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The paper by Ryan et al., (2007), “evaluating the effectiveness of an educational and experiential intervention on nursing students attitudes towards older people”, was critiqued using the Cormack Framework (Cormack 2000). Caldwell et al. (2005) stated that healthcare was a multi-disciplinary field and the importance of evidence based research, consumption of research and critiquing research was of immense importance. Cullum et al., (2007) have also stated the importance for evidence based research in the ever-changing field of medicine. The Cormack framework is usually used to comprehensively critique quantitative research and includes details regarding the hypothesis, operational definitions and validity of data-collection tools (Caldwell et al., 2005).
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In 2007, Ryan et al. published their research aimed at evaluating the effectiveness of an educational and experiential intervention on nursing students’ attitudes towards older people. The main objective of the study was to report the results of a study that aimed at evaluating the effectiveness of an educational and experiential intervention on nursing students’ attitudes towards older people. Ryan et al. have stated that by being exposed to sick and old regularly, nursing students may be at a risk of developing stereotypical views about these people considering them frail and dependent.
The title is concise and directly points out the purpose of the study indicating that the study will evaluate the educational and experiential intervention on nursing students’ attitudes towards older people. The title concisely points out that the study will focus on the attitude of the nurses, thereby making them the subjects of research. One can also infer from the title that a quantitative procedure has been employed for data collection and analysis as it includes the word ‘evaluation’. The authors are thoroughly qualified, each having completed their Masters coupled with a number of other qualifications. Ryan A. is especially well qualified having completed a PhD along with a number of other qualifications. All the authors are Lecturers in Nursing schools and universities in Northern Ireland.
The study has been systematically laid down and is introduced with an abstract. The research problem has been clearly stated and the objectives have been laid down. The methodology has been outlined, the term methodology and design have been used interchangeably in the abstract and the method of data collection has been mentioned. The hypothesis have not been explicitly provided or included in the abstract. Yet, the hypotheses can be inferred from the abstract with educational and experiential intervention as the independent variable and the nurses’ attitude as the dependent variable (Parahoo 2006). Creswell & Plano-Clark (2007) stated that it is recommended to include hypotheses in a research project in order to signify what direction the study will take, and that hypotheses employ statistical procedures, according to which a researcher draws inferences about the population from the study sample. The abstract mentions the sample subjects, but the details of the sample have not been given. DePoy and Gitlin (1993) have stated that the main purpose of sampling is to draw accurate conclusion about a larger population by selecting a smaller sample out of the same.
The abstract provides a brief description of the results, although the numbers have not been mentioned. The overall result has been given and the conclusion has been clearly laid out. The results and the conclusion are congruent with the aim and objectives of the research. The conclusion has been supplemented by a reference to the relevance to clinical practice.
Introduction and Literature Review
A number of studies have been carried out before and after this study regarding the nurses’ attitudes towards the older patients (Giardina-Roche & Black, 1990; Aday et al., 1991; Adelman et al., 1991; Higgins et al. 2007; Slevin 1991; Tierney et al., 1998; Cozort 2008; Hope, 1994; Hartley et al., 1995). Thus, this study carried out by Ryan et al. is not a unique study and thus makes review of relevant literature a must. The literature review and introduction have been provided as a single unit using various sub-heads like ‘Impact of attitudes on career choices’, ‘Educational and experiential interventions’ and ‘The study’ to structurally lay down the importance of the study.
The aim and the objectives of the study have clearly been laid out towards the end of the study; however, the aim lacks a build-up that could justify the choice of the topic. The rationale of the study has not been explicitly laid down though it can be inferred from the sub-texts lying in the Introduction as being an important study as it analyses an important aspect of nursing that deals with ethical and professional integrity of the profession. It has been stated by Ryan et al. (2007) that earlier studies/interventions have helped improving the attitudes of nurses towards older patients, thus the intervention or study by Ryan et al. by also bring a significant improvement in these attitudes.
Depoy and Gitlin (1993) stated that an introduction to a research problem must include five elements, namely professional experience, societal trends, professional trends, published research and existing theory. The author has covered four out of the five requisites to introduce the problem but has failed to incorporate societal trends, which might determine the viewpoint of the society on the same topic, i.e. from the perspective of the older patients.
