The following critique is a requirement for the nursing research class NUR 304. The article under review is How Nurses Learn Advocacy, written by Barbara Jo Foley, M. Ptlene Minick, and Carolyn C. Kee. Barbara Jo Foley's credentials are as follows: RN, PhD, FAAN, Alpha Alpha, Colonel (Ret.), Army Nurse Corps, Clinical Associate Professor, University of North Carolina School of Nursing, Chapel Hill, NC (Foley, Minick, & Kee, 2002). M. Ptlene Minick's credentials are as follows: RN, PhD, Epsilon Alpha, Visiting Associate Professor, School of Nursing, Georgia State University, Atlanta, GA (Foley et al., 2002). Carolyn C. Kee's credentials are as follows: RN, PhD, Epsilon Alpha, Professor, School of Nursing, Georgia State University, Atlanta, GA (Foley et al., 2002).
How Nurses Learn Advocacy was submitted for publication on October 13, 2001 and published by the Journal of Nursing Scholarship in the Second Quarter 2002 issue. How Nurses Learn Advocacy is a qualitative study to find out how nurses learn to be a patient advocate. The purpose of this article is to critique the title, research problem, research purpose, review of literature, research question, research design, setting, subjects, data collection method, data analysis procedures, findings, author's discussion, theoretical development, and provide a an over all conclusion of the research article, How Nurses Learn Advocacy.
The title, How Nurses Learn Advocacy, is to the point of the article's purpose. The title does not reflect, however, the limitation of the sample. I believe a better general title would be the following: How Military Nurses Learn Advocacy. The original title still provides insight into what the article is trying to accomplish. The title does imply a qualitative research approach because it is hard to quantify a person's learning experience of developing a skill.
The research problem is the following (Foley et al., 2002):
Patient Advocacy is assumed to be an inherent part of all nursing curricula and present in clinical practice settings. Yet the nursing literature contains little description of how nurses learn the advocacy role. (p. 181)
This problem is clearly stated and found in the article. It is in the first paragraph of the article and is the topic of the paragraph. Foley et al., (2002) makes a good argument for the need of advocacy for the patient. The authors also point out advocacy could be used as an organizing concept for a nursing curricula but their review of literature did not reveal such a curricula.
The purpose of the article is clearly stated on the very first line of the article. The purpose is also clearly stated at the end of the literature review as follows:
The purpose of this study was to describe how nurses learn the skill of advocating for patients. (p. 182)
Review of Literature
The reader has to take the authors' word that there is not enough research out there on development of patient advocacy. The authors do not state where they looked for literature. There was no mention of any literature that told how advocacy was taught and the reader is told there is no literature to that regard.
Since the authors could not find any literature on the development of advocacy in the nurse, they emphasized the importance of advocacy and when it is used in nursing. The authors used mainly four studies to relate advocacy to the workplace. The four studies were dated as follows: 1993, 1993, 1996 and 2000.
The literature review had other studies supporting advocacy was being used internationally. These works came from the United Kingdom and the years of publication ranged from 1981 to 2000.
No research question could be clearly found but one was implied. The implied research question is: How do nurses learn advocacy? The authors jump around the subject but never clearly state the question. Answering the question is the purpose of the research article.
The design of How Nurses Learn Advocacy is a "Heideggerrian hermeneutic phenomenological approach" (Foley et al., 2002). This type of design is controversial for this study. The phenomenological approach is appropriate for the purpose of the study, but the authors try to form theories to help in the real world. The phenomenological approach is used to explain a concept the investigators are unclear about, not to apply it to other situations. Grounded theory may be appropriate for this study. "The primary purpose of the grounded theory approach is to generate comprehensive explanations of phenomena that are grounded in reality" (Polit, Beck, & Hungler, 2001). This approach allows the investigators to draw generalized conclusions of their findings.
"Each participant was interviewed in a quiet office or conference room with measures taken to avoid interruptions" (Foley et al., 2002). This is different than some qualitative studies. Some qualitative researches believe taking the person out of their environment will bias the study. The participant's interviews ranged from 30 to 90 minutes. The article does not say how big the room was, the color of the room, the lighting of the room, or who did the interview. These aspects are important because they may influence the quality of response from the participant. The interview took place while the nurses were on assignment in Bosnia on a military establishment. This might influence the results because nurses in these types of settings are usually more independent than hospital nurses.
