Running head: RESEARCH CRITIQUE

A Critique of Research: Nursing 531

Michelle A. Stimson
Ferris State University

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Abstract
Without the use of evidence-based practice (EBP), cost-effective, high-quality patient care
cannot manifest in the healthcare setting (Melnyk & Fineout-Overholt, 2015). Reliable evidence,
generated through rigorous research, is a foundational principle of EBP (Melnyk & FineoutOverholt, 2015). However, evidence cannot be taken at face value as not all evidence is equal.
Healthcare professionals, including nurses, must critically appraise empirical data for validity,
reliability, and applicability (Melnyk & Fineout-Overholt, 2015). Critical appraisal allows for
proper discernment of whether certain pieces of evidence should be translated into practice
(Melnyk & Fineout-Overholt, 2015). In order to bridge the gap between what is known and what
is practiced, nurses must invest time and energy in developing and fine tuning their ability to
critically appraise findings generated by research (Melnyk & Fineout-Overholt, 2015).

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A Critique of Research: Nursing 531

The three prongs of evidence-based practice (EBP) include the best available evidence,
clinician expertise, and patient preferences and values (Melnyk & Fineout-Overholt, 2015). The
combination of all three components is necessary for optimal patient outcomes and contained
healthcare costs (Melnyk & Fineout-Overholt, 2015). The process of critical appraisal provides a
systematic approach for determining the strength and quality of evidence generated by research
(Melnyk & Fineout-Overholt, 2015). Critical appraisal is a necessary step in the translation of
evidence into practice and is a skill every clinician should learn and master (Melnyk & FineoutOverholt, 2015). The purpose of this paper is to provide a critique of four research articles for
strength and quality based on the concepts of validity, reliability, and applicability.
Research Article Critiques
Crowe, M., Jordan, J., Burrell, B., Jones, V., Gillon, D., & Harris, S. (2016). Mindfulness-based
stress reduction for long-term physical conditions: A systematic review. Australian &
New Zealand Journal of Psychiatry, 50(1), 21-32. doi: 10.1177/0004867415607984
Summary & Critique
A systematic review was conducted to answer the following question: Does mindfulnessbased stress reduction (MBSR) reduce physical symptoms, and as a result, improve physical
health outcomes for individuals with long-term physical conditions? Data supporting the use of
MBSR in reducing symptoms of anxiety and depression exist, however, a knowledge gap is
present regarding the use of MBSR as a strategy for reducing physical symptoms in long-term
illness. The literature review provided support for the hypothesis based on the discovery of the
following bi-directional process: individuals with mental health disorders are prone to long-term
illness and individuals with long-term illness are prone to mental health disorders; possibly at a
rate of two to three times the general population. Fifteen articles were indentified for the
systemic review using the Cochrane method and defined selection criteria. Of the 15 articles, 11
were randomized controlled trials (RCTs) and four were quasi-experimental in design.

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Several strengths of the study were noted. The article was peer reviewed, well referenced,
recently published, and no conflicts of interest were identified. The theoretical foundations of
psychology, physiology, and Buddhism ground the article and a majority of the studies used a
consistent, reliable, and valid evaluation tool (Short-Form Health Survey 36). Further increasing
credibility, systematic reviews and RCTs are high levels of evidence; Levels 1 and 2 respectively
(Melnyk & Fineout-Overholt, 2015). Unfortunately, credentials of the authors and human subject
data protection were not provided. Some studies had ungeneralizable demographics and small
sample sizes decreasing applicability. Objective data such as vital signs and/or biomarkers were
not measured increasing subjectivity. Further reducing validity and reliability, several RCTs were
not blinded leaving only four of the 15 studies with a low risk of bias.
The challenges facing this study involves issues of clarity and applicability. The authors
did not define what constitutes a long-term illness nor identify specific physical symptoms that
lead to improved physical outcomes. Therefore, the studies reviewed measured a variety of
health outcomes (pain, tinnitus, insomnia, and dyspnea) and medical conditions (arthritis,
asthma, and fibromyalgia) making it difficult to generalize the pooled data to anyone with a
long-term illness. Only two studies demonstrated a significant improvement in physical
symptoms (insomnia and irritable bowel syndrome [IBS] symptom severity) making it difficult
to discern whether or not MBSR would have a significant effect on a specific type of symptom or
outcome for a specific long-term illness. Although not completely generalizable nor translatable,
the study opens up the possibility for using MBSR as a strategy for reducing insomnia and IBS
symptoms in individuals with long-term illness. Further research is needed.
Lengacher, C. A., Kip, K. E., Reich, R. R., Craig, B. M., Mogos, M., Ramesar, S., ... & Pracht,
E. (2015). A cost-effective mindfulness stress reduction program: A randomized control
trial for breast cancer survivors. Nursing Economic$, 33(4), 210-218, 232.
Summary & Critique