The literature review contains references that date back to before the year 2000. Burns and Grove (2007) have stated that amidst scientific interventions and fast changing medical practices, it is important to provide references that are up to date in order to avoid discounting the validity if data and statistics. Nevertheless, the literature review clearly underlines the background and theoretical framework for the issue. The review has been put down in a structured format and the underlying framework has been highlighted by emphasising points, such as the impact of such attitudes on practice and the impact of interventions on them.
Ryan et al. have presented both sides of the picture, although, more emphasis has been laid on the negative attitudes and their implications. The author has concentrated on the reasons that lead to such behaviour or attitudes and has not focussed on the societal aspect or social consequences of the same. This might be a drawback as societal implications are very important in respect to medical research as society and medicine are inter-related and inter-dependent (DePoy and Gitlin, 1993). The literature reviewed presents a fairly balanced evaluation of material both in support of positive attitudes and negative attitudes, thus both supporting and challenging the position being proposed. The literature has been put forth in a structured manner leading to the need for a research/study that could make a necessary intervention in the regard of nurses’ attitudes towards older patients. It is of immense importance to present a balanced view of the literature in order to minimise the chances of bias (Creswell 2003).
The author has used a number of earlier studies as references to lay down the foundation for a detailed literature review, although, a number of crucial references (Mellor et al., 2007; Courtney et al., 2000) have been omitted. The author has also failed to highlight or mention the same in the study.
Hypotheses and operational Definitions
The study uses a number of approaches in order to meet the prescribed objectives. One of the approaches used is experimental in nature and demands proper hypotheses that can be tested and validated to conclude the research (Creswell and Plano-Clark, 2007). Ryan et al. have failed to provide concise and clear hypotheses to the study and the hypotheses are mainly implied.
Similarly, the operational definitions have not been clearly stated or defined either. Due to the lack of a proper hypothesis, the operational definitions have been omitted as well. DePoy and Gitlin (1993) stated that “based on hypothesis, the researcher next develops an “operational” definition of the concept so that it can be measured by a scale or other instrument”. Although Kogan’s attitude towards old people scale has been used, no operational definitions have been provided.
The research methodology has been clearly stated as explicitly indicates the research method that is being used. The words research ‘design’ and ‘method’ have been used interchangeably as no broad research design (Creswell 2008) has been mentioned in the methodology. The method used in the study was conducted in two phases with a gap of one year in between. Educational and experiential interventions were also made in order to influence the attitudes of the students. The research approach is clearly defined but there is no justification for the use of the use of this method, although the author has emphasised that this method has been successfully used before. Due to the lack of a justification, it may be perceived that the research method may not have been appropriate or that other research methods, such as survey, observational study, structured & semi-structured interviews or Randomized controlled trial (RCT), may have been better options to gauge the behaviour or attitudes of the nurses towards the older patients.
Ryan et al. have also failed to identify the limitations of the research method used. The method may not be able to get the required information from the population as some people may not be able to perceive their own behaviour towards the old patients as negative. In-depth interviews (Denzin and Lincoln, 2000) may have been used to improvise on the questions in order to get better assessment of the subject. Berry (1999) has stated that this method of research is more appropriate in understanding human experiences and emotions at a holistic level. Also, due to the lack of mention of any weaknesses, the author has failed to bring it to the notice if any challenges were faced and how they were overcome.
The methods of research clearly signify that the author focuses on the nurses’ attitudes towards older patients, thus making the nurses the attitude of the nurses the primary focus of the research. There are a number of independent variables, such as the educational and the experiential intervention that could change the outcome of the dependent variable, i.e. the subject.
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The sample was 130 adult nursing students at a university in the UK who were present in week 2 of semester 1 in the year 2001. The number of nurses had been mentioned in the abstract. There is no particular mention of any sampling technique used by the researcher. DePoy and Gitlin (1993) stated that the researches have to use experimental designs and relevant literature to properly identify the sample with characteristics that the researcher may want to include or exclude from the research. Neither of the two has been mentioned in the sampling. Simultaneously, the justification of the sampling method and its relevance with the research method cannot be understood.
One of the major concerns of a researcher is how to select a smaller part of a bigger population in order to represent the whole accurately. “Accurate representation is critical for the findings from the sample to be generalised to the larger group from which the sample is drawn” (Depoy and Gitlin, 1993). Moreover, DePoy and Gitlin (1993) have also stated that sampling designs have been developed in order to let the researcher select individuals or elements, which are the representatives of a larger population from which they are drawn. “The more representative the sample, the more assured the researcher is that the findings from the sample also apply to the population” (DePoy and Gitlin, 1993). Parahoo (2006) also stated the sampling is one of the most important aspects of an experimental research. Not using a scientific method in this research, Ryan et al. have risked the collected data to be non-congruent to the larger population.
