine how studies within the body of evidence agree or disagree by identifying common patterns of information across studies. For example, an evaluator may compare whether the same intervention is used or if the outcomes are measured in the same way across all studies. A useful tool to help clinicians accomplish this is an evaluation table. This table serves two purposes: first, it enables clinicians to extract data from the studies and place the information in one table for easy comparison with other studies; and second, it eliminates the need for further searching through piles of periodicals for the information. (See Bonus Content: Evaluation table headings .) Although the information for each of the columns may not be what clinicians consider as part of their daily work, the information is important for them to understand about the body of evidence so that they can explain the patterns of agreement or disagreement they identify across studies. Further, the in-depth understanding of the body of evidence from the evaluation table helps with discussing the relevant clinical issue to facilitate best practice. Their discussion comes from a place of knowledge and experience, which affords the most confidence. The patterns and in-depth understanding are what lead to the synthesis phase of critical appraisal.

The key to a successful evaluation table is simplicity. Entering data into the table in a simple, consistent manner offers more opportunity for comparing studies. 6-9 For example, using abbreviations versus complete sentences in all columns except the final one allows for ease of comparison. An example might be the dependent variable of depression defined as “feelings of severe despondency and dejection” in one study and as “feeling sad and lonely” in another study. 10 Because these are two different definitions, they need to be different dependent variables. Clinicians must use their clinical judgment to discern that these different dependent variables require different names and abbreviations and how these further their comparison across studies.

Sample and theoretical or conceptual underpinnings are important to understanding how studies compare. Similar samples and settings across studies increase agreement. Several studies with the same conceptual framework increase the likelihood of common independent variables and dependent variables. The findings of a study are dependent on the analyses conducted. That is why an analysis column is dedicated to recording the kind of analysis used (for example, the name of the statistical analyses for quantitative studies). Only statistics that help answer the clinical question belong in this column. The findings column must have a result for each of the analyses listed; however, in the actual results, not in words. For example, a clinician lists a t -test as a statistic in the analysis column, so a t -value should reflect whether the groups are different as well as probability ( P -value or confidence interval) that reflects statistical significance. The explanation for these results would go in the last column that describes worth of the research to practice. This column is much more flexible and contains other information such as the level of evidence, the studies' strengths and limitations, any caveats about the methodology, or other aspects of the study that would be helpful to its use in practice. The final piece of information in this column is a recommendation for how this study would be used in practice. Each of the studies in the body of evidence that addresses the clinical question is placed in one evaluation table to facilitate the ease of comparing across the studies. This comparison sets the stage for synthesis.

Phase 3: Synthesis . In the synthesis phase, clinicians pull out key information from the evaluation table to produce a snapshot of the body of evidence. A table also is used here to feature what is known and help all those viewing the synthesis table to come to the same conclusion. A hypothetical example table included here demonstrates that a music therapy intervention is effective in reducing the outcome of oxygen saturation (SaO 2 ) in six of the eight studies in the body of evidence that evaluated that outcome (see Sample synthesis table: Impact on outcomes ). Simply using arrows to indicate effect offers readers a collective view of the agreement across studies that prompts action. Action may be to change practice, affirm current practice, or conduct research to strengthen the body of evidence by collaborating with nurse scientists.

When synthesizing evidence, there are at least two recommended synthesis tables, including the level-of-evidence table and the impact-on-outcomes table for quantitative questions, such as therapy or relevant themes table for “meaning” questions about human experience. (See Bonus Content: Level of evidence for intervention studies: Synthesis of type .) The sample synthesis table also demonstrates that a final column labeled synthesis indicates agreement across the studies. Of the three outcomes, the most reliable for clinicians to see with music therapy is SaO 2 , with positive results in six out of eight studies. The second most reliable outcome would be reducing increased respiratory rate (RR). Parental engagement has the least support as a reliable outcome, with only two of five studies showing positive results. Synthesis tables make the recommendation clear to all those who are involved in caring for that patient population. Although the two synthesis tables mentioned are a great start, the evidence may require more synthesis tables to adequately explain what is known. These tables are the foundation that supports clinically meaningful recommendations.

Phase 4: Recommendation . Recommendations are definitive statements based on what is known from the body of evidence. For example, with an intervention question, clinicians should be able to discern from the evidence if they will reliably get the desired outcome when they deliver the intervention as it was in the studies. In the sample synthesis table, the recommendation would be to implement the music therapy intervention across all settings with the population, and measure SaO 2 and RR, with the expectation that both would be optimally improved with the intervention. When the synthesis demonstrates that studies consistently verify an outcome occurs as a result of an intervention, however that intervention is not currently practiced, care is not best practice. Therefore, a firm recommendation to deliver the intervention and measure the appropriate outcomes must be made, which concludes critical appraisal of the evidence.

