Critique

Running Head: NAME QUALITATIVE CRITIQUE 1

Qualitative Critique of Hall, Griffiths, & McKenna’s Study, “Navigating a safe path together: A

theory of midwives’ responses to the use of complementary and alternative medicine”

Student Name

NURS 3135 Critical Inquiry: Nursing Research

Spring 2017

NAME QUALITATIVE CRITIQUE 2

Qualitative Critique of Hall, Griffiths, & McKenna’s Study, “Navigating a safe path

together: A theory of midwives responses to use of complementary & alternative medicine”

The following paper includes a qualitative critique regarding Hall, Griffiths, and

McKenna’s (2013) study published in a well-known journal, Midwifery. The critique follows a

template provided by Georgia Southern University which enhances organization through explicit

headings, subheadings, and relevant questions that allow for a concisely but well-written critique

to follow.

Title

Is the title a good one, succinctly suggesting key variables and the study population?

The title is thorough and well-worded with detail which implies the title is a good one.

The title included the central phenomenon, namely the theory “Navigating a safe path together;”

and also the group under investigation, which were the midwives who participated in the study.

Although the title may be considered lengthy at 18 words, it succinctly conveys the focus of the

study and suggests the key variables and the study population. The key variable, complementary

and alternative medicine, was included in the title which allows further exploration for the reader

to identify what the researchers were investigating regarding the midwives’ responses. No

recommendations for changes are noted for the title, as Hall, Griffiths, and McKenna (2013) did

an exemplary job at naming the study.

Abstract

Does the abstract clearly and concisely summarize the main features of the report

(problem, methods, results, conclusions)?

The abstract was not written in the traditional abstract style of single paragraphs. Instead,

it is structured with the headings: Objective, Design, Findings, Key Conclusion, and Implications

for practice. The abstract did an excellent job at clearly and concisely summarizing the main

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features of the report. It began with the Objective of the study, which was a summary of the

problem. The abstract then included the design of the study which mentioned that the qualitative

research design was grounded theory methodology. Some information about the sample was

provided (e.g., that data was collected from 25 midwives who worked in 4 hospitals and

associated community clinics in Victoria, Australia). Details about the specific grounded theory

method were also included in the abstract (e.g., in-depth interviews and non-participant

observation); however, the time spent in the field was not mentioned. The abstract included the

findings of the study briefly in which mentioning the theory that emerged: “Navigating a safe

path together.” It also included the three primary themes that emerged from the analysis. The

abstract then summarized the conclusions of the study. The final heading of the abstract,

Implications for practice, was a single sentence that prompts ideas for further research in the

nursing setting regarding improved education and greater professional guidance for midwives

incorporating CAM in their practice. This abstract provided an adequate and brief description of

the study which allows readers to judge whether or not they want to read the full report.

Introduction

Statement of the Problem

• Is the problem stated unambiguously and is it easy to identify?

The introduction was very brief, leaving out important aspects that are generally required

in order to build upon a strong foundation for a research study. The problem is stated

unambiguously and it is easy to identify. The problem being identified is presented in the last

sentence of the first paragraph. The researchers present the problem that CAM has proposed

challenges for midwives that warrant attention regarding expectant mothers.

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• Does the problem statement build a cogent and persuasive argument for the new study?

The problem statement does build a cogent and persuasive argument for the new study.

However, certain important components are left out of this introduction that if included could

make it stronger. For example, the scope of the problem is not included. The reader is not

informed of how big of a problem this is, nor how many people are affected. The problem

statement also fails to include long-term consequences of not identifying midwives’ views and

their implication in practice regarding CAM. The argument is built on the explicit need for in-

depth qualitative research and it addresses the knowledge gap about what information is lacking.

A proposed solution is also included which mentions the utilization of a grounded theory

methodology with a theory emerging that relates to the social processes of the midwives included

in the study.

• Does the problem have significance for nursing?

The researchers did not specifically address the significance of the problem for nursing.

However, hospitals and community clinics involve health care teams that include nurses in the

maternity care setting. Nurse play an important role in whether or not expectant mothers follow

prescribed treatment plans and are often the mediator between the patient and the midwife.

Therefore, nurses must adequately inform the midwives of any CAM treatments that the patient

may have failed to inform them of which could affect patient care. As well as, inform the

midwife of expectant women who would like to purse CAM into their maternity care.

• Is there a good match between the research problem on the one hand and the paradigm

tradition and methods on the other?

There is a good match between the research problem and the paradigm tradition and

methods. Hall, Griffiths, and McKenna (2013) chose a naturalistic paradigm, so that the

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interpretations of the midwives could yield insights regarding the processes midwives use when

considered CAM for their maternity patients.

