Critical Appraisal
This critical appraisal must be written in narrative format. Use headings for each section of the paper as
identified in the guidelines, such as Strengths, Weaknesses, and Evaluation. You can also use
subheadings of Problem and Purpose, Literature Review, and so forth as needed to organize your paper.
Do not use outline numbers in this paper (i., ii., iii., etc.) or present the paper in outline format. This
assignment is worth 100 points.
Guidelines for Preparing Critical Appraisal:
A. Review the chapters of your textbook (Grove, Burns, & Gray, 2013) and other research sources (i.e.,
Grove, 2007, articles and assigned readings, discussion board, research textbook from undergraduate
program) to determine what is quality research.
B. Compare the steps in this study to criteria established in your textbook or other research sources to
determine the study�s strengths and weaknesses. You can use the questions on pages 459-462 in
Grove et al. (2013) to help you identify study strengths and weaknesses.
C. Evaluate the study findings using the questions in your text as a guideline (Grove et al., 2013, p. 462).
D. Prepare the critical appraisal using the following guidelines:
? Paper should be a maximum of 15 double-spaced pages of text (excluding reference list).
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? Use appropriate documentation and develop a reference list using APA (2010) format.
? Write in a narrative style, not an outline format.
E. Document throughout your paper using your textbooks and other research sources to support the
statements you making in your critical appraisal of the article.
Critical Appraisal
Cossette, S., Frasure-Smith, N., Dupuis, J., Juneau, M., & Guertin, M. (2012). Randomized
Controlled Trial of Tailored Nursing Interventions to Improve Cardiac Rehabilitation
Enrollment. Nursing Research, 61(2): 111-120
Purpose/Problem
The strength of this purpose section is that the problem is adequately delimited in scope
so that it is actually researchable and not trivial. The problem is researchable since it is not very
complex, it is important, and it can be conducted with adequate support. The other strength of
this purpose section is that it narrows and clarifies the aim of the study being carried out by the
researchers. It has narrowed and made clear the aim as being to establish if a nursing intervention
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that is focused in individual acute coronary syndrome patients’ perceptions of their illness and
treatment would increase rehabilitation enrollment following discharge (Cossette et al., 2012).
The other strength of the problem is that it is significant to clinical practice and nursing.
This is primarily because it illustrates whether individualized, progressive nursing interventions
would lead to greater rehabilitation enrollment, and in so doing improving long-term outcome.
The approach that the researchers apply in the study provides a clinical pathway to addressing
the significant concerns encountered by patients following a cardiac event (Cossette et al., 2012).
Equally important, this study was feasible to carry out in terms of the availability of subjects and
ethical consideration. It is of note that 242 ACS patients who had been hospitalized to a
specialized tertiary cardiac center were available to take part. The Research Ethics Board of the
hospital reviewed and approved this research study, and there was informed consent (Cossette et
al., 2012).
Literature review
The strength of the literature review section is that it is organized to show the progressive
development of evidence from previous research. This is evident from the fact that Cossette et al.
(2012) have critically analyzed several actual research studies whose main objective was to
increase enrollment to rehabilitation. Another strength is that a summary of the empirical
knowledge in the subject of the research study is presented clearly and concisely. In literature
review, Cossette et al. (2012) included four randomized controlled trials (RCTs) whose aims
were to increase rehabilitation enrollment. Three sorts of interventions were tested in the trials
including liaison, automatic referrals, and a combination of liaison and automatic referrals. Of
the four RCTs, three of them actually showed a considerable increase in rehabilitation enrollment
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with intervention, and one did not. The knowledge from the four RCTs has been presented in a
terse and succinct manner such that the readers will find it rather easy to read and understand.
Furthermore, the literature review section actually identifies what is unknown and what is
already known as regards the research problem and it offers direction for the formation of the
research purpose. Thus, Cossette et al. (2012) point out that there is lack of randomized and
controlled trials that evaluate the effect of interventions on enrollment.
