Critical Appraisal of a Nursing Study on Nurse Empowerment Program

This report provides a critical appraisal of a randomized controlled trial (RCT) focused on the impact of a nurse empowerment educational program on patient safety culture. The study, conducted by Amiri, Khademian, and Nikandish (2018), investigated the effects of workshops and educational materials on the cultural safety of adult patients in ICU units. The appraisal examines various aspects of the study, including its aim, population, intervention, comparator, and outcomes. It assesses the study's randomization process, sampling techniques, and the inclusion/exclusion criteria for participants. The report also evaluates the study's limitations, such as the lack of blinding and drop-out rates, and discusses the generalizability and clinical importance of the findings. Overall, the appraisal highlights the strengths and weaknesses of the study, offering insights into its methodology, results, and implications for nursing practice. The report concludes by summarizing the study's key findings and their relevance to healthcare.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Selected study: Amiri, M., Khademian, Z., & Nikandish, R. (2018). The effect of nurse
empowerment educational program on patient safety culture: a randomized controlled
trial. BMC medical education, 18(1), 158.
https://doi.org/10.1186/s12909-018-1255-6

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Answer 1
Yes.
The aim of this randomised control trial (RCT) is to determine the effect of nursing
empowerment through educational approach on increasing the cultural safety of the adult
patients of the ICU units (Amiri, Khademian & Nikandish, 2018).
The main population studied in this study is nurses and nursing supervisors. The level
of the cultural safety of the nurses will be monitored based on their activities or care plan
procured over the 6 adult patients in the ICU units. Schneider and Whitehead (2013) are of
the opinion that while conducting randomized control trial (RCTs), the selection of the
population must be based on the scope of the study. In this study the culturally safety care of
the nurses will be monitored based on their professionals conduct upon training session and
thus recruitment of the nurses and the adult patients coincides with the scope of the study.
The intervention selected for this study include workshops for two days conducted for
8 hours at a stretch along with education given with the help of posters and distribution of
pamphlets (Amiri, Khademian and Nikandish 2018). It is the rule of the RCTs to select
specific intervention in order to test the efficacy of the interventions with the help of trial
(Hemming et al., 2015).
The comparator used in this study was the control groups of nurses and the
supervisors who did not participated in the workshops. Use of control groups provided the
provision for comparative analysis (Hemming et al., 2015).
The main outcomes that were considered in the study include inproved cultural safety
in the nursing care. However, primary and secondary outcomes were not considered distinctly
in the study and this can be regarded as one of its drawbacks.

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Answer 2
No
Randomization was done by the use of the pre-test and post-test of the control groups
(Amiri, Khademian & Nikandish 2018). Shuster (2019) highlighted that use of the pre-tests
and post-test in the RCTs help to increase the strength of the overall results by helping to
compare the test data with the baseline data.
Selection of 60 nurses was done by the use of proportional stratified sampling.
Stratified sampling techniques help to gain higher accuracy in the selection and comparing
same sample size at the same time in a cost effective manner (Shuster, 2019). Of 60 nurses,
20 nurses were recruited in the control group. For the incorporation of the supervisors, the
authors used a different sampling technique, known as block randomization and out of 20, 10
were recruited in the control groups (Amiri, Khademian & Nikandish 2018). Importance of
block randomization is it helps to divide the total sample into two groups that are known as
blocks. The generation of these blocks helps to promote generation variability within the two
blocks and help to perform the randomization further (Kim, & Shin, 2014).
The selection criteria used for the recruitment of the nurses and supervisors is
experience of at least 6 months (minimum) in adult patients ward. The minimum educational
qualification taken is bachelors degree in nursing. The overall allocation and the groups of
the nursing professionals or the supervisors who were excluded from the sampling or the
study were elaborated in detail in the CONSORT diagram. Vohra et al. (2016) stated that use
of the flow chart in the form of CONSORT diagram helps to study the process of
randomization in a parallel manner. However, the study failed to mention that whether the
participants that are the nurses and the supervisors were blinded about the scope of the study.