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An RCT was conducted to answer the following question: Does the use of MBSR reduce
healthcare and personal costs in breast cancer survivors (BCSs) over the course of survivorship
by improving health-related quality of life (HRQOL)? Cancer treatment can have long-term
psychological and physiological effects leading to increased healthcare utilization, lost wages,
and reduced productivity. For BCSs, data supports the use of MBSR as a successful method for
improving anxiety, depression, and HRQOL but data does not exist regarding its role in reducing
individual, societal, and healthcare related costs. Therefore, 104 subjects were divided into two
study arms; usual care (UC) and MBSR. Healthcare costs were calculated based on national
averages, personal costs were self-reported, and HRQOL was measured using the SF-12v1 tool.
Several strengths of the study were noted. The article was refereed, well referenced,
recently published, well credentialed (6 PhD's), and no conflicts of interest were identified. The
theoretical foundations of psychology, physiology, and economics grounded the study. Human
subjects were properly protected. Low risk of bias exists in RCTs making RCTs a credible
research methodology (Melnyk & Fineout-Overholt, 2015). The SF12v1 is considered a valid
and reliable measurement tool. Unfortunately, several limitations were noted in the subject
demographics decreasing applicability: 79% were Caucasian, 85% had some college education,
66% were married, several were retired, and all were recruited from similar geographic locations.
Data could have been skewed by not permitting UC group participants to continue practicing
alternative therapies even if they did so on a regular basis. This change in their daily routine
could affected their HRQOL and impact results of the study. The study design did not minimize
the MBSR participants from recognizing the treatment arm from the UC arm. Participants joined
based on interest and many measurements were based on self-reported tools further increasing
bias and subjectivity. Eight subjects dropped from the study without explanation.

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Challenges with this study involve validity and applicability. Cost-effective analysis,
which was used in this study, can be used in RCTs to measure the costs and realized savings of a
planned intervention with reasonable accuracy (Hlatky, Owens & Sanders, 2006). The challenge
comes during the follow-up period as RCTs typically do not follow their subjects long enough to
determine the full benefits of treatment which happens to be the case in this study (Hlatky,
Owens & Sanders, 2006). The authors recommend rapid implementation of MBSR in all
organizations supporting BCSs. Although relatively low cost to implement, significant cost
savings of MBSR were only realized if survivors lived 5-20 years post-treatment. Follow-up did
not extend beyond the 12 week post-intervention period making claims that MBSR is efficacious
in the long-term outlandish. Also, no power analysis was provided. The study could be improved
by finding more cost-effective ways to deliver MBSR; possibly shortening the intervention timeframe or offering the intervention virtually. Effects of MBSR need to be studied for a longer
duration in order to prove long-term effectiveness. The study shows promise and potential for
future research in the use of MBSR in BCSs for improving HRQOL along with cost savings.
Roberts, K. C., & Danoff-Burg, S. (2010). Mindfulness and health behaviors: Is paying attention
good for you? Journal of American College Health, 59(3), 165-173.
Summary & Critique
A cross-sectional study was conducted to determine if correlations exist between college
students' perceived level of stress, MBSR, and health outcomes. Several hypotheses were tested
including MBSR's role in mediating stress-related cigarette smoking, sleep impairment, binge
eating, and risky sexual behavior. Data to support the use of MBSR in reducing stress-related
sleep disturbances and cigarette smoking were found. Also noted, college students are considered
high risk for engaging in unhealthy behaviors due to high levels of stress; MBSR is linked to
reduced stress. Therefore, the question remains: Can MBSR reduce stress in college students,

