Quantitative Research Critique and Ethical Considerations PICOT
Details:
Use the practice problem and a quantitative, peer-reviewed research article you identified in the Topic 1 assignment to complete this assignment.
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In a 1000-1,250 word essay, summarize the study, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study. Quantitative Research Critique and Ethical Considerations PICOT.
Refer to the resource ”Research Critique Guidelines” for suggested headings and content for your paper.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center. Quantitative Research Critique and Ethical Considerations PICOT.
PICOT Question and Literature Search
Nursing practice problem
Although nicotine replacement therapy is acknowledged as a strategy for smoking cessation, its efficacy is not well established. As such, there is a need to provide tangible evidence that compares nicotine replacement therapy with other strategies applied for the same purpose. The intention is to establish whether nicotine replacement therapy is worth receiving special attention from nursing practitioners. Quantitative Research Critique and Ethical Considerations PICOT.
PICOT Statement
Population: in cigarette smokers older than 17 years
Intervention: does nicotine replacement therapy
Control: versus using other smoking cessation therapies
Outcome: affect smoking cessation outcomes
Quantitative Research Critique and Ethical Considerations PICOT
Time: over a period of three months?
Literature Search (References List and Abstract)
Silla, K., Beard, E. & Shahab, L. (2014). Nicotine replacement therapy use among smokers and ex-smokers: associated attitudes and beliefs: a qualitative study. BMC Public Health, 14, 1311. doi: 10.1186/1471-2458-14-1311
Abstract
Background: Smokers who are unwilling or unable to quit smoking may benefit from using nicotine replacement therapy (NRT) for harm reduction. This may include the partial or complete substitution of cigarettes with NRT. Quantitative Research Critique and Ethical Considerations PICOT. A taxonomy of the characteristics of those using NRT for harm reduction would be helpful in tailoring advice and treatment. Although attempts to categorize those using NRT for harm reduction have been made, these have largely been based on quantitative data. In order to provide further in-depth exploration of views, beliefs and experiences, the current study probed issues surrounding NRT and harm reduction qualitatively to better understand barriers and facilitators to this approach. Quantitative Research Critique and Ethical Considerations PICOT.
Methods: Three groups of participants (n = 15) were recruited from a student sample: current smokers with a history of NRT use, smokers without a history of NRT use, and ex-smokers with a history of NRT use. Participants were asked about their demographic characteristics, smoking behaviors, intention and perceived ability to quit smoking, awareness and use of NRT, beliefs about the health consequences of using NRT, and the safety and efficacy of NRT, using semi-structured telephone interviews. Quantitative Research Critique and Ethical Considerations PICOT.
Results: Twenty-four themes were identified; these themes were clustered into three main issues of cross-cutting themes: attitudes towards smoking and motivation to quit; smoking reduction and quit attempts; and beliefs, use and concerns about NRT. Quantitative Research Critique and Ethical Considerations PICOT. Those with a history of NRT use were more motivated and engaged with the quitting process than non-users. However, irrespective of smoking status and past NRT use, all participants showed misperceptions about NRT, such as the health consequences associated with NRT use.
Conclusions: NRT users are more motivated to quit smoking than non-users and are more likely to employ techniques to assist their cessation attempts. The majority of smokers have misperceptions regarding the safety and efficacy of NRT which may act as a barrier to its usage.
Barbeau, A., Burda, J. & Siegel, M. (2013). Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: a qualitative approach. Addict Sci Clin Pract., 8, 5. doi: 10.1186/1940-0640-8-5 Quantitative Research Critique and Ethical Considerations PICOT.
Abstract
Background: Nicotine is widely recognized as an addictive psychoactive drug. Since most smokers are bio-behaviorally addicted, quitting can be very difficult and is often accompanied by withdrawal symptoms. Research indicates that nicotine replacement therapy (NRT) can double quit rates. However, the success rate for quitting remains low. E-cigarettes (electronic cigarettes) are battery-powered nicotine delivery devices used to inhale doses of vaporized nicotine from a handheld device similar in shape to a cigarette without the harmful chemicals present in tobacco products. Anecdotal evidence strongly suggests that e-cigarettes may be effective in helping smokers quit and preventing relapse, but there have been few published qualitative studies, especially among successful e-cigarette users, to support this evidence Quantitative Research Critique and Ethical Considerations PICOT.
