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Critiquing Research

Part 1Answer all questions that apply to the quantitative and/or qualitative study that you selected.The paper should be in narrative form, use APA format, and include a title page and a reference page. Use your research textbook to help you answer the questions and explain/define the terms.

When doing a research critique, it is acceptable to put the reference for the article on the bottom of the title page. Do not cite the article within the body of the paper. All other resources (such as the research textbook) must be cited and referenced as usual.

Critiquing Research Part II

IV. Research Design

Is the research quantitative or qualitative?

If quantitative is it experimental or non-experimental?

If it is a mixed-method design, did this approach enhance the study?

Is the design appropriate to answer the questions indicated by the problem and/or hypotheses?

Is the target population identified? Are eligibility criteria specified?

What type of sampling plan was used? What are the key characteristics of the sample?

Is the setting appropriate for the study?

V. Data Collection

Is informed consent utilized?

Who collected the data?

How were the data collected? (survey, interview, etc.)

Are the measurement instruments or tools clearly described?

What statistical tests were utilized?

Is reliability (consistency) and validity (accuracy and precision of measurement instruments) addressed?

VI. Interpretation, Discussion, and Clinical Application

Are all of the important results discussed?

State author’s conclusion and recommendations.

What are the author’s implications for practice?

Identify 3 researchable questions for further study.

State if and when/where you would put the research findings into practice.

References are required: One from the course textbook. Other references from a peer-reviewed NURSING journal less than 5 years old. National professional, governmental, or educational organizations (.org, .gov, or.edu) be used as supplemental references.

Must use the textbook as Reference

Here is the textbook!

Polit, D. E & Beck, C. T. (2018). Essentials of Nursing Research: Appraising Evidence for

