Downloaded on 10 13 2016. Single-user license only. Copyright 2016 by the Oncology Nursing Society. For permission to post online, reprint, adapt, or reuse, please email pubpermissions@ons.org © Oncology Nursing Society. Unauthorized reproduction, in part or in whole, is strictly prohibited. For permission to photocopy, post online, reprint, adapt, or otherwise reuse any or all content from this article, e-mail pubpermissions@ons.org. To purchase high-quality reprints, e-mail reprints@ons.org. Journal Club Article See page 49 for suggested questions to begin discussion in your journal club. A Randomized, Clinical Trial of Education or Motivational-Interviewing–Based Coaching Compared to Usual Care to Improve Cancer Pain Management Mary Laudon Thomas, RN, MS, AOCN®, Janette E. Elliott, RN-BC, MS, AOCN®, Stephen M. Rao, PhD, Kathleen F. Fahey, RN, MS, CNS, Steven M. Paul, PhD, and Christine Miaskowski, RN, PhD, FAAN D espite important advances in its management, cancer pain remains a significant clinical problem (Apolone et al., 2009; McGuire, 2004; van den Beuken-van Everdingen et al., 2007). In a meta-analysis, cancer pain was found in 64% of patients with metastatic disease, 59% of patients receiving antineoplastic therapy, and 33% of patients who had received curative cancer treatment (van den Beukenvan Everdingen et al., 2007). Cancer pain also has a negative effect on patients’ functional status (Ferreira et al., 2008; Holen, Lydersen, Klepstad, Loge, & Kassa, 2008; Vallerand, Templin, Sasenau, & Riley-Doucet, 2007) and is associated with psychological distress (Cohen et al., 2003; Vallerand, Hasenau, Templin, & Collins-Bohler, 2005). The effect of cancer pain on an individual’s quality of life (QOL) can be significant and extend beyond disturbances in mood and physical function (Burckhardt & Jones, 2005; Dahl, 2004; Fortner et al., 2003). Although advances in pain management can reduce cancer pain for a significant number of patients, numerous clinician, healthcare system, and societal barriers (e.g., knowledge deficits, reimbursement and regulatory constraints, religious or cultural views) contribute to ineffective pain management (Brockopp et al., 1998; Dahl, 2004; Hill, 1993; Sun et al., 2007). Attitudinal barriers held by patients can be a substantive factor in the inadequate treatment of cancer pain (Anderson et al., 2002; Ward et al., 2008). Those attitudinal barriers need to be addressed if cancer pain management is to be improved (Fahey et al., 2008). In a meta-analysis of the benefits of patient-based psychoeducational interventions for cancer pain management, Bennett, Bagnall, and Closs (2009) concluded Oncology Nursing Forum • Vol. 39, No. 1, January 2012 Purpose/Objectives: To test the effectiveness of two interventions compared to usual care in decreasing attitudinal barriers to cancer pain management, decreasing pain intensity, and improving functional status and quality of life (QOL). Design: Randomized clinical trial. Setting: Six outpatient oncology clinics (three Veterans Affairs [VA] facilities, one county hospital, and one community-based practice in California, and one VA clinic in New Jersey) Sample: 318 adults with various types of cancer-related pain. Methods: Patients were randomly assigned to one of three groups: control, standardized education, or coaching. Patients in the education and coaching groups viewed a video and received a pamphlet on managing cancer pain. In addition, patients in the coaching group participated in four telephone sessions with an advanced practice nurse interventionist using motivational interviewing techniques to decrease attitudinal barriers to cancer pain management. Questionnaires were completed at baseline and six weeks after the final telephone calls. Analysis of covariance was used to evaluate for differences in study outcomes among the three groups. Main Research Variables: Pain intensity, pain relief, pain interference, attitudinal barriers, functional status, and QOL. Findings: Attitudinal barrier scores did not change over time among groups. Patients randomized to the coaching group reported significant improvement in their ratings of painrelated interference with function, as well as general health, vitality, and mental health. Conclusions: Although additional evaluation is needed, coaching may be a useful strategy to help patients decrease attitudinal barriers toward cancer pain management and to better manage their cancer pain. Implications for Nursing: By using motivational interviewing techniques, advanced practice oncology nurses can help patients develop an appropriate plan of care to decrease pain and other symptoms. 39 that, compared to usual care, educational interventions improved knowledge and attitudes and reduced average and worst pain intensity scores. However, those interventions had no effect on medication adherence or in reducing pain’s level of interference with daily activities. Bennett et al. (2009) suggested that additional trials are warranted to test different approaches to cancer pain education and to clarify the exact relationships between education and improved patient outcomes. Many psychoeducational intervention studies were conducted in the hospital setting (Chang, Chang, Chiou, Tsou, & Lin, 2002; de Wit et al., 2001; Jahn et al., 2010) or in patients’ homes (Given et al., 2002; Miaskowski et al., 2004), which limited the generalizability of the findings to the outpatient clinic setting. In addition, although they achieved a positive outcome, many of the studies were labor-intensive, which also limited their ability to be implemented in a busy oncology clinic (Given et al., 2002; Miaskowski et al., 2004). Unfortunately, studies using less labor-intensive interventions were not as successful in decreasing cancer pain (Anderson et al., 2002; Oliver, Kravitz, Kaplan, & Meyers, 2001; Syrjala et al., 2008). Coaching is a useful strategy to improve cancer pain management (Kalauokalani, Franks, Oliver, Meyers, & Kravitz, 2007; Miaskowski et al., 2004). Incorporating principles of motivational interviewing into a coaching intervention affords a unique method of exploring personal attitudes, behaviors, and beliefs that can interfere with effective cancer pain management (Fahey et al., 2008; Prochaska & DiClemente, 1984). Change theory, specifically the Transtheoretical Model (Prochaska & DiClemente, 1984), is a useful conceptual framework for coaching. In this model, behavioral change is a function of a person’s state of readiness or motivation to modify a particular behavior. Motivational interviewing is a nonauthoritarian counseling technique that can assist patients in recognizing and resolving ambivalence about making constructive behavioral changes. It matches the patients’ readiness to change and can motivate the patient to move through the stages of the Transtheoretical Model: precontemplation (unaware of need for change), contemplation (thinking about change), preparation (actively considering change), action (engaging in changing behavior), and maintenance (maintaining a changed behavior) (Fahey et al., 2008; Prochaska & DiClemente, 1984). Given the limitations of previous intervention studies, additional research is warranted using approaches that can be implemented in the outpatient setting. Therefore, the purposes of this randomized clinical trial were to test the effectiveness of two interventions compared to usual care in decreasing attitudinal barriers to cancer pain management, decreasing pain intensity, and improving pain relief, functional status, and QOL. The authors hypothesized that the motivational-interviewing–based 40 coaching group would demonstrate greater benefit (i.e., decreasing attitudinal barriers; decreasing pain intensity; and improving pain relief, functional status, and QOL) than either the conventional