“A Randomized Trial of Rocking-Chair Motion on the Effect of Postoperative Ileus Duration in Patients with Cancer Recovering from Abdominal Surgery,

compare your critique with that of the author. List one point you learned in this process and one area you need
to continue to work on.

Critique of a Quantitative Research Study

The study “A Randomized Trial of Rocking-Chair Motion on the Effect of Postoperative Ileus Duration in Patients
with Cancer Recovering from Abdominal Surgery,” by Robert L. Massey, published in Applied Nursing Research, is
critiqued. The article is presented in its entirety and followed by the critique on p. 361.
A Randomized Trial of Rocking-Chair Motion on the Effect of Postoperative Ileus Duration in Patients with Cancer
Recovering from Abdominal Surgery
Robert L. Massey, PhD, RN, NEA–BC, *
Division of Nursing, The University of Texas MD Anderson Cancer Center Houston, Texas
Received 2 November 2007; revised 27 May 2008; accepted 5 June 2008.
Abstract
Patients who undergo abdominal surgery experience a phenomenon commonly called postoperative ileus (POI). Standard
of care requires patients to get out of bed, sit in a chair, and begin ambulating the first postoperative day. No
evidence supports standard care activities reduce POI duration. Rocking-chair motion has shown promise in reducing
POI duration. Sixty-six participants were randomized into 2 groups. The experimental group (n = 34) received
standard care plus the rocking-chair intervention; the control group (n = 32) received standard care. Participants
in the experimental group had shorter duration of POI, no effect on medication use, and time to discharge.
1. INTRODUCTION
Postoperative ileus (POI) is a form of gastrointestinal dysfunction that commonly occurs after abdominal surgery
and results in absent or delayed gastrointestinal motility. POI is hypothesized to be the body’s
sympathetic-induced response to overstimulation and stress imposed by large abdominal incisions, extensive
manipulation of the bowel, and dissection of abdominal lesions (Holte & Kehlet, 2002; Le Blanc-Louvry,
Costaglioli, Boulon, Leroi, & Ducrotte, 2002; Luckey, Livingston, & Tache, 2003, Miedema & Johnson, 2003; Schuster
& Montie, 2002). POI presents as absent, abnormal, or disorganized motor function of the stomach, small bowel, and
colon resulting in the accumulation of gas that cannot be dissipated causing abdominal distention, nausea,
vomiting, and severe pain that can last for up to 7 days after surgery, complicating the full and timely recovery.
Patients often describe the period immediately after surgery, prior to the resolution of POI, as the most
uncomfortable part of their post abdominal surgery recovery experience. Both patients and clinicians eagerly
anticipate the passage of flatus, commonly known as “surgeon’s music,” a sign that POI is resolving (Prasad &
Matthews, 1999).
Recognized since 1899, minimal progress has been made toward the prevention and treatment of POI (Bayliss &
Starling, 1899). Studies suggest there are multiple contributing causes of POI. Multiple factors have been
reported to contribute to its onset and persistence and include activation of inflammatory mediators, secretion of
gastrointestinal hormones, various forms of anesthesia during surgery, opiates given for pain control, previous
abdominal surgery, surgery time, anesthesia time and American Society of Anesthesia (ASA) physical status
classification have all been implicated. To date no specific interventions that prevent and successfully resolve
POI have been discovered (Luckey et al., 2003; Miedema & Johnson, 2003). Physicians and nurses have had little to
offer their patients other than reassurance that POI will resolve over time and bowel function will return (Matros
et al., 2006).
One noninvasive postoperative standard-of-care intervention that is believed to resolve POI is having the patient
get out of bed, sit in a chair, and walk beginning the first day after surgery, increasing the duration of each
daily until passage of flatus or stool occurs (Waldhausen & Schirmer, 1990; Waldhausen, Shaffrey, Skenderis,
Jones, & Schirmer, 1990). Evidence that these activities effectively treat POI remains unconvincing. However,
there is consensus other positive benefits occur for the postoperative patient to thrombosis, and other negative
physiological changes that occur with prolonged bed rest. A need exists for controlled studies of this and other
interventions using randomized comparison treatment groups set into motion the design and conduct of this study.
