Nursing: Critical Care Issue, Article Critique Example


      This study is a systemic review confirming to the following Critical Appraisal Skills Program (CASP) pattern expressed in the evaluation below.

Section A

Are the Results of the review valid?

In deciding whether the results of this review are valid it would necessitate an examination into  the reliability and validity issues contained in this study itself. According to Golafshani (2003) quoting Watling (2003) both reliability and validity are essential tools applied by researchers in establishing truth derived from facts. They further advance that reliability really pertains towards the degree to which results are consistent. The consistency must be maintained over a period of time. It also relates to whether the sample chosen was an accurate representation of the entire population. In this case it was a number of studies pertaining to an association between Registered nurses’ (RN) performance and patients’ outcomes. More importantly, reliability seeks to find out whether the results of this study can be reproduced if another methodology was used. Once this can be proven the research instrument, which in this study is a meta-analysis is considered reliable and can validate the results retrieved (Golafshani, 2003).

Hence, concepts replicability or repeatability becomes the focus of establishing reliability and validity in quantitative research studies of this nature. Therefore, pretesting, testing and retesting of instruments are absolutely necessary in excluding all reliability issues in research studies as this one. Precisely, when evaluating reliability of a study in establishing validity of results it must be understood that validity distinctly seeks to show that measurements used in the study are accurately aligned to the concepts/variables being researched.

For example, key words used for the search in this meta-analysis were, nursing staff, hospital, quality, length of stay, mortality, safety and failure to rescue. Hospital-related mortality emerged as a concept related to registered nurses’ (RN) performance and patients’ outcomes. However, it was not listed as a concept for the systematic review within the protocol that was created according to the recommendations for Meta-Analysis of Observational Studies in Epidemiology (MOOSE) (Institute of Medicine, 20004).

Another validity issue contained in this study relates to generalization of these results, which from close scrutiny may have internal and external validity issues. There are eight known threats to internal validity. They pertain to history and unusual events occurring between pretest and testing time. There was no pretesting of this instrument. Also, maturation; time changes in administration of instruments; testing irregularities of the instrument; the Hawthorne Effect; instrumentation and human error, and  Statistical Regression (Institute of Medicine, 20004).

Scores moving in the direction of the mean is another discrepancy along with attitudinal variations in sample selection; morality of the population and diffusion or imitation of treatment too. Subjects can correlate and decide to write the same views which may not be authentic (Cohen et, al, 2001). There is no certainty that the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) instrument was pretested enough to exclude these internal validity issues (Institute of Medicine, 20004). From this perspective the results contained in this study may not be entirely valid.

 Section B

What are the results?

          Results were displayed in both quantitative and qualitative patterns of data analysis presentation. Search engine results gathered 2858 studies that met the initial potential criteria for selection and 101 were eligible. However, 96 of them were eventually used for the meta-analysis. This means 5 were excluded. No reasons were given for the exclusion. Twenty-eight studies out of 30 reports reviewed showed adjusted odds ratios pertaining to patient outcomes. Researchers identified 17 cohort studies; 7 cross-sectional and 4 case-control studies (Kane, 2007).

An average quality index of the studies selected was assessed as 43 out of 50 and the internal validity estimation was calculated based on an adjustment for confounding factors. Four studies validated staffing variables and 10 patient outcomes. Researchers concluded that hospital-related mortality was related to registered nurses’ (RN) performance and patients’ outcomes due to staffing inadequacies (Kane, 2007).

Section C

Will the results help locally?

These results will definitely help locally because staffing in healthcare has always been investigated since it is a huge challenge. Once again internal validity issues in this study may make it difficult to generalize across healthcare populations outside of the local setting.


The foregoing appraisal sought to explain how valid results of this study were by citing the evidences of reliability and generalization limitations. These impact the extent to which results of qualitative systemic meta-analyses can be extremely valid. The actual results were discussed and the potential for local use was established.


Cohen, L, Manion, L; Morrison, K. (2001). Part 2, Planning Educational and Social Research, in Research Methods in Education. London: Routledge

Golafshani, N. (2003). Understanding Reliability and Validity in Qualitative Research. The Qualitative Report 8(4); 597-607

Institute of Medicine (2004). Committee on the Work Environment for Nurses and Patient Safety, NetLibrary Inc. Keeping Patients Safe: Transforming the Work Environment of Nurses. A report of the Committee on the Work Environment for Nurses and Patient Safety Board on Health Care Services. Washington, DC: National Academy Press.

Kane, R. Shamliyan, T. Mueller, C. Duval, S., & Wilt, T. (2007). The Association of Registered Nurse Staffing Levels and Patient Outcomes Systematic Review and Meta-Analysis. Medical Care, 45(12); 1195-1204