nursing practice (9th ed.) Philadelphia: Wolters Kluwer Health

ISBN: 9781496351296 (Book) Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
Jia-Ling Sun, PhD, RN
Chia-Chin Lin, PhD, RN
Relationships Among Daytime Napping
and Fatigue, Sleep Quality, and Quality of
Life in Cancer Patients
K E Y
W O R D S
Background: The relationships among napping and sleep quality, fatigue, and
Cancer
quality of life (QOL) in cancer patients are not clearly understood. Objective: The
Fatigue
aim of the study was to determine whether daytime napping is associated with nighttime
Napping
sleep, fatigue, and QOL in cancer patients. Methods: In total, 187 cancer patients
Quality of life (QOL)
were recruited. Daytime napping, nighttime self-reported sleep, fatigue, and QOL
Sleep quality
were assessed using a questionnaire. Objective sleep parameters were collected using
a wrist actigraph. Results: According to waking-after-sleep-onset measurements,
patients who napped during the day experienced poorer nighttime sleep than did
patients who did not (t = j2.44, P = .02). Daytime napping duration was significantly
negatively correlated with QOL. Patients who napped after 4
PM
had poorer sleep
quality (t = j1.93, P = .05) and a poorer Short-Form Health Survey mental
component score (t = 2.06, P = .04) than did patients who did not. Fatigue, daytime
napping duration, and sleep quality were significant predictors of the mental
component score and physical component score, accounting for 45.7% and 39.3% of
the variance, respectively. Conclusions: Daytime napping duration was negatively
associated with QOL. Napping should be avoided after 4
PM.
Implications for
Practice: Daytime napping affects the QOL of cancer patients. Future research can
determine the role of napping in the sleep hygiene of cancer patients.
C
ancer diagnosis and treatment cause patients to experience symptom distress, particularly sleep disturbance,
fatigue, and poor quality of life (QOL). Fatigue and sleep
disturbance are 2 of the most prevalent and distressing symptoms
experienced by cancer patients.1 Studies have reported that poor
sleep quality negatively influences health-related QOL.2,3 Sleep
Author Affiliations: Department of Nursing, Yuanpei University of Medical
Technology, Hsinchu (Dr Sun); and School of Nursing, College of Nursing,
Taipei Medical University, Taipei (Dr Lin), Taiwan.
This study was supported by the Ministry of Science and Technology (97-2314B-038-044-MY3).
The authors have no conflicts of interest to disclose.
Correspondence: Chia-Chin Lin, PhD, RN, School of Nursing, College of
Nursing, Taipei Medical University, 250 Wuxing St, Taipei 11031, Taiwan,
Republic of China (clin@tmu.edu.tw).
Accepted for publication June 3, 2015.
DOI: 10.1097/NCC.0000000000000299
Napping, Fatigue, Sleep Quality, QOL in Cancer Patients
Cancer NursingTM, Vol. 39, No. 5, 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
n
383
disturbances are a series of sleep problems, such as difficulty
initiating and maintaining sleep, nonrestorative sleep, short duration of sleep, and impairment of daytime functioning.4 Sleep
is crucial in the health-related QOL of cancer patients. A previous study revealed that the sleep quality of cancer patients is
associated with the mental component score (MCS) of the 36-item
Short-Form Health Survey (SF-36) used to measure QOL and that
sleep quality and daytime napping are associated with the physical
component score (PCS).3 Moreover, another study indicated that
fatigue may be associated with total nap time in cancer patients
undergoing chemotherapy.1
Numerous people habitually take naps, which help maintain
energy levels. The prevalence of daytime napping in the British
population was 29.8%, 90% of whom napped for less than 1 h/d.5
The prevalence rates of napping are high among elderly people
(56.34%), retired people (53%), and people older than 50 years
(42%).6,7 A previous study reported that 25% of the world population engages in regular daytime napping and that the median
nap duration is 60 minutes.8 People typically nap for 20 to 30 minutes, and 30 and 60 minutes are the 2 most common total
daytime napping durations.7 A short nap less than 30 minutes
helps prevent afternoon sleepiness.9 An electroencephalogram
study revealed that longer naps cannot improve the daytime performance in elderly people.10 However, 60- to 90-minute naps
lead to slow-wave sleep and rapid eye movement.11 People with
inadequate nighttime sleep can experience daytime sleepiness
and may require daytime napping, particularly in the early afternoon.12 Napping compensates for sleep lost the previous night
and improves the immune system.13 A short nap (e20 minutes)
is effective in maintaining alertness throughout the rest of the
day and compensates for a poor night of sleep.13
Although naps are effective in managing fatigue,14 prolonged
daytime napping has harmful outcomes. In addition, afternoon