A recommendation that is off limits is conducting more research, as this is not the focus of clinicians' critical appraisal. In the case of insufficient evidence to make a recommendation for practice change, the recommendation would be to continue current practice and monitor outcomes and processes until there are more reliable studies to be added to the body of evidence. Researchers who use the critical appraisal process may indeed identify gaps in knowledge, research methods, or analyses, for example, that they then recommend studies that would fill in the identified gaps. In this way, clinicians and nurse scientists work together to build relevant, efficient bodies of evidence that guide clinical practice.

Evidence into action

Critical appraisal helps clinicians understand the literature so they can implement it. Critical care nurses have a professional and ethical responsibility to make sure their care is based on a solid foundation of available evidence that is carefully appraised using the phases outlined here. Critical appraisal allows for decision-making based on evidence that demonstrates reliable outcomes. Any other approach to the literature is likely haphazard and may lead to misguided care and unreliable outcomes. 11 Evidence translated into practice should have the desired outcomes and their measurement defined from the body of evidence. It is also imperative that all critical care nurses carefully monitor care delivery outcomes to establish that best outcomes are sustained. With the EBP paradigm as the basis for decision-making and the EBP process as the basis for addressing clinical issues, critical care nurses can improve patient, provider, and system outcomes by providing best care.

Seven steps to EBP

Step 0–A spirit of inquiry to notice internal data that indicate an opportunity for positive change.

Step 1– Ask a clinical question using the PICOT question format.

Step 2–Conduct a systematic search to find out what is already known about a clinical issue.

Step 3–Conduct a critical appraisal (rapid critical appraisal, evaluation, synthesis, and recommendation).

Step 4–Implement best practices by blending external evidence with clinician expertise and patient preferences and values.

Step 5–Evaluate evidence implementation to see if study outcomes happened in practice and if the implementation went well.

Step 6–Share project results, good or bad, with others in healthcare.

Adapted from: Steps of the evidence-based practice (EBP) process leading to high-quality healthcare and best patient outcomes. © Melnyk & Fineout-Overholt, 2017. Used with permission.

Critical appraisal resources

• The Joanna Briggs Institute http://joannabriggs.org/research/critical-appraisal-tools.html
• Critical Appraisal Skills Programme (CASP) www.casp-uk.net/casp-tools-checklists
• Center for Evidence-Based Medicine www.cebm.net/critical-appraisal
• Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice . 3rd ed. Philadelphia, PA: Wolters Kluwer; 2015.

A full set of critical appraisal checklists are available in the appendices.

Bonus content!

This article includes supplementary online-exclusive material. Visit the online version of this article at www.nursingcriticalcare.com to access this content.

critical appraisal; decision-making; evaluation of research; evidence-based practice; synthesis

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• How to appraise qualitative research
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• Calvin Moorley 1 ,
• Xabi Cathala 2
• 1 Nursing Research and Diversity in Care, School of Health and Social Care , London South Bank University , London , UK
• 2 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

https://doi.org/10.1136/ebnurs-2018-103044

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Introduction

In order to make a decision about implementing evidence into practice, nurses need to be able to critically appraise research. Nurses also have a professional responsibility to maintain up-to-date practice. 1 This paper provides a guide on how to critically appraise a qualitative research paper.

What is qualitative research?

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Useful terms

Some of the qualitative approaches used in nursing research include grounded theory, phenomenology, ethnography, case study (can lend itself to mixed methods) and narrative analysis. The data collection methods used in qualitative research include in depth interviews, focus groups, observations and stories in the form of diaries or other documents. 3

Authenticity

Title, keywords, authors and abstract.

In a previous paper, we discussed how the title, keywords, authors’ positions and affiliations and abstract can influence the authenticity and readability of quantitative research papers, 4 the same applies to qualitative research. However, other areas such as the purpose of the study and the research question, theoretical and conceptual frameworks, sampling and methodology also need consideration when appraising a qualitative paper.