A relatively new noninvasive clinical intervention that is believed to potentially reduce the duration and effects
of POI is a rocking motion delivered using a rocking chair. The back and forth motion of rocking was previously
found to reduce intestinal gas accumulation, abdominal distention, and pain associated with POI in abdominal
surgery patients (Moore, Shannon, Richard, & Vacca, 1995; Thomas, Ptak, Giddings, Moore, & Opperman, 1990). Thomas
et al. (1990) found that mothers who rocked after a cesarean birth used less pain medication, passed flatus
earlier, and had a reduced length of hospital stay compared with those who did not rock in a rocking chair. Moore
et al. (1995) reported similar findings among postoperative abdominal hysterectomy patients. Concomitant clinical
observations and data analysis revealed that rocking in 10- to 20-minute increments for at least 60 minutes per
day reported reduced gas pain scores, promoted earlier ambulation and expulsion of gas, and facilitated patient’s
discharge from the hospital earlier than patients in the nonrocking group.
1.1. Theoretical Basis for Intervention
A key physiologic factor in the development of POI is the body’s response to the stress of surgery (Desborough,
2000). This surgical stress response is not limited to patients who undergo abdominal surgeries. Other surgical
procedures such as hip replacement and thoracic surgeries also are implicated as stimuli for the surgical stress
response and POI that is associated with abdominal dysfunction, dysmotility, and disorganization of neural stimuli
that normally are responsible to coordinate propulsion within the gastrointestinal tract (Behm & Stollman, 2003).
Although the exact physiological mechanisms that are influenced by rocking motions are not well known, theorists
and researchers hypothesize that the gentle, rhythmic, repetitive motion of rocking stimulates the vestibular
nerves to send signals of pleasure and alertness to the reticular activating system, which is the body’s “flight
or fight” response center (De Marco-Sinatra, 2004; Moore et al., 1995). The gentle rhythmic, repetitive motion of
rocking is hypothesized to have a modulating effect on the stress response, thereby mediating the symptoms of POI,
and is an important theoretical foundation for this study. No recent studies have further explained or tested the
rocking intervention in both genders or in patients with cancer recovering from abdominal surgery.
1.2. Purpose
The purpose of this study was to test the effect of a nurse-derived intervention, rocking-chair motion on POI
duration, total pain medication received, and time to discharge in patients with cancer recovering from abdominal
surgery. This article reports the results of the effectiveness of the rocking-chair intervention in both genders
of patients with cancer recovering from abdominal surgery.
1.3. Research Questions
Three research questions were evaluated. Does the rocking intervention reduce the mean time in days to passage of
first flatus compared to standard care? Does the rocking intervention reduce the total mean pain Morphine
Equivalent Dose (MED) medication in milligrams received compared to standard care? Does the rocking intervention
reduce the mean time in days to hospital discharge compared to standard postoperative care compared to standard
care?
2. METHODS
2.1. Design
This study was conducted between July 2005 and February 2007 at The University of Texas M. D. Anderson Cancer
Center. A posttest-only randomized control trial design was chosen with measurement taken each day after abdominal
surgery until passage of first flatus. A pretest randomized trial was not plausible owing to the subjects having
to undergo surgery prior to measurement of the dependent variables: time to first flatus, postoperative pain
medication received, and time to discharge. The study was approved by the institutional review board, and informed
consent was obtained from each patient prior to enrollment.
2.2. Inclusion Criteria
Patients who were 21 years and older, scheduled to undergo abdominal surgery for gastrointestinal cancers,
scheduled to receive postoperative patient-controlled epidural or intravenous analgesia, cognitively intact, able
to read and speak English, able to tolerate rocking or sitting in a chair, and able to ambulate were eligible to
participate in the study.