napping was associated with increased daytime sleepiness in patients with chronic fatigue syndrome.15 Fatigue severely peaks
between 2 and 4 PM,16 and daytime sleepiness typically occurs
during this time interval17; afternoon napping is recommended
in such a scenario. Napping for less than 30 minutes between 1
and 3 PM has been indicated to enhance QOL and sleep quality
in elderly people.16,18 By contrast, elderly people who nap in
the evening or before going to bed have poor nighttime sleep
quality and daily function.18 Sleep is a crucial component of
the circadian rhythm in humans. Circadian-rhythm sleep disorders arise from internal desynchronization.
The National Comprehensive Cancer Network defines cancerrelated fatigue as a distressing and persistent subjective sense of
physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to
recent activity and interferes with usual functioning.19,20 Fatigue
can be relieved by identifying the cause and providing mitigating
interventions. The National Comprehensive Cancer Network21
and a previous study20 have reported that fatigue arises from pain,
emotional distress, sleep disturbance, anemia, poor nutrition, deconditioning because of reduced activity, and comorbidities. Previous studies have shown that awareness and counseling, increased
activity, exercise and sports therapy, and psychosocial interventions
are effective strategies for preventing and managing fatigue.22,23
Fatigue and sleepiness are overlapping phenomena with similar
manifestations, and distinguishing the two is difficult.24,25 Daytime sleepiness is a disorder characterized by the inability to stay
awake and the tendency to fall asleep during daytime.26 Patients
with fatigue or sleepiness experience poor sleep quality and desire sleep during daytime. In a previous study, patients with chronic
fatigue syndrome experienced adequate sleep, and insufficient sleep
was not a factor that caused fatigue.25 This finding explains why
fatigue patients could not resolve their fatigue by sleeping.
Few studies have examined the relationships among daytime
napping, fatigue, sleep quality, and QOL in cancer patients. The
relationships among napping and sleep quality, fatigue, and QOL
in cancer patients are not clearly understood; therefore, we explored these relationships. In addition, we examined whether
daytime napping after 4 PM is a significant factor affecting fatigue, nighttime sleep quality, and QOL and whether daytime
napping, fatigue, and sleep quality are predictors of QOL.
n
Methods
Study Design
A cross-sectional research design and consecutive sampling were
used for recruiting participants. Participants were recruited from
the oncology outpatient clinic of a teaching hospital in northern
Taiwan. To ensure inclusion of all of the accessible subjects, the
researcher invited the patients to join the research after explaining the research purposes, procedure, and design when each patient completed the clinic visit.
n
Participants
The selection criteria were as follows. Patients should (a) have a
confirmed pathological diagnosis of cancer, (b) be at least 18 years
old, and (c) be able to communicate in Mandarin or Taiwanese.
Patients with a history of (a) mental impairment, including depression, psychologically ill health, schizophrenia, or psychosis
(determined through chart history review), or (b) any form of
impairment of the upper extremities were excluded from the
study because participants were required to wear Actiwatch, a
wrist actigraph. Consecutive sampling was used in this study, and
the researchers approached patients who satisfied the selection
criteria. All recruited participants provided written informed consent.
Among the 269 recruited cancer patients, 74 were excluded
because of deficiencies in the actigraph data, and 8 were excluded because of incomplete questionnaires. In total, 187 patients completed all procedures.
Instruments
Napping. The researcher developed a self-report napping questionnaire with 3 items to collect daytime napping habits, namely,
daytime napping habits, daytime napping duration, and napping
duration after 4 PM. Napping after 4 PM was recorded separately
because such late napping affects the circadian rhythm.16,17,26
384 n Cancer NursingTM, Vol. 39, No. 5, 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Sun and Lin
Napping habits were recorded using the item ‘‘Do you engage in
daytime sleep?’’ (yes or no) and ‘‘Do you take a nap after 4 PM?’’
(yes or no). Daytime napping duration, defined as the total duration of all naps per day, was recorded in minutes (>60 and
e60 minutes), with participants recalling the past month; the
threshold of 60 minutes was obtained from a previous study.27
Sleep. Subjective sleep quality was assessed using the Taiwanese
version of the Pittsburgh Sleep Quality Index (PSQI-T). The
PSQI-T was proven as a valid and reliable instrument for assessing sleep quality and has been applied in several studies to