Purpose and question

The topic under investigation in the study should be guided by a clear research question or a statement of the problem or purpose. An example of a statement can be seen in table 2 . Unlike most quantitative studies, qualitative research does not seek to test a hypothesis. The research statement should be specific to the problem and should be reflected in the design. This will inform the reader of what will be studied and justify the purpose of the study. 5

Example of research question and problem statement

An appropriate literature review should have been conducted and summarised in the paper. It should be linked to the subject, using peer-reviewed primary research which is up to date. We suggest papers with a age limit of 5–8 years excluding original work. The literature review should give the reader a balanced view on what has been written on the subject. It is worth noting that for some qualitative approaches some literature reviews are conducted after the data collection to minimise bias, for example, in grounded theory studies. In phenomenological studies, the review sometimes occurs after the data analysis. If this is the case, the author(s) should make this clear.

Theoretical and conceptual frameworks

Most authors use the terms theoretical and conceptual frameworks interchangeably. Usually, a theoretical framework is used when research is underpinned by one theory that aims to help predict, explain and understand the topic investigated. A theoretical framework is the blueprint that can hold or scaffold a study’s theory. Conceptual frameworks are based on concepts from various theories and findings which help to guide the research. 6 It is the researcher’s understanding of how different variables are connected in the study, for example, the literature review and research question. Theoretical and conceptual frameworks connect the researcher to existing knowledge and these are used in a study to help to explain and understand what is being investigated. A framework is the design or map for a study. When you are appraising a qualitative paper, you should be able to see how the framework helped with (1) providing a rationale and (2) the development of research questions or statements. 7 You should be able to identify how the framework, research question, purpose and literature review all complement each other.

There remains an ongoing debate in relation to what an appropriate sample size should be for a qualitative study. We hold the view that qualitative research does not seek to power and a sample size can be as small as one (eg, a single case study) or any number above one (a grounded theory study) providing that it is appropriate and answers the research problem. Shorten and Moorley 8 explain that three main types of sampling exist in qualitative research: (1) convenience (2) judgement or (3) theoretical. In the paper , the sample size should be stated and a rationale for how it was decided should be clear.

Methodology

Qualitative research encompasses a variety of methods and designs. Based on the chosen method or design, the findings may be reported in a variety of different formats. Table 3 provides the main qualitative approaches used in nursing with a short description.

Different qualitative approaches

The authors should make it clear why they are using a qualitative methodology and the chosen theoretical approach or framework. The paper should provide details of participant inclusion and exclusion criteria as well as recruitment sites where the sample was drawn from, for example, urban, rural, hospital inpatient or community. Methods of data collection should be identified and be appropriate for the research statement/question.

Data collection

Overall there should be a clear trail of data collection. The paper should explain when and how the study was advertised, participants were recruited and consented. it should also state when and where the data collection took place. Data collection methods include interviews, this can be structured or unstructured and in depth one to one or group. 9 Group interviews are often referred to as focus group interviews these are often voice recorded and transcribed verbatim. It should be clear if these were conducted face to face, telephone or any other type of media used. Table 3 includes some data collection methods. Other collection methods not included in table 3 examples are observation, diaries, video recording, photographs, documents or objects (artefacts). The schedule of questions for interview or the protocol for non-interview data collection should be provided, available or discussed in the paper. Some authors may use the term ‘recruitment ended once data saturation was reached’. This simply mean that the researchers were not gaining any new information at subsequent interviews, so they stopped data collection.

The data collection section should include details of the ethical approval gained to carry out the study. For example, the strategies used to gain participants’ consent to take part in the study. The authors should make clear if any ethical issues arose and how these were resolved or managed.

The approach to data analysis (see ref  10 ) needs to be clearly articulated, for example, was there more than one person responsible for analysing the data? How were any discrepancies in findings resolved? An audit trail of how the data were analysed including its management should be documented. If member checking was used this should also be reported. This level of transparency contributes to the trustworthiness and credibility of qualitative research. Some researchers provide a diagram of how they approached data analysis to demonstrate the rigour applied ( figure 1 ).

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Example of data analysis diagram.

Validity and rigour

The study’s validity is reliant on the statement of the question/problem, theoretical/conceptual framework, design, method, sample and data analysis. When critiquing qualitative research, these elements will help you to determine the study’s reliability. Noble and Smith 11 explain that validity is the integrity of data methods applied and that findings should accurately reflect the data. Rigour should acknowledge the researcher’s role and involvement as well as any biases. Essentially it should focus on truth value, consistency and neutrality and applicability. 11 The authors should discuss if they used triangulation (see table 2 ) to develop the best possible understanding of the phenomena.

