Evidence based practice typically comes from research conducted by nurses and other health care professionals to answer questions or solve problems in a disciplined manner (Taylor, Kermode & Roberts, 2006). Nursing research has experienced remarkable growth, providing nurses with an increasingly sound evidence base from which to practice. (Polit, Beck & Hungler, 1999). Therefore, the authenticity of research findings needs to be assessed by careful critical analysis, which broadens the understanding and determines evidence for use in practice as well as providing a background for conducting further study.
According to Polit et al. (1999), the aim of critically appraising an article is ???an attempt to determine its strengths and limitations.??™ Therefore, the research critique should reflect an objective and balanced consideration of the study??™s validity and significance (Polit et al. 1999). This assignment will critically appraise a piece of nursing research on horizontal violence and reflect on its impact on nursing practice today. In order to effectively critique the research article on horizontal violence, the guidelines produced by Ryan, Coughlan & Cronin (2007) will assist the writer in producing an organised piece of work.
What is horizontal violence
In the research article ???You have no credibility: Nursing students??™ experiences of horizontal violence??? Curtis, Bowen and Reid (2006) define horizontal violence as bullying and aggression within a group (p. 157). This is further supported by Duffy (1995) who describes horizontal violence as hostile and aggressive behaviour by an individual or group members towards another individual or members of a group, or a larger group.
Duffy (1995) states that horizontal violence, bullying and self esteem are major issues which influence nursing students socially, psychologically and physically. McKenna, Smith, Poole and Coverdale (2003) found that horizontal violence is often seen as psychological harassment as opposed to physical violence. ???This harassment involves verbal abuse, threats, intimidation, humiliation, excessive criticism, innuendo, exclusion, denial of access to opportunities, disinterest, discouragement and the withholding of information??? (p. 91). While not overtly physically harmful, studies indicate that this range of behaviours can result in social and psychological concerns such as sleep disturbances, reduced self-esteem, increased anxiety, impaired personal relationships, feelings of isolation and social disconnectedness and depression, and may contribute to some physiological manifestations such as hypertension (Hadikin & O??™Driscoll, 2002). Research indicates this type of abuse is found globally in all areas of nursing and affects not only individuals, but groups within larger nursing populations, and permeates the entire health care system (American Association of Critical Care Nurses, 2010).
The relevance of horizontal violence to professional nursing practice.
A New Zealand study by McKenna et al. (2003) found that ???34% of new graduates experienced verbal abuse including unjustified criticism, humiliation and abusive statements made by other nurses??? (p.91). The impact of this aggression from colleagues has been said to be more distressing than being assaulted by a patient (Farrell, 2001). Statistics from the International Council of Nurses (2010) reveal that world wide, nurses are three times more likely than any other service occupational group to experience violence in the workplace. From these studies we see that the issues of horizontal violence are likely to be widespread in New Zealand and internationally.
The culture of the health care setting has been historically populated by images of the nurse as a ???handmaiden??? in a patriarchal environment (Kelly, 2006), where the balance of power has not been in the nurse??™s favour. Too often, in a hierarchical environment nurses have given in to a victim mentality that perpetuates a sense of powerlessness (Curtis et al. 2006). When people feel put down, victimised or powerless they will often try to exert power of influence over those around them, or subordinate to them. They will react with abusive words, actions or behaviours (Rigby, 2002). Consequently, any conflict in a workplace that creates a hostile environment, hinders communication, which can have a flow-on effect on the professional and personal development of nurses, and can in turn influence the quality of care and patient safety (Cherry & Jacob, 2002). Horizontal violence also been cited as a contributing factor in the ability of the nursing profession to retain new graduates and long term nurses. (McHarg, 2007). Many nurses reported they were reluctant to work in an atmosphere where they feel unappreciated, intimidated or threatened. (Curtis et al. 2006)
According to Ryan et al, (2007) the title of a research article should be ???clear, accurate and unambiguous??? (p.739). The purpose and meaning of the opening phrase in the title of this article, ???You have no credibility??? is unclear and does not seem to correlate well to the second part of the title, ???Nursing students??™ experiences of horizontal violence,??? which does describe clearly what the research is about. The research does not explain who ???you??™ refers to; it fails to explain where the statement is coming from, and it does not explain why horizontal violence reduces credibility in any sense. Therefore, the first part of the title as it is expressed is not clear or accurate. It appears ambiguous and is not useful in clearly identifying the purpose of the study.
Abstract or Summary
Polit et al. (2001) describes ???an abstract as a brief description of the study placed at the beginning of the research article??? (p. 54). The abstract or summary of Curtis et al. (2006) research describes clearly and concisely what the research article is about. It outlines the research problem of horizontal violence as an issue and highlights the fact that there is a lack of research on the topic of horizontal violence. It identifies how the sample was conducted, briefly discusses methodology, findings and recommendations (Curtis et al. 2006). The abstract, in most aspects, provides a succinct overview of the research article, however, the abstract does not explain or add to our understanding of the phrase ???you have no credibility???.