measure sleep quality in Taiwanese cancer patients.28,29 The
PSQI-T is a 19-item questionnaire comprising 7 dimensions:
subjective sleep quality, sleep latency, sleep duration, sleep efficiency (SE), sleep disturbances, sleep medications, and daytime
dysfunction. Each dimension is rated on a scale of 0 to 3, with
the total score ranging from 0 to 21. A total score higher than
5 indicates poor sleep quality.
Objective Sleep Quality. Objective sleep quality was measured using an Actiwatch (MiniMitter-Respironics Co, Inc, Bend,
Oregon) ambulatory device; this device measures arm movements
and collects activity data in 1-minute epochs. The data were
uploaded to a computer and manually marked sleep duration
according to the participants’ night-sleep bedtimes and wakingtime recordings. The data for sleep onset latency (SOL), SE,
waking after sleep onset (WASO), and total sleep time (TST)
were obtained.
The data were used as physiological parameters in analyzing
sleep variability. Sleep onset latency is the time elapsed from
attempting to fall asleep to the onset of sleep, SE is the percentage of the scored TST against total duration of bedtime,
WASO is the total number of epochs between the start and end
times of a given sleep interval, and TST is the duration of sleep
between the start and end times of a given interval. Actiwatch is
as effective as polysomnography and exhibits high specificity
and sensitivity.30,31
Fatigue. Fatigue was assessed using the Taiwanese version
of the Brief Fatigue Inventory (BFI-T), which was developed
at the University of Texas M. D. Anderson Cancer Center for
measuring fatigue in cancer patients.32 In the BFI-T, fatigue
severity and interference with life activities in the preceding
24 hours are measured on a scale of 0 to 10. The first section
of the BFI-T entails measuring the most severe fatigue during
the preceding 24 hours, typical fatigue during the preceding
24 hours, and current fatigue. Each item is rated from 0 (no
fatigue) to 10 (fatigue as bad as you can imagine); the average
score of these was adopted. The second section entails assessing
the extent to which fatigue interferes with general activities, mood,
walking, normal work, interpersonal relationships, and the QOL
enjoyment. Each item is rated on a scale of 0 (does not interfere
with activity) to 10 (completely interferes with activity), and the
average score of the 6 items was adopted. Higher scores indicate
higher fatigue severity. The fatigue interference score is the
average of the 6 interference items and has been shown to be a
valid and reliable tool for assessing cancer-related fatigue.32,33
Quality of Life. The Taiwanese version of the SF-36 (SF-36YT)
was adopted as the measure of QOL in this study. The SF-36,
developed in a Medical Outcomes Study,34 contains 36 variable
Napping, Fatigue, Sleep Quality, QOL in Cancer Patients
items from 8 dimensions, namely, physical functioning (10 items),
role limitations caused by physical health problems (RP, 4 items),
bodily pain (2 items), general health (5 items), vitality (4 items), social
functioning (2 items), role limitations caused by emotional problems
(RE, 3 items), and mental health (5 items). These 8 measurement
dimensions are used to calculate the PCS and MCS. The PCS is
determined by averaging the physical functioning, RP, bodily
pain, and general health scores, and the MCS is calculated by
averaging the vitality, social functioning, RE, and mental health
scores. This generic QOL instrument has been widely used
across different disease populations. SF-36YT has been validated
in a sample of healthy adults.35,36 Scores of each variable item
are coded and summed. For comparing the results of this study
with those of other studies and disease populations, all raw scale
scores were transformed to standardized scores ranging from
0 (worst possible health state measured by the questionnaire) to
100 (best possible health state).
Demographic and Disease Information. We administered a
self-report demographic and disease information questionnaire
to collect information on age, sex, education level, and marital
status. We collected the diagnosis, staging, current cancer treatment, and time since diagnosis from chart records.
Study Procedure
The institutional review board of the teaching hospital approved
this study. Data were collected from the outpatient department.
When patients finished the clinic visit, the researcher approached
the eligible patients. The researcher invited patients to participate
in the study after the study objectives were explained. The patients
were recruited if they passed the screening selection criteria. Participants signed a written consent form and completed a paperpencil questionnaire. All data in this study were collected by the
same researchers. Diagnosis, staging, and treatment data were
collected from chart records, and the remaining demographic
data were obtained through a self-rated questionnaire. Patients