Research Questions

• Are research questions explicitly stated? If not, is their absence justified?

A research question is not explicitly stated; however, the specific aim of the study is

portrayed, namely that it “explicates the resulting substantive grounded theory, conceptualized as

navigating a safe path together, which offers a possible explanation of the processes midwives

utilize when considering CAM” (Hall, Griffiths, & McKenna, 2013, p. 801). Therefore, the

absence is justified.

• Are the questions consistent with the study’s philosophical basis, underlying tradition,

conceptual framework or ideological orientation?

Although no research question is explicitly stated, the study’s theoretical framework is

consistent with the aim of the study. It is implied in the introduction, and then later specifically

mentioned under the Research Method heading, that upon using a grounded theory approach, a

theory was developed. The theoretical underpinning is mentioned after the introduction which

was identified as symbolic interactionism.

Literature Review

• Does the report summarize the existing body of knowledge related to the problem or

phenomenon of interest?

Literature relating to the phenomena of interest was not described in the introduction.

There was not a summarization of prior research on this central topic. Nevertheless, it is useful

for the reader to know that there have been previous studies regarding midwives’ views, but the

fact that “how they behave in practice is largely unknown” (Hall, Griffiths, & McKenna, 2013, p.

801). Therefore, it is mentioned that researchers have emphasized the need for new research.

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There are also a few citations in the introduction that highlight the problem yet fail to focus on

the success or failure of prior research.

• Does the literature review lay a solid basis for the new study?

Due to the lack of a literature review in the introduction, it fails to provide a solid basis

for the new study. However, with qualitative studies, Polit & Beck (2014) mention that “once the

theory starts to take shape, grounded theorists use previous literature for comparison with the

emerging categories of the theory” (p. 140). This implies that it is not unusual that the

researchers have decided to waive a literature review in the introduction, because it will be

included as the process unfolds throughout the study.

Conceptual Underpinnings

• Are key concepts adequately defined conceptually?

The key concepts are not adequately defined in the introduction. As mentioned

previously, the theoretical framework and theoretical underpinnings are mentioned in the

Research Method portion that follows the Introduction.

• Is the philosophical basis, underlying tradition, conceptual framework or ideological

orientation made explicit?

The theoretical framework and theoretical underpinnings are made explicit in the

Research Method portion of the study. In the introduction, the only implications of the

framework lies in the inclusion that a grounded theory methodology was used and that a theory

emerged. Due to the mention of explaining the processes of the midwives, it can be assumed that

symbolic interactionism was utilized which is further made explicit later on in the study.

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Methods

Protection of Participants’ Rights

• Were appropriate procedures used to safeguard the rights of study participants?

Appropriate procedures were used to safeguard the rights of study participants. It is noted

that written informed consent from participants was received. Consent from pregnant women

that the midwives were interacting with was also obtained from the researchers due to the

requirement of observation. Also, pseudonyms were used instead of the participants’ real

identities.

• Was the study subject to external review by an IRB/ethics review board?

Under the Ethical Considerations subheading, it is mentioned that the researchers

received permission to conduct the study from relevant human ethics committees. The names of

these committees could have been included here.

• Was the study designed to minimize risks and maximize benefits to participants?

This study was not designed to minimize risks and maximize benefits, but instead to

construct a possible explanation of midwives’ responses and the processes that they go through

when considering CAM use. In the end, it will maximize the participants (25 midwives) by

offering insight and raising awareness of the midwives’ role in CAM use.

Research Design and Research Tradition

• Is the identified research tradition (if any) congruent with the methods used to collect and analyze data?

The research tradition was identified as grounded theory. This is congruent with the

methods used to collect and analyze the data. Polit & Beck (2014) mention that “in-depth

interviews and participant observation are common data sources in grounded theory studies;” the

data for this study was collected using semi-structure interviews and non-participant observation.

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• Was an adequate amount of time spent in the field or with study participants?

The time spent with the study participants was over an 18 month period during 2010-

2011. This is considered an adequate amount of time.

• Did the design unfold in the field, giving researchers opportunities to capitalize on early understandings?

The design did unfold in the field, which gave the researchers opportunities to capitalize

on early understandings. The research tradition was identified at the beginning of the study

which made it easy to follow through with understanding of the phenomenon.

• Were there an adequate number of contracts with study participants?

There is no mention of contacts with the study participants.

Sample and Setting

• Was the group or population of interest adequately described? Were the setting and sample described in sufficient detail?

The population of interest was adequately described as midwives. The sample, twenty-

five midwives, was described in sufficient detail. The setting, one private and three public

hospitals in metropolitan Melbourne, Australia, were also described in sufficient detail.

