A Critique of the Qualitative Research: “Missed Nursing Care” Mamdouh Nakada
February 18, 2015
Beatrice J. Kalisch, PhD, RN, FAAN, reports her qualitative study “Missed Nursing Care” on medical-surgical units in the Journal of Nursing Care Quality. In the article, " Nursing Care: A Qualitative Study," the researcher helps us understand what nursing care regularly missed on medical-surgical unit and what are the reasons nursing staff give for not completing these aspects of care. The reader will examine her use of grounded theory qualitative research method based on the guidelines provided by Geri LoBiondo-Wood and Judith Haber (2014). This research report will be analyzed using the criteria found in the Critiquing Criteria box on p. 135-136 in Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. Statement of the Phenomenon of Interest
In Research: Methods and Critical Appraisal for Evidence-Based Practice, the authors define phenomena as those things that are perceived by our senses (LoBiondo-Wood & Haber, 2014). The research clearly states the phenomenon of internet in the introduction, “…specific aspects of nursing care missed routinely and nursing staff reasons why these elements of care are prioritized as less important than others” (Kalisch, 2006, p. 306). Beatrice Kalisch (2006) used the qualitative research method because the she had to discover information about her phenomenon from nurses experiences in their medical-surgical units. Kalisch (2006) explained, “A literature search revealed a lack of studies…” about “The specific aspects of missed nursing care” and “the association between less staffing and the negative outcomes” (Kalisch, 2006, p. 306). The researcher realizes current relationship between nursing staff and poor patient outcomes. Kalisch found there was a gap and wanted to discover what "the missing nursing care" was and why it is missing. Kalisch helps her audience understand the philosophical underpinnings by explaining the utility of grounded theory in phenomenal sense making. The authors of Methods and Critical Appraisal for Evidence-Based Practice differentiate ground theory from other qualitative research methods by stating that ground theory focus on process. The research identifies the process elements of her phenomenon rather than just describing it (LoBiondo-Wood & Haber, 2014, p.153). Purpose
Kalisch tells the reader the purpose in her first line of her abstract which is “…to determine nursing care regularly missed on medical-surgical units and reason for missed care” (Kalisch, 2006, p. 306). ). Kalisch conveyed to the reader, “Ensuring quality nursing care and patient safety is a major challenge facing nurses and nurse leaders today” (Kalisch, 2006, p. 306). Thus, this research is done to discover what can change nursing practice to ensure better patient outcomes. Method
The authors of Research: Methods and Critical Appraisal for Evidence-Based Practice defines grounded theory as "different types of qualitative research method in that it goes beyond the traditional methods of phenomenology and ethnography, which focus on the process that is at the heart of the inquiry" (LoBiondo-Wood & Haber, 2014, p.154). According to Glaser and Strauss (1967), grounded theory method was “developed originally as a sociologist’s tool” and Denzin and Lincoln (1998) add “researchers…use the grounded theory method when they are interested in social process from the perspective of human interactions…” (LoBiondo-Wood & Haber, 2014, p. 116). Kalisch analyzed social process among nurses who are divided by job title into focus groups. She properly use grounded theory method to discover the phenomenon and collect data for the stated purpose. However, it is unclear if the study followed the guidelines of the grounded theory method. Sampling
In Methods and Critical Appraisal for Evidence-Based Practice, LoBiondo-Wood and Haber (2014) explains “In qualitative studies, the researchers are usually looking for purposive sampling…a particular kind of person who can illuminate the phenomenon they want to study” (p. 100). The reader knows Kalisch (2006) purpose is about the views of nurses on medical-surgical units, and the author does interviews with “A total of 107 registered nurses, 15 licensed practical nurses, and 51 nursing assistants, working in medical-surgical patient care units…” from two different hospitals (Kalisch, 2006, p. 306). These nurses live the experiences of “missed nursing care” and can shed light on why care is missed on medical-surgical unit; therefore, they are an appropriate sample for this phenomenon of study. However, Kalisch could made a stronger sample for the grounded theory method if she included the words "purposive sample" , explained why this group of nursing staff was chosen, and given details about the inclusion/exclusion criteria for the sample (LoBiondo-Wood & Haber, 2014, p. 100). Data Collection
The description of data collection lacks details in Kalisch (2006). The reader knows the author interviewed “25 focus groups” using “semistructured design and each interview “lasted 90-120 minutes” and the interviewees “were asked to commit to confidentiality” (Kalisch, 2006, p. 306-7). The data collection did include human experience which was the nursing staff. Though the author states asking the interviewees to “commit to confidentiality", but this is not enough to protect them from disclosure. In addition, data saturation isn't confirmed and little known about the data collection process. The author should have stated during the interviews “nothing new is emerging” (LoBiondo-Wood & Haber, 2014, p. 101). Furthermore, the author should included clues about questions that were asked and if anything collected from the interviews focused her study. Data Analysis