Themes and interpretations and implications for practice

In qualitative research no hypothesis is tested, therefore, there is no specific result. Instead, qualitative findings are often reported in themes based on the data analysed. The findings should be clearly linked to, and reflect, the data. This contributes to the soundness of the research. 11 The researchers should make it clear how they arrived at the interpretations of the findings. The theoretical or conceptual framework used should be discussed aiding the rigour of the study. The implications of the findings need to be made clear and where appropriate their applicability or transferability should be identified. 12

Discussions, recommendations and conclusions

The discussion should relate to the research findings as the authors seek to make connections with the literature reviewed earlier in the paper to contextualise their work. A strong discussion will connect the research aims and objectives to the findings and will be supported with literature if possible. A paper that seeks to influence nursing practice will have a recommendations section for clinical practice and research. A good conclusion will focus on the findings and discussion of the phenomena investigated.

Qualitative research has much to offer nursing and healthcare, in terms of understanding patients’ experience of illness, treatment and recovery, it can also help to understand better areas of healthcare practice. However, it must be done with rigour and this paper provides some guidance for appraising such research. To help you critique a qualitative research paper some guidance is provided in table 4 .

Some guidance for critiquing qualitative research

• ↵ Nursing and Midwifery Council . The code: Standard of conduct, performance and ethics for nurses and midwives . 2015 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21 Aug 18 ).
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Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Selecting a theoretical framework to guide research on the COVID-19 pandemic impacts on nursing care delivery and the critical care work system (using Reed's Intermodern approach to theory critique)

Understanding the impact of COVID-19 on nursing care delivery in critical care work systems is urgently needed. Theoretical frameworks guide understanding of phenomena in research. In this paper, we critique four theoretical frameworks (Donabedian's Quality Model, the Quality Health Outcomes Model, the Systems Research Organizing Model, and the Systems Engineering (SEIPS) 2.0 Model) using Reed's (2018) Intermodern philosophical perspective of nursing science. Reed's (2018) Intermodern approach to theory critique was selected for its pragmatic perspective and focus on personal and professional health and wellbeing. The SEIPS 2.0 Model was ultimately selected to guide the study of the impact of the COVID-19 Pandemic on nursing care delivery in the critical care work systems.

Nursing care delivery impacts both patient and nurse outcomes ( Cheung et al., 2008 ). Some researchers have explored the early impact of the COVID-19 Pandemic on nursing care delivery broadly in acute care settings ( Schroeder et al., 2020 ), yet few have concentrated on critical care settings (ICUs). ICUs are work systems designed to provide care to critically ill patients ( Marshall et al., 2017 ). COVID-19 illness has caused unparalleled patient admissions to ICUs ( Huang et al., 2020 ).

Theoretical frameworks are essential to understand phenomena of interest in healthcare systems (Brewer et al., 2008). Theory-based research into systems shifts attention from a superficial focus on problem-elimination and outcomes to a broader and deeper analysis of structures and processes that affect delivery of care ( Verran, 1997 ). This paper presents the process of analyzing and evaluating four theoretical framework for selection to study the impact of the COVID-19 Pandemic on nursing care delivery in the critical care work system. The four frameworks evaluated are Donabedian's (1988) Quality Model, Mitchell et al.' (1998) Quality Health Outcomes Model, Brewer and colleagues' (2008) Systems Research Organizing Model, and Holden et al.’ (2013) Systems Engineering Initiative for Patient Safety 2.0 Model. The critique was completed using Reed's (2018) Intermodern perspective of nursing science and theory development.

1. Frameworks and models for understanding work systems

The four theoretical frameworks, also called models, were selected for their potential to describe systems, processes, and outcomes in healthcare. Each model was analyzed and evaluated for relevance to describe the critical care work system, processes of nursing care delivery, and subsequent outcomes. Other important concepts included in the analysis/evaluation were patients' family members, healthcare professionals' well-being, and the explicit inclusion of the external environment. These concepts were added because patients' family members play a crucial role in the social support of patients, healthcare professionals' well-being has the potential to impact patient outcomes ( Cheung et al., 2008 ), and because of the nature of how drastically the COVID-19 Pandemic altered care delivery ( Schroeder et al., 2020 ), respectively. Reed's (2019) Intermodern perspective of nursing science was used to critique and select a theoretical framework to describe the impact of COVID-19 on nursing care delivery in critical care work systems for the following reasons: its congruence with the nursing metaparadigm, situation and broad use in a human factors/systems research, consideration of the external environment, and explicit inclusion of the professionals' health and wellness as an outcome.