2.3. Setting and Sample
The study was conducted on a 32-bed surgical oncology unit composed of two separate 16-bed pods. Power calculation
was based on the primary end point of time to first passage of flatus used by Disbrow, Bennett, and Owings (1993)
in their study of the effects of specific instructions on POI duration, pain medication used, and time to
discharge. Given the similarities in aims and research questions between the Disbrow et al. (1993) study and this
study, SPSS Sample Power 2.0 (Borenstein, Rothstein, Cohen, Schoenfeld, & Berlin, 2000) software was used to
perform the sample size calculations by setting the criterion for significance at .05, two-tailed tests (an effect
in either direction was accepted), and power at 0.80. A total sample size of 54 participants was determined
necessary to yield statistically significant results (27 in the intervention group and 27 in the control group).
2.4. Procedures
Patients scheduled to undergo abdominal surgery for gastrointestinal cancer were screened by the primary
investigator during preoperative evaluation clinic visits. After completing written consent, eligible patients
were randomly assigned to the intervention (rocking) or control (nonrocking) group. Study participants, nurses,
and surgeons were blinded to group assignment until the first day after surgery. To reduce interaction bias, we
placed intervention and control patients on separate 16-bed pods, and each pod could care for a control or
intervention patient.
The control group received standard care that included walking and sitting up out of bed in a nonrocking chair
beginning the first day after surgery. The experimental group received care that included walking and rocking in a
rocking chair beginning the first day after surgery. The rocking intervention group had their nonrocking chair
removed and replaced with a rocking chair upon arrival to the inpatient room. Only nonrocking chairs were
available in the nonrocking group rooms. Intervention and control subjects were instructed to sit in the rocking
and nonrocking chairs and begin to ambulate around the triangle-shaped pod beginning the first day after surgery
and increase the frequency and duration of each activity each day. Nurses and surgeons were instructed and
reminded of the activities for each group, and a sign was placed in the patient’s chart as to group assignment.
Time in rocking and nonrocking chairs and number of laps ambulated were recorded by participants, and the nurses
on a datasheet for each 24-hour period.
2.5. Data Collection
The principal investigator collected all data. Demographic data and surgical characteristics collected included
age, gender, ethnic group, marital status, and diagnosis, type of surgical procedure, anesthesia time, surgical
time, and history of previous abdominal surgery. Each day the investigator met with each subject in each of the
groups until passage of first flatus. Participants were provided a pen and pad and instructed to record the date
and time they passed first flatus from the rectum after surgery.
This self-estimate assessment method was chosen because a previous study found high correlation between carbon
dioxide levels expelled from the rectum and self-report of date and time of first flatus passage in abdominal
surgery patients (Yukiokab, Bogod, & Rosen, 1987). Total opioid pain medication (milligrams) received was obtained
every 24 hours from each patient’s patient-controlled analgesia (PCA) or epidural infusion pump. Nonmorphine
opioids (Fentanyl and Dilaudid) were converted to MEDs in milligrams. PCA intravenous opioids were Morphine
Sulfate, Fentanyl, or Dilaudid. Epidural opioids were Fentanyl and Dilaudid. Date and time of the end of surgery
were obtained from the operative record and used as a starting point for measurements of time to first flatus and
time to discharge. Times of discharge were obtained from the institutional discharge system.
2.6. Data Analysis
Data were analyzed using SPSS 12.0 statistical software. Statistical analysis of demographic and clinical
characteristics was summarized using descriptive statistics. The two intervention groups were compared with
respect to various demographic and clinical characteristics using the appropriate statistical t tests for interval
data and chi-square analyses for ordinal data. To examine group differences in the duration of POI (time to first
passage of flatus), pain medication use (total doses in milligrams used per 24 hours), and postoperative patient
recovery time (time to discharge), we used the two-sample t test if assumptions of normality (Levene’s test) and
homogeneity of variance on the dependent variable were upheld (Field, 2005). Descriptive statistics were used to
summarize each outcome (time to first flatus, total pain medication used, and time to discharge). If assumptions
underlying the two-sample t test were violated, appropriate nonparametric tests were run for the involved
variables (Mann-Whitney U). A significance level of .05 was
used.