• Was the approach used to gain access to the site or to recruit participants appropriate?

The approach used to gain access to recruit participants was appropriate. The researchers

mention that all midwives who were employed by the hospitals were able to be a part of the

study if they wished. Also, the fact that the participants worked in all models of maternity care

increased the access to different sites for evaluation.

• Was the best possible method of sampling used to enhance information richness and address the needs of the study?

It is noted that purposive sampling was initially used; however, theoretical sampling was

undertaken after concepts from the participants began to emerge. When the researchers switched

Commented [KT1]: Why, rationale?

Commented [KT2]: The word contracts here should have been contacts, and

therefore the student did not

address accurately, but this has been corrected in the

course template and so I

would expect an accurate answer.

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to theoretical sampling, this initiated the best possible method of sampling to enhance

information richness and to address the needs of the study. Theoretical sampling allowed the

researchers to discover categories and new insight into the relationships, such as the factor of

how behavior towards CAM is affected by a midwives’ work environment (Polit & Beck, 2014,

p. 286).

• Was the sample size adequate? Was saturation achieved?

Polit & Beck (2014) mention that sampling in grounded theory research is typically done

with 20-30 people (p. 287). Therefore, since the sample size was 25, one would assume that the

sample size is adequate. This allowed for saturation to be achieved in which, the participants

contributed to the evolving theory in a beneficial way. The researchers mention that “data

collection and analysis continued simultaneously until all important concepts were fully

explored” (Hall, Griffiths, & McKenna, 2013, p. 802). This implies that the researchers achieved

data saturation. A suggestion for additional research may include utilizing negative cases or

midwives with unusual experiences to further achieve saturation.

Data Collection

• Were the methods of gathering data appropriate? Were data gathered through two or more methods to achieve triangulation?

The methods of gathering data were appropriate. Due to data being collected from in-

depth interviews and non-participant observation, two methods were used to achieve

triangulation.

• Did the researcher ask the right questions or make the right observations, and were they recorded in an appropriate fashion?

Table 1 includes the initial open-ended research questions that were asked to the

midwives during the interview. Later on, the interviews explored the themes that were emerging

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among the midwives. The interviews were tape-recorded and transcribed which prevents any

answers from being missed. Observations were also made while the midwives interacted with the

expectant mothers. Because the researcher’s discussed their interpretation with the participants

this prevented bias or misconstruing of data on the researchers’ part.

• Was a sufficient amount of data gathered? Was the data of sufficient depth and richness?

Sufficient amount of data was gathered and it was also sufficient in depth and richness.

The data achieved space triangulation due to researchers collecting at multiple sites which is

used “to test for cross-site consistency” (Polit & Beck, 2014, p. 327). Also, person triangulation

was achieved due to the data being collected from different levels of people (p. 327). The study

mentioned that the ages ranged from early 20s to late 50s with an average of 16 years’

experience. Also the model of maternity care ranged from case load midwifery to obstetric.

Procedures

• Were data collection and recording procedures adequately described and do they appear appropriate?

The data collection and recording procedures were adequately described. The researchers

include how they collected the data (e.g., through in-depth interviews and non-participant

observation) and the recording procedures (e.g., tape recording and field notes). These

procedures were appropriate for the study.

• Were data collected in a manner that minimized bias or behavioral distortions? Was the staff that collected data appropriately trained?

Data was collected in a manner than minimized bias or behavioral distortions. Due to the

fact that the researchers discussed with the participants what their interpretation was, this ensured

that the generalizations made reflected the experiences of the midwives. The staff that collected

the data appears to be appropriately trained. They are all professors at major nursing universities.

Commented [KT3]: Ratio nale?

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Enhancement of Rigor

• Did the researchers use strategies to enhance the trustworthiness/integrity of the study and was the description of those strategies adequate?

The researchers used the strategy of observation and tape-recording to enhance the

credibility of the study, as well as the authenticity of the study. Triangulation of the data and

methods provided enhancement of the credibility and the dependability of the study also. Since

the researchers utilized field notes, transferability was heightened. These strategies were

adequate and according to Lincoln and Guba (1985) (as cited in Polit & Beck, 2014, p. 323)

credibility, dependability, confirmability, and transferability are considered the criteria that is

used to develop trustworthiness of a research study.

• Were the methods used to enhance trustworthiness appropriate and sufficient?

The methods used to enhance trustworthiness were appropriate and sufficient. More

quality-enhancement strategies could have been utilized; however, the researchers may have had

page and space constraints in the journal.