The participants were found by convenience sampling. "The investigator chose to study U.S. military nurses' advocacy role during an operational mission" (Foley et al., 2002). All of the participants were "chosen because they were supporting the operational mission in Bosnia at the time of the study" (Foley et al., 2002). The sample chosen is not representative of the population and therefore cannot be generalized to the overall population. Normally, generalizing your findings is not a problem in a qualitative study, but the authors tried to generalize their findings in the nursing practice.
Data Collection Method
The researchers used the hermeneutic phenomenological approach (Foley et al., 2002). This approach is a "qualitative research tradition, drawing on interpretive phenomenology, that focuses on the lived experiences of humans, and on how they interpret those experiences" (Polit et al., 2001).
Demographics were obtained by asking questions about age, race, marital status, rank, and nursing education. All other data was gathered during the interview by having the participants tell stories reflecting their experiences during the military operation when they assumed patient advocacy roles. "The participants were then asked how they believed they had learned skills in becoming patients' advocates" (Foley et al., 2002).
The author only tells the reader the participants signed the informed consent, the participants are allowed to withdraw from the study at any time, and there were no known risks associated with the study. The author does tell us the general idea of obtaining idea but does not give specific details. More information on the type of communication during the interview would be helpful. The plan of the interview was to "interview the nurses until the data became redundant" (Foley et al., 2002). The article never mentioned if the interview followed the plan.
The research team consisted of two researchers and the investigator. The two phenomenological researchers and investigator performed individual analysis of the data and then participated in a group analysis. "Transcriptions of the interviews and field notes were analyzed using the interpretive method of hermeneutics...and further refined and delineated as a seven-step process" (Foley et al., 2002).
The type of analysis completed was appropriate for the data. Having more than one researcher interpret the data helps validity of the interpretation. Credibility was verified in five ways helping the credibility of the data analysis. The five ways of creating credibility are the following: two methods of data collection were used, more than one researcher participated in the analysis, multiple stages of analysis were used, verification by external researchers was done, and verification by key participants.
The major findings of how nurses learn advocacy are as follows: who they were as people, watching other nurses interact with patients, and the nurse gaining confidence. The findings are clear and to the point. The author picked out excerpts of the transcriptions of the interviews to validate the findings. The reader has to trust that the analysis was correct in the findings because only a few examples are present. It does not say how the answer was elicited. The findings do explain the purpose of the study in a general manner.
The author concluded "beginning nursing students may hear the word advocacy for the first time, they may recognize the concept. Nursing faculty may need to define advocacy in relationship to patient care rather than teach a new idea" (Foley et al., 2002).
Other major conclusions involved helping the confidence of the nurse, positive role modeling, and teaching advocacy in different way in the curricula to aid advocacy development in the new nurse (Foley et al., 2002).
The authors proposed the faculty could help nursing students develop advocacy by describing the critical thinking process used in patient advocacy and demonstrating advocacy in clinical practice throughout the nursing education process (Foley et al., 2002). This is useful to nursing because it could be a solution to develop patient advocacy better in nursing students than the current way.
The strengths of the article are the data analysis, research design and purpose. There is a need for research on the nursing curricula. Finding out if the lessons being taught in the classroom is being applied in the field is a very important step of nursing as a profession.
The weaknesses of the article are the sampling, the research design, and possibly the setting. The sample limits the findings to the population interviewed only. The author seemed to want to generalize it many nursing curriculums. It is not possible because the people in sample are military which are a different kind of people, and also a different setting. The research design was a weakness because it did not follow the conclusions of the paper. The authors wanted to form a theory and implement it into nursing. The phenomenal approach is used to clear up a subject the author is unsure about and progress from there. The setting is a possible weakness because there are many variables that may make a person nervous which can cause a person to forget items that may be relevant to the study. Since there is not enough information on the setting, I am not able to draw a conclusion.