2. Reed's Intermodern approach to theory critique

The Intermodern ( Reed, 2018 ) approach to theory critique was selected for its emphasis on the role of practice in knowledge development, and its useful perspective for theory critique among researchers who consider themselves pragmatists who value scientific theories for their success in practical application. The Intermodern approach focuses on professional well-being, which is an important issue of concern during the COVID-19 Pandemic for its potential to impact patient outcomes ( National Academy of Medicine, n.d. ).

Like other theory critique approaches, an Intermodern approach includes analysis and evaluation. Analysis includes a look at the 1) theory components, 2) underlying assumptions, and 3) relationships among concepts. Evaluation includes assessment of multiple components of the theory for a specific research or theory purpose. These components include the following: 1) meaning and significance for ethical and effective practice, 2) underlying worldview as congruent with nursing practice needs, 3) contribution to practice knowledge that stimulates new ideas or challenges the status quo, and 4) applications in supporting professional and personal practices that promote health and well-being ( Reed, 2018 ).

3. Theoretical frameworks

The theoretical frameworks described below were selected for their potential to describe the critical care work system, processes of nursing care delivery, and subsequent outcomes. The first model described in this paper is Donabedian's (1988) Quality Model, which is broadly considered the first model describing the healthcare system structures, processes, and patient outcomes. The subsequent models are predicated on the structures, processes, and outcomes as described in Donabedian's (1988) Quality Model. Mitchell et al. (1998) Quality Health Outcomes Model, Brewer and colleagues' (2008) Systems Research Organizing Model, and Holden et al. (2013) Systems Engineering Initiative for Patient Safety 2.0 Model are critiqued below using Reed's (2018) Intermodern approach in order of chronology.

3.1. Donabedian's quality model

Donabedian's Quality Model (1988) is a theoretical framework for evaluating the quality of healthcare. The model depicts the relationship between the structures and processes that contribute to the outcomes of care. The structures construct in the model represents the attributes of the setting where care occurs; for example, organizational structures refer to settings such as teaching, urban, or rural hospitals and the processes of each involved in giving and receiving care. These settings in turn impact the processes that occur in giving and receiving care. The outcomes construct denotes the impact of care processes on the health status of patients ( Donabedian, 1988 ). The Quality Model has mechanistic philosophic roots as evidenced by the simple, unidirectional, and linear relationships ( Pepper, 1942 ) proposed among the structures, processes, and outcomes.

The constructs within the model are sufficiently broad, allowing for consistency with the metaparadigm of nursing, and inclusion of the patient's family/caregivers, the environment beyond where care occurs, and the impact on clinicians. However, the model lacks an explicit focus on professional practices that promote health and well-being for professionals.

Donabedian's Quality Model (1988) has been used in many research studies and supported by many research studies in healthcare research ( Berwick & Fox, 2016 ), particularly in reference to promoting understanding phenomena in healthcare research of quality patient outcomes ( Ayanian & Markel, 2016 ). The Quality Model has stimulated new thinking and generated development of models based loosely on this model.

3.2. Quality health outcomes model

The Quality Health Outcomes Model (QHOM) (1998) is a theoretical framework of the relationships between multiple factors that affect care quality. Proposed in 1998, the QHOM was built on Donabedian's Quality Model (1988) by the American Academy of Nursing Expert panel on Quality to guide quality of care evaluation and research ( Mitchell et al., 1998 ). When the QHOM was first published, it challenged the status quo through its consideration of the reciprocal relationships between system and client characteristics to produce outcomes, and its inclusion of policy implications ( Mitchell et al., 1998 ). The QHOM has been used widely in nursing quality research and improvement efforts ( Aiken et al., 2018 ), although the model is nearly a quarter century old.

The model is comprised of four main concepts including: system characteristics (structure and process elements), interventions (clinical processes), client characteristics (to whom interventions are directed), and outcomes (impact of clinical processes on patients) ( Mitchell et al., 1998 ). The QHOM reflects an organismic philosophical view ( Pepper, 1942 ) in that health outcomes are depicted within an organization of dynamic, interrelated factors, and the whole system is not necessarily predictable by the sum of its parts.

The model has several weaknesses. The interventions construct is not directly related to outcomes, but rather indirectly related through system and client characteristics ( Pepper, 1942 ). The constructs of the QHOM are quite broad for applications in databases used for quality improvement and intervention research ( Mitchell et al., 1998 ). While the theoretical ideas are consistent with the metaparadigm of nursing, there is an internal inconsistency in the model's theoretical separation of the system characteristics processes from clinical intervention processes; in reality, the system has considerable influence over clinical processes. Further, similar to the Quality Model (1988), the QHOM lacks consideration of environment beyond the immediate context of care. The model does not address professional practices in promoting health and wellbeing, however it has been cited over 500 times.

