This is a critique paper on a selected qualitative research-based article. The title of the article is The Role Transition of Nurses in a University Teaching Hospital in Pakistan. The article is written by N. S. Lalani and J. M. Dias, who are Senior Instructor and Director BScN program respectively in Aga Khan University School of Nursing, Karachi, Pakistan. This qualitative study was conducted among new nursing graduates in a private university teaching hospital in Pakistan. The transitional experiences from student to a staff nurse role were researched using grounded theory design and the substantive theoretical framework was formulated named as “Sailing forward”. In this paper, all components of the research report will be critically appraised and evaluated for strengths and weaknesses.
Statement of phenomenon of interest
Every qualitative study has some philosophical underpinning which helps in designing research processes. This study is based on a Grounded Theory approach. According to burns and grove (2007)
However, in the article the authors have not explicitly defined the philosophical underpinning of this study. Moreover, authors have also not explained that why the phenomenon of the study requires a qualitative format.
Authors have explained the research problem in the very first paragraph of the article. It is explicitly highlighted that in developed and developing countries new nursing graduates faced difficulties in adjusting with the professional requirements to a new work role. Thus, addressing the issue to the nursing faculties and nursing administrators is vital. Moreover, it is also clearly stated that there is a high turnover rate among new graduate nurses within the first 6 months of graduation despite intense clinical training and educational preparation. In addition, the authors have very nicely mentioned in the first paragraph about their aims and objectives of the study that what they wanted to achieve. It is underlined that based on the experiences of graduate nurses the aim is to generate theory of role transition (Lalani & Dias, 2011). However, the authors have failed to explained that why it is important to conduct this study. The research question is not explicitly mentioned in the statement of the aim. Thus, it is difficult for the reader to infer the true purpose of the study and does not provide insight into the advance nursing practice. Assumptions of the study to the research problem are not well defined by the authors which is hard for readers to interpret the extent of the problem. Furthermore, the limitations of the study are mentioned in the article which will be critique in the later part of this paper.
Review of the literature
Authors have provided logical theoretical and empirical evidences under the heading of discussion which are relevant to the study findings but there is a lack of literature review which addresses the background of the researched problem. However, there is not a separate heading of literature review due to which it fails to provide comprehensive review. The referenced articles used were from recent and classic literature five of them are from year 2000-2005 and five of them are from 1985-1998 which are clearly and completely cited. Moreover, there is a collection of opinions presented from different authors and varying point of views about the problem has also been provided explicitly in the article and the review is not concluded with a brief summary of the literature and its connotation for the problem. According to Creswell (2002), “In a qualitative study, use the literature sparingly in the beginning of the plan in order to convey an inductive design”. However, the authors of this study have not mentioned that either the literature review has been conducted before the interview or at the time of data analysis. Overall, the literature review in this article is found to be comprehensive, rationale, logical, critical and pertinent to support the purpose of the study. The authors have explicitly mentioned that based on the review “the study allocates a new arena for exploration of how a nurse can provide effective spiritual care to the patients if he or she is not feeling spiritually satisfied” (Lalani & Dias, 2011, p. E4). Therefore, one can infer that there must be lack of information available regarding spirituality affected by role transition process among nurses.
Theoretical/ Conceptual Framework
Burns and Grove (2007) states that in qualitative researches the philosophy of the research design or the world view of the phenomenon acts as a framework and guides the study. Therefore, qualitative studies do not have any framework to follow as the phenomenon of the interest under researched is not yet much discovered. In the study, the authors have come up with their own framework formulated through the study findings named as “sailing forward” which is very much appropriate to the grounded theory study design.
The authors have very descriptively defined the theoretical framework with the integration of role transition process into four categories which were getting on board- Stepping into the new role, Sailing through the rough sea-Initial adjustment, clinging to the life savers-support system, and reaching the shore-resolution phase. Authors have explicitly stated and illustrated the components of the diagram of the substantive theory, which is very helpful for a reader to follow the flow of the study. Overall, the theoretical framework was very well established and utilized and integrated in the study.
Population and Sampling
The target population was defined clearly; however, inclusion and exclusion criteria could have been defined more explicitly. The authors have only stated the inclusion criteria that they took the sample of nurses who were recently graduated from three years diploma program and they had been working in working for last 6-12 months. But the authors have failed to state other characteristics of the nurses. Moreover, authors have stated that they selected participants from medical, surgical, and intensive care areas which provide readers an insight that authors have considered maximum variation in the sample. According to Streubert and Carpenter (2007) “participants for a grounded theory investigation must be selected based on their experience with the social process under investigation” (p. 140).Therefore, one can infer from the study that the population is appropriate for the research design.
