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Learning Outcomes:

On successful completion of this unit, you should be able to:

1. identify health care situations and contexts where evidence-based practice can be applied;

2. critically discuss the factors which influence the use of evidence-based practice to deliver best management practices across a range of health care settings; (GA3, 4)

3. describe the range of information sources and levels of evidence to inform health practice; (GA4, 8)

4. demonstrate foundational level skills in accessing, appreciating and applying evidence from a range of sources to inform health practice; (GA4, 8, 9)

5. apply information literacy capabilities to the construction of evidence-based practice. (GA10)

Research Questions

Critical-appraisal involves a systematic way of determining the strengths and weaknesses of the methods employed in the study (Boswell, n. d., p.412). This report carefully scrutinizes the cross-sectional study on ‘the real-world effectiveness of e-cigarettes that aids in smoking cessation’. Brown (2014, p.1531) has given a clear title with an focused-abstract condensing the main points of the study. They stated an understandable purpose that is appropriate to health-practice. It answers their study-questions with a detailed description about scope and limitations. It gives the rationale and potential importance in conducting the study with a clear background to this study.

Authorship includes the person who has conducted the study, their job-titles, and qualifications with designations (Boswell, n. d, p.414). The study-authors Brown, Beard, Kotz & West are expertise in the cancer-research and health-behavior research field while Brown and Michie are from the Clinical, educational with health-psychology department whereas Kotz is from the Family-Medicine and Public-health & Primary-Care department whereas Michie & West is from the Nation’s Centre for smoking-cessation & training. This indicates that the study-authors’ qualifications and affiliations are related to their topic written. They have avoided all the possible biases in measurement, sampling, response and publication aspects.   

They acknowledged Jarvis, Shahab & Raupach for issuing valuable comments in their draft. No conflicts of interest were noted. The study’s funding sources include UK-Society’ fellowship for the Addiction-study, Cancer-Research centre UK; Pfizer (includes Pfizer investigator-initiated award) and GlaxoSmithKline & Johnson-and-Johnson.

Brown (2014, p.1532) has stated an achievable research-question as ‘How electronic-cigarettes are more effective as compared to NRT (nicotine-replacement therapy) bought over-the-counter as well as un-aided smoke-quitting among the general smoking-population, those who aim to quit’, as suggested by Grove (2015, p.150-151). According to Greenhalgh (2017), justifications has to be given for selecting particular research-question, which is evidenced here by mentioning that though smokers are licensed to use NRT to quit-smoking, the effectiveness of e-cigarettes should be evaluated to rule-out the most effective quitting method. Moreover, the increased popularity of e-cigarettes, presence of evidence in 2-RCTs suggesting effect of electronic-cigarettes in smoking-cessation but with several factors affecting real-world effectiveness and use of NRT without professional-support with lack of greater-success in it (Kotz, 2014, p.491–9) has motivated them to propose this study.

According to Liamputtong (2016), research-design is defined as the overall-plan that addresses the study’s question. They have selected cross-sectional house-hold survey-design under non-experimental type to gather data from representative-samples of smoking-population (sample-surveys) to evaluate the e-cigarette’s real-world effectiveness by comparing the abstinence rates (self-reported) of smokers between the e-cigarettes users (without behavior-supports and/or pharmacological cessation) and NRT users to achieve their research-question.

Research Methods

Research-methods are the specialized techniques utilized to structure a research-study and to gather and analyze information in a systematic-manner (Polit, 2017, p.764-766). They recruited 5863 adult-smokers (within past 12 months), who has tried to quit at-least once in their study-period either in case of e-cigarette (n=464; 219 females), NRT-purchased OTC (n=1922; 982 females) or without aid in their last cessation attempt (n=3477; 1699 females).

They recruited 1800 new-participants aged ≥16years each month through random-location sampling (different-locations) and computer-aided face-to-face survey with the help of trained interviewer. They used larger representative samples of the adult-English population by giving equal chance to the entire population to get recruited to avoid sampling bias (Polit, 2017, p.337-340). They obtained informed consent from all the participating samples for anonymized data sharing. They got ethical-clearance from the University-College’s ethics-committee, London. They haven’t mentioned about the protection of study-samples but their text suggests that they haven’t imposed any harm on them. It is noted that they have randomized the study-location and has surveyed newer samples every month to avoid bias, which is highly-acceptable.

Surveys usually get information from samples through self-reporting method in which the subjects respond to a set of questions that are posed by interviewers (Gerrish, 2015, p.255). They used computerized face-to-face interviews to gather self-reported abstinence data which will not be subjected to any biases as noted in clinical-trials (Wong, 2012, p.47–53). They have measured the confounders of varied quitting-methods that could affect the outcome adequately.

In quantitative-analysis, the numerical data is manipulated to evaluate the magnitude and reliability of the relationships between them. They performed point-estimation (confidence-interval) to draw inferences (Newcombe, 2012, p.26) and Bi-variate analysis to analyze usage of varied quitting-methods and confounding-variables; through χ2-tests for categorical and ANOVA for continuous-variables. ANCOVA is used to evaluate the difference between the smokers and non-smokers in-regard to the strength of smoking-urge, based on varied quitting-method and omnibus findings were examined by post-hoc (Sidak-adjusted) χ2 & t-tests, which will aid to achieve their research-question.