TABLE 1 Demographics of Patients (N= 66)
Characteristics
Rocking, n (%)
Nonrocking, n (%)
p
Total patients
34 (51.5)
32 (48.5)
±SD
±SD
Median age ± standard deviation
56.2 ± 10.1 years
54.8 ± 11.4 years
.600
Gender
Male
14 (41.0)
19 (59.0)
.218
Female
20 (59.0)
13 (41.0)
Ethnic group
White non-Hispanic
26 (76.0)
27 (85.0)
.875
African American
2 (6.0)
1 (3.0)
Hispanic
3 (9.0)
2 (6.0)
Asian
3 (9.0)
2 (6.0)
Marital status
Single
5 (15.0)
3 (10.0)
.757
Married
27 (79.0)
25 (78.0)
Divorced
1 (3.0)
2 (6.0)
Widowed
1 (3.0)
2 (6.0)
Diagnosis
Colon cancer
20 (59.0)
22 (69.0)
.752
Liver cancer
4 (12.0)
4 (12.0)
Sarcoma
5 (14.0)
3 (10.0)
Gastric cancer
2 (6.0)
2 (6.0)
Pancreatic cancer
3 (9.0)
1 (3.0)
3. RESULTS
3.1. Sample
A total of 66 patients (n = 32 nonrocking and n = 34 rocking) completed the study. Attrition consisted of 2
rocking patients who could not continue rocking due to dizziness and returned to surgery due to internal bleeding.
Both were included in the analysis based on intent-to-treat guidelines and the fact that both passed flatus after
rocking during the 24 hours prior to removal from the study.
3.2. Subjects’ characteristics
Demographic characteristics of the study participants are shown in Table 1. There were no significant differences
between groups in age, gender, ethnicity, marital status, and diagnosis. Overall, male participants in this study
were significantly older (mean age = 59.09, SD = 9.85) than female participants (mean age = 52.03, SD = 10.38;
t(64) = 2.832, p < .006), but this demonstrated only a small effect size (d = 0.33).
3.3. Surgical Characteristics
Surgical attributes of the study participants are presented in Table 2. There were no significant differences
between the study groups in surgical procedure types or ASA status categories. Participants in both arms of this
study, overall, had high incidence of previous abdominal surgeries; however, there were no significant differences
between the groups.
TABLE 2 Surgical Characteristics
Characteristic
Rocking, n (%)
Nonrocking, n (%)
p
Total patients
34 (51.5)
32 (48.5)
Procedure
Colectomy
13 (38.0)
10 (31.0)
.668
Liver resection
8 (24.0)
12 (38.0)
Small bowel resection
1 (3.0)
1 (3.0)
Exploratory laparotomy
12 (35.0)
9 (28.0)
ASA status
ASA 1
0 (0.0)
1 (3.0)
.533
ASA 2
19 (56.0)
17 (53.0)
ASA 3
15 (44.0)
14 (41.0)
ASA 4
0 (0.0)
1 (3.0)
Previous abdominal surgery
Yes
30 (88.0)
25 (78.0)
.333
No
4 (12.0)
7 (22.0)
Note. ASA = Anesthesia Society of Anesthesia.
TABLE 3 Anesthesia and Surgery Time
Characteristic
Rocking (n= 34)
Nonrocking (n= 32)
p
Anesthesia time hours
M±SD
4.77 ± 2.50
4.03 ± 2.13
.204
Surgery time hours
3.61 ± 2.35
3.01 ± 2.08
.280
M±SD
3.03
2.05
TABLE 4 Times to First Flatus (Days)
Rocking (n= 34)
Nonrocking (n= 32)
p
M±SD
3.16 ± 0.86
3.88 ± 0.80
.001*
Note. Significant p< .05.