Also, Authors did not mention that how many participants will be involved in the study because in grounded theory it is impossible to define sample size (Streubert & Carpenter, 2007). Furthermore, Authors have failed to mention the method of sampling and sample size in the introduction part. However, under the heading of findings it is implicitly mentioned that seven staff nurses were selected.
In the study, qualitative grounded theory approach has been used to develop substantive theory and it is the most appropriate one to be utilized in the study as it was aimed to generate a theory of role transition based on the experience of the nurses who are newly graduated. According to Strauss and Corbin (1990) grounded theory includes “systematic techniques and procedures of analysis that enable the researcher to develop a substantive theory that means the criteria for doing ‘good’ science: significance, theory, observation compatibility, generalizability, reproducibility, precision, rigor, and verification” (p. 31). In the study, authors have ensured all these points to be achieved. Therefore, the design used is appropriate and compatible with the purpose of the research. Though, the authors could have clearly mentioned and described the purpose and rationale for selecting a particular design. Moreover, authors have failed to mention about the replication of the study but one could infer that this study can be replicated in other settings as well because every nurse throughout the world experiences the role transition process. However, for replication of the study other factors should be kept in mind according to the social and cultural context.
The data collection was focused on the experiences of the newly graduated nurses. Streubert and Carpenter (2007) asserted that for grounded theory data can be collected through observations, formal or semi-structured interviews, or documents, or from the combination of all. In this study the authors have mentioned that they conducted formal un-structured interviews of 50-90 minutes from each participant. The interviews were tape recorded, and were transcribed. Also, for keeping record of the nonverbal gestures of the participants during interview separate notes was taken and all the personal identifiers were also been removed during tape recording. Therefore, it can be concluded that the data collection method is congruent with the research question. However, authors have failed to explain the rationales for using these data collection methods. Besides, authors have stated that they conducted interviews until saturation was achieved but they failed to state the total number of interviews taken from each participant. This could have provided clarity to a reader about attainment of exhaustive stage and saturation in data collection. Moreover, procedure for collecting data would have made more explicit under separate heading of data collection.
Protection of Human Rights
In order to evaluate the participant’s rights who were involved in this study, critical analysis was done for the data collection process and potential threats to ethical standards. Authors have explicitly mentioned that voluntary consent was obtained from the participants and their identities were kept confidential. However, authors have failed to provide any evidence of an independent ethics review by board or committee. Streubert and Carpenter (2007) recommended that to use the direct quotation of participants in the manuscript author should seek permission from the participants. Though, this is not explicitly mentioned in the article but one can assume that this must have taken under consideration while taking informed consent. Moreover, in grounded theory investigation, the researcher must be prepared for unexpected concerns as it is not possible to anticipate what kind of sensitive concerns might appear (Streubert & Carpenter, 2007). It can be critiqued from the study that spiritual concern was the most common highlighted finding of the study but authors have failed to state that how they took care of this issue.
Though the appropriate time for signing the consent is not stated but consent appeared to be voluntary and no indication of dishonesty like “covert participant observation”(Spaziale & Carpenter, 2002) is establish from the provided details. Furthermore, authors have allocated the code numbers to each participant which gives evidence that participants cannot be identified but no evidence for obliterating the audiotape is point out with which anonymity is difficult (Spaziale & Carpenter, 2002). There is also no evidence of whether the study facilitated participants in providing benefits and minimizing risk.
Qualitative content analysis was used in analyzing the participant’s interviews. The authors have mentioned that they analyze data through continuous comparative analysis till concepts were interconnected and hypothesis were formed (lalani & Dias, 2011). Later they grouped phrases, statements, and observation in to categories and sub-categories. Overall, the strategies used by the authors to analyze data are explicitly provided in the article. Creswell (2007) and Polit and Beck (2004) have provided six steps of data analysis given by Colaizzi, authors have followed these steps through describing the phenomenon of interest, colleting participant’s description, transcription, extraction of significant statements and theme coding. Therefore, all the explanation provided for the data analysis seems to be coherent and plausible. Moreover, the references used by the authors in the data analysis process fit to the level of inquiry that is grounded theory.
Authors have also performed verbal validation of emerging themes from participants for validity of findings which is one the most important step. Creswell (2007) reported that the most credible way of authenticating the findings and interpretations are member checking. Streubert and Carpenter (2007) have also regarded that it’s the ethical responsibility of a researcher to determine data validation from participants. In addition, it is evident that the themes and the substantive theory was supported by the raw data as authors have reflected on the data obtained, generated ideas were put on separate notes and need was identified for further clarification. Finally, by using theoretical codes the authors moved the conceptual framework from the level of description to the theoretical level (Lalani & Dias, 2011). In the grounded theory approach the data analysis process is advocate by Glaser’s (1978, 1992) and Strauss’s (1987, 1990). The authors have failed to mention that for data analysis process which approach is utilized however it can be infer from the study that Strauss model has been used.