Methods: Qualitative design using focus groups (N = 11); 9 men and 2 women. Focus groups were conducted by posing open-ended questions relating to the use of e-cigarettes, comparison of effectiveness between NRTs and e-cigarettes, barriers to quitting, and reasons for choosing e-cigarettes over other methods. Quantitative Research Critique and Ethical Considerations PICOT.
Results: Five themes emerged that describe users’ perceptions of why e-cigarettes are efficacious in quitting smoking: 1) bio-behavioral feedback, 2) social benefits, 3) hobby elements, 4) personal identity, and 5) distinction between smoking cessation and nicotine cessation. Additionally, subjects reported their experiences with NRTs compared with e-cigarettes, citing negative side effects of NRTs and their ineffectiveness at preventing relapse Quantitative Research Critique and Ethical Considerations PICOT.
Conclusion: These findings suggest tobacco control practitioners must pay increased attention to the importance of the behavioral and social components of smoking addiction. By addressing these components in addition to nicotine dependence, e-cigarettes appear to help some tobacco smokers transition to a less harmful replacement tool, thereby maintaining cigarette abstinence.
Buller, D., Halperin, A., Severson, H., Borland, R., Slater, M., Bettinghaus, E., Tinkelman, D., Cutter, G. & Woodall, G. (2014). Effect of Nicotine Replacement Therapy on Quitting by Young Adults in a Trial Comparing Cessation Services. J Public Health Manag Pract., 20(2), E7-E15. doi: 10.1097/PHH.0b013e3182a0b8c7
Abstract
Context: Young adult smokers have the highest smoking prevalence among all US age groups but are least likely to use evidence-based cessation counseling or medication to quit.
Objective: Use and effectiveness of nicotine patch were explored in a randomized trial evaluating smoking cessation interventions with this population. Quantitative Research Critique and Ethical Considerations PICOT.
Participants: Smokers aged 18 to 30 (n = 3094) were recruited through online and off-line methods and from telephone quit lines and analyzed.
Design: Smokers were enrolled in a pretest-posttest trial, and randomized to 1 of 3 cessation services.
Setting: Trial delivering counseling services by self-help booklet, telephone quit lines, or online expert system in the 48 continental United States.
Intervention: Smokers could request a free 2-week course of nicotine replacement therapy (NRT) patches from the project.
Main Outcome Measure: Follow-up surveys at 12 and 26 weeks assessed smoking abstinence, use of NRT, counseling, and other cessation medications, and smoking-related variables. Quantitative Research Critique and Ethical Considerations PICOT.
Results: Overall, 69.0% of smokers reported using NRT (M = 3.2 weeks) at 12 weeks and 74.8% (M = 3.3 weeks) at 26 weeks. More smokers who were sent the free nicotine patches (n = 1695; 54.8%) reported using NRT than those who did not receive them (12 weeks: 84.3% vs 41.9%, P < .001; 26 weeks: 87.6% vs 51.1%, P < .001). The use of NRT was associated with greater smoking abstinence at 12 weeks (P < .001) and 26 weeks (P < .05), especially if used for more than 2 weeks (P < .001). Smokers assigned to a self-help booklet or cessation Web site and heavier smokers were most likely to use NRT (P < .05), whereas those reporting marijuana use and binge drinking used NRT less (P < .05).
Conclusions: Many young adults were willing to try NRT, and it appeared to help them quit in the context of community-based cessation services. Strategies should be developed to make NRT available to this age group and support them in using it to prevent lifelong smoking. Quantitative Research Critique and Ethical Considerations PICOT.