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therefore, cause an increase in positive health outcomes and ultimately become a useful
intervention for reducing public health concerns in this population?
The article was peer reviewed, well referenced, properly credentialed (one PhD), and no
conflicts of interest were found. Theories of psychology and Buddhism guided the study. All
subjects had equal access and opportunity to the online questionnaire and ethical considerations
for protecting human subjects were taken. The study had a relatively large sample size (n=553)
and valid and reliable measurement tools were used. Unfortunately, several challenges with the
study were noted. Many hypotheses were tested making the study confusing and difficult to
follow. In some cases, hand-selected questions from various measurement tools were used
potentially decreasing credibility and reliability. Sample demographics were predominately
female, Caucasian, and geographically identical. Level 4 evidence is highly biased due to a lack
of randomization limiting the ability of the study to draw causal pathways (Melnyk & FineoutOverholt, 2015). Data were self-reported challenging validity due to potential memory lapse,
estimations, and subjectivity. The tables were confusing and difficult to understand.
Regression analysis, which was used in this study, is appropriate when determining
causal effects of multiple independent variables upon a dependant variable (Cohen, Cohen, West
& Aiken, 2003). A link was discovered between higher levels of mindfulness and improved sleep
quality, increased physical activity, and less binge eating. The study did not demonstrate reduced
cigarette smoking nor risky sexual behavior as a result of increased mindfulness. The
significance of the study correlates with data in the literature; college students are sleep deprived
and have significant stress causing increased utilization of healthcare services. Although this
study in and of itself should not translate into evidence due to its high level of bias, subjectivity,
and ungeneralizability, the results warrant further research on the use of MBSR to mediate stress
in college students, and in turn, improved health outcomes.

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Hjeltnes, A., Binder, P., Moltu, C., & Dundas, I. (2015). Facing the fear of failure: An
explorative qualitative study of client experiences in a mindfulness-based stress reduction
program for university students with academic evaluation anxiety. International Journal
of Qualitative Studies on Health and Well-being, 10(27990), 1-14. doi: http://dx.doi.org/
10.3402/qhw.v10.27990
Summary & Critique
A qualitative study was completed to answer the following question: Can an 8-week
MBSR program improve self-perceived academic evaluation anxiety in university students?
University students self-report high levels of anxiety disorders and are subjected to high levels of
academic stress. According to the research, anxiety can impair academic performance impacting
students' well-being and academic learning. Efficacious results have been shown in the use of
MBSR for managing anxiety disorders. However, qualitative research conducted on MBSR
interventions and anxiety disorders is lacking leaving a gap in what is understood about how
individuals perceive why and how MBSR reduces anxiety. Seventy university students from
various academic majors volunteered to participate in the study. The study consisted of an 8week MBSR course, group discussion, and semi-structured interviews.
The study was peer reviewed, recently published, well referenced, properly credentialed,
and demonstrated no conflicts of interest. Theories of psychology, neurobiology, and Buddhism
grounded the study. Ethical considerations for the protection of human subjects were taken. Data
were collected using the hermeneutic-phenomenological framework. Several limitations of the
study were noted. The subjects were geographically identical and overwhelmingly female.
Interviews, as a collection method, can be highly biased as human recollection can be faulty.
Another great limitation to the study involves the use of three out of four authors as the actual
MBSR instructors. The authors attempted to decrease bias and subjectivity by not interviewing
their actual students and adding a non-MBSR colleague to the interview team. However, the