education or usual care groups. Methods Sample and Settings A convenience sample was obtained by recruiting patients from six outpatient oncology clinics (three Veterans Affairs [VA] facilities, one county hospital, and one community-based practice in California, and one VA clinic in New Jersey). Patients were eligible to participate if they were able to read and understand the English language, had access to a telephone, had a life expectancy longer than six months, and had an average pain intensity score of 2 or higher as measured on a 0–10 scale, with higher scores indicating more pain. Patients were excluded if they had a concurrent cognitive or psychiatric condition or substance abuse problem that would prevent adherence to the protocol, had severe pain unrelated to their cancer, or resided in a setting where the patient could not self-administer pain medication (e.g., nursing home, board and care facility). The study was approved by the institutional review board and research committee at each of the sites. To test the interaction of time (change in scores from pre- to poststudy) by assignment to the three treatment groups (i.e., control, education, or coaching), a sample size of 240 was needed to detect a medium effect (f = 0.25; h2 = 6% of explained variance). As shown in Figure 1, of the 1,911 patients who were screened, 406 were eligible to participate, 322 provided written informed consent, and 289 completed baseline assessments after being randomized to one of three groups. Procedures Prior to beginning participant recruitment, all research team members were trained extensively so that the procedures for enrollment, data collection, and interventions were standardized across all clinic sites. Research associates (RNs or psychology interns) were trained in procedures for evaluating potential participants, approaching them, obtaining consent to participate, and administering the instruments and videotapes. Importantly, the research associates were trained in providing attention-control telephone calls. The nurse interventionist was trained extensively in motivational interviewing and change theory by a cognitive behavioral psychologist and then in procedures related to the specific coaching protocol. Details of this training are described in Fahey et al. (2008). Monthly team meetings were held throughout the study to ensure procedural fidelity was maintained. Vol. 39, No. 1, January 2012 • Oncology Nursing Forum Patients and clinicians at the study sites were blinded to the patient’s group assignment. At the time of enrollment, pa• Did not meet inclusion criteria (n = 1,505) tients completed a demographic • Declined to participate (n = 84) questionnaire, the Karnofsky Performance Status (KPS) scale (Karnofsky & Burchenal, 1949), Stratify (N = 322)a the Brief Pain Inventory (Daut, • Treatment (chemotherapy, radiation therapy, Cleeland, & Flanery, 1983), the or none) Barriers Questionnaire (BQ) • Pain (low, medium, or high) (Ward et al., 1993), the 36-Item Short Form Health Survey (SF36®) (Ware & Sherbourne, 1992), Randomize into groups (N = 318)a and the Functional Assessment of Cancer Therapy–General (FACT-G) (Cella et al., 1993). Control (n = 109) Education (n = 103) Coaching (n = 105) The patients’ medical records were reviewed for disease and treatment information. Completed T1 (n = 104) Completed T1 (n = 94) Completed T1 (n = 91) Patients in the usual care group viewed a video on cancer (American Cancer Society, 1994). PaCompleted coaching tients assigned to the education intervention (n = 74) group viewed a video on managing cancer pain that focused on overcoming attitudinal barriers Completed T2 (n = 88) Completed T2 (n = 75) Completed T2 (n = 64) (Syrjala, Abrams, Du Pen, Niles, a Four patients withdrew before randomization, and one was lost to follow-up before completing T1. & Rupert, 1995) and received the Note. Reasons for lack of completion included being too ill, withdrawing, fatigue, being lost to Agency for Health Care Policy follow-up, death, ineligibility, prolonged hospitalization, protocol violation, or other. and Research (1994) pamphlet Figure 1. Trial Participation at Baseline (T1) and Six Months (T2) entitled, Managing Cancer Pain, Consumer Version, Clinical Practice Guideline Number 9. To simulate the time constraints in many oncology outpatient clinPatients were identified by clinic staff and screened ics, no reinforcement of the material was provided for eligibility by the research associate, who then apunless the patient sought additional information or proached eligible patients, explained the study, and asked questions of the clinic staff. Patients assigned obtained written informed consent. Patients were stratito the coaching group received the same intervention fied based on pain intensity (i.e., low, medium, or high) as those assigned to the education group. In addition, and cancer treatment (i.e., chemotherapy or radiation they participated in four 30-minute telephone sessions therapy) to control for the confounding variables of pain that explored beliefs about pain, use of analgesics and intensity and the effects of cancer treatment. Stratifying nonpharmacologic pain management strategies, and by pain intensity accounts for the curvilinear relationcommunication about pain management. Those four ship between pain severity and functional status (e.g., calls were conducted about every other week over a changes in pain intensity at the upper levels of the scale six-week time period by the nurse interventionist, a have a different effect on functional status compared to clinical nurse specialist trained in motivational interchanges at the lower levels of the scale). Stratification viewing techniques. For a detailed description of the by cancer therapy was used to control for the effect of coaching intervention, see Fahey et al. (2008). Patients treatment in either decreasing pain from shrinking the assigned to the usual care and education groups also tumor or increasing pain because of toxicity of treatreceived four telephone calls (about every other week ment. Patients at each clinic site then were randomized over a six-week time period) from the research asbased on the stratification criteria using permuted sistance for attention-control purposes. Six weeks blocks with variable sizes into one of three groups: usual after the final telephone call (i.e., 12 weeks postrancare (control), education, or coaching. This method of domization), all patients completed the same quesrandomization was used to ensure balance across the tionnaires that were done at enrollment. Participants treatment groups within each stratification cell. Assessed for eligibility (N = 1,911) Oncology Nursing Forum • Vol. 39, No. 1, January 2012 41 received a $25 gift certificate after completing each set of questionnaires. The BQ has demonstrated adequate validity and reliability (Ward et al., 1993; Ward & Gatwood, 1994). Pain was assessed with the Brief Pain Inventory, a self-report instrument designed to assess the intensity and quality of pain, the extent to which pain relief was obtained, and the extent to which pain interferes with function (Daut et al., 1983). Severity and interference are rated on a numeric score from 0 (does not interfere) to 10 (completely interferes). A mean interference score was calculated (Serlin, Mendoza, Nakamura, & Cleeland, 1995), with higher scores reflecting greater pain intensity and greater interference with function. Functional status was measured with the SF-36 (Ware & Sherbourne, 1992). Eight health concepts Instruments Attitudinal barriers were assessed with the BQ (Ward et al., 1993; Ward & Gatwood, 1994), a 27-item instrument that measures eight barriers to cancer pain management (concern about side effects, concern about tolerance, fear of addiction, fatalism, fear of