Rath, J., Villanti, A., Abrams, D. & Vallone, D. (2012). Patterns of Tobacco Use and Dual Use in US Young Adults: The Missing Link between Youth Prevention and Adult Cessation. Journal of Environmental and Public Health, Volume 2012 (2012), Article ID 679134. doi: 10.1155/2012/679134
Abstract
Few studies address the developmental transition from youth tobacco use uptake to regular adulthood use, especially for noncigarette tobacco products. The current study uses online panel data from the Legacy Young Adult Cohort Study to describe the prevalence of cigarette, other tobacco product, and dual use in a nationally representative sample of young adults aged 18-34 (N = 4,201). Of the 23% of young adults who were current tobacco users, 30% reported dual use. Ever use, first product used, and current use were highest for cigarettes, cigars, little cigars, and hookah. Thirty-two percent of ever tobacco users reported tobacco product initiation after the age of 18 and 39% of regular users reported progressing to regular use during young adulthood. This study highlights the need for improved monitoring of polytobacco use across the life course and developing tailored efforts for young adults to prevent progression and further reduce overall population prevalence. Quantitative Research Critique and Ethical Considerations PICOT.
Thurgood, S., McNeill, A., Clark-Carter, D. & Brose, L. (2015). A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery. Nicotine & Tobacco Research, 18(5), 993-1001. doi: 10.1093/ntr/ntv127
Abstract
Introduction: The aim was to evaluate the effectiveness of smoking cessation interventions for patients with substance use disorders. The secondary aim was to evaluate the impact on substance use treatment outcomes.
Methods: Randomized controlled trials involving adult smokers, recently or currently receiving inpatient or outpatient treatment for substance use disorders were reviewed. Databases, grey literature, reference lists, and journals were searched for relevant studies between 1990 and August 2014. Two authors extracted data and assessed quality. The primary outcome was biochemically verified continuous abstinence from smoking at 6 or 12 months, secondary outcomes were biochemically verified 7-day point prevalence smoking abstinence (PPA) at 6 or 12 months and substance use outcomes. Quantitative Research Critique and Ethical Considerations PICOT. Heterogeneity between studies precluded pooled analyses of the data.
Results: Seventeen of 847 publications were included. Five studies reported significant effects on smoking cessation: (1) nicotine patches improved continuous abstinence at 6 months; (2) nicotine gum improved continuous abstinence at 12 months; (3) counseling, contingency management and relapse prevention improved continuous abstinence at 6 and 12 months; (4) cognitive behavioral therapy, plus nicotine replacement therapy (NRT), improved PPA at 6 months; and (5) a combination of bupropion, NRT, counseling and contingency management improved PPA at 6 months. Two studies showed some evidence of improved substance use outcomes with the remaining eight studies measuring substance use outcomes showing no difference. Quantitative Research Critique and Ethical Considerations PICOT.
Conclusions: NRT, behavioral support, and combination approaches appear to increase smoking abstinence in those treated for substance use disorders. Higher quality studies are required to strengthen the evidence base.
Garcia-Rodriguez, O., Secades-Villa, R., Florez-Salamanca, L., Okuda, M., Liu, S. & Blanco, C. (2014). Effect of Nicotine Replacement Therapy on Quitting by Young Adults in a Trial Comparing Cessation Services. Drug Alcohol Depend., 132(3), 479-485. doi: 10.1016/j.drugalcdep.2013.03.008 Quantitative Research Critique and Ethical Considerations PICOT.
Abstract
Context: Young adult smokers have the highest smoking prevalence among all US age groups but are least likely to use evidence-based cessation counseling or medication to quit.
Objective: Use and effectiveness of nicotine patch were explored in a randomized trial evaluating smoking cessation interventions with this population.
Participants: Smokers aged 18 to 30 (n = 3094) were recruited through online and off-line methods and from telephone quit lines and analyzed. Quantitative Research Critique and Ethical Considerations PICOT.
Design: Smokers were enrolled in a pretest-posttest trial, and randomized to 1 of 3 cessation services.
Setting: Trial delivering counseling services by self-help booklet, telephone quit lines, or online expert system in the 48 continental United States.
Intervention: Smokers could request a free 2-week course of nicotine replacement therapy (NRT) patches from the project Quantitative Research Critique and Ethical Considerations PICOT.
Main Outcome Measure: Follow-up surveys at 12 and 26 weeks assessed smoking abstinence, use of NRT, counseling, and other cessation medications, and smoking-related variables.