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This can be regarded as one of the drawback of the study as lack of blinding might lad t the
generation of biased results (Vohra et al. 2016).
Answer 3
No.
A total of 20 nurses and 9 supervisors of the experimental group participated in the
educational campaigns. During the follow-up session, one of the nurse failed to complete the
pro-test. The decrease in the sample size during the follow-up session due to drop-ours can be
regarded as one of the drawbacks of the study as it restricted the generalization of the data
and restricts the path of data saturation (Singh & Masuku, 2014). In relation to this study
result, it can be said that the entire sample those were recruited failed to complete the study
till the end and this can be considered as one of the limitation of the study. However, both the
control group and the experimental group were treated separately and helping to highlight the
significant outcome in the RCTs.
Answer 4
No
The authors did not highlight that whether the participants were blinded about the
study outcome. Moreover, the study also failed to mention that whether the educators who
were recruited to provide the treatment were blinded about the scope and the outcome of the
study. Probst et al. (2016) stated that blinding is defined as an approach in which the either
the participants or the reviewer of the study or the both are blinded about the scope of the
study. When both the reviewer and the participants were blinded about the outcome of the
study then it is known as double-blinded trial when the participants were blinded it is known

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as single blinded trial. Probst et al. (2016) reported that lack of blinding increase the risk of
generating performance bias distort treatment effects.
Answer 5
Yes.
The patients over whom the affects of the nursing practice if cultural safety was
studied were adults. However, whether these patients were from same origin are not stated in
the study. Betancour et al. (2016) stated that adults who are aboriginal origin are vulnerable
towards becoming victims of cultural incompetency and generally demands culturally
sensitive care. Thus, nurses are require to handle aboriginal patients with special dignity and
respect toward their culture. In case to the case study, it can be said that analysis of the
culturally competency over an un characterized population might lead to biased analysis of
the cultural competency of the training empower nurses. The nurses who are included in the
trial have at least 6 month of experiences in handling adult patients. However, the authors
failed to mention whether the nurses have any previous experience of cultural competency.
Almutairi, McCarthy and Gardner (2015) stated that nurses who have previous exposure
cultural competency training during their graduation phase are more likely to refine their
cultural skills upon getting additional training during their professional practice. Thus,
analysis of the selected group of nurses as a whole might provide biased results.
Answer 6
No.
Experimental groups attended the workshop for 2 days for duration of 8 hours.
However, the study failed to mention that whether the nurses or the supervisors who were
included in the training sessions are enrolled in any additional inter-professional courses for

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refining their cultural competency. This can be regarded as a confounding bias during the
follow-up session. According to Jackson and Swanson (2015) confounding bias hamper the
association between the exposure and outcome and thus leading to bias judgement.
Answer 7
The main outcome of the study is improvement in the patients’ cultural safety upon
nursing training (Amiri, Khademian & Nikandish, 2018). Overall treatment effects was large
as education of cultural competency was given with the help of team building strategies, team
work and use of other tools in order to increase the team based performance of the patient.
Performance and Patient Safety (Team STEPPS) tool that was used in the workshop covered
the parameters like leadership management, communication strategies, situational monitoring
skills and mutual support. Schneider and Whitehead (2013) stated that use of different
approaches for the promotion of patients’ cultural safety help to increase the overall treatment
effect. Each outcome of the study were studied separately along with the simultaneous
tabulation of confidence interval this helped in easy interpretation of the data analysis
(Freeman, 2017).
Answer 8
The confidence interval (CI) used in this study is 95%. Greenland et al. (2016)
reported that CI of 95% ensure that same results will be replicated in other population s well
thus helping to generalize the data.
Answer 9
Yes.

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The results highlighted in the study can be applicable to other population as a
generalised population was included in the study. Thus the outcome of the study can be
applied to other population as well. However, the approach will be only suitable for adult
population and not for paediatric population as paediatric population are require friendly and
different approach for ensuring cultural safety and recruitment of the parents also become
important in that case ((Douglas et al., 2014).
Answer 10.
Yes.
All the clinically important outcomes were considered in the study like team building,
cultural safety and improvement in the communication skills. Schneider and Whitehead
(2013) sated those clinically important outcomes in RCT helps to refine the results and help
to in the generation of the policy planning and framing of the evidence-based practice.
Answer 11
Yes. The benefits of the study showed that training and proper knowledge awareness
of the nursing professionals help to improve the cultural safety quotient of the patients’.
Betancourt et al. (2016) stated that delivering culturally competent care helps to improve the
mental and physical well-being of the patients and thus helping to improve the overall health
outcome.

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https://doi.org/10.1186/s12909-018-1255-6
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