completed the questionnaire. The participants recalled their sleep
quality and disturbances, QOL, and fatigue for the past 1 month.
The researchers reviewed the data for missing items. After the
procedure of complete questionnaire, the researchers demonstrated
how to the use the Actiwatch on the dominant wrist. The participants were then requested to wear it for 3 consecutive nights
while sleeping and to record their bedtimes and waking times in
a sleep recording. When the Actiwatch data were collected, the
research procedure was completed.
Data Analyses
Data were analyzed using SPSS Statistics (version 19.0; IBM, USA).
We used descriptive statistics to present the questionnaire data.
One-way analysis of variance and a # 2 test were performed to
compare the differences between nappers and nonnappers groups.
The t test was used to assess differences between 2 groups, including the nappers and nonnappers groups, napping after 4 PM
and not napping after 4 PM groups, nap duration of 60 minutes
or less and more than 60 minutes groups, and the follow-up and
consulting group and undergoing treatment group. The relationships
Cancer NursingTM, Vol. 39, No. 5, 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
n
385
among the objective sleep parameters, sleep quality, fatigue,
napping habits, daytime napping duration, and napping duration after 4 PM based on the MCS or PCS were investigated using
Pearson correlation coefficients. These significance variables were
used as predictors of MCS or PCS; therefore, stepwise regression
was used. Statistical significance was defined as P e .05.
n
Results
Demographic and Disease-Related Characteristics
We collected data from 187 participants, whose average age was
54.97 (SD, 12.83) years. The participants had received a diagnosis of breast (37.4%), gastrointestinal (26.2%), head and neck
(12.3%), genitourinary (8.0%), lung (6.4%), and other cancers
(9.7%). At the time of the study, 81.3% of the participants were
undergoing cancer treatments, and the remaining 18.7% were
in the follow-up and consulting stage. Furthermore, Of the participants currently undergoing treatment, 19.7% were undergoing chemotherapy, 33.6% radiotherapy, 27.6% both chemotherapy
and radiotherapy, 5.9% hormone therapy, 2.0% target therapy,
3.3% both radiotherapy and hormone therapy, 4.0% both radio-
therapy and target therapy, 3.3% both chemotherapy and hormone,
and 0.6% were undergoing both chemotherapy and target therapy. Table 1 lists the demographic and disease-related characteristics of the participants. The mean time since the completion
of treatment was 24.51 (SD, 28.97) months for participants in
the follow-up and consulting group. No significant differences
were observed in nap habits, sleep quality, fatigue, objective sleep
parameters, MCS, and PCS (t = j0.32, j0.38, j1.16, j0.85 to
0.13, 1.9, and 1.49, respectively, all P > .05) between the follow-up
and consulting group and undergoing treatment group.
Sleep Quality, Fatigue, and Quality of Life
The global sleep quality score of the participants, measured
using the PSQI-T, was 7.16 (SD, 4.25). The PSQI-T scores of
subjective sleep quality, sleep latency, and sleep duration were
1.50 (SD, 0.91), 1.29 (SD, 1.06), and 1.19 (SD, 1.01), respectively.
The subjective sleep parameters were obtained from the Actiwatch. The average SE was 76.20% (SD, 10.75%), the average
SOL was 22.28 (SD, 29.58) minutes, the WASO was 72.48
(SD, 31.55) minutes, and the TST was 355.75 (SD, 76.26) minutes.
Fatigue severity and interference were 3.52 (SD, 2.40) and
1.50 (SD, 1.98), respectively. The PCS and MCS, measured
Table 1 & Patient Demographics and Cancer-Related Information (N = 187)
All (N = 187)
Characteristics
Sex
Female
Male
Marital status
Married
Other
Diagnosis
Lung
Gastrointestinal
Head and neck
Genitourinary
Breast
Other
Stage of cancer
I
II
III
IV
Unknown
Treatment
Chemotherapy
Radiotherapy
Chemotherapy + radiotherapy
Other treatments
Follow-up + consulting
Age, y
Education, y
a
Nappers (n = 106)
Nonnappers (n = 81)
n
%
n
%
n
%
115
72
61.5
38.5
62
44
58.5
41.5
53
28
65.4
34.6
152
35
81.3
18.7
92
14
86.8
13.2
60
21
74.1
25.9
12
49
23
15
70
18
6.4
26.2
12.3
8.0
37.4
9.7
9
32
13
11
32
9
8.5
30.2
12.3
10.4
30.2
8.5
3
17
10
4
38
9
3.7
21.0
12.3
4.9
46.9
11.1
44
35
45
54
9
24.7
19.7
25.3
30.3
20
19
25
33
9
20.6
1967
25.8
34.0
24
16
20
21
29.6
19.8
24.7
25.9
30
51
42
29
35
16.0
27.3
22.5
15.5
18.7
16
29
22
20
19
15.1
27.4
20.8
18.9
17.8
14
22
20
9
16
17.3
27.2
24.7
11.1
19.7
Mean
SD
Mean
SD
Mean
SD
54.97
11.60
12.83
3.62
57.35
11.16
12.41
3.64
51.86
12.18
12.79
3.55
t/F/# 2
P
0.93
.36
4.88
.03a
8.57
.13
2.42
.48
2.31
.68
j2.96
j1.93
.003a
.06
P e .05.
386 n Cancer NursingTM, Vol. 39, No. 5, 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Sun and Lin
using the SF-36YT, were 59.51 (SD, 19.99) and 60.32 (SD,
22.16), respectively. Bodily pain was the highest PCS dimensi…
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