The research article was published in the Nurse Education in Practice Journal in 2007 after being accepted for publication on the 11th June 2006. The reader assumes that as this research study is recent, and as it is published in a credible journal, that the research itself is credible and that it has been peer reviewed.
The aim and scope of the journal is to demonstrate the actual practice of education and to publish papers that make the link between education and practice (Elsevier, n.d.). The research article is appropriate material for this journal because it highlights issues in nursing education with links to clinical practice. However, there is no information about the qualifications of the researchers, Curtis et al. (2006), or what their professional positions are, that might indicate their degree of knowledge or experience in this subject(Ryan et al. 2007).
Taylor, Kermode and Roberts (2007) state that an introduction should familiarise the reader with the problem, background and justification for the study. The information in the background section of the article by Curtis et al. (2006) is thorough and includes the topics the researchers wish to address. These include defining horizontal violence, its implications in nursing and the relationship between horizontal violence and student attrition Curtis et al. (2006). Although the justification for the study is not apparent, it could be assumed that the research was undertaken because of the lack of available research information. Curtis et al. (2006) said that the literature as reviewed, contained few practical recommendations to deal with the issue of horizontal violence.
Method and Design
Curtis et al. (2006) conducted a qualitative study, but the research did not state or discuss this. Qualitative methods lend themselves to questions that seek answers from feelings, experiences and attitudes, (Polit and Beck, 2010). While both quantitative and qualitative research hold relevance to nursing practice, in the research article by Curtis et al. (2006) qualitative research was the preferred method of choice. A qualitative approach can be viewed as being more relevant to this nursing problem as horizontal violence is a subjective, experiential issue that is only identified through individual perception (Schneider, 2007).
The research method Curtis et al. (2006) used was to distribute surveys with a range of questions to second and third year nursing students at an Australian university-based nursing school. The survey obtained basic demographic data of age and sex only and contained five questions eliciting the students??™ experiences of horizontal violence on their clinical placements. Three of the five questions were open and two were closed.
Open questions are beneficial in extracting rich data due to participants having the opportunity to expand on, and express feelings and experiences. However this method can be time consuming with the potential for participants to change the direction of the discussion (Rees, 2004). Conversely closed questions reduce the scope for a variety of meaning to be extracted and may lead the responses in the direction determined by the way the question was framed (Wickham, 2006). The reasons why closed questions were used are not justified by the researchers, leaving the reader to question whether the closed questions may have influenced the responses given.
From the qualitative questions, a process of thematic analysis was conducted in order to organise the information into themes Curtis et al. (2006). This method of analysis aims to provide a data set which doesn??™t contain a comprehensive analysis of all the data. Rather, it provides detailed analysis of a small selection or aspect of the data, so the researcher can concentrate on just a few main themes which link to the research question itself. (Braun & Clarke, 2006).
After the themes emerged through the survey, the participants could participate in informal, small group discussions with the researchers. According to Krueger (1994), discussions are an effective method for qualitative research, as the data collected can provide insight into the perceptions, attitudes and opinions of participants. Rees (2004) states that there is the possibility of a power struggle amongst participants when using open discussions in a focus group which could potentially leave quiet and shy participants unable to voice their opinions, feelings and experiences.
In the research by Curtis et al, (2006) the researchers did not acknowledge the purpose or limitations of this method. In addition the research did not indicate the number or percentage of students who these discussions were with, what was discussed or the outcome of the discussions, as there appeared to be no summary or verbatim record of the discussions. These factors could potentially affect research validity, Rees (2004), but were not addressed. Therefore, it could be argued that small group discussions were not a very reliable method of research in this case.
In this research, convenience sampling was used, which is described by Nagy, Mills, Waters and Birks (2010) as using the most readily available or convenient group of people for the sample. In the article by Curtis et al. (2006) the researchers have used second and third year nursing students at the University of Wollongong. Convenience sampling was used in gathering data for this study, as the researchers were co-located with the sample group on the university campus. The researchers also had ready access to the nursing students during class time to introduce the surveys, and the nursing school made time available to the students to complete the surveys in class. Although this appears to the writer to be an acceptable form of sampling in this instance, the question could be raised about the closeness of convenience sampling and whether some students may have known some of the researchers. Curtis et.al (2006) did not appear to give researcher bias concerns any consideration. They failed to examine their own roles, and the potential bias and influence they may have had on the participants (Polit et al. 2006). In this case the nursing students may have felt more inclined to provide information and answer the questions in the affirmative in order to assist researchers who were known to them.