3.4. Surgery and Anesthesia Duration
Durations of surgery and anesthesia in hours for each group are summarized in Table 3. The rocking group
participants experienced slightly lengthier anesthesia times than nonrocking participants, and the difference was
not significant (t(64) = -1.284, p = .204, d = 0.15). The rocking participants also experienced slightly lengthier
surgical times than nonrocking participants. Again, this difference was not significant (t(64) = -1.089, p = .280,
d = 0.13).
3.5. Time to First Flatus
The time-to-first-flatus data are presented in Table 4. The rocking group passed flatus an average 0.7 days (16.8
hours) earlier than the nonrocking group. The nonrocking group, on average, experienced significantly longer time
to passage of first flatus as compared with the rocking group (t(64) = -3.542, 95% confidence interval [CI] =
0.3174–1.1383, p = .001, d = 0.40). Therefore, a significant difference and effect size between means of the
rocking and nonrocking group time to first flatus were identified.
TABLE 5 Total Pain Medication Received (mg)
Rocking (n= 34)
Nonrocking (n= 32)
p
M±SD
29.35 ± 58.99
36.48 ± 51.66
.604
TABLE 6 Surgical Characteristics
Characteristics
Rocking (n= 34)
Nonrocking (n= 32)
p
M±SD
7.69 ± 4.57
7.89 ± 3.20
.837
3.6. Total Pain Medication Received
Data for both the rocking and nonrocking groups are presented in Table 5. Analysis of total pain medication
received revealed nonnormality for both groups (nonrocking, D(32) = .298, p < .001; rocking D(34) = .335, p <
.001). However, Levene’s test for homogeneity was not violated (F (1, 64) = .243, p = .624), and therefore, the
variances were assumed to be equal. The total pain medication received was, on average, greater for the nonrocking
group as compared with the rocking group, and this difference was not statistically significant.
3.7. Time to Discharge
Time-to-discharge data are presented in Table 6. The time-to-discharge data with the outliers included indicated
that the nonrocking group experienced essentially the same time in the hospital as compared with the rocking arm.
Therefore, there was no significant difference between the means of the rocking and nonrocking groups in time to
discharge from the hospital (t(64) = .206, p = .837, d = 0.02).
3.8. Time in Rocking/Nonrocking Chairs
Time (hours) spent in rocking and nonrocking chairs is presented in Table 7. There were no significant differences
in time in chair for either group except for Day 3 when the nonrocking group spent more time in the chair (t(64) =
2.108, p = .039, CI = 0.0673–2.4996).
3.9. Laps Ambulated
Laps ambulated by the rocking and nonrocking groups are presented in Table 8. Number of laps ambulated around the
triangular shaped pods were not significantly different for either the rocking or nonrocking participants.
4. DISCUSSION
4.1. Conclusions
The goal of this randomized trial was to explore the effects of rocking-chair motion on POI duration, total pain
medications received, and time to discharge among patients with cancer recovering from abdominal surgery. There
were no differences in age, marital status, and ethnicity between the two groups. Surgical characteristic data
revealed the rocking group experienced longer surgical and anesthesia times. However, the differences were not
significant and demonstrate that these characteristics may not actually contribute to the prolonged POI duration.
Both the groups had high percentages (rocking 88% and nonrocking 78%) having had previous abdominal surgery.
However, this did not affect the duration of POI.
TABLE 7 Laps Ambulated
Time in Chair
RANDOMIZED ARM
M
SD
Sig.
Day 1
Nonrocking
1.13
±1.31
.307
Rocking
1.57
±2.03
Day 2
Nonrocking
2.28
±1.65
.567
Rocking
2.55
±1.65
Day 3
Nonrocking
3.25
±2.21
.039*
Rocking
1.97
±2.23
Day 4
Nonrocking
1.70
±2.52
.650
Rocking
1.39
±3.02
Day 5
Nonrocking
0.978
±2.50
.462
Rocking
0.529
±2.41
* Significant p< .50.
TABLE 8 Time in Chairs (Hours)
Time in Chair
RANDOMIZED ARM
M
SD
Sig.