The tools used for data collection are clearly mentioned. The questionnaires were the main tools used for data collection. The author has clearly stated the procedure and laid down the details regarding the collection of data. However, the form in which the data was collected and stored has not been mentioned. The variables have been clearly stated and the inter-dependence has been well stated.
There are no indications of any change in method during the process of data collection; at least, there is no mention of any such change or improvisation. The data gained was congruent with the need for the data and the research aims and objectives. The data collected through the Scale method (questionnaire) was validated using the measure of authoritarianism and anti-minority attitudes (Kogan 1961; cited in Ryan et al., 2007).
There was no mention of limitations of the methods used for data collection or any challenges that the researcher faced during the collection process.
The author has failed to provide details for any ethical considerations that may have been important in this particular study. Due to no mention of any ethical considerations, it may be perceived that the author has not taken any approval from an ethics committee. The only approval that has been taken is from the Head of School of Nursing for collection of data. Atici and Erdemir (2008) have stated that “in medical practice and research it is necessary to consider the rights of the researcher or physician and of the subject or patient, to conform to scientific standards and to examine the appropriateness with respect to laws and moral values”.
The students answering the questionnaires were guaranteed anonymity and confidentiality was assured by asking the students to not sign or mention their name on the questionnaires.
The methods used for data analysis were congruent to the methods of data collection. The methods have been thoroughly explained and the method is also suitable for the type of data collected. The statistical analysis was correctly performed using renowned computer software to minimize any discrepancies. DePoy and Gitlin (1993) stated that “in experimental type research, computer-based statistical programs are routinely used to analyse data. All the steps of analysis have been clearly put down and the method of checking for statistical significance has been explained. The author has failed to mention any limitations to the method of data analysis and/or if any challenges or difficulties were met during the process.
DePoy and Gitlin (2003) have stated that in an experimental setting, organising the data before analysis is very important. Ryan et al. have mentioned that the first two authors jointly coded the questionnaire to ensure consistency of analysis.
Result and Discussion
The results have been clearly stated in the form of tables. The reasons for the decrease in the number of subjects (n=90) over the period of one year are given. The results indicate positive and very positive attitudes and the reasons for the change in statistics in the first phase and the second phase have been given. The discussion that follows is thoroughly robust and neatly explained. The results have been discussed and the discussion also draws from the previous researches although the mention of the previous researches in limited. The discussion is long and the results have been discussed thoroughly. The discussion has been ended with a short summary of the same in order to emphasise the important points.
DePoy and Gitlin (1993) have stated that the discussion section is the most creative part of an experimental research. “In this section, the researcher discusses the implications and meanings of the findings, poses alternative implications, relates the findings to previous work, and suggests the use of research results” (DePoy and Gitlin, 1993).
The weaknesses of the study have not been mentioned in the discussion, however, have been mentioned towards the end of the study. The weaknesses of the entire study have been summed up in a precise manner. The clinical implications of the findings have hardly been mentioned in the discussion. The author has failed to discuss whether the findings can be transferred to other populations or other universe. The author has also failed to provide any alternate implications for the future.
“The conclusion section is a short summary that draws conclusions about the findings of the study in regard to future directions for research or health care practices” (DePoy and Gitlin, 1993). The last few paragraphs of the research study conclude by stating that it is important for the nurses to work with the older patients in order to develop positive attitudes towards them. The conclusion has not been supported by enough evidence from the data obtained by the study. Thus, the conclusion is not fully congruent with the aim of the research. Moreover the implications of the study are not clearly identified although there is a mention of the study being helpful in attempting to change the negative behaviour towards the older patients.
The implications for future research have been clearly stated. The author has suggested a qualitative research on the same topic to get into the details of the subject. Qualitative research is a preferred research design in healthcare (Cowan 2009). The limitations have been identified and many suggestions have been made regarding the betterment of the research. The main limitation identified by the author was the inability to establish any casual relationship between attitudes towards older people and attitudes towards working with older patients. The author has failed to identify whether the research can be used in any other way or in any other given setting.
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