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Critical Appraisal

Taylor Butterfield

Northwest Nazarene University

NURS4030: Nursing Research

Dr. Jan Crabill

12/9/2022
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Critical Appraisal

This research paper will include a critical appraisal of the study Post-operative Benefits

of Animal-Assisted Therapy in Pediatric Surgery: A Randomised Study by Valeria Calcaterra,

Pierangelo Veggiotti, Clara Palestrini, Valentina De Giorgis, Roberto Raschetti, Massimiliano

Tumminelli, Simonetta Mencherini, Francesca Papotti, Catherine Klersy, Riccardo Albertini,

Selene Ostuni, and Gloria Pelizzo. I have utilized the text, Essentials of Nursing Research:

Appraising Evidence for Nursing Practice by Denise F. Polit & CHeryl Tatano Beck, to critique

this article. The goal of this paper is to identify the steps of the research design, methods utilized,

and any other nursing research strategy and critique their scientific process. I will also be looking

for events of reliability, credibility, validity, bias, and applicability to determine if this article is

appropriate for use in the healthcare clinical setting.

METHOD

The level of evidence identified in this study is a level II: a randomized controlled trial

(RCT), according to the ”Polit-Beck Evidence Hierarchy/Level of Evidence Scale” (Polit &

Beck, 2022). This was the highest level of evidence possible for the study due to this study being

an experimental and randomized study, as well as a quantitative study. We know this study is

quantitative because there is a measurement of the findings instead of an interpretation.

The researchers did well with the comparisons they made in order to interpret the

findings, first by specifying the two groups to be studied: a group with animal-assisted therapy

(AAT) and a group with standard post-operative care. Table 1 shows the demographic and

auxological features reported in the two groups upon admission, Table 2 shows the vital signs
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measured during the AAT and during standard care, Table 3 shows the pain rating between the

two groups, and Figure 2 shows the comparison of the data findings in each section via a charted

line graph.

The number of data points was appropriate in regards to the data they were hoping to

collect and interpret. The researchers wanted to see if there was a positive increase in pain

reduction and comfort during post-operative care, meaning they would need to have a way to

measure the pain and comfort levels of their participants. In the medical field, the best way to

confirm hypothesis or possible diagnoses is through an objective assessment of vital signs and

bodily reactions that we can see with numbers), therefore, their method of data collection is

congruent with the best data collection strategies as well as the depth of their collection. In

regards to the follow-up section of their study, researchers stated, “The participants were

followed for the duration of the immediate postoperative period, an expected average of four

hours” (Calcaterra et al., 2015).

This study did minimize biases and threats to validity in their study by using evidence

based practice for data collection.

POPULATION AND SAMPLE

The researchers clearly identified the population of interest as postoperative children. The

study encompassed forty children aged three years to seventeen years which adequately

describes the sample and intended population.

For the goal of determining if a sample is representative in a study, you want to utilize

probability sampling to limit bias, which the researchers did include in their study. A potential

complication of using an alternative sampling method could be that only children who like
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animals participate in the study, which would ultimately skew the results. Using probability

sampling allows for the study to still use volunteers, but also minimize the risk for extreme

skewed results. The exclusion criteria in this study included, “allergy or fear of dogs, previous

AAT experience, immunodeficiency, chronic illness, obesity, and use of any medications”

(Calcaterra et al., 2015); this allowed the study to collect results with a lesser risk for ingenuity.

In regards to the setting, exclusion criteria, and the nature of the study (a pilot study) the

sample size of forty participants was adequate. A power analysis was not identified as utilized to

estimate sample size in this study.

DATA COLLECTION AND MEASUREMENT

The researchers used biomarkers—biophysiological measures—as their observational

method. This was the best possible method for the type of data they were collecting. The two

types of measurements the researchers used were “in vivo measurements [and] in vitro

measurements” (Polit & Beck, 2022), which are biophysical data and chemical data, both of

which are considered biomarkers.

The outcome statement from the study was, “The outcomes of the study were to define

the impact of AAT on neurological (primary endpoint), cardiovascular (secondary endpoint 2),

and endocrinological signs (secondary endpoint 3), in response to stress and pain in children

undergoing surgical procedures (Calcaterra et al., 2015). These outcomes are relative to patient

centered care because they allow an insight into the potential reduction of stress and pain for our

postoperative patients. The collection of data from admission to the conclusion of the study

parameters were very detailed and the instructions were very specific and in-depth regarding the

steps of the data collection.

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There was no explicit evidence stating that the data collection methods were evaluated

for reliability and validity, however, it can be assumed that since the data was collected by

medical professionals in the inpatient setting, that it would be accurate and reliable.