disease progression, desire to be a good patient, fear of injections, and concern about distracting the physician from curing disease). Each item is rated on a scale from 0 (not at all agree) to 5 (agree very much). Mean subscale and total scores were calculated for the BQ, with higher scores reflecting stronger barriers. Table 1. Demographic and Clinical Characteristics by Study Group Characteristic Age (years) Education (years) Time since diagnosis (months) Karnofsky Performance Status scorec Characteristic Gender Male Female Ethnicity African American Caucasian Latino Other Marital status Married or partnered Widowed, divorced, or separated Never married Living arrangements Alone With family or friends Other Employment Full- or part-time Disability, leave of absence, or retired Unemployed Other Cancer diagnosis Breast Colon Head and neck Lung Myeloma Prostate Other (mixed types) Control (N = 88)a Education (N = 75)b Coaching (N = 64) — — — X SD X SD X SD Statistics 58.7 13.8 31.9 76.6 11.5 2.7 52.7 12.5 62.5 12.8 37.5 72.3 11.2 2.6 45 12.7 61.8 13.1 30 77.6 11.3 3.2 42.5 13.2 F(2, 223) = 2.54, p = 0.08 F(2, 222) = 2.57, p = 0.08 F(2, 222) = 0.48, p = 0.62 F(2, 222) = 3.53, p = 0.03* n % n % n % Statistics 79 9 90 10 71 4 95 5 54 10 84 16 21 48 6 11 24 56 7 13 15 44 8 7 20 60 11 10 7 44 7 6 11 69 11 9 40 33 15 46 38 17 37 23 14 50 31 19 33 27 4 52 42 6 23 55 10 26 63 11 12 57 6 16 76 8 15 47 2 23 73 3 10 54 18 4 12 63 21 5 4 57 11 2 5 77 15 3 5 48 10 1 8 75 16 2 5 6 12 21 6 12 26 6 7 14 24 7 14 30 3 2 7 14 5 16 28 4 3 9 19 7 21 37 8 4 6 9 6 11 20 13 6 9 14 9 17 31 c2 = 4; p = 0.13 c2 = 13.4, p = 0.65 c2 = 8.3, p = 0.61 c2 = 6.4, p = 0.38 c2 = 10.1, p = 0.61 c2 = 45.7, p = 0.72 * Education < coaching, p < 0.05 a Because patients could refuse to complete items, N = 86 for ethnicity and employment. b Because patients could refuse to complete items, N = 74 for ethnicity, marital status, and employment. c Scores indicate functional status on a 0–100 scale, with higher scores reflecting higher function. Note. Because of rounding, not all percentages total 100. 42 Vol. 39, No. 1, January 2012 • Oncology Nursing Forum Of the 289 patients who enrolled, 227 completed the end-of-study evaluation. The length of time from cancer diagnosis to study enrollment averaged 30–38 months. The most common cancer types were lung, prostate, and head and neck. Most patients were men and middleaged, and about half of the sample was married or partnered. No differences were found among the three groups on any demographic or clinical characteristic except KPS score. Patients in the education group reported significantly lower KPS scores than patients in the coaching group (p = 0.03) (see Table 1). Instrument Scores Barrier Questionnaire: Barrier subscale scores were modest in all three groups, with concerns about addiction and disease progression rated higher than those related to fatalism or the need to be a “good patient” (data not shown). However, after controlling for each of the BQ scores at baseline, no differences were found among the three groups in any of the subscale or total BQ scores. Pain intensity, interference, and relief: After controlling for average pain at baseline, no differences were found among the three groups in average pain intensity scores at the end of the study (p = 0.08) (see Figure 2). Similarly, nonsignificant scores were found among the three groups in worst pain intensity scores (data not shown). However, significant differences were found among the three groups in mean pain interference scores at the end of the study (p = 0.01) (see Figure 3). Post-hoc Average Pain Intensity 7 6 5 s 4 s 3 2 1 0 Baseline Control End of Study s s Oncology Nursing Forum • Vol. 39, No. 1, January 2012 Sample s Differences in demographic and clinical characteristics among the three groups were evaluated using analyses of variance and chi-square tests. Analyses of covariance were performed to evaluate for differences in scores on average and worst pain intensity, pain relief, mean pain interference, the BQ, the SF-36, and the FACT-G among the three patient groups. That procedure allows for the evaluation of the end-of-study outcomes while controlling for those same outcomes at baseline. The examination of differences among groups in end-of-study outcomes, with baseline measurements of those outcomes covaried out, often is a preferred method for examining changes in outcome measures from the beginning to the end of a study (Cohen, 1988). All calculations used actual values. Adjustments were not made for missing data; therefore, the cohort for each analysis was dependent on the largest set of data across groups. If the overall analysis of covariance for a particular outcome indicated differences among the three groups, pairwise contrasts were conducted to determine the location of the difference. The Bonferroni procedure was used to distribute a family alpha Results ss Data Analysis of 0.05 across the three pairwise contrasts. All p values have been adjusted so that values lower than 0.05 are considered statistically significant. s were assessed (physical functioning, role limitations because of physical health problems, bodily pain, social functioning, role limitations because of emotional health problems, general mental health, vitality, and perception of general health). In addition, physical and mental component summary scores are obtained by combining scores related to physical and mental functioning, respectively. For each scale, scores are reversed (as needed so that higher scores reflect better health states), summed, and linearly transformed on a 0–100 scale, with higher scores reflecting higher functioning. The SF-36 has been used extensively and has wellestablished validity and reliability (Given, Given, Azzouz, Stommel, & Kozachick, 2000; McHorney, Ware, & Raczek, 1993; Miaskowski et al., 2007; Thong, Mols, Coebergh, Roukema, & van de Poll-Franse, 2009). QOL was measured with the FACT-G (Cella et al., 1993). Four QOL domains (physical, social, emotional, and functional well-being) are measured. Patients were asked to rate the extent to which they agreed with each item using a five-point Likert-type scale that ranged from 0 (not at all) to 4 (very much). Scores for items within each subscale are summed to obtain a subscale score, and all of the individual items are summed to obtain a total score, which can range from 0–112. The FACT-G has been used in numerous studies of patients with cancer (Elting et al., 2008; Wittmann, Vollmer, Schweiger, & Hiddemann, 2006; Zimmerman et al., 2010) and specifically in studies of patients with cancer-related pain (Chang, Hwang, & Kasimis, 2002; Harris et al., 2009). The FACT-G has well-established validity and reliability (Cella et al., 1993). Education s Coaching Note. F = 2.58; p = 0.08 Figure 2. Changes Over Time in Average Pain Intensity Scores by Patient Group 43 40 s s ss 30 s — 50 s X Pain Interference Scorea 60 20 Discussion 10 0 Baseline End of Study 100 s s s Baseline End of Study s s s Pain Relief (%)b 80 60 40 20 0 s s Control Education s Coaching F = 4.53, p = 0.01; coaching > control, p = 0.02; coaching > education, p = 0.03 b F = 2.63, p = 0.07 Note. All values are plotted as means and standard deviations of the mean. a Figure 3. Changes Over Time in Mean Pain Interference and Pain Relief Scores by Group contrasts demonstrated that the coaching group had lower mean pain interference scores at the end of the study compared to the education and control groups (p = 0.03 and 0.02, respectively). After controlling for baseline pain relief scores, no significant differences were found among the three groups in the percentage of pain relief (p = 0.07) at the end of the study. Short-Form Health Survey: Table 2 lists the pre- and post-study SF-36 subscale and component scores for the three groups. After controlling for each of the baseline SF-36 subscale and component scores, no significant differences were found among the groups in social functioning, physical or emotional role functioning, bodily pain, or physical component scores. However, after controlling for each of the subscale scores at baseline, significant differences were found among the groups in general health, vitality, mental health, and the mental component summary score. Post-hoc contrasts demonstrated that the coaching group had higher mental health component scores compared to the control group. All other post-hoc comparisons were not significant. 