3.3. Systems research organizing model

The Systems Research Organizing Model (SROM) is a theoretical framework that explains the relationships among variables of interest in healthcare (e.g. person, environment, healthcare professionals, and health) (Brewer et al., 2008). The model contains four main constructs including the client that drives the model, the environment which is not the focus of change but can influence other constructs, an action focus which is the process measures, and the outcomes or performance measures. All of the constructs are interrelated and comprise the system as a whole (Brewer et al., 2008). The SROM has contextualistic philosophic roots as evidenced by the client depicted as interconnected with their environment and inseparable from the system ( Pepper, 1942 ). Brewer along with faculty and doctoral students at The University of Arizona developed the SROM to evaluate nursing systems research by examining the systems' influences on outcomes of care and healthcare design (Brewer et al., 2008).

The SROM constructs are clear and broad yet sufficiently diverse. The theoretical ideas are consistent with the metaparadigm of nursing and with a systems-focus as evidenced by depiction of the constructs comprising the whole system ( Von Bertalanffy, 1969 ). The SROM has been used to explain and predict patient mental health outcomes ( Saewert, 2003 ) and healthcare facilities design (Brewer et al., 2008). Though it has not been used in research in the last ten years, knowledge from the SROM contributed to a systems view in nursing research by which individuals are inseparable from their environment (Brewer et al., 2008). Unlike Donabedian's (1988) Quality Model and Mitchell et al. (1998) QHOM, the SROM challenged the status quo in its flexibility and its view of interaction among all model constructs. This enables a focus on professional practices that promote health and wellbeing.

3.4. Systems engineering initiative for patient safety 2.0 model

The Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 Model is a theoretical framework for studying and improving health and healthcare ( Holden et al., 2013 ). The model is comprised of three main constructs including work systems, processes, and outcomes . The work system is further delineated into person(s) including the healthcare professionals and patients/their families, hospital organization, tasks, internal environment (e.g. sounds, temperature) and external environment (e.g. state policy, economics).

Processes are delineated into professional work, collaborative professional-patient work, and patient work. Outcomes are delineated into patient, professional, and organizational outcomes ( Holden et al., 2013 ). The SEIPS 2.0 Model has contextualistic philosophic roots ( Pepper, 1942 ) as evidenced by the patient depicted as inseparable from the internal environment of care and impacted by the external environment ( Holden et al., 2013 ). The original SEIPS model was developed by Carayon et al. (2006) and was based on Donabedian's Quality Model (1988) and Balance Theory, which emphasizes the relationships between the components of the system and importance of considering the entire system as other system elements may act as barriers or facilitators. While a SEIPS 3.0 Model does exist, its focus is on patient safety during the transition out of the acute care setting; and therefore, was not included in this theory critique ( Carayon et al., 2020 ).

The SEIPS 2.0 Model (2013) is comprised of three main constructs with sub-concepts that further define how the constructs are sufficiently broad yet diverse. There is ample contemporary research evidence supporting the use of the SEIPS 2.0 Model in practice ( Center for Quality and Productivity Improvement, n.d. ). The SEIPS 2.0 Model was recently used by Lumley et al. (2020) to conceptualize what nursing care delivery may look like in critical care settings during the COVID-19 Pandemic. The model has applications for evidence-based practice, quality evaluation, testing interventions, and supporting professional and personal practices promoting personal and professional health and wellbeing as evidenced by inclusion of professional outcomes in the model ( Holden et al., 2013 ). Finally, the SEIPS 2.0 Model challenged the status quo by proposing that negative elements or barriers to work processes can be overcome by focusing on the positive elements of the system ( Carayon, 2009 ).