The major weakness is that the researchers focused largely on empirical knowledge in the
subject matter and have not provided a summary of the current theoretical knowledge, which is
of great importance for the purpose and problem of the study. Another weakness is that out of the
four RCTs summarized in the review of literature, two of them are not current since they are
older than 10 years. In essence, one study was conducted in 1999, the second one in 2001, the
third and forth ones in 2007, hence only the last two studies that were reviewed can be
considered as current.
Theory framework
The strength is that the researchers have applied a theoretical framework and it is
presented in the article. Cossette et al. (2012) used the self-regulation theory, which states that
people’s perception of their disease regulates their health behavior as well as risk factor
management. According to this theory, cognitive and emotional processes determine disease
perceptions, and thus the plan of action in a health crisis (McNamara, 2011). Ryan (2006) stated
that it is essential for investigators to link the research framework they use to the purpose of the
research. In this research study, Cossette et al. (2012) have linked Leventhal’s self-regulation
theory to the research purpose, and this is a strength. Cossette et al. (2012) pointed out that
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interventions could be obtained from this self-regulation theory, and they added that nursing
interventions have to strive to reframe the more conceptual representations of the event to one
that are more tangible.
For research studies conducted that pertain to nursing and clinical practice, a framework
should be employed by the investigators that actually relates to the body of knowledge in nursing
and clinical practice (Breslow & Day, 2012). In this study, self-regulation theory applied relates
to the body of knowledge in clinical practice and nursing, and this is a major strength. In this
study, there is no relationship or proposition from a theory that needs to be tested; hence no
proposition is identified and linked to the hypothesis of the research study.
Variable definitions
The strength of variable definitions section is that the variables are reflective of the
concepts identified in the framework. It is of note that the primary outcome in this study was
enrollment in the free-access rehabilitation program that was situation close to the hospital in
which the patients were recruited. Enrollment for this research study was defined as having
attended at least 1 session of rehabilitation within a period of six weeks following discharge from
the hospital. Enrollment data were gathered in a computerized database. The other independent
entry of data was also carried out by the coordinating center (Cossette et al., 2012). Secondary
outcomes have been identified and included anxiety level, medication adherence, family support,
and illness perception.
A major weakness of this section is that variables are not clearly defined conceptually.
Nonetheless, they are clearly defined operationally. The other strength is that the variables are
based on a theory, Leventhal’s self-regulation theory in particular (Cossette et al., 2012) since
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the 38-item Revised Illness Perception Questionnaire (IPQ-R) comprised seven dimensions of
illness perception, basing on Leventhal’s self-regulation theory. Another weakness is that since
there is no conceptual definition of variables in the study, the conceptual definition of a variable
cannot be considered as being consistent with the operational definition.
Objectives and hypothesis
The strength of this section is that the objectives and hypothesis of the research study are
expressed clearly. Cossette et al. (2012) stated that the aim of their study was to find out whether
a nursing intervention focused on individual acute coronary syndrome patients’ perceptions of
their illness and treatment would actually increase rehabilitation enrollment following discharge.
The hypothesis is also clearly stated. Cossette et al. (2012) hypothesized that patients in the
experimental group would demonstrate greater rehabilitation enrollment within a period of six
months following hospital discharge after an Acute Coronary Syndrome than would patients in
the control group. This hypothesis is stated to direct the conduct of quasi-experimental and
experimental research, and this is another major strength of this section.
Another strength of this section is that the objectives and hypothesis are logically linked
to the research purpose. In the objectives section, Cossette et al. (2012) have pointed out that the
objective of the Transit-CCU clinical trial was to evaluate the effectiveness of the CCU transit
nursing intervention on rehabilitation enrollment 6 months after discharge from hospital in
patients who had been admitted for an acute coronary syndrome. Moreover, the objectives and
hypothesis are logically linked to the concepts as well as relationships/propositions in the
framework.