44 Functional Assessment of Cancer Therapy–General: Table 3 lists the pre- and post-study subscale and total QOL scores for the three groups. Scores for all four subscales remained stable over time. After controlling for each of the FACT-G scores at baseline, no significant differences were found among the groups on any of the subscale or total scores. Educational interventions have demonstrated positive outcomes in decreasing cancer pain (Clotfelter, 1999; Dalton, Keefe, Carlson, & Youngblood, 2004; de Wit et al., 2001; Syrjala et al., 2008; Ward et al., 2008; Yates et al., 2004). Coaching has been tested less frequently as a pain management intervention, but it resulted in positive outcomes in three studies (Kalauokalani et al., 2007; Miaskowski et al., 2004; Oliver et al., 2001). Although successful, the labor-intensive nature of those interventions may limit their use in clinical practice. The current study tested the effects of two interventions (standardized education and coaching) that were feasible for implementation in an outpatient oncology clinic setting. The coaching intervention was designed to afford flexibility for both the patient and the nurse interventionist to enhance its utility in clinical practice. Patients assigned to the coaching group reported a statistically significant decrease in pain’s interference with function and improved ratings of vitality, mental health, and general health. Compared to standardized education, coaching also was associated with clinical improvements in cancer pain management (i.e., decreased cancer pain intensity and improvement or stability in functional status and quality of life). However, most of the improvements were not statistically significant. Several possible explanations exist for the lack of statistical significance for most of the outcome measures. The current study was unique in that the coaching intervention used principles of motivational interviewing and was based on the Transtheoretical Model of change theory. Those basic principles involve addressing issues of greatest importance from the patient’s perspective and assessing the individual’s readiness to change a particular behavior. Some patients in the coaching group exhibited persistent reluctance to consider changing a given attitude or behavior that might result in improving their cancer pain management. More commonly, the issue of priorities had a significant effect on the nurse interventionist’s ability to address attitudinal barriers that might affect cancer pain management. Cancer pain does not exist in a vacuum. Other issues, related—or not—to cancer and its treatment, often were more pressing from the patient’s perspective. True to the theoretical underpinnings of the intervention, the nurse interventionist, in turn, focused on those more pressing issues. That adaptation posed challenges in adhering to the attitudinal content within the Vol. 39, No. 1, January 2012 • Oncology Nursing Forum study design was modified at the request of the peer reviewers to delay the post-test to six weeks after the coaching intervention was completed. In hindsight, anStatistics other measurement should have F = 1.179, p = 0.309 been made immediately after the coaching intervention was completed (six weeks after baseF = 2.817, p = 0.062 line), with a third measurement at 12 weeks after baseline. The F = 4.249, p = 0.015a additional measurement would have allowed for an assessment F = 3.963, p = 0.02b of the immediate effects of the intervention, particularly with patients who were able to comF = 3.207, p = 0.042c plete the intervention, but died or were too ill to complete the F = 3.397, p = 0.035d questionnaires at 12 weeks. If a more significant effect was seen immediately after completing the intervention, but was not sustained, an argument could then be made for providing some brief ongoing sessions to reinforce the coaching intervention. In isolation, a behavioral intervention to decrease cancer pain likely will demonstrate a small effect size. Therefore, the lack of statistical significance may simply be a reflection of inadequate sample size. The sample size also was affected by a high attrition rate (30% of those who enrolled to participate), often because of death or disease progression, which could have contributed to the lack of statistical significance in many of the outcome Table 2. Short-Form Health Survey Scores by Study Group Control (N = 88) Subscale Physical functioning Prestudy Post-study Body pain Prestudy Post-study General health Prestudy Post-study Vitality Prestudy Post-study Mental health Prestudy Post-study Mental component Prestudy Post-study — X SD 42.4 37.3 Education (N = 75) — X SD 25.4 23.7 40.3 35 36.9 37.4 19 21.3 41.7 40.4 Coaching (N = 64) — X SD 27.4 25.3 43.5 42.2 27.9 29.2 32.5 38.4 16.2 23.4 33.9 43.2 20.6 21.8 21.5 22.9 41.4 35.3 19.3 18.2 47.8 47.4 23.6 24.3 34.7 32 18.9 19.7 35.5 30 20.8 19.5 37.1 39.3 21.2 22.7 64 63.6 20.6 19.3 62.3 62 21.2 22 66.3 70.8 19.4 20.4 42.5 41 11.9 12.1 41.6 41.1 12.6 12.5 43.3 45.7 11.8 12.1 Coaching > education, p = 0.016 Coaching > education, p = 0.02 c Coaching > control, p = 0.089; coaching > education, p = 0.07 d Coaching > control, p = 0.043 a b coaching protocol, but addressed the unique needs presented by the patient. Although the variation was viewed very positively by patients in their study exit interview, its effect on decreasing cancer pain likely was reduced. Similarly, the researchers had difficulty maintaining the attention-control telephone calls for their intended purpose (i.e., to control for the attention received by those in the coaching group). A substantial number of patients (assigned to either the education or control groups) voiced significant problems or Table 3. Functional Assessment of Cancer Therapy–General Scores concerns to the research associate by Study Group during those calls, which required Control Education Coaching the research associate to notify (N = 88) (N = 75) (N = 64) the patients’ clinicians. Although — — — X SD X SD X SD Statistics such notification was important Subscale from a clinical and ethical stand- Physical well-being F = 1.373, p = 0.26 point, the patients did not seek Prestudy 15.5 6.1 15.2 5.8 16.9 5.5 Post-study 15.7 5.7 15.5 6.1 17.6 6.2 intervention on their own, but F = 0.465, p = 0.63 rather waited for support and as- Social well-being Prestudy 19 6.3 20.2 6.1 21.1 5.4 sistance from the research associPost-study 19 6.4 19.3 6.3 20.5 6.1 ate beyond that offered from the Emotional well-being F = 2.41, p = 0.09 attention control design, which Prestudy 16.7 5.3 16.7 4.7 16.5 5.6 Post-study 16.8 4.9 16.2 5.3 17.6 5.3 may have blunted the effects of Functional well-being F = 1.382, p = 0.25 the coaching intervention. Prestudy 12.4 5.3 12.9 5.7 14.1 6.1 Another possible explanation Post-study 12.8 5.7 12.3 5.8 14.4 6.4 for the current findings is that Total score F = 2.164, p = 0.12 the coaching intervention yieldPrestudy 63.6 15.6 65.1 16.9 68.8 15.9 Post-study 64.4 16.3 63.3 17.5 70.5 17.3 ed a positive benefit, but the benefit was not sustainable. The Oncology Nursing Forum • Vol. 39, No. 1, January 2012 45 measures. In addition, more patients assigned to the