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teachers could have steered the MBSR course in a purposeful direction in an attempt to benefit
study findings. Also, fifteen students dropped from the study without explanation.
Challenges with this study involve validity and applicability. Sample size was small.
Subjects were overwhelmingly female making applicability to male students difficult. The
interviews had varying levels of detail challenging data analysis. Qualitative research is
considered a low level of evidence (Level 6) and cannot link causality (Melnyk & FineoutOverholt, 2015). Thematic analysis, often used in qualitative research, was used in this study.
The analysis indentified themes and patterns within the data including: sharing a human
struggle, improved self-acceptance, and finding an inner source of calm. Links in previous
research exist between MBSR, a sense of calm, and emotional regulation. Links also exist
between MBSR and self-acceptance as well as between self-acceptance and increased potential
to cope with academic failure. The authors were outright about the study's lack of causality due
to research design, bias introduced by using authors as MBSR instructors, and the benefits of
group dynamics in sharing a human struggle separate from MBSR programs. The evidence
generated is not translatable into practice as it does not show causality, is highly biased, and
gender and geographically specific. No reliable, quantitative tools measured anxiety and
academic performance, therefore the hypothesis was not truly answered. However, qualitative
research can lead to quantitative research and can also answer questions about the human
experience which is necessary patient-centered care (Melnyk & Fineout-Overholt, 2015).
Conclusion
Scrutinizing evidence, generated through research, for validity and reliability is necessary
and important when considering the translation of evidence into practice. The ability to critically
appraise evidence for quality and strength is one of the most important skills a nurse can possess
(Melnyk & Fineout-Overholt, 2015). Florence Nightingale believed human beings have a
responsibility to improve human conditions for the better (Tourville & Ingalls, 2003). The

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10

American Nurses Association [ANA] (2010) states, "nursing interventions are intended to
produce beneficial effects, contribute to quality outcomes, and above all, do no harm" (p. 4). This
concept could apply to the process of research, the critical appraisal of empirical data, and the
translation of evidence into practice. Nurses have a professional responsibility to learn the skill
of critical appraisal and also advocate for the integration of high-quality, best practices into their
places of employment, the profession of nursing, and healthcare as a whole.

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11

References
American Nurses Association [ANA]. (2010). Nursing: Scope and standards of nursing practice.
(2nd ed.). Silver Spring, MD: Nursebooks.org.
Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Applied multiple regression/correlation
analysis for the behavioral sciences. (3rd ed.). Mahwah, NJ: Lawrence Earlbaum
Associates, Inc.
Crowe, M., Jordan, J., Burrell, B., Jones, V., Gillon, D., & Harris, S. (2016). Mindfulness-based
stress reduction for long-term physical conditions: A systematic review. Australian &
New Zealand Journal of Psychiatry, 50(1), 21-32. doi: 10.1177/0004867415607984
Hjeltnes, A., Binder, P., Moltu, C., & Dundas, I. (2015). Facing the fear of failure: An explorative
qualitative study of client experiences in a mindfulness-based stress reduction program
for university students with academic evaluation anxiety. International Journal of
Qualitative Studies on Health and Well-being, 10(27990), 1-14. doi: http://dx.doi.org/
10.3402/qhw.v10.27990
Hlatky, M. A., Owens, D. K., & Sanders, G. D. (2006). Cost-effectiveness as an outcome in
randomized clinical trials. Clinical Trials, 3(6), 543-551.
Lengacher, C. A., Kip, K. E., Reich, R. R., Craig, B. M., Mogos, M., Ramesar, S., ... & Pracht, E.
(2015). A cost-effective mindfulness stress reduction program: A randomized control trial
for breast cancer survivors. Nursing Economic$, 33(4), 210-218, 232.
Melnyk, B., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare:
A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health.
Roberts, K. C., & Danoff-Burg, S. (2010). Mindfulness and health behaviors: Is paying attention
good for you? Journal of American College Health, 59(3), 165-173.
Tourville, C., & Ingalls, K. (2003). The living tree of nursing theories. Nursing Forum, 38(3),
2130, 36.