Nursing is focused on providing appropriate multicultural care to all populations, decreasing health disparities, and providing the best possible care for communities (Hunter & Krantz, 2010). The concept of best cultural care requires that health care providers understand historical, social, political, and cultural influences on groups of people and how that history impacts their health and interactions with the health care system (Leininger & McFarland, 2002; Patterson, 2009). This article describes the Critical Research Evaluation Tool (CRET)'s utility for teaching nursing students about multiculturalism, social justice, and nursing research.
All researchers bring their worldview to research, influencing how research is done and the questions that are asked. In this sense, all research has bias. However, critical research methods have been found that produce culturally appropriate outcomes, accuracy of data, and useful and relevant interventions (Fontana, 2004; Swardt, Toit, & Botha, 2012). Tools are available to teach nursing students to critique research, but tools that include a critical or multicultural perspective are needed, specifically tools that teach students how to evaluate a research article for acceptability beyond a Western biomedical interpretation of what substantiates "good research" (AGREE Enterprises, 2013; Knowles & Gray, 2011).
Such a gap in nursing research education is explained as the influence of the hidden curriculum, the unintended learning that shapes students' attitudes, values, beliefs, and associated behaviors (McCurry & Martins, 2010). It is arguedin in multicultural research on health disparities that health care providers are socialized to a Western worldview (also to a heterosexual, Christian, able-bodied, middle-class worldview). This value system can result in inappropriate care, ignorance to alternative perspectives related to privilege, and cultural misunderstandings in practice and research (Fontana, 2004; Love, 2010; Swardt et al., 2012).
The critical evaluation questions highlighted in the CRET enable students to assess research around issues of privilege, oppression, and multiculturalism. It is proposed that the CRET, developed by this author based on research, teaches nursing students of all levels to be culturally competent as consumers of research, users of evidence-based practice, and novice researchers.
THE TOOL AND HOW IT IS USED
The CRET is a 45-item tool (see Supplemental Digital Content, http://links.lww.com/NEP/A17) with questions for each major section of a research article: Introduction, Abstract, Problem Statement, Literature Review, Methodology, Method, Results, and Discussion. Each section includes items that reflect foundational principles of understanding research. For example, "Is the problem statement easy to find or ambiguous?" is a question asked for the Problem Statement section. Each section also includes items that reflect a critical appraisal of the research, for example, "What assumptions are made in the form of worldview and methodology?" The questions help students think beyond what was written in the article and question aspects of the research that are often taken for granted.
The tool's construct validity was assessed and confirmed for total and individual items using t-tests and found to be statistically significant (p < .001). Internal consistency was calculated with Cronbach's alpha at .96 and compared to the intraclass correlation coefficient for each major section. All sections were >0.8, which was interpreted as reflecting excellent interrater reliability.
The CRET has been used in 14 nursing research courses, including twice in a traditional baccalaureate undergraduate program, five times in an RN-BS program, and seven times in a graduate-level course. It has been used in both online and onsite classrooms, for qualitative and quantitative articles, and in both individual and group learning projects.
A pragmatic qualitative design was used to assess students' views of the CRET. As part of their written CRET papers, students were asked to provide reflection answering three questions: 1) What was your experience with the CRET? 2) What did you learn? 3) How did the CRET impact your views toward nursing research? The reflection section was answered by all students but was not graded. Data from these responses were collected and analyzed. Institutional review board approval was received for this research.
STUDENT VIEWS
All 138 students surveyed responded to the three questions. Of these, 32 were graduate-level students (23 percent), 26 were RN-BS students (19 percent), and 80 (58 percent) were traditional undergraduate students. Only 4 of the 132 students were male. No other demographic data were collected. Students discussed many different ways that the CRET demonstrated the benefits of collaboration and communication with communities. More than 20 students (14 percent) commented that the CRET highlighted the importance of community engagement on the effectiveness of an intervention. Over half of the students (61 percent, n = 84) referenced the benefits of collaboration and navigating any limitations or problems. Because the CRET highlights critical evaluation, students gained a better understanding on how studies where collaboration, researcher self-reflection, and awareness of multicultural issues were present impacted research (n = 101, 74 percent).
The tool was also found to be useful for teaching the fundamentals of research. All students reported that the CRET taught them how to read and understand the basics of research, stating they would feel confident assessing research for integration into nursing practice. Overall the students had a positive experience with the CRET, learning the foundations of nursing research and critical frameworks. A large number noted that they learned about themselves through the assignment. Of the 138 students, 91 (66 percent) reported learning more about their own privilege, power, or values/beliefs.
DISCUSSION AND LIMITATIONS
The student responses provide support for the CRET as an effective tool for teaching students both the foundations of research and understanding research from a critical perspective. Students found the CRET to be a strong tool for teaching the foundations of nursing research including terminology, traditional evaluations of rigor and validity, and the major sections of a research article. For nurse educators considering using the CRET in their own nursing courses, these findings offer evidence that the traditional fundamentals of research comprehension are strongly present.
The strength of the CRET as an effective tool for teaching critical analysis is also shown. Faculty interested in such concepts as emancipatory knowing, critical social theory, transculturalism, multiculturalism in general, or postcolonialism, feminism, and antiracism can use the CRET to analyze research on a variety of topics. It can also be used as a case study approach in a variety of courses to support discussions around issues of diversity, oppression, and disparity. Students who used the CRET described gaining awareness of their own privilege as health care providers and the power that comes with that position over patients and communities. Students overwhelmingly considered how their own cultural beliefs and values have the potential to impact patient care, and they began reflecting on ways to overcome gaps in care.
Collaboration and communication with patients and communities are not established as standards by the CRET. It is possible, however, that the process of reflecting on the impact of the absence of such activities can lead to unforeseen learning experiences.
The main limitations of this study include the risk that social desirability is high when students are asked to reflect on their experiences with a course project. It is also worth noting that, for the CRET project, students were allowed to pick the articles they analyzed and the variety of learning experiences that resulted related to the strength of the articles they picked. For example, if an article did not implement multicultural measures to support a community, students were more likely to be aware of the impact of such a deficit. Allowing students to choose articles had the advantage of supporting their interests and buy-in for the project. Perhaps a group discussion of articles would better equalize the differences in experiences.
CONCLUSION
There are a few tools available for helping students learn to critique a research article, but only the CRET includes a critical analysis of the article for multiculturalism and social justice. The three themes found here show the strength of the CRET as a learning/teaching tool for gaining an understanding of the principles of research and critical analysis, and of strengthening students' self-awareness of their own identity and how to better provide multicultural care.
The CRET can be useful for teaching critical perspectives related to health disparities and disenfranchised peoples. It is hoped that inclusion in a nursing research curriculum will provide nurses from all levels of preparation with a more critical view of how evidence can be applied to diverse populations, how to evaluate research for its bias, and how to develop research to minimize barriers between historically oppressed groups and health care providers.
REFERENCES