Lap Day 1
Nonrocking
4.60
±9.10
.802
Rocking
5.01
±7.03
Lap Day 2
Nonrocking
11.07
±19.88
.909
Rocking
10.62
±12.07
Lap Day 3
Nonrocking
13.93
±16.47
.759
Rocking
15.95
±33.35
Lap Day 4
Nonrocking
7.07
±10.92
.498
Rocking
10.22
±23.85
Lap Day 5
Nonrocking
3.80
±10.17
.527
Rocking
2.14
±10.88
A significant difference between group means for time to first flatus provides support that the rocking-chair
motion reduced the duration of POI in this group of study participants. The nonrocking group in this study, on
average, used more pain medication than the rocking group. However, a lack of significance did not support rocking
motion reduced pain medication use compared to previous research. Time-to-discharge data were nonsignificant and
indicated the nonrocking and rocking groups experienced essentially an equal number of postoperative days in the
hospital. Again, the data from this study were contrary to previous research reporting reduced time to discharge
of at least 1 day.
Participants in both groups spent the same amount of time in the rocking and nonrocking chairs except on Day 3 for
the nonrocking group. This can be explained due to the rocking group passing flatus an average of 0.7 days earlier
than the nonrocking and were no longer participating in the study. Both groups also ambulated, on average, the
same number of laps implying that both groups received similar interventions except for the rocking-chair motion
in the rocking group. Therefore, this study contributes new evidence to support the use of rocking-chair motion as
a modulator of POI duration in patients with cancer who have abdominal surgery.
4.2. Limitations
Limitations of this study include the small sample size, wide variation in diagnoses, surgical procedures,
variation in types of pain medications used, and routes of administration. Therefore, the results of this study
must be interpreted with caution.
4.3. Implications for Nursing
The standard of care that was challenged in this study has rarely been evaluated in a randomized clinical trial.
This study does makes a contribution to evidence-based practice due to its statistically and clinically
significant findings, as well as the limitations discussed herein may be used as guides for the design and conduct
of future, more rigorous investigations. Generalization beyond this patient population is limited to patients with
cancer recovering from abdominal surgery. Rocking in a rocking chair after surgery was readily accepted by the
intervention group. A key factor identified is that the rocking motion had no effect on surgical incision site
pain. Participants consistently voiced the rocking motion relaxed them, although relaxation was not measured.
4.4. Implications for Future Research
The results of this study indicate the feasibility of a nursing-derived intervention, rocking-chair motion, as a
therapy to reduce duration of POI in patients with cancer recovering from abdominal surgery. Future research to
further explore the use of rocking-chair motion on POI duration is warranted. Rocking-chair motion may provide
abdominal surgery patients earlier relief from POI, the most difficult part of the postoperative recovery process,
and improve short-term postoperative quality of life.
This is a critical appraisal of the article, “A Randomized Trial of Rocking-Chair Motion on the Effect of
Postoperative Ileus (POI) Duration in Patients with Cancer Recovering from Abdominal Surgery” (Massey, 2007) to
determine its usefulness for nursing practice.
Test the effect of a nurse-derived intervention, rocking-chair motion on POI duration, medication received and
time to discharge in patients with cancer recovering from abdominal surgery,” is concise and clearly stated. The
independent variable is the rocking-chair intervention and the dependent variables are POI duration, total pain
medications, and time to discharge. The population under study is clearly defined, and the importance to nursing
is evident as this is described as a “nurse-derived” intervention.

Significant physical discomfort is associated with POI, and this is well documented in the literature review.
There is no prior convincing evidence that other interventions to minimize POI are useful. These measures have
included the following:
• Getting the patient out of bed as soon as possible postoperatively
• Sitting in a chair
• Walking the first postoperative day
• Increasing the duration of ambulation until passage of flatus or stool occurs.
This intervention has been tested in prior abdominal surgery patients and a significant decrease in intestinal gas
accumulation, abdominal distention, and pain was observed. The majority of the references in the literature review
appear to be primary sources. The articles by Moore and colleagues (1995) and Thomas and colleagues (1990) are
both RCTs and provide much of the rationale for the rocking-chair intervention. The identified gap in the
literature is appropriately addressed by testing the intervention in patients with cancer recovering from
abdominal surgery.