coaching group were unable to complete the end-ofstudy measures. Another possible explanation for the lack of statistical significance on many of the outcome measures is that the instruments used were not sensitive enough to detect change. As a group, the sample scored low on each barrier subscale and total score; the scores were similar to those reported in other studies (Ward et al., 2008). Although participants in the coaching group achieved an improvement in each subscale (except fear of injections) that was greater than the improvement in the other two groups, the differences were not significant. Given the low baseline scores and smaller number of patients assigned to the coaching group, the ability to improve those scores would be extremely difficult. More importantly, during the coaching telephone calls, unique barriers were identified by the patients and discussed that were not always reflected in the scores on the BQ (Fahey et al., 2008). The strength of such beliefs or barriers may be so great that four coaching calls may have been inadequate to overcome that enduring attitude. In addition, motivational interviewing is based on change theory, in which an individual’s readiness to change behavior is crucial to the success of a behavioral intervention (Prochaska & DiClemente, 1984). The current study did not assess, nor stratify for, an individual’s readiness to change a priori, which also could be a contributing factor to those findings. At baseline, the FACT-G subscale and total scores in the current study were markedly lower than in the general population, particularly the physical and functional well-being subscale scores (Holzner et al., 2004). Similarly, functional well-being scores were lower than those previously reported by patients with cancer (Burckhardt & Jones, 2005; Sherman, Simonton, Latif, Plante, & Anaissie, 2009). However, baseline scores for all FACT-G subscales were similar to those obtained in another study of U.S. Veterans with cancer pain (Chang et al., 2002). QOL scores did not change substantially over time in any group, which suggests that cancer pain was not a significant factor in the QOL of those patients. An alternative explanation is that the stability of scores may reflect the inability of the FACT-G to detect subtle changes in QOL. Niv and Kreitler (2001) acknowledge that pain can be an important factor in one’s QOL, but also suggested that it may not always be the most important. Therefore, focusing solely on managing pain may not necessarily have a significant effect on QOL. This view was substantiated in the coaching group, in which other issues that affected the patient’s QOL often took precedence over cancer pain (e.g., those related to cancer treatment, family, or economic hardship). The SF-36 scores reported by patients in the current study were lower than those reported by the general 46 U.S. population (Miaskowski et al., 2007; Wensing, Vingerhoets, & Grol, 2001) and other samples of patients with cancer (Boini, Briançon, Guillemin, Galan, & Hercberg, 2004; Miaskowski et al., 2007; Mols, Coebergh, & van de Poll-Franse, 2007; Wensing et al., 2001). Perhaps reflective of the supportive and alliance-building nature of the intervention, scores related to mental health, mental component summary score, and even vitality and social function improved from baseline in the coaching group. In contrast, those scores declined in the other two groups. As expected, physical functioning and general health declined over time in the control and education groups, yet surprisingly remained stable in the coaching group. Although bodily pain scores improved in the coaching group (p = 0.06), attempts to improve cancer pain management are unlikely to fully explain all of those differences. However, the improvement may better reflect the nurse interventionist’s willingness to adapt to more pressing issues facing the patient during the coaching telephone calls. That action is consistent with motivational interviewing, but not captured by standardized instruments. Finally, the current study was not designed to alter the amount and types of analgesics prescribed. The types and amount of opioids prescribed and taken varied widely among referral sites (Thomas, Annis, & Hwang, 2004). Interestingly, in this subanalysis, the amount of opioids prescribed or taken did not appear to affect pain intensity ratings, pain relief, or satisfaction with pain management. Although interventions that focus on medication use alone also have not been consistently effective in controlling cancer pain, integrating pharmacologic interventions with cognitive-behavioral interventions might produce results that are more significant. This study highlights the challenges of testing interventions that focus on clinical processes regarding provider advice, communication, and education in a severely ill patient population. Those clinical processes often are complex, and several interacting components may account for the outcomes. As a result, the authors encourage the use of design methodologies and outcome measures that address the complexities of clinical translational studies and use of nonpharmacologic interventions. Future studies should compare a coaching intervention with different types of controls to ensure that the specific effect of the intervention can be better distinguished from those of other controlled factors, such as time, attention, motivation, expectations, and experience (Bennett, 2010; Bennett et al., 2009). Conclusions and Implications for Nursing Practice Findings from the current study did not support the use of mass-produced educational materials as an Vol. 39, No. 1, January 2012 • Oncology Nursing Forum effective means of managing cancer pain. However, in the busy clinic setting, too often this approach is all a patient with cancer in pain may receive. Symptoms including cancer pain may not be carefully assessed, nor interventions carefully selected, implemented, and discussed. Advanced practice nurses (APNs) provide comprehensive assessments of symptoms and problems faced by patients with cancer. Using motivational interviewing, APNs and patients can jointly develop an appropriate plan of care to decrease those symptoms. Motivational interviewing is a skill that can be mastered by an APN with sufficient training. In working with patients over time, the use of motivational interviewing can yield positive outcomes that extend beyond traditional cancer pain management. Indeed, the use of motivational interviewing is becoming more popular as a mechanism to increase patient adherence with medical treatment. Cancer pain management needs to be addressed from an integrated biopsychosocial approach (e.g., pharmacologic, cognitive, behavioral, motivational, educational) for its effectiveness to be achieved fully. The authors gratefully acknowledge Marilyn (Marty) Douglas, DNSc, RN, FAAN, who was coprincipal investigator of this study. They also gratefully acknowledge the time and commitment on the part of the patients who participated in this study. Mary Laudon Thomas, RN, MS, AOCN®, is a hematology clinical nurse specialist and Janette E. Elliott, RN-BC, MS, AOCN®, is a pain management clinical nurse specialist, both at the Veterans Administration Palo Alto Healthcare System in California; Stephen M. Rao, PhD, is the health behavior coordinator and director of the Training Psychology Postdoctoral Fellowship Program at the San Francisco Veterans Administration Healthcare System in California; Kathleen F. Fahey, RN, MS, CNS, is the palliative care coordinator at El Camino Hospital in Mountain View, CA; and Steven M. Paul, PhD, is the principal statistician and Christine Miaskowski, RN, PhD, FAAN, is a professor and associate dean for Academic Affairs, both in the Department of Nursing at the University of California, San Francisco. This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (Project Number NRI-97026). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Thomas can be reached at mary.thomas4@va.gov, with copy to editor at ONFEditor@ons.org. (Submitted July 2010. Accepted for publication May 17, 2011.) Digital Object Identifier: 10.1188/12.ONF.39-49 References Agency for Health Care Policy and Research. (1994). Managing cancer pain, consumer version, clinical practice guideline number 9. Rockville, MD: U.S. Department of Health and Human Services. American Cancer Society. (1994). The cancer experience: Living with treatment [Videotape]. Atlanta, GA: American Cancer Society. Anderson, K.O., Richman, S.P., Hurley, J., Palos, G., Valero, V., Mendoza, T.R., . . . Cleeland, C.S. (2002). 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Wittmann, M., Vollmer, T., Schweiger, C., & Hiddemann, W. (2006). Vol. 39, No. 1, January 2012 • Oncology Nursing Forum The relation between the experience of time and psychological distress in patients with hematological malignancies. Palliative and Supportive Care, 4, 357–363. doi:10.1017/S1478951506060469 Yates, P., Edward, H., Nash, R., Aranda, S., Purdie, D., Najman, J., . . . Walsh, A. (2004). A randomized controlled trial of a nurseadministered educational intervention for improving cancer pain management in ambulatory settings. Patient Education and Counseling, 53, 227–237. doi:10.1016/S0738-3991(03)00165-4 Zimmerman, C., Burman, D., Swami, N., Krzyzanowska, M.K., Leighl, N., Moore, M., . . . Tannock, I. (2010). Determinants of quality of life in patients with advanced cancer. Supportive Care in Cancer, 19, 621–629. doi:10.1007/s00520-010-0866-1 For Further Exploration Use This Article in Your Next Journal Club Meeting Journal club programs can help to increase your ability to evaluate the literature and translate those research findings to clinical practice, education, administration, and research. Use the following questions to start the discussion at your next journal club meeting. At the end of the meeting, take time to recap the discussion and make plans to follow through with suggested strategies. 1. 2. 3. 4. What is motivational interviewing? How does motivational interviewing differ from counseling? What is the purpose of having a control group? What was the intervention for the control group? What is stratification and why was it important to stratify participants in this study based on (a) pain and (b) cancer therapy? 5. In the discussion section of the article, the authors state, “Cancer pain does not exist in a vacuum.” What do you think this means? How does this concept affect the efforts of the nurse to manage cancer pain? 6. In our practice, what types of nonpharmacologic resources do we provide to help patients manage cancer pain? Do you feel these resources are effective? Why or why not? Visit www.ons.org/Publications/VJC for details on creating and participating in a journal club. Photocopying of this article for discussion purposes is permitted. Oncology Nursing Forum • Vol. 39, No. 1, January 2012 49 Running head: RESEARCH CRITIQUE 1 Research Critique SAMPLE 1 Stratford University RESEARCH CRITIQUE 2 One of the obligation as a nurse is to use current best practice when caring for patients. The nurse must be able to correctly appraise the research in order to confirm its dependability. In order to verify the evidence-based practice, the study needs to be evaluated in varying degrees. The article “Extending the Continuum of Care in Congestive Heart Failure” was written by Austin, Landis, and Hanger and was published in the Journal of Nursing Administration in 2012. This paper will appraise the writing style, author, title, purpose of the study, logical consistency, literature review, theoretical framework, research question, sample, ethics, operational definitions, methodology, analysis, results, and recommendations for the future study. The study investigated the effect of an interactive voice response system (IVRS) and clinical monitoring messages in patient’s self-management skill and its relationship with the readmission rate in congestive heart failure (CHF) patients. Participants received IVRS messages regarding self-management skills and were asked to answer a set of questions using a telephone keypad. Participants who gained two pounds all contacted their physicians. This finding indicated success in self-management. The readmission rate was reduced by fifty percent compared to Roper hospital’s baseline heart failure patients. Currently, due to Hospital Readmissions Reduction Program, the hospitals are now penalized when the readmission rates exceed the national benchmarks (Austin, Landis, & Hanger, 2012). Thus, the effective selfmonitoring system is needed. The future research proposal will use this particular article in answering the following clinical PICOT question: In older adult patients who have heart failure, how does having a stand-alone integrated telemonitoring system compared to interactive voice response system (IVRS) influence the rate of patient's readmissions over 6 months? Overall, the article was well organized and written clearly to target a specific audience. Austin et al. (2012) titled their research “Extending the Continuum of Care in Congestive Heart RESEARCH CRITIQUE 3 Failure: An Interactive Technology Self-management Solution”. Although it was quite long, it was clear and accurate which enabled the audience to understand the main idea of the study. However, the term ‘interactive technology’ or “IVRS’ was not clearly identified. Readers might not be able to recognize that the IVRS was later called ListenUP! For health. When the operational definitions are provided, it can enhance an audience’s understanding. Unfortunately, the study does not clearly define any of the terms used. In order to investigate reliability, each author was searched using Google. By visiting the actual website, it was found that Dr. Austin was, in fact, the CEO of AudiaHealth. Her involvement introduced bias and decreased intervention fidelity. She was a threat to the internal validity. The fact that the article only mentioned her as an employer by AudiaHealth raised a concern of trustworthiness of the study. On the other hand, the study was laid out in a logical manner by providing an abstract, followed by research background, patient selection, study design, results, discussion, and conclusion. These sequence of research process allowed the article to flow naturally. In the beginning of the article, the authors clearly provided the purpose of the study. They used the terms such as ‘tested’, ‘goal’, and ‘to determine’ to allow readers to clearly identify their aim of the study (Austin et al., 2012). Authors described the objective of their study in the abstract and also incorporated them into the introduction section. However, because the research hypothesis was not clearly stated, it can cause confusion. The literature review section was omitted in the article. A literature review can strengthen the research article by providing gaps in the literature, supporting the research question, and identifying the appropriateness of the methodology and data collection (Coughlan, Cronin, & Ryan, 2007). Some authors incorporate the literature review into the introduction but it was not presented in the introduction. The possible explanation could be due to lack of research being RESEARCH CRITIQUE 4 done on telehealth. Also, this study was a pilot program. Without the literature review, the article failed to “demonstrate an appropriate depth and breadth of reading around the topic in question” (Coughlan et al., 2007, p. 660). Since other studies were not evaluated through the process of the literature review, the finding cannot be compared with other studies. Due to the