3.5. Summary of a comparison of theoretical frameworks

The four theoretical frameworks presented above were compared overall for selecting the one most appropriate for the research on the impact of the COVID-19 Pandemic on the critical care work system from a nursing perspective. First, while Donabedian's (1988) Quality Model has been widely used in healthcare systems research to understand quality outcomes, several key details including the patients' family members, the external environment, and the consideration of the healthcare professional were not explicitly included in the model. Second, Mitchell and colleagues' (1998) QHOM also does not include consideration of the external environment. Neither model explicitly addresses promotion of professionals' health and wellness. Third, while the SROM is nested in the nursing metaparadigm, is consistent with a systems view (Brewer et al., 2008), and includes consideration of the external environment and promotion of professionals' health and wellness; however, it has not been recently used in research. Fourth, the SEIPS 2.0 Model ( Holden et al., 2013 ) is consistent with the nursing metaparadigm, is situated in a human factors/systems view, includes consideration of the external environment, explicitly includes the professional health and wellness as an outcome, and has been used widely in recent nursing research and implemented in critical care work systems ( Center for Quality and Productivity Improvement, n.d. ). Therefore, the SEIPS 2.0 Model was selected to guide a research study describing the impact of the COVID-19 Pandemic on the critical care work system from a nursing perspective.

3.6. The SEIPS 2.0 model and the impact of COVID-19 on the critical care work system

Because the SEIPS 2.0 Model can be used to describe work systems design with a focus on patient safety ( Holden et al., 2013 ), it is ideal for comprehensively describing nursing care delivery which aims to deliver safe nursing care to patients. More specifically, the SEIPS 2.0 Model will be used as a framework to guide development of semi-structured interviews with critical care nurse participants to elicit their descriptions of describing the impact of the COVID-19 Pandemic on nursing care delivery in the critical care work system.

The SEIPS model in Fig. 1 depicts the components of the critical care work system during COVID-19 and the process of nursing care delivery. The model's major components of the work system, work process, and outcomes outline the major interview areas designed for data collection in the research as described briefly below.

SEIPS 2.0 model as adapted for this study.

3.6.1. Work system

3.6.1.1. person(s).

Consistent with SEIPS 2.0 ( Holden et al., 2013 ), both the nurse and patient (and their family) will be simultaneously represented at the center of the model. Nurses will be asked to describe characteristics of their patients including their needs, preferences and goals ( Holden et al., 2013 ). The nurses will be described through demographic characteristics including age, gender, highest level of nursing education, and years of experience.

3.6.1.2. Nursing tasks

The focus of the nursing tasks will be those completed by the nurse for the patient. These tasks vary in difficulty, complexity, and ambiguity as described by Holden et al. (2013) . Nurses will be asked about the tasks completed for critically ill patients in the critical care work system. Other factors, such as who was responsible for completing the task and who was responsible for delegation of tasks, will be used to provide a comprehensive description of nursing care delivery models.

3.6.1.3. Tools & technology

Tools and technologies include information technologies, devices, and resources used to facilitate patient care ( Holden et al., 2013 ). Nurses will be asked about the tools and technology used in caring for patients in the ICU during COVID-19. As Holden et al. (2013) describe, tools and technology factors in the SEIPS 2.0 Model include usability, accessibility, familiarity, portability, and functionality.

3.6.1.4. Organization

According to Holden et al. (2013) , organizations are structures that organize time, space, resources, and activities that may be put in place by people but are external to people. Nurses will be asked about factors related to organizations. Organizational factors include work assignments, such as number of patients and complexity and how work was assigned to be completed for the patient, work schedules, availability of resources such as personal protective equipment and ventilators, and management and incentive systems, and training and policies and procedures specific to caring patients in the ICU during the COVID-19 Pandemic ( Holden et al., 2013 ).

3.6.1.5. Internal environment

Internal environments include layout, noise, temperature, and lighting in the work setting ( Holden et al., 2013 ). Nurse participants will be asked about what the internal environment of an ICU looked, sounded, and physically felt like during the COVID-19 Pandemic.

3.6.1.6. External environment

Because COVID-19 is ravaging our nation and globe, it will be important to include a macroergonomic (work system design) approach. External factors which may impact the work system include societal, economic, and policy factors ( Holden et al., 2013 ). Nurse participants will be asked about how greater society, economics, and policy impacted their ICU and their experiences with care delivery.

3.6.2. Nursing care delivery as a process

Nursing care delivery is an example of professional work process completed by a nurse ( Holden et al., 2013 ). The different components of the critical care work system will be explored for how each impacted nursing care delivery including physical, cognitive, and social/behavioral work processes. Physical work processes describe the actual process of delivering nursing care to the patient, while cognitive work processes describe the critical thinking processes and the social/behavioral work processes describe the interaction between the patient/family member and the professional and the team member interaction ( Holden et al., 2013 ).