The students may also have felt constrained in their answers by the limitations of whatever time was allowed in class. Some students may have preferred the greater privacy and extended time frames afforded by an option to complete the surveys in their own time and in their own homes. A greater level of autonomy may have strengthened the validity of the research data by minimising potential pressure to conform to their peers??™ thinking…
Of the 251 surveys that were distributed, 152 or 61% were completed. According to the University of Texas (2010), an acceptable response rate of 50% is a good level of participation, therefore the response rate of 61% is acceptable in this instance. There is no explanation for the 99 or 39% of surveys that were not completed. The reader is left to question why 39% of the students did not participate in the research when they were given time in class to complete the survey. Perhaps these students felt they could not cope with or divulge concerns regarding horizontal violence, and therefore they did not participate Perhaps the non-responders had no concerns or experience with horizontal violence The number of surveys not completed raises questions about whether any conclusions can be drawn from the research, about the percentage of horizontal violence.
Of the completed surveys, only 16 were male. The research findings suggested that horizontal violence is predominantly a concern for female nurses. Curtis et al. (2006) could be criticised for drawing this conclusion from the research if they were reliant on such a small sample of 16 male nurses, or only 11% of completed surveys to inform any discussion about the question of gender in relation to horizontal violence. 62% of respondents were under 29 years and 28% were 30 to 58 years. According to Randle (2003), self esteem is subjectively evaluated and is based on life experiences. It is the reader??™s critique that there was a higher proportion of younger students with less collective life experience. This could have affected their self esteem, making the sample somewhat skewed.
According to Aronson (1994), thematic analysis focuses on identifiable themes and patterns of living and/or behaviour. In the research article by Curtis et al. (2006) a thematic content analysis was undertaken from the survey questions and data was coded from these themes. This enabled the themes that emerged from the students stories to be pieced together to form a picture of their collective experience. However, it appears to the reader that the analysis was limited in its depth and scope. Firstly, data from the open discussions was not reported or was only included within the general themes, secondly, Curtis et al. (2006) did not include a description of how the categories and themes were derived from the data. Thirdly, there was no mention of the frequency of responses that were recorded in the data to support the findings, and fourthly, the researcher did not discuss any research bias potential. Holloway and Wheeler (2002) state that findings such as these could have the potential to skew the findings of the entire research.
Ethics is an important part of nursing and nursing research. Ethics is about researchers doing what is fair, decent and moral. (Crookes & Davies, 2004). According to Polit et al. (2006) when critiquing a study consideration must be given to establishing whether the researcher considered the main ethical principles of autonomy, beneficence, non-maleficence and justice, in undertaking the particular research. The researchers discussed questions of privacy, confidentiality and the right to participate or not. However, given the sensitive nature of the research, all of the four principles should have been included to ensure the wellbeing of the participants. Respect for autonomy was considered as participation was explained verbally and accompanied by an information sheet (Curtis et al. 2006), conversely the protection of participants (beneficence/non-maleficence) was not discussed beyond privacy and confidentiality of the study (Curtis et al. 2006). There was no mention of the potential after effects of the interviews for the participants as they delved into some complex and emotional feelings without the provision of support. The principle of justice was acknowledged by stating there was no penalty for non-participation, (Curtis et al. 2006), however it is the readers opinion that it was not clear if the participants had a right to withdraw at anytime.
The findings of Curtis et al. (2006) are clearly written and explicit concluding that horizontal violence is common within the nursing profession. The research and the analysis of the findings successfully raised the reader??™s awareness and interest in horizontal violence by the common discussion of themes that arose from the research. However, the reader questioned whether forum discussions, allowed for the participants to feel safe and whether their privacy may have been at risk. The conclusion that half of the students in the study had experienced or witnessed horizontal violence, is open to question, and needs greater scrutiny in further research studies. Taylor et al. (2007) suggest that one of the categories to determine rigour is credibility. As there are unanswered questions about researcher bias, method and design, ethical considerations, the title of the research and limitation of the analysis, the reader is left to question the credibility given to the findings.
The relevance and potential utilisation of this research for the nursing profession
Curtis et al. (2006) have shown us evidence that horizontal violence exists, and appears to be quite widespread. Awareness of this issue, and acceptance that it is a problem, forces us to confront its relevance in nursing training and professional practice. There are at least three areas where the nursing profession can utilise the research information. Firstly, if nursing students are likely to encounter horizontal violence in any of its subtle and covert forms during their clinical placements, they must be aware of its potential, they must be taught to recognise it and they must be given tools to enable them to deal with it appropriately. Codes of behaviour with consequences for any failures to adhere to the standards may be useful. Secondly, clinical nursing tutors should include specific discussion about how the student nurse??™s colleagues talked to them, directed them and interacted with them, when they are reviewing each nurses individual clinical performance, to provide support and debriefing as necessary. Thirdly, as individual nursing students and registered professionals, nurses should look to their own words, behaviours, directions, and expectations of their colleagues, to ensure they maintain the highest standards of fairness and respect in working alongside each other, and in teaching and training. References
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