absence of the literature review, the article lacked some historical context and made it hard for readers to visualize the study. Although the authors did not reference primary or secondary sources, they did provide evidence of previous studies on interactive technology used in self-management. They described the importance of patient compliance in reducing readmissions within the introduction section of the article. The conceptual framework was not clearly stated in the article. The authors did not link any theory that correlates with their study. There could have been a restriction on the length of the article. Upon a brief search in the CINAHL database, the social cognitive theory appeared to support the authors’ finding which implied that an increase in selfefficacy can enhance patient’s transition and self-care (Bandura, 1997). From the total population of hundred twenty-four patients, sixty patients were targeted at Roger Hospital. All participants were diagnosed with CHF and purposively selected by the unit charge nurse, physician, and cardiologist to identify their qualification. The study started with a total of seventy-two participants but twelve were lost after the discharge. When there is a small sample size, the risk of sampling errors increase. The exclusion criteria for the study were clearly stated and included diagnosis of dementia and participant who lives in assisted-living facilities. Inclusion criteria included a primary diagnosis of CHF and possession of a telephone. Because participants were selected by the researchers, it is considered non-probability sampling. Thus, the findings lacked generalizability. The article could have been stronger if the samples were collected in different locations. The ethical consideration was hard to determine because how the RESEARCH CRITIQUE 5 participants were informed about the research was excluded. Key ethical principles such as autonomy and confidentiality need to be clearly identified in a research study. The article failed to mention anything about patient harm, the principle of beneficence, HIPPA, and permission from Ethics Service. The information about informed consent was missing from the article. Thus, it was hard to note whether the participants’ confidentiality was guaranteed or not. The research study itself was a pilot program and the research design was not clearly outlined. Even though the article had its own research design section, the type of research design was not made explicit in the article. By looking at the result, readers could assume that this was quantitative research. They provided a figure to demonstrate their research design but it was uncertain which type of quantitative study was used. Based on the article, it was most likely a quasi-experimental design except participants were not randomly selected. The data was collected daily in a remote location. According to the study, the set of clinical questions were answered via telephone key pads and the data were stored electronically by ListenUP! For health user interface (Austin et al., 2012). Then, the clinical staff reviewed the responses on a daily basis. Within the method section, the authors did not fully describe the process of data collection. Austin et al. (2012) provide what instruments were used within the study design section. In order to verify the reliability and validity of the instrument used in their research, a brief search on ‘ListenUP! For health’ was conducted in ProQuest which revealed forty seven results. However, only one article was about this particular program. Thus, an additional search was undertaken of the term ‘audiahealth’ which revealed twelve results. However, only one article discussed this particular instrument and that information cannot be verified either because it was not a peer-reviewed article. Also, the whole article consisted of the inventors quote regarding the program. In addition, this study was a pilot program, where the design of the instrument was first RESEARCH CRITIQUE 6 introduced. Thus, validity and reliability of the instrument cannot be confirmed. Further study is needed to ensure the validity and reliability of the findings. The authors forgot to mention how the results were collected. In the results section of the study, the authors did not clearly describe the analysis process. However, they discussed the significance of the findings. They stated that the readmission rate was 10 percent which was lower compared to Roper baseline CHF readmission rate, which was twenty one percent (Austin et al., 2012). In the results section, the authors mentioned twelve participants lost during the research process. Also, they analyzed different races and the average age. Austin et al. (2012) reported that self-management skills were developed by IVRS as evidenced by the fifty percent reduction in readmission rates. Also, they boasted that all participants who gained more than two pounds were successful in calling their provider. They argued that these results support the effectiveness of IVRS in a development of self-management skill which was critical in reducing the number of readmission rate. The article discussed the limitations at the end. One of the limitations the authors mentioned was the process of patient selection. They said that some patients were suffering from a variety of diagnoses and this could have influenced the results. Also, the study did not use a randomized controlled group. In addition, the results were only compared against the Roper Hospital baseline for readmission rate. For future studies the authors recommended performing a randomized trial in order to investigate whether their positive results were due to selection bias (Austin et al., 2012). While the authors did not specify the strength of their research, they concluded that the objective of the study was adequately addressed. They described how an inexpensive IVRS can help in reducing the readmission rate by improving self-management skill in CHF patients. In the references section, every article and books used in the article were accurately stated. RESEARCH CRITIQUE 7 Reference Austin, L., Landis, C., & Hanger, K. (2012). Extending the continuum of care in congestive heart failure: An interactive technology self-management solution. The Journal of Nursing Administration, 42(9), 442-6. Bandura, A. (1997). Self-efficacy: the exercise of control. 1997, W.H. Freeman, New York. Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research. Part 1: Quantitative research. British Journal Of Nursing, 16(11), 658-663 6p. Running head: CRITIQUE 1 Critique SAMPLE 2 Stratford University CRITIQUE 2 According to Alfes (2011), advancements in technology of healthcare are impacting the way nursing education is being designed, delivered and evaluated (Alfes, 2011, p.89). The expectation is for new nurses to transition into clinical practice as quickly as possible. New nursing graduates are faced with several challenges as they enter clinical practice. One of the major challenges include the inability to apply skills attained in a classroom setting into clinical practice. For this reason, this writer wants to explore interventions that can be implemented throughout nursing school to better prepare nurses in transitioning to clinical practice. The article “Evaluating the use of simulation with beginning nursing students” written by Alfes (2011), seeks to address the effectiveness of simulation as compared to traditional learning methods. This paper will analyze the purpose, conceptual framework, literature review, methodology, limitations, results, and validity of this research study. The study compared the use of simulation at the beginning level of nursing programs versus the traditional method of learning. First semester baccalaureate nursing students were divided into two