Results: Overall, 69.0% of smokers reported using NRT (M = 3.2 weeks) at 12 weeks and 74.8% (M = 3.3 weeks) at 26 weeks. More smokers who were sent the free nicotine patches (n = 1695; 54.8%) reported using NRT than those who did not receive them (12 weeks: 84.3% vs 41.9%, P < .001; 26 weeks: 87.6% vs 51.1%, P < .001). The use of NRT was associated with greater smoking abstinence at 12 weeks (P < .001) and 26 weeks (P < .05), especially if used for more than 2 weeks (P < .001). Smokers assigned to a self-help booklet or cessation Web site and heavier smokers were most likely to use NRT (P < .05), whereas those reporting marijuana use and binge drinking used NRT less (P < .05). Quantitative Research Critique and Ethical Considerations PICOT.
Conclusions: Many young adults were willing to try NRT, and it appeared to help them quit in the context of community-based cessation services. Strategies should be developed to make NRT available to this age group and support them in using it to prevent lifelong smoking.
Research Critique Guidelines
Qualitative Study
Background of Study:
- Identify the clinical problem and research problem that led to the study. What was not known about the clinical problem that, if understood, could be used to improve health care delivery or patient outcomes? This gap in knowledge is the research problem.
- How did the author establish the significance of the study? In other words, why should the reader care about this study? Look for statements about human suffering, costs of treatment, or the number of people affected by the clinical problem. Quantitative Research Critique and Ethical Considerations PICOT.
- Identify the purpose of the study. An author may clearly state the purpose of the study or may describe the purpose as the study goals, objectives, or aims.
- List research questions that the study was designed to answer. If the author does not explicitly provide the questions, attempt to infer the questions from the answers.
- Were the purpose and research questions related to the problem?
Method of Study:
- Were qualitative methods appropriate to answer the research questions?
- Did the author identify a specific perspective from which the study was developed? If so, what was it?
- Did the author cite quantitative and qualitative studies relevant to the focus of the study? What other types of literature did the author include?
- Are the references current? For qualitative studies, the author may have included studies older than the 5-year limit typically used for quantitative studies. Findings of older qualitative studies may be relevant to a qualitative study. Quantitative Research Critique and Ethical Considerations PICOT.
- Did the author evaluate or indicate the weaknesses of the available studies?
- Did the literature review include adequate information to build a logical argument?
- When a researcher uses the grounded theory method of qualitative inquiry, the researcher may develop a framework or diagram as part of the findings of the study. Was a framework developed from the study findings?
Results of Study
- What were the study findings?
- What are the implications to nursing?
- Explain how the findings contribute to nursing knowledge/science. Would this impact practice, education, administration, or all areas of nursing?
Ethical Considerations
- Was the study approved by an Institutional Review Board?
- Was patient privacy protected?
- Were there ethical considerations regarding the treatment or lack of? Quantitative Research Critique and Ethical Considerations PICOT.
Conclusion
- Emphasize the importance and congruity of the thesis statement.
- Provide a logical wrap-up to bring the appraisal to completion and to leave a lasting impression and take-away points useful in nursing practice.
- Incorporate a critical appraisal and a brief analysis of the utility and applicability of the findings to nursing practice. Quantitative Research Critique and Ethical Considerations PICOT.
- Integrate a summary of the knowledge learned.
Quantitative Study
Background of Study:
- Identify the clinical problem and research problem that led to the study. What was not known about the clinical problem that, if understood, could be used to improve health care delivery or patient outcomes? This gap in knowledge is the research problem.
- How did the author establish the significance of the study? Quantitative Research Critique and Ethical Considerations PICOT. In other words, why should the reader care about this study? Look for statements about human suffering, costs of treatment, or the number of people affected by the clinical problem.
- Identify the purpose of the study. An author may clearly state the purpose of the study or may describe the purpose as the study goals, objectives, or aims.
- List research questions that the study was designed to answer. If the author does not explicitly provide the questions, attempt to infer the questions from the answers. Quantitative Research Critique and Ethical Considerations PICOT.
- Were the purpose and research questions related to the problem?
Methods of Study
- Identify the benefits and risks of participation addressed by the authors. Were there benefits or risks the authors do not identify?
- Was informed consent obtained from the subjects or participants?
- Did it seem that the subjects participated voluntarily in the study?
- Was institutional review board approval obtained from the agency in which the study was conducted? Quantitative Research Critique and Ethical Considerations PICOT.
- Are the major variables (independent and dependent variables) identified and defined? What were these variables?