The rocking-chair intervention and control group (standard care) are well defined in the “Procedures” section. The
patient environment was manipulated so that nonrocking chairs were not available in rooms where patients were
assigned to the intervention group so that every time the patient was up in a chair, it was a rocking chair.
Passage of first flatus was recorded by the patient, and although the article does not specifically state this, it
is implied that duration of POI is measured from the date and time of the end of surgery to passage of first
flatus. Total opioid pain medications are operationally defined in milligrams and nonmorphine opioids were
converted to milligrams and summed. Time to discharge was defined as the duration of time between the date and
time of the end of surgery and hospital discharge.

Three research questions clearly guided this study:

1. Does the rocking intervention reduce the mean time in days to passage of first flatus compared to standard
care?
2. Does the rocking intervention reduce the total mean pain Morphine Equivalent Dose (MED) medication in
milligrams received compared to standard care?
3. Does the rocking intervention reduce the mean time in days to hospital discharge compared to standard
postoperative care compared to standard care?
Research questions versus hypotheses are appropriate for this study because the relationships between the
variables have not been previously tested.
SAMPLE
The convenience sample consisted of 66 patients with cancer who were undergoing abdominal surgery. Sample size was
appropriately calculated using SPSS Sample Power 2.0, with significance set at .05 and using a two-tailed test and
power of .80. A total sample of 54 subjects was determined to yield statistically significant results.
Appropriately, the sample size was adjusted to account for dropouts. The final sample included 32 patients in the
standard treatment group and 34 patients in the rocking intervention group. Participant attrition was minimal and
included two patients who could not continue in the rocking group because of dizziness and internal bleeding,
requiring return to the operating room. Although the sample was not randomly selected, there were no demographic
differences between the intervention and control groups in terms of age (p = .600), gender (p = .218), ethnicity
(p = .875), marital status (p = .757), and cancer diagnosis (p = .752), indicating that the groups were equivalent
at baseline.
TABLE 16-1 Summary of Major Content Sections of a Research Report and Related Critical Appraisal
1. Is the background and significance of the research question or hypothesis appropriately presented in the
introduction to the study report?
Research Question and Hypothesis (see Chapter 2)
1. What hypotheses or research questions are stated and are they appropriate to express a relationship between an
independent and a dependent variable?
2. Has the research question or hypothesis been placed in the context of an appropriate theoretical framework?
3. Has the research question or hypothesis been substantiated by adequate experiential and scientific background
material?
4. How have the purpose, aims, or goals of the study been substantiated?
5. Is each hypothesis or research question specific to one relationship so that each hypothesis or research
question can be either supported or not supported?
6. Given the level of evidence suggested by the research question, hypothesis, and design, what is the potential
applicability to practice?
Review of the Literature (see Chapter 3)
1. Does the search strategy include an appropriate and adequate number of databases and other resources to
identify key published and unpublished research and theoretical resources?
2. Is there an appropriate theoretical/conceptual framework that guides development of the research study?
3. Are both primary source theoretical and research literature used?
4. What gaps or inconsistencies in knowledge or research does the literature uncover so that it builds on earlier
studies?
5. Does the review include a summary/critique of each study that includes the strengths and weakness or
limitations of the study?
6. Is the literature review presented in an organized format that flows logically?
7. Is there a synthesis summary that presents the overall strengths and weaknesses and arrives at a logical
conclusion that generates hypotheses or research questions?
METHODS
Internal and External Validity (see Chapter 7)
1. What are the controls for the threats to internal validity? Are they appropriate?
2. What are the controls for the threats to external validity? Are they appropriate?
3. What are the sources of bias and are they dealt with appropriately?
4. How do the threats to internal and external validity contribute to the strength and quality of evidence
provided by the design and findings?