3.6.3. Outcomes

Outcomes in the SEIPS 2.0 Model include patient, professional, and organizational outcomes ( Holden et al., 2013 ). Patient outcomes include satisfaction and quality of care, while professional outcomes include the health versus illness, job satisfaction, and burnout of the healthcare team members, and organizational outcomes include staffing difficulties, financial performance, and cultural changes ( Holden et al., 2013 ). Nurses will be asked about nurse outcomes relating to care delivery during the COVID-19 Pandemic.

4. Conclusion

Theory critique including in-depth analysis and evaluation is time-consuming, yet critically important. There must be a match between the purpose of the research, the researcher's views, and the theoretical framework. One must not only consider the theories to critique, but also the approach to theory critique. Reed's (2018) Intermodern approach to critique was used for its pragmatic perspective of theory critique, which includes evaluation of a theory in terms of its practice implications and its emphasis on personal and professional health and well-being. Use of Reed's (2018) Intermodern approach facilitated selection of the SEIPS 2.0 Model was selected in part because it will provide a comprehensive framework for describing the critical care work system, processes of nursing care delivery, and subsequent outcomes with an emphasizes on professional wellbeing ( Carayon et al., 2006 ). This model offers a systems perspective to guide research on describing impact of the COVID-19 Pandemic on the critical care work systems, processes, and outcomes while emphasizing professional well-being.

This work was supported by the Sigma Beta Mu Dissertation Grant.

CRediT authorship contribution statement

Claire Bethel: Conceptualization, Writing – Original Draft, Funding Acquisition, Investigation/Analysis, Project Administration, Supervision.

Pamela Reed: Methodology, Writing – Original Draft, Writing – Review & Editing, Investigation/Analysis.

Barbara Brewer: Writing – Original Draft, Writing – Review & Editing.

Jessica Rainbow: Writing – Review & Editing.

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How to Read and Critique Research A Guide for Nursing and Healthcare Students

• Helen Aveyard - Oxford Brookes University, UK
• Nancy Preston - Lancaster University
• Morag Farquhar - University of East Anglia, UK
• Description

Do you find research challenging to read? Do you struggle to get to grips with a research paper?

Understanding, critiquing and using research is a key requirement of students studying nursing and healthcare. This bookwill equip you with the skills you need to understand research and use it in your practice and academic assignments. The approach used in this book is unique: each chapter focuses on a published research paper – one you might be asked to read for a seminar or include in your academic work. In clear, straightforward language, the authors take you through each paper step by step, using it as a basis for exploring the underpinning research method or design, and how it has been reported.

Key features:

·       Each chapter focuses on a different research method by working through a relevant research paper

·       Identifies the main skills you need for your course: understanding research methods and critiquing articles

·       Written specifically for nursing and healthcare students by experienced nursing and health care lecturers

·       Develops your confidence in understanding research by helping you to apply your knowledge to real research papers.

This is an ideal text for undergraduate nursing and paramedic students reading and learning to appraise research. This is pitched at the right level and students will find this extremely helpful as they develop these appraisal skills. 

This is a practical textbook for students which does exactly what it says in the title -demonstrates how to read and critique research. Using examples, it leads the student through the process and is an essential textbook for any research module. 

I am excited for this book release, as I find the work by Helen Aveyard incredibly helpful and aligned to teachers/students' requirements. The chapter 3 is very well written, it provides an excellent overview on generic qualitative research. It provides key words, examples and a contemporary approach which will certainly benefit both undergraduate and postgraduate students and lecturers alike. 

This book is an ideal introduction to research and methodologies used for undergraduate healthcare students as it provides clear, systematic discussions throughout, building knowledge and understanding. It is also well placed further develop healthcare professionals understanding of research.

Great for easy explanations for nursing students new to studying

It is really helpful to have this set out by research type, and to be able to direct learners to it when they come across one of these documents.

Relevance to the module descriptor

Adopted for the academic literacy project to develop midwifery students academic skills

Excellent book to accompany our research methods module.

Excellent easy to read textbook for Level 5 and Level 6 students.

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Critiquing Research Evidence for Use in Practice: Revisited

• PMID: 30871968
• DOI: 10.1016/j.pedhc.2019.01.005

Nurse practitioners need to critically appraise the abundance of research evidence and clinical practice guidelines to make astute decisions about the implementation of the best available evidence to clinical practice. There are numerous ways to appraise research and practice guidelines that are designed to inform clinical practice with the overall goals of improving patient outcomes. This article presents existing tools to appraise the research evidence in addition to a guide for providers on critical appraisal of a research study.

Keywords: Clinical decision-making; evidence-based practice; nurse practitioners; nursing research.

Copyright © 2019 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

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