• Did the researcher document research procedures and decision processes sufficiently that findings are auditable and confirmable?

The researcher did document the research procedures and decision processes sufficiently

which allowed the findings to be auditable and confirmable. The interviews allowed the data to

represent the participants’ voice and not the researchers’ biases or perspectives.

• Is there evidence of researcher reflexivity?

There is no evidence of researcher reflexivity. The reader is not provided any background

information regarding the researchers, besides their title and university they work for. If

provided, this could have enhanced the credibility of the study.

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Results

Data Analysis

• Were the data management and data analysis methods sufficiently described?

The data management and data analysis methods were described as open, axial, and

selective coding. The researchers provided two tables, one that showed an overview of the data

analysis process and then one that showed how the raw data was categorized.

• Was the data analysis strategy compatible with the research tradition and with the nature and type of the data gathered?

The data analysis strategy was compatible with the research tradition and with the nature

and type of the data gathered. The researchers used constant comparison, which continued until

all of the sources had been compared and explored (Polit & Beck, 2014, p. 311). Polit & Beck

(2014) mention that Strauss and Corbin’s (1998) approach to grounded theory analysis can

utilize three types of coding, which the researchers used all three, and the outcome of the

approach represents a full conceptual description (p. 314).

• Did the analysis yield an appropriate “product” (e.g., a theory, taxonomy, thematic pattern, etc.)?

The analysis did yield an appropriate “product,” which can be defined as a theory:

navigating a safe path together.

• Did the analytic procedures suggest the possibility of biases?

The analytic procedures did not suggest the possibility of biases. The researchers include

that theoretical memos and diagrams were used to conceptualize the data, and they mention that

because of this it created a “valuable audit trail” and a means to explore the internal logic of the

theory (Hall, Griffiths, & McKenna, 2013, p. 802).

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Findings

• Were the findings effectively summarized, with good use of excerpts and supporting arguments?

The researchers did an excellent job at effectively summarizing the findings. This portion

of the research article was the most lengthy and included the bulk of the information. Three

transitional phases (themes) were identified: individualizing pregnancy care, encountering

diverse perspectives, and minimizing the risks of childbearing. Four interrelated categories were

also identified and described in detail. The researchers used good excerpts from the participants

to bring alive the transitional phases and categories for the readers.

• Do themes capture the meaning of the data? Does it appear that the researcher satisfactorily conceptualized themes or patterns in the data?

The themes capture the meaning of the data adequately. It also appears that the

researchers satisfactorily conceptualized the themes or patterns in the data. The researchers broke

down each theme into a separate subheading and explained in detail the meaning of each

particular data. They also separated the interrelated categories by individual subheadings and

explained each. Polit & Beck (2014) state that studies designed to create a theory involve

abstract, conceptual categories (p. 301). They further mention that the researchers must break the

data down into segments and compare these segments to others in order to convey the meaning

of the phenomena (p. 301). Hall, Griffiths, and McKenna (2013) did a good job of doing this in

their research study.

• Did the analysis yield an insightful, provocative, authentic and meaningful picture of the phenomenon under investigation?

The analysis yielded an insightful, provocative, authentic and meaningful picture of the

phenomenon under investigation. The researchers used thick description, which is described as

“a rich, thorough, and vivid description of the research context, the people who participated in

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the study, and the experiences and processes observed during the inquiry” (Polit & Beck, 2014,

p. 331). The results suggest a well-organized and powerful depiction of competing demands

midwives should negotiate when considered CAM use.

Theoretical Integration

• Are the themes or patterns logically connected to each other to form a convincing and integrated whole?

The themes are logically connected to each other and they form a convincing and

integrated whole. Hall, Griffiths, and McKenna (2013) state that “the basic social process (BSP)

that they utilize to deal with the central problem is conceptualized as navigating a safe path

together” (p. 803). That process was also considered the core category. The researchers were

able to use the various themes and interrelated categories to create an overall structure, such as

the theory that emerged, for the data.

• Were figures, maps or models used effectively to summarize conceptualizations?

Three different tables were provided that allowed summarization of conceptualizations.

The authors created a theoretical model or figure to further emphasize the relationships between

the transitional themes, the interrelated categories and the contextual conditions. This allowed a

visual representation for readers to summarize the conceptualizations further.

• If a conceptual framework or ideological orientation guided the study, are the themes or patterns linked to it in a cogent manner?

The themes are linked to the theoretical framework and approach in a cogent manner.

The themes emerged from the data in which a theory could be formed.

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Discussion

Interpretation of the Findings

• Are the findings interpreted within an appropriate social or cultural context?