5. How was the fidelity of the study maintained?
Research Design (see Chapters 8 and 9)
1. What type of design is used in the study?
2. Is the rationale for the design appropriate?
3. Does the design used seem to flow from the proposed research question(s) or hypothesis(es), theoretical
framework, and literature review?
4. What types of controls are provided by the design that increase or decrease bias?
Sampling (see Chapter 10)
1. What type of sampling strategy is used? Is it appropriate for the design?
2. How was the sample selected? Was the strategy used appropriate for the design?
3. Does the sample reflect the population as identified in the research question or hypothesis?
4. Is the sample size appropriate? How is it substantiated?
5. To what population may the findings be generalized? What are the limitations in generalizability?
Legal-Ethical Issues (see Chapter 11)
1. How have the rights of subjects been protected?
2. What indications are given that institutional review board (IRB) approval has been obtained?
3. What evidence is given that informed consent of the subjects has been ensured?
Data-Collection Methods and Procedures (see Chapter 12)
1. Physiological measurement:
a. Is a rationale given for why a particular instrument or method was selected? If so, what is it?
b. What provision is made for maintaining accuracy of the instrument and its use, if any?
2. Observation:
a. Who did the observing?
b. How were the observers trained and supervised to minimize bias?
c. Was there an observation guide?
d. Was interrater reliability calculated?
e. Is there any reason to believe that the presence of observers affected the behavior of the subjects?
3. Interviews:
a. Who were the interviewers? How were they trained and supervised to minimize bias?
b. Is there any evidence of interview bias, and if so, what is it? How does it affect the strength and
quality of evidence?
4. Questionnaires:
a. What is the type and/or format of the questionnaires (e.g., Likert, open ended)? Are the operational
definitions provided by the instruments consistent with the conceptual definition(s)?
b. Is the format appropriate for use with this population?
c. What type of bias is possible with this questionnaire format?
5. Available data and records:
a. Are the records or data sets used appropriate for the research question(s) or hypothesis(es)?
b. What sources of bias are possible with use of records or existing data sets?
Reliability and Validity (see Chapter 13)
1. Was an appropriate method used to test the reliability of the instrument(s)?
2. Was the reliability of the instrument(s) adequate?
3. Was the appropriate method(s) used to test the validity of the instrument(s)?
4. Have the strengths and weaknesses related to reliability and validity of each instrument been presented?
5. What kinds of threats to internal and external validity are presented as weaknesses in reliability and/or
validity?
6. How do the reliability and/or validity affect the strength and quality of evidence provided by the study
findings?
Data Analysis (see Chapter 14)
1. Were the descriptive or inferential statistics appropriate to the level of measurement for each variable?
2. Are the inferential statistics appropriate for the type of design, hypothesis(es), or research question(s)?
3. If tables or figures are used, do they meet the following standards?
a. They supplement and economize the text.
b. They have precise titles and headings.
c. They do not repeat the text.
4. Did testing of the hypothesis(es) or research question(s) clearly support or not support each hypothesis or
research question?
Conclusions, Implications, and Recommendations (see Chapter 15)
1. Are the results of each hypothesis or research question presented objectively?
2. Is the information regarding the results concisely and sequentially presented?
3. If the data are supportive of the hypothesis or research question, does the investigator provide a discussion
of how the theoretical framework was supported?
4. How does the investigator attempt to identify the study’s weaknesses (e.g., threats to internal and external
validity) and strengths and suggest possible research solutions in future studies in light of the limitations of
this study?
5. Does the researcher discuss the study’s relevance?
6. Are any generalizations made and, if so, are they made within the scope of the findings?
7. Are any recommendations for future research stated or implied?
Applicability to Nursing Practice (see Chapter 15)
1. What are the risks/benefits involved for patients if the findings are applied in practice?
2. What are the costs/benefits of applying the findings of the study?
3. Do the strengths of the study outweigh the weaknesses?
4. What is the strength, quality, and consistency of evidence provided by the study findings?
5. Are the study findings applicable in terms of feasibility?
6. Would it be possible to replicate this study in another clinical setting?

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