Study design
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Validity
Construct validity is understood as to whether the operational definition of a given
variable in reality reflects the factual theoretical meaning of a concept. It ensures that the
researcher is actually measuring the construct that she or he wants to study, and it measures how
well an experiment or test measures up to its claims (Breslow & Day, 2012). In this study, some
of the threats to construct validity include (i) the apprehension of study participants about being
evaluated by the researchers, and (ii) bias introduced in the research study by expectancies on the
part of the researchers. The strength of construct validity as applied in this study is that the study
actually evaluated the effectiveness of CCU transit nursing intervention on rehabilitation
enrollment within six weeks of discharge from hospital in patients who had been admitted for an
ACS.
Internal validity occurs when one can make cause and effect statements basing on the
research study. Internal validity is essentially the approximate truth with regard to inferences
about causal or cause-effect relationships (Breslow & Day, 2012). In this study, the strength of
internal validity is that the researchers were able to conclude that their intervention made a
difference. From their study, Cossette et al. (2012) found that there was a considerably higher
rate of rehabilitation enrolment in the intervention group compared with the control group. For
the secondary outcomes, the researchers reported that the personal control dimension of illness
perception was substantially improved with the intervention.
External validity as used in research addresses the issue of the ability to generalize the
research findings to other persons, places, and times (Ryan, 2006). Since this study was
conducted in only one setting – a specialized cardiac hospital in Montreal, Quebec – the
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generalizability of the findings is limited. The threats to external validity are being able to obtain
similar findings if the study was carried out in a different setting, and if similar results would be
found with a different sample.
Intervention if applicable
The strength of the intervention section is that the treatment is described clearly. The
intervention was based upon empirical evidence that suggested a progression in disease
perceptions from the acute hospital to post-discharge. The intervention comprised three
encounters. Another strength of this section is that the study framework, which is Leventhal’s
self-regulation framework, explains the links between the proposed outcomes/dependent
variables, and the treatment/independent variables (Cossette et al., 2012). The treatment is
appropriate for examining the study purpose as well as hypothesis, and this is another major
strength of this section. The researchers monitored the implementation of the treatment to ensure
consistency in all the three encounters.
The design is logically linked to the sampling method as well as statistical analyses, a
noteworthy strength. Another strength is that two groups were used and they appear equivalent:
both the intervention group and usual care group consisted of 121 participants each. Moreover,
the subjects were randomly assigned to the treatment group and comparison group. Cossette et
al. (2012) point out that the participants were randomized to either the usual-care group or the
intervention group, and this is a major strength of this section. The comparison and treatment
group assignments were appropriate for the purpose of the study since each comprised 121
participants; an adequate number of participants that is actually appropriate for the study
purpose. One weakness is that a protocol was not developed for promoting consistent
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implementation of the treatment to ensure intervention fidelity since it is not described in the
article.
Sample selection
The weakness of this section is that the sampling method was insufficient to produce a
sample that is representative. This is because the subjects were not representative of the
population: 85% of them were men, and there were children or minorities. In essence, this
section did not include an understudied population such as minority or young subjects, since the
participants comprised largely of elderly ≥ 65 years old, and adult male patients. The strength is
that the sampling criteria were appropriate for the type of study conducted. The criteria for
exclusion included being discharged to a long-term care or to a short-term rehabilitation center;
being unable to speak English or French; living over 50 miles from the rehabilitation center.
Other exclusion criteria included having psychological, physical, or cognitive problems; already
receiving outpatient follow-up; referred for surgery; having a final diagnosis besides ACS; or
previously completed a rehabilitation program (Cossette et al., 2012). As such, the exclusion
criterion was appropriate for the type of study conducted. The potential biases in the sampling
method include excluding subjects because of the aforesaid exclusion criteria, and this is a
strength since it allowed the researchers to obtain a sample that is appropriate for the study.