The findings are interpreted within an appropriate social context. Basic social processes

were used to create the core category of navigating a safe path together. The researchers include

the social process that midwives encounter when considering CAM use is common to all

participants. They further mention that symbolic interactionism allowed for the readers to

understand how meaning is created for individuals in social situations. Socially, the researchers

mention that CAM is becoming more accepted and utilized in the communities of Australia.

There are no cultural contexts mentioned in the study.

• Are major findings interpreted and discussed within the context of prior studies?

The major findings of each transitional phase or theme that emerged from the study were

discussed within the context of prior studies. Hall, Griffiths, and McKenna (2013) compared

their results with previous research on the integration of CAM into hospital maternity care. They

mention that they also utilized previous Australian research to compare the findings with. In the

study, they found that “midwives presented the therapies as harmless or complementary and

emphasize historical ties and philosophical congruence” (p. 806). This excerpt from the

discussion was noted similar to other research including approximately 10 studies.

• Are the interpretations consistent with the study’s limitations?

The study only mentions one limitation, namely that the study may not be transferable to

different settings due to the small sample. The researchers could have been more insightful in

considering other limitations of the study. However, numerous strengths of the study were

explicitly stated.

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• Does the report support transferability of the findings?

The researchers specifically state that due to the data being generated from a “small

group of self-selected midwives working in Australian hospitals” the findings may not be

transferable to a different setting (Hall, Griffiths, & McKenna, 2013, p. 807).

Implications/Recommendations

• Do the researchers discuss the implications for clinical practice or further research

and are those implications reasonable and complete?

The implications for clinical practice are mentioned, such as awareness is now raised

regarding the midwives’ role with CAM and thus can improve maternity care for individuals in

similar situations. Also, it is noted that this theory could be used in other situations when

midwives are working with childbearing women in whom choices may be made by the patient

that challenges standard medical care. The researchers discussed the implications for further

research, namely that there is a need for improved education and better professional guidance to

allow midwives the ability to respond with understanding when considering CAM use with the

patient. These are both discussed in the conclusion portion of the article and the implications are

reasonable and complete.

Global Issues

Presentation

• Was the report well-written, well-organized, and sufficiently detailed for critical

analysis?

Hall, Griffiths, and McKenna’s (2013) report was well-written, well-organized, and

sufficiently detailed for critical analysis. The organizational structure of the report included

headings and subheadings that made for location of specifics easy for the reader. It allowed for

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the theory to be broken down and explained thoroughly without important information being left

out or forgotten.

• Was the description of the methods, findings and interpretations sufficiently rich and

vivid?

The methods, findings and interpretations were sufficiently rich and vivid. The use of

tables and the theoretical model presented as a figure further elaborated the findings. The

researchers did an excellent job at interpreting the findings and took strides to ensure that the

interpretation of the data reflected the participants’ meanings.

Researcher Credibility

• Do the researchers’ clinical, substantive, or methodologic qualifications and experience

enhance confidence in the findings and their interpretation?

We are not provided much information regarding the researchers’ clinical, substantive, or

methodologic qualifications and experience. The only information we are provided with are the

credentials of the three researchers and the universities in Australia that they work for and

completed the research under. Perhaps, the authors could have provided information about

personal connections the researchers had to the topic under study which could have enhanced the

researcher credibility. They also could have described the efforts they took to be reflexive and to

take their own perspectives into account.

Summary Assessment

• Do the findings appear to be trustworthy-do you have confidence in the truth value of

the results?

The findings appear to be trustworthy which allows for confidence in the truth value of

the results. Due to the researchers providing the section that includes the strengths of the study,

the reader is able to determine that the findings further enhance the trustworthiness of the report.

The methodological rigor was enriched by the use of multiple quality enhancing strategies which

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addressed numerous criteria and promoted trustworthiness. Furthermore, the report was both

descriptively accurate and explicit.

• Does the study contribute meaningful evidence that can be used in nursing practice or

that is useful to the nursing discipline?

The study implies that the evidence can be used in nursing practice in regard to obstetrics

in diverse situations that challenge standard medicine. Also, the consideration of using CAM can

affect doctors and practitioners in other fields of medicine in which this theory could be

applicable to them as well.

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References

Hall, H. G., Griffiths, D. L., & McKenna, L. G. (2013). Navigating a safe path together: A theory

of midwives' responses to the use of complementary and alternative medicine. Midwifery,

29(7), 801-808. doi:10.1016/j.midw.2012.06.019

Polit, D. F., & Beck, C. T. (2014). Essentials of nursing research: Appraising evidence for

nursing practice (8th ed.). Philadelphia: Lippincott, Williams, & Wilkins.