PROCEDURES

The intervention used in this study was the use of Animal-Assisted Therapy but it was

not explained in depth. The researchers included information about the length of the session with

the AAT dog and that the dog was especially prepared for certain interactions, however the

specific interactions were not noted. They also mentioned that the handler remained in the room

with the AAT dog, monitored the interactions, and answered any questions about the dog. The

study utilized “permuted blocks randomization” to ensure that each participant in the

experimental group received the AAT intervention.

The data was collected in an unbiased manner because the data was numbers, however,

there is always a chance of deception or human error in recording the data.

RESULTS

The statistical methods that were used in this study were the Fischer method to test the

effects of AAT on vital signs and endocrinological parameters as well as the comparison of pain

scores, and regression models were used for repeated measures. Both bivariate and multivariate

statistical tests were used during the statistical analysis portion of the study. The Fischer exact

test was the most powerful analytic method because it interpreted the majority of the data that

was used for hypothesis testing. The researchers state that, “All statistical analyses were

performed using Stata 13.1 (StataCorp, College Station, TX, USA)” (Calcaterra et al., 2015).
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Type 1 and Type 2 errors were avoided in this study. There was a secondary hypothesis

for each category of data that was compared between the two groups and each was stated in the

study. The first was “no correlation” established between vital signs up on admission; the second

was a correlation between AAT and electroencephalogram activity and increased activity with

the entrance of the dog; the third was no correlation between anesthesia times; fourth was a

correlation between cerebral oxygenation during AAT; fifth was no correlation between

endocrinological data; and sixth, a correlation between pain scale findings.

Some potential limitations to this study were mentioned in the discussion portion when

researchers stated, “This pilot study was limited by the small sample size, thus further studies

with a larger number of patients are mandatory to confirm the positive role of AAT after-surgery

in children” (Calcaterra et al., 2015). I would also suggest taking a deeper look into the potential

limitations, such as lack of follow up to confirm results, only having one AAT session per

postoperative time frame, and a lack of confirmation of reliability and validity of data collection

tools (it was just assumed that the data was collected with reliability and validity because it was

collected by healthcare professionals).

FINDINGS AND INTERPRETATION

Each subcategory (stated as primary and secondary endpoints) had its own evaluation of

the statistical significance and its validity. They also included information about the effect size

and precision of estimates in each subcategory with its own sets of data.

The clinical significance was discussed through the interpretation of their statistical

findings. The researchers explained the statistics by explaining the relation to the data that was
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collected in each of the categories, then elaborated on what the statistical significance of each

category.

The design and analysis did well in explaining how the study is applicable and

generalizable to other populations. In the discussion portion of the study, the researchers state,

“We showed that AAT intervention during post-surgical procedures indeuces neurological and

cardiovascular responses in the immediate postoperative period in children undergoing surgical

procedures” (Calcaterra et al., 2015); however, after identifying the correlation between AAT and

biophysical responses, the researchers explained the processes and how they positively impacted

the recovery of pediatric postoperative patients.

SUMMARY

The study findings do appear to be valid, based on the fact that I now know some of the

biological responses that animals have on the mental and physical health of individuals. I do

have confidence in the value of the results as well as the reliability because the data was

collected in an inpatient setting with licensed healthcare professionals obtaining the data. While

it is always important to evaluate credibility, I choose to believe that healthcare professionals are

acting with integrity while being involved with research studies.

This study provided numerous pieces of evidence that can be very useful for the nursing

profession and in the healthcare setting. The meaningful evidence that is identified in the study is

the biophysiological and chemical responses to AAT with postoperative patients. There would

need to be further studies to confirm, although I hypothesize that the data and findings presented

could be applicable to other age groups, as well as different care settings. As nurses and

healthcare professionals, we would almost always rather find a nonpharmacological way to

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minimize stress and pain in our patients, in this study, AAT has proven to be an effective way to

minimize these symptoms.

CONCLUSION

This was definitely a study that brought great benefit to pediatric postoperative nursing.

The effectiveness of AAT on stress and pain reduction in these patients will be able to help other

patients—pediatric or not—in managing their postoperative symptoms. It would be interesting to

see advances in AAT by potentially increasing the scope of patients or by utilizing additional

animals based on paitient preference. This study leaves room for improvement and expansion

that will increase our knowledge about methods and theories for postoperative recovery.
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REFERENCES

Calcaterra, V., Veggiotti, P., Palestrini, C., De Giorgis, V., Raschetti, R., Tumminelli, M.,

Mencherini, S., Papotti, F., Klersy, C., Albertini, R., Ostuni, S., & Pelizzo, G. (2015).

Post-Operative Benefits of Animal-Assisted Therapy in Pediatric Surgery: A

Polit, D. F., & Beck, C. T. (2022). Essentials of Nursing Research: Appraising Evidence For

Nursing Practice (10th ed.). Wolters Kluwer.

Randomised Study. PLoS ONE, 10(6), e0125813.

https://doi.org/10.1371/journal.pone.0125813