- How were data collected in this study?
- What rationale did the author provide for using this data collection method?
- Identify the time period for data collection of the study.
- Describe the sequence of data collection events for a participant.
- Describe the data management and analysis methods used in the study.
- Did the author discuss how the rigor of the process was assured? For example, does the author describe maintaining a paper trail of critical decisions that were made during the analysis of the data? Was statistical software used to ensure accuracy of the analysis?
- What measures were used to minimize the effects of researcher bias (their experiences and perspectives)? For example, did two researchers independently analyze the data and compare their analyses? Quantitative Research Critique and Ethical Considerations PICOT.
Results of Study
- What is the researcher’s interpretation of findings?
- Are the findings valid or an accurate reflection of reality? Do you have confidence in the findings?
- What limitations of the study were identified by researchers?
- Was there a coherent logic to the presentation of findings?
- What implications do the findings have for nursing practice? For example, can the findings of the study be applied to general nursing practice, to a specific population, or to a specific area of nursing?
- What suggestions are made for further studies?
Ethical Considerations
- Was the study approved by an Institutional Review Board?
- Was patient privacy protected? Quantitative Research Critique and Ethical Considerations PICOT.
- Were there ethical considerations regarding the treatment or lack of?
Conclusion
- Emphasize the importance and congruity of the thesis statement.
- Provide a logical wrap-up to bring the appraisal to completion and to leave a lasting impression and take-away points useful in nursing practice.
- Incorporate a critical appraisal and a brief analysis of the utility and applicability of the findings to nursing practice. Quantitative Research Critique and Ethical Considerations PICOT.
- Integrate a summary of the knowledge learned.
Reference
Burns, N., & Grove, S. (2011). Understanding nursing research (5th ed.). St. Louis, MO: Elsevier.
Quantitative Research Critique
Background of Study
The article presented the outcome of a research where the effectiveness of nicotine replacement therapy use among young adults was determined. It presented the understanding that the therapy is a tool that facilitates smoking cessation, allowing smokers to quit with minimal risk of reversion or experiencing other undesirable side effects such as withdrawal symptoms. Quantitative Research Critique and Ethical Considerations PICOT. In line with this awareness, the study objective was to review the effectiveness of nicotine patch as a nicotine replacement therapy for use when quitting smoking. The underlying intention was to address smoking cessation needs among young adults in the US since they represent the single largest age group with results to smoking prevalence. In this respect, the article explores the likelihood of positioning nicotine patches as useful for young adult smokers who seek to cease smoking. Quantitative Research Critique and Ethical Considerations PICOT.
Methods of Study
The research applied a quantitative methodology that used a post-test and pre-test trial design. In this case, 3,094 young adult (between 18 and 30 years) smoking participants were recruited using online and offline methods. Other than age and identity as current smokers, the participants also had to exhibit an intention to quit smoking before inclusion in the study. Once all the participants had been recruited, they were enrolled into the trial before being randomized into three groups that include a nicotine patch group representing nicotine replacement therapy, counselling, and medication to facilitate cessation. Quantitative Research Critique and Ethical Considerations PICOT. Once the trial began and the participants were subjected to the interventions in the three groups, they were then subjected to two evaluation surveys at the 12-week and 26-week points of the trial. The data collected from the evaluations was then subjected to statistical analysis that compared the cessation figures for the three groups. The data focus was on smoking abstinence with the comparison showing how the three programs performed in terms of effectiveness. Quantitative Research Critique and Ethical Considerations PICOT.
The research methodology can be considered appropriate since it allowed for a large sample to be recruited for the research, the right data to be collected, and interpretation carried out on the data. It presented a true comparison between nicotine patches, counselling and medication so that the results were reliable. Also, the detailed presentation of the research methodology facilitates the research replication. In addition, researcher bias was minimized by using pre-structured tools to collect primary data directly from the participants. Perhaps, the only shortcoming in the methodology is that there is no mention of whether the data analysis was verified by a third party to confirm its accuracy. Another shortcoming is that the specific software that was used for data analysis has not been mentioned thereby making it difficult to ascertain the truthfulness of the analysis. These shortcomings create an opportunity for researcher bias since a third party cannot verify the truthfulness of the results analysis. Quantitative Research Critique and Ethical Considerations PICOT.