Authors have mentioned about the data collection process which seems to be reliable. They have tape recorded the interviews, separate notes were taken and observation was also considered. Authors have not mentioned about any observation taken in the course of the study, nor are any range of circumstances in terms of timings for data collection method addressed. Furthermore, the authors have failed to mention that how many authors were involved in the data analysis but one can infer that since the comparative analysis was done there must be more than one data collectors who were involved in the data analysis process. Also the researchers have not mentioned any negative cases encountered during study.
The rigor of the study is assured by credibility, dependability, and transferability as described by Creswell (2007) the quality criteria involves credibility, dependability, and transferability. Firstly, in the article credibility was assured by selecting nurses with varying experiences, collecting data from three different units i.e. medical, surgical, and intensive care areas. It is also assured by using participant’s quotes in the article. For achieving credibility authors could have mentioned about the bracketing of their perceptions and beliefs as both the authors must had the experience of role transition. Creswell (2002) recommended that the researcher should “bracket” his or her own experiences in order to understand those of the participants in the study. Additionally, Creswell (2002) also suggested that data analysis process can be enhanced by the use of computer qualitative software programs. Though, the authors have not mentioned use of any computer software for data analysis. Under each category, sub-categories are also presented explicitly and supported by participant’s quotes. Secondly, for achieving dependability the authors have acknowledged that data was analyzed throughout the literature review via constant comparative analysis and categories were formed after until concepts were related. However, triangulation of data was not presented in the study which if used could have improved accuracy of data (Spaziale & Carpenter, 2002). Thirdly, in order to enhance the rigor and ensure transferability the authors have kept record of the non-verbal behaviors of the participants and any kind of interruption and significant occurrence. Therefore, findings can be fit outside the study situation in other settings but with limitations and the results are meaningful to readers who are not involved in the study. Spaziale and Carpenter (2002) describes researcher’s role as the instrument of data collection and has central accountability to transform participant’s experiences, his own observations and understanding of those experiences in to language. This assists researcher in acknowledging his strengths and weakness and provides credibility to the research. However, authors have failed to mention it in this article.
Burns and Grooves (2007) stated that audibility decreases when authors failed to include enough participants’ quotes to support the findings. In the article authors have mentioned multiple quotes under each sub-category which gives the clear picture to the readers and increases audibility. Furthermore, authors could have provided the numbers of interviews taken by participants in order to understand exhaustion description and saturation level. As recommended by Colaizzi that after obtaining essence and themes an exhaustive description of the phenomena should be formulated (Polit & Beck, 2008).
Conclusion and Recommendations
The authors have mentioned the significance of the result in relation to the research purpose explicitly under the heading of discussion. In addition, the authors have given the recommendations for future research studies in same context and implications for nursing practice that in order to reduce the turnover rate among novice nurses during their role transition managers should be supportive, appropriate feedback and appreciation should be provided on regular basis and by improving work conditions (Lalani & Dias, 2011). Moreover, the authors have also emphasized the collaboration among the school of nursing and nursing services, increases clinical hours, and prolong post conferences were suggested by the study participants. The study results also provide opportunity to conduct future research on “how a nurse can provide effective spiritual care to the patients if he or she is not feeling spiritually satisfied” (Lalani & Dias, 2011). This study can be generalized in other settings with slight modifications. Moreover, Authors themselves have acknowledged the study limitations; firstly, it is possible that participants might have forgotten or overcome some of the transitional experiences and secondly, the participants might have been influenced by the investigator or felt compel in giving socially acceptable views. Authors have also anticipated that the findings may be transferable to other similar settings. Lastly, the findings of this study are probable to be transferable to similar setting in Pakistan, because role transition process is the phenomenon which is experienced by all the nurses. However, the experiences can be different according to the cultural and social context.
Moreover, this article is written in such a way that it teaches novice researcher or research students to understand the concepts and fundamental steps of grounded theory research. For instance, the authors have described the research question, its design and steps of data analysis clearly. There were few things that could have been entertained in the study to help reader comprehend the research process without making implicit assumptions. For example, research problem and purpose could have been stated more explicitly, number of interviews taken could also have described the saturation in data, bracketing evidence could have improved the credibility of the research report, evidence of validation of analyzed data by different members could have been mentioned, and addition of more evidences in the explanation and discussion could have added more amplification. In addition, reference list is the good source for the reader who has the interest in the same topic. According to Polit and Beck (2004) “an accurate list of all the books, journal articles, reports and other media referred to in the study should be included in a reference list at the end of the study”. However, the authors have accurately and extensively mentioned the reference list at the end of the article.
Finally, after reading the article the reader gets information about role transition process and importance of making it smooth for novice nurses. Overall, the article provides new knowledge to the reader and anticipates recommendations for future research.