They have well-presented their data in tables about associations between sample characteristics and varied quitting-techniques, difference between smoking and non-smoking people in strength of smoking-urges by quitting-method and associations between quitting-techniques and abstinence. The results suggest that use of e-cigarettes is highly effective than NRT-products. The limitations that include increased reliance upon recalling data-questions and absence of biochemical verification for abstinence, questions the reliability of the study. But, use of bi-variate analysis and measures to control possible confounders confirms that the study-finding can be best used in practice.     

At the end of detailed appraisal, this research-study is found to meet all the PICO elements that are provided in the scenario’s clinical question. P (Population)- Adult English population, I (Intervention)- Using electronic-cigarettes, C (Comparator)- NRT purchased by OTC or without professional-support for smoke-cessation and O (outcome)- Real-world effect in smoke-quitting (Hoffmann, 2017, p.22-23).  

The author’s recommendations include: 1). Use of electronic-cigarettes are found to aid in long-lasting smoke cessation than that of NRT products obtained by over-the-counter or without professional guidance. 2). It is the first research-study to identify the benefits of using electronic-cigarettes in smoke quitting, especially in its emerging period. 3). Further studies should be conducted in a broader area of smoke-dependency measures along with evaluation of smoke-dependence before quitting attempt to draw high-quality inferences.

The study-findings yields a stronger-evidence based measure to be practiced in the healthcare settings. It is definitely best evidence that is obtained by controlling several confounders to avoid biased outcome. It enable clinical expertise in the health-professionals with appropriate evidence to motivate Joanne to use electronic-cigarettes to aid in continued smoking-cessation than that of NRT-products that are bought Over-the-counter and/or un-aided without professional-support (Brown, 2014, pp.1538). This quality-evidence will enable patient values within their preferences by easing their smoke-quitting in a shorter duration with lesser complications but with continued cessation than NRT-products as given by Melnyk (2014, p.5). This quality-evidence can help Jonnane to quit smoking by e-cigarettes rather than ineffective NRT-products and enhance her values. No organization barriers but the individual barriers such as acceptance and reliability in using e-cigarettes can prevent these recommendations from being adopted.          

Conclusion

The critical-appraisal suggests that this study has a clear background, focused-objective, testable research-questions, elaborate literature-review, appropriate design, large sample-size, control of confounders, random-location sampling and personal survey with detailed statistical-methods and relevant findings indicating that the study forms the best-evidence for practice. In-spite of certain drawbacks, this study forms best-evidence suggesting the real-world effectiveness of using electronic-cigarettes to quit smoking as compared with NRT-products got OTC and un-aided support.

Reference

Boswell, C. (n. d.). Chapter-14: The research critique process and the evidence based appraisal process, 412-414. Retrieved from https://samples.jbpub.com/9781284079654/9781284108958_CH14_Pass03.pdf

Brown, J., Beard, E., Kotz, D., Michie, S., & West, R. (2014). Real-world effectiveness of e-cigarettes when used to aid smoking cessation: A cross-sectional population study. Addiction, 109(9), 1531- 1540. doi:10.1111/add.12623

Gerrish, K., & Lathlean, J. (2015). The research process in nursing (7th ed.). Malden, MA: John Wiley & Sons, 255-256.

Greenhalgh, T.H., Bidewell, J., Crisp, E., Lambros, A., & Warland, J. (2017). Understanding research methods for evidence-based practice in health (online). Milton, Australia: Wiley.

Grove, S. K., Grey, J. R., & Burns, N. (2015). Understanding nursing research: Building an evidence-based practice (6th ed.). London, United Kingdom: Elsevier, 150-151

Hoffmann, T., Bennett, S., & Del Mar, C. (2017). Evidence-based practice across the health professions (3rd ed.). Chatswood, Australia: Elsevier, 22-23.

Kotz, D., Brown, J & West, R. (2014). Real-world effectiveness of smoking cessation treatments: a population study. Addiction, 109, 491–9.

Liamputtong, P. (2016). Research methods in health: Foundations for evidence-based practice. (3rd ed.). South Melbourne, Australia: Oxford University Press. Retrieved from 
https://ezproxy.acu.edu.au/login?url=https://ACU.eblib.com/patron/FullRecord.aspx?p=1986006 

Melnyk, B.M et al. (2014).  The establishment of EBP competencies for practicing RNs and advanced practice nurses in real world clinical settings: Proficiencies to improve health care quality, reliability, patient outcomes and cost: worldview on Evidence based practice, 11 (1), 5-15. doi.10.1111./WBN.12021  

Newcombe, R.G. (2012). Confidence Intervals for Proportions and Related Measures of Effect Size, 26. Retrieved from https://books.google.co.in/books?isbn=1439812780

Polit, D.F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer, 764-766, 337-340

Wong, S. L., Shields, M., Leatherdale, S., Malaison, E & Hammond, D. (2012). Assessment of validity of self-reported smoking status. Health Rep, 23, 47–53.

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