Moreover, the sample size is adequate to avoid a type II error considering that the sample size
comprised 242 participants, and this is a noteworthy strength. The other strength is that the
setting used in the study is typical of clinical settings since the study was carried out in adult
patients admitted for a suspected ACS at the medical ward or CCU of a specialized cardiac
hospital in Montreal, and this is a strength (Cossette et al. (2012). The refusal to participate rate
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was not a problem since only one participant refused the initial hospital encounter because of
hurry to go home, and participants filled a consent form, and this is a strength.
Measurement tools
A key strength of this section is that the measurement methods selected for the study
adequately measure the variables of the study; data on enrolment were derived from a
computerized database that records each appointment in the rehabilitation program. One
weakness is that the measurement methods are not sufficiently sensitive to detect small
differences between the subjects. As such, additional methods of measurements should have
been utilized to improve the quality of the study. A noteworthy strength of this section is that the
measurement methods used have adequate reliability and validity; they actually measure what
they were intended to measure and have consistency since with the use of the same
measurements methods, the same findings could be obtained in a similar study.
Moreover, the instruments used in the study are clearly described as Cossette et al. (2012)
point out that illness perceptions were assessed with the use of a 38-item Revised Illness
Perception Questionnaire, and basing on Leventhal’s theory, this questionnaire consisted of
seven dimensions of illness perception. A 14-item Family Care Climate Questionnaire-Patient
version was also used. The researchers assessed anxiety with the use of the state portion of the
State-Trait Anxiety Inventory comprising 20 items. Another strength is that the instrument
development process has been described satisfactorily considering that the instrument was
developed particularly for this study. In addition, the reliability and validity of instruments have
been described amply. Cossette et al. (2012) stated that they assessed concurrent validity by
examining correlation coefficients with related constructs, and there was test-retest reliability.
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Data collection & Data analysis
An important strength of this section is that the data collection process is described
clearly. The authors used a 14-item Family Care Climate Questionnaire-Patient version, a 38-
item Revised Illness Perception Questionnaire, and a 20-item state portion of the State-Trait
Anxiety Inventory. A 4-item Self-Reported Medication-Taking Scale was also used to collect
data, in addition to the “Are You Eating Healthy?” scale, which had 20 questions. The other
strength is that the forms used to collect data are organized to facilitate computerizing the data.
Moreover, the process of data collection is conducted in a manner that is consistent, and this is a
key strength of this strength of this section.
Another strength is that the collected data actually address the research hypothesis and
the research objectives. For instance, the Revised Illness Perception Questionnaire comprised a
total of seven aspects of illness perception, and the patients’ perceptions of the support offered
by their family members and relatives relating to their health situation were evaluated with the
use of the 14-item Family Care Climate Questionnaire-Patient Version. Medication adherence
and anxiety were also assessed. The data gathered using the various instruments address the
objectives and hypothesis. No adverse events occurred during collection of data, and this is also
a strength of this section. Another strength of this section is that the training of data collectors is
clearly described and is adequate. Cossette et al. (2012) pointed out that they provided the study
nurses with a box of sealed opaque envelopes which they opened after every patient had
completed the baseline questionnaire.
The procedures for data analysis are appropriate for the type of data collected and this is a
strength. Clinical and sociodemographic variables were summarized as mean ± standard
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deviation for continuous variables and as percentage and count for categorical variables. The
procedures for data analysis are described clearly, which is also a strength of this section. The
chi-square test was applied by Cossette et al. (2012) for the primary outcome. The researchers
used logistic regression to evaluate models adjusting for baseline variables that were thought to
influence the findings (Cossette et al., 2012). The secondary outcomes were analyzed with the
use of analysis of covariance models and including the baseline score as a covariate. The other
strength is that the results are presented in an understandable way by narrative and includes
participant flow, sample description, intervention description, primary outcome, and the
secondary outcomes (Cossette et al., 2012). Additionally, the results of the study are interpreted
aptly and this is also a strength of this section. Cossette et al. (2012) reported that the findings
are in line with three of the four published Randomized Controlled Trials evaluating
rehabilitation enrolment after a liaison kind of intervention.