groups. One group used simulation and the second group used the traditional learning methods. These two teaching methods were compared in regards to their impact on level of self-confidence and learning satisfaction. The levels of self-confidence and learning satisfaction were found to be higher with the nursing students that were involved in simulation style learning. The findings of this article can be used as an intervention to enhance the process of future research on evaluating the effectiveness of simulation lab. The findings from this article can be used to support one aspect of the following clinical question: Does implementing simulation lab in undergraduate nursing programs improve nurse competency and preparedness for clinical practice compared to new graduate nurse residency programs within a year? CRITIQUE 3 The title of this study is appropriate and congruent with the content of the research study. The title clearly identified the key variable, the use of simulation, as well as the population, which was beginning nursing students. The abstract clearly summarized the purpose, methods, sample size and conclusion of the research. In the introduction, the author clearly identified the purpose of the study. The author acknowledged that while previous studies have documented the effectiveness of simulation use for advanced clinical skills in more advanced level students, not enough research has been conducted to test the effectiveness of simulation when implemented at the beginning of the nursing curriculum (Alfes, 2011, p.89). The purpose of the research was clearly stated as such “to compare the effectiveness of using simulation versus a traditional learning method to promote self-confidence and satisfaction with learning among beginning nursing students learning effective comfort measures” (Alfes, 2011,p.89). The purpose was imperative to the research study. It served as a guide to readers. There were four different research questions mentioned by the author. The independent and dependent variables are clearly stated. The beginning nursing students were the independent variables. Self-confidence and learning satisfaction were the dependent variables. There was no hypothesis stated as the purpose of the study was to compare different to interventions for effectiveness. The author clearly states this research study was quasi-experimental. The conceptual framework used in this research study was Kolb’s experiential learning theory. Kolb’s theory was appropriate for this research. The research aligned with one of the stages of Kolb’s experiential learning. Kolb’s active experimentation stage identified simulation as a way for learners to translate knowledge attained into practice. The author successfully supported the applicability of kolbs theory to the research study by citing primary sources. According to Alfes, Kolb’s theory advocates for instructional programs that develops all types of CRITIQUE 4 learners through different range of learning experiences in a variety of learning environments ( Alfes, 2011, p.89). The literature review was extensive and comprehensive. It allowed the reader to understand the study. The literature review provided support through primary sources that simulation based learning was effective and also identified a gap in the study. It is also noted that the best outcome was evident when simulation based learning was implemented in the beginning of the nursing curriculum to the end. The reviewed literature mainly consisted of research published within ten years from the publication year of study. In methodology, the author listed steps taken to obtain an approval to conduct the study. An approval for the study was obtained through the School of Nursing’s Center for Research and the University’s Institutional Review Board (Alfes, 2011, p.91). This ensured that the study met ethical standards. The issue of confidentiality was also addressed and stated as maintained through the use of coding by laboratory session and learning strategy (Alfes, 2011, p.91). Even though the inclusion criteria was not addressed specifically, it was stated that the sample of the research consisted of first semester baccalaureate nursing students enrolled in a foundation of practice course (Alfes, 2011, p.91). The author did not specify exclusion criteria for the control or experimental group which hurts the internal and external validity but also the intervention fidelity. In both the control and experimental group, the researcher did not consider prior health care experiences of the students, which could have directly affected the outcome of this study. A licensed practical nurse in a baccalaureate nursing program can pose a bias to the evaluation of self-confidence due to prior clinical experience. CRITIQUE 5 The national league of nursing’s student satisfaction and self-confidence in learning questionnaires was used as an instrument to evaluate the study results (Alfes, 2011, p.91). The author stated that written permission was obtained from the national league for nursing to use this tool. The reliability of the questionnaires was addressed by the researcher. “Reported reliability for the questionnaire, with Cronbach alpha coefficients of 0.94 and 0.87 for the satisfaction with currently learning and self confidence in learning subscales respectively” (Alfes, 2011, p.91). However upon further research on the questionnaires used, it was found that the NLN clearly stated that the use of student satisfaction and self-confidence in learning questionnaire should be limited. The study on simulation has grown significantly since the development of this instrument by the NLN in 2003. There are several current instruments that the author could have selected. This affects the reliability of the outcome. Result analysis showed that students that participated in simulation learning showed more confidence statistically than those in a traditional learning group. With learning satisfaction, the difference was not significant between the control and experimental group. The researcher stated that the explanation for this finding might be due to the opportunities given to the control and experimental group to be active participants in the learning experience. The participants were able to ask questions and had the ability to equally receive feedback. The result analysis was greatly detailed and addressed all four research questions. Some limitations of the study were acknowledged by the researcher. The only areas assessed were self-confidence and satisfaction with learning. This limits the translation of results to performance outcome (Alfes, 2011, p.92). The author used convenience sampling which subjects the study for risk of bias. Since convenience sampling was self-selecting representativeness was also affected. The setting of the study was not clearly stated but it was CRITIQUE 6 implied that it took place in a school. The time frame of the study was not mentioned. The name of the nursing school was not mentioned however this could be due to confidentiality. The study only represents a small sample of students from one school which affects the generalizability of the study. Overall, the research study was well organized and easy to comprehend. Further research to explore the effectiveness of simulation as a learning strategy is needed to add to the strength of this study. This research encouraged nursing programs to utilize technological advances in health care and implement simulation based teaching at the beginners’ level to produce nurses that are better prepared to take on the real world clinical patients effectively. CRITIQUE 7 References Alfes, C. M., (2011). Evaluating the use of simulation with beginning nursing students. Journal of Nursing Education, 50(2), 89-93.
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