The author used “qualitative analysis software” to apply “a grounded theory approach by which empirical data are thematically categorized by induction” (Kalisch, 2006, p. 307). There are two analyses of the “tape-recorded, fully transcribed” interviews, and “to be included as a theme, supporting data had to be contained… in all of the focus groups” (Kalisch, 2006, p. 307). The reader identifies the research to be true to data because, as the two analyses “extracted the same issues from the empirical material” (Kalischp. 307). Trustworthiness, known as rigor for qualitative research, is established through credibility, auditability, and fittingness, none of which is communicated by Kalisch (LoBiondo-Wood & Haber, 2014, p. 126). Credibility requires that the "informants recognize the experience to be their own" (LoBiondo-Wood & Haber, 2014, p. 155). The author never discussed taking the themes obtained from the interviews back to the nurses to allow the interviewees the opportunity to confirm the findings. Nor does the author give any indication that enough time was allowed for full understanding of the phenomenon. Auditability requires that others, "not engaged in the research, be able to follow the auditrial of the primary researcher" (LoBiondo-Wood & Haber, 2014, p. 155). The author should have described data saturation as mentioned previously. In the data analyses section of Kalisch (2006) the author mentioned grounded theory method was used for extraction of themes from the interviews. However, the reader doesn’t know the systematic process used, if there was “open coding” and “constant comparative method” (LoBiondo-Wood & Haber, 2014, p. 117). The neglect of giving the step-by-step process inhibits the reader’s ability to follow the thinking of the researcher. Fittingness is the "criterion that provides the reader with an opportunity to determine the usefulness of the data outside of the study" (LoBiondo-Wood & Haber, 2014, p.156). The reader knows the author chose grounded theory method appropriately for the purpose of Kalisch (2006); however, because of missing information the reader is unsure if this is study is repeated in other hospitals or other units if the same themes would evolve (LoBiondo-Wood & Haber, 2014, p. 117-120). If the author gave the systematic process the study could be replicated. This necessary information would allow wider application to other professions. Findings
The author gives great details in the findings section of Kalisch (2006) allowing the reader “to apprehend the essences of the experience” (LoBiondo-Wood & Haber, 2010, p. 130). Use of quotes from the interviews allowed the reader to understand how the themes emerged (LoBiondo-Wood & Haber, 2010, p. 108). The author’s conceptualizations are sincere to the findings. The “Nine elements of regularly missed nursing care…and 7 themes relative to the reasons for missing this care…” described in Kalisch (2006) abstract is clearly defined throughout the findings section (p. 306-310). Additionally, in the discussion section the author relates the findings to the literature review (Kalisch, 2006, p. 310-311). The author discussed how other research “corroborate[d] these findings” and “many studies have pointed to the relationship between number of patients per nurse and negative outcomes” (Kalisch, 2006, p. 311). Conclusions, Implications, and Recommendations
In the implication section, the author expresses the use of her findings to change nursing practice and “decrease the problem of missed nursing care” (Kalisch, 2006, p. 312). The author continues to maintain confidence about her findings in the conclusion, “it is clear that nurses are often distracted for care...and should be engaged in delegation training and performance follow-up” (Kalisch, 2006, p. 312). Yet, the author declares a need for further research because “only 2 facilities” were studied and “additional studies are needed to determine the validity of these findings” (Kalisch, 2006, p. 312). The author recommends implications for nursing practice by the details to examine this phenomenon on their unit by doing “root cause and other analyses…to determine the causes of the problem and strategies to address them” (Kalisch, 2006, p. 312). Plus, the author gives suggestions about “development of a tool to measure missed care” and questions to answer in future research.
After scrutiny of Kalisch (2006) the reader has an understanding the author used qualitative, grounded theory method to study “missed nursing care” and “staff reasons why” they were missed. However, before application of these findings the reader should conduct more research and more analyses because Kalisch (2006) findings are not conclusive. Also, the reader would have to do more literature review or even contact author if possible to gain more knowledge about her process of sampling, collection and analyses so the study can be repeated and validity of the findings can be affirmed.
Denzin, N.K., & Lincoln, Y.S. (1998). The landscape of qualitative research. Thousand Oaks, CA: Sage. Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine. Kalisch, B.J. (2006). Missed Nursing Care: A qualitative study. Journal of nursing care quality, 21(4), 306-13. LoBiondo-Wood, G., & Haber, J. (2014). Nursing research: Methods and critical appraisal for evidence based practice (8th ed.). St. Louis, MO: Mosby-Elsevier.