Discussion
The key strength is that the findings are discussed in relation to the hypothesis and
objective. Cossette et al. (2012) stated that the findings of the study demonstrated a virtually
doubling of enrolment by the experimental group relative to the control group. They added that
the findings are actually consistent with 3 of the 4 published RCTs. The other strength is that the
implications that were identified for practice were appropriate based on the study findings as
well as the findings from previous studies, and the findings are clinically significant. Cossette et
al. (2012) reported that since the literature shows that referral is an essential requirement for
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enrolment in rehabilitation, their study shows that a nursing intervention is able to provide a
considerable benefit beyond simple referral.
The other strength of this section is that the findings are an accurate reflection of reality
and valid for use in clinical practice. Another strength of this section is that various explanations
for nonsignificant and significant findings are adequately examined. Cossette et al. (2012)
reported that a slight but significantly greater increase was found in perceived personal control in
the experimental group compared with the usual-care group, which suggests one possible
explanation for the increase in rehabilitation experiment.
Confidence in the study findings
There is not much confidence in the findings considering that a small, inadequate sample
size was used and this limits generalizability of results; a small proportion of the general CCU
population was used. The confidence of the findings is also limited by another weakness of the
study in that the study was conducted in only a single setting and did not include minorities and
children. This also serves to limit the generalizability of the research findings. The study findings
could have been improved if the study was conducted in multiple settings. Furthermore, more
children, minorities, and more women – there were only 35 women out of the 242 participants –
should have been involved. Nonetheless, the appropriate sample/participants were used, and the
methodology applied by the researchers is satisfactory. In addition, the process of data collection
and analysis is adequate, and so is the review of existing literature.
Consistency of this study’s findings with the findings from other studies
There is consistency of the results. The results of this research study are in fact consistent
with the those of other studies. Cossette et al. (2012) noted that their findings are actually in line
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with 3 of the 4 published randomized controlled trials that evaluated rehabilitation enrollment
after liaison sort of intervention. Just like in the study by Cossette et al. (2012), the interventions
in the three trials were bedside practice nursing staff members, or nursing staffs supervising
practice nurses or peers.
Readiness of findings for use in practice
Cardiac illnesses are the main causes of mortality as well as hospitalization in
industrialized nations. Acute Coronary Syndromes such as unstable angina and myocardial
infarction are responsible for most of the cardiac deaths and admissions (Cossette et al., 2012).
The approach used by the researchers provides a clinical pathway that can be utilized in
addressing the major concerns faced by patients following a cardiac event. Nursing staffs are on
the forefront of offering care to cardiac patients and they really require findings such as these on
which to base their clinical as well as practice judgment. The research study by Cossette et al.
(2012) is a case in point of how scientific knowledge, combined with clinical practice can
actually contribute to better outcomes of patients.
Contribution of the study to nursing knowledge
The research study actually contributes to the existing literature by testing a progressive
intervention that was tailored particularly to the psychological and clinical trajectories of patients
following a cardiac event. Individualized, progressive interventions by nursing staffs led to
greater rehabilitation enrolment, thus potentially improving long-term outcomes. The study is of
major importance considering that there was a dearth of randomized controlled trials that assess
the effect of interventions on enrolment. The study also contributes to nursing knowledge by
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demonstrating that a nursing intervention could actually offer a considerable benefit beyond
referral.
References
Breslow, N. E., & Day, N. E. (2012). The Analysis of Case-Control Studies. IARC Scientific
Publications, 32.
Cossette, S., Frasure-Smith, N., Dupuis, J., Juneau, M., & Guertin, M. (2012). Randomized
Controlled Trial of Tailored Nursing Interventions to Improve Cardiac Rehabilitation
Enrollment. Nursing Research, 61(2): 111-120
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McNamara, C. (2011). Analyzing, Interpreting and Reporting Basic Research Results. Boston,
MA: CRC Press.
Ryan, A. (2006). Methodology: Analyzing Qualitative Data and Writing Your Findings.
Columbus, OH: Springer Publishers.