Results of Study
The data analysis determined that nicotine patches produce comparably favorable results when used by young adult smokers. That is because they increased the possibility of enrolling for and adhering to the process set by nicotine replacement therapy. At the 12th week evaluation, 84.3% of the participants using nicotine patches enrolled for nicotine replacement therapy when compared to 41.9% who used other programs (p<0.001). At the 26th week evaluation, 87.6% of the participants using nicotine patches enrolled for nicotine replacement therapy when compared to 51.1% who used other programs (p<0.001). Following this results that showed greater willingness for the persons who use patches to pursue other smoking cessation programs concurrently, the research made the recommendation that nicotine patches should be offered as part of the smoking cessation standard package program for young adult smokers who have enrolled in a cessation program Quantitative Research Critique and Ethical Considerations PICOT. These results are valuable to nursing practitioners since it presents evidence to supports advice they may offer young adult smokers to use nicotine patches to improve enrollment in smoking cessation programs. Although the research does not make suggestions for future studies, it is cautious when advocating for nicotine patches use. This implies that there is need for additional research to ascertain the exact value of nicotine patches. Quantitative Research Critique and Ethical Considerations PICOT.
Ethical Considerations
There is evidence to show that the research was carried out following ethical considerations. Firstly, the research mentions that approval was sought and received from the Western Institutional Review Board before the research could proceed. The approval shows that the board was convinced that the research would not harm the participants (whether the harm was intentional or unintentional) and sufficient measures had been put in place for their protection. Secondly, although there is no mention of a consent form and whether the participants signed one to show that they were cognizant of the study objectives and voluntarily agree to participate, the fact that they were not coerced and were politely asked to participate in the study and allowed to withdraw without a penalty is sufficient to show that their participation was voluntary. Quantitative Research Critique and Ethical Considerations PICOT. Thirdly, the participants were not offered any remuneration for their participation in the study thereby showing that they were motivated to advance the research (and would be truthful by extension) and eliminated the possibility that they would haphazardly participate in the research (not being truthful) just to get paid. Finally, the treatments (nicotine replacement therapy, counseling and medication) applied in the three groups did not pose any harm to the participants since they are approved therapies for smoking cessation programs. The four measures show that the research was conducted in an ethical manner Quantitative Research Critique and Ethical Considerations PICOT.
Conclusion
The research evaluates the effectiveness of nicotine replacement therapy as a smoking cessation tool for use among young adult smokers. This is based on the understanding that the therapy is a tool that facilitates smoking cessation, allowing smokers to quit with minimal risk of reversion or experiencing other undesirable side effects such as withdrawal symptoms. Applying a quantitative methodology that recruited 3,094 young adult smokers between 18 and 30 years of age, the research randomized the participants’ group assignment into nicotine patch (nicotine replacement therapy), counseling and medication groups. Ethical consideration were undertaken to ensure that the participants were protected to include receiving approval from a review board, voluntary participation, no remuneration was offered, and treatment did not pose any harm. The three randomized groups were then evaluated for program effectiveness at the 12-week and 26-week milestones. Quantitative Research Critique and Ethical Considerations PICOT. The results showed that using the nicotine patch improved enrollment in nicotine replacement therapy from 84.3% at the 12th week to 87.6% at the 26th week, almost doubling the figures reported by the other programs. Following this results that showed greater willingness for the persons who use patches to pursue other smoking cessation programs concurrently, the research made the recommendation that nicotine patches should be offered as part of the smoking cessation standard package program for young adult smokers who have enrolled in a cessation program. As such, nicotine patches should be included in cessation services for young adult smokers. Quantitative Research Critique and Ethical Considerations PICOT.
Reference
Buller, D., Halperin, A., Severson, H., Borland, R., Slater, M., Bettinghaus, E., Tinkelman, D., Cutter, G. & Woodall, G. (2014). Effect of Nicotine Replacement Therapy on Quitting by Young Adults in a Trial Comparing Cessation Services. J Public Health Manag Pract., 20(2), E7-E15. doi: 10.1097/PHH.0b013e3182a0b8c7 Quantitative Research Critique and Ethical Considerations PICOT.
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