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“The TrueBlue Study”: Qualitative Article Critique


Quantitative research is a fundamentally significant tool in the nursing practice since it does not only facilitate the continual development of knowledge, but also generates rigorous, objective, and controllable information which helps define the distinctive role of nursing as a contemporary profession (Burns & Grove, 2005). In this perspective, the following analysis of the article “The TrueBlue Study: Is Practice Nurse-Led Collaborative Care Effective in the Management of Depression for Patients with Heart Disease or Diabetes?”, by Morgan et al (2009), aims to determine the value of the study’s findings in nursing practice.

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Problem Statement

The projected problem – that co-morbid depression is frequently under-diagnosed and under-treated in patients with type 2 diabetes (T2DM) or coronary heart disease (CHD) even though it is usually linked to undesirable clinical outcomes – is particularly important for the nursing practice to explore since findings will provide a framework to initiate nurse-led collaborative care, which can then be used to monitor and manage the conditions rather than relying on GP-led care (Morgan et al., 2009).

Study Purpose

The study purposes to “…determine whether practice nurse-led collaborative care is better than the usual method of GP-led episodic care for the management of co-morbid depression in patients with heart disease or diabetes by testing whether there is an improvement in the depression score at the end of the study” (Morgan et al., 2009, p. 2). From the review of literature, it is evident that depression in patients suffering from diabetes or heart disease is correlated to high incidences of morbidity and mortality. In consequence, the proposed nurse-led collaborative care will initiate better treatment and management for co-morbid depression, therefore reducing complex and increasing chronic disease burden.

Research Question

Although the article does not have stated research questions, the following would have served as the main research questions:

  • Does nurse-led collaborative care promise better outcomes in the management of co-morbid depression, diabetes, and heart disease than GP-led episodic care?


Although the analyzed article does not have set hypotheses, the following would have formed the hypotheses of the study:

  • H1: The proposed nurse-led collaborative care is positively correlated to positive outcomes in the management of depression.

Study Variables

Independent variables, according to StatSoft (n.d.), are manipulated or varied, while dependent variables are the responses that are measured to offer useful insights into the phenomena under study. As such, the nurse-led collaborative care forms the independent variable for this study whereas the GP-led care and at-risk patients with depression and heart disease form the dependent variables.

Conceptual model

The conceptual model uses a two-way channel to guide this study. This implies that the participants are divided into two groups whereby the first at-risk group of patients is exposed to GP-led care while the other group is exposed to nurse-led collaborative care (Morgan, et al., 2009). Those in the intervention group are provided with collaborative care after the nurses undergo training, while those in the control group are provided with the usual care for a period of 6 months. Afterward, the practice nurse (PN) assesses the patients for physiological, lifestyle, and psychological risks before initiating follow-up visits for the two groups to evaluate the outcomes of the two groups in terms of disease management.

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Review of Related Literature

A review of the literature demonstrates that GP-led care has been ineffective in diagnosing co-morbid depression in patients with CHD or T2DM in addition to demonstrating that the presence of depression in patients with heart disease and diabetes in Australia and abroad is directly associated with high incidences of morbidity and mortality. This study is therefore informed by the need to come up with a new practice model that can facilitate the diagnosis of depression among patients suffering from diabetes and heart disease (Morgan et al, 2009).

Study Design

The current study, which is quantitative in design, employs a cluster-randomized intervention strategy. This design is appropriate since it allows the researchers to correlate the intervention group in which nurse-led collaborative care is to be administered to subjects with the control group in which GP-led care is to be continued (Morgan et al., 2009). The design is appropriate since it will provide insights into how the nursing practice can be strengthened to provide care for patients with depression and heart disease or diabetes.

In this particular study, some uncontrolled variables such as the presence of other illnesses apart from those under study may present a threat to the internal validity. The questionnaires used may also be unable to elicit the needed information from the subjects, thus muddling the research results. In addition, situational specifics such as treatment administration and the nature of the investigators may pose threats to the external validity. Still, the presence of other health conditions in the sample may adversely interact with the independent variable, limiting the study’s generalizability (Burns & Grove, 2005).

Sample & Setting

According to Length (2001), the study must be of adequate size and “…big enough that an effect of such magnitude as to be of scientific significance will also be statistically significant” (p. 2). The sample for the study consists of 9 intervention and 9 control practices, each with 50 subjects, thus it is a statistically significant sample to achieve the interests of a scientific study (Morgan et al., 2009). The sample can also be said to be representative since the researchers are dealing with subjects in their population of interest. The setting in which the data were collected in the appropriate one for the study since the researchers are directly dealing with the right people, that is, patients suffering from the health conditions under study.

Identification & Control of Extraneous Variables

Extraneous variables are issues that, if not well managed, occasions undesirable inaccuracies to the research process (Burns & Grove, 2005). Some extraneous variables in the study include patients who may be unaware of some underlying medical conditions, patients who may take medications that end up confounding the investigator’s ability to measure the desired outcomes, and nurses who may be unable to follow the training guidelines. To control such externalities, the investigators took time to design a multi-purpose document that allows patients to detail their medical history as well as any medications used in the course of the study.

Study Instruments

The support provided for the reliability and validity of the data gathering tools is adequate because these instruments had not only been used in previous clinical practice to evaluate variables such as depression, health and lifestyle issues but the self-report capabilities and scales of the instruments used offered investigators a framework through which they could observe and record authenticated outcomes from patients (Nicoli & Beyea, n.d.). The research instruments used in the study are appropriate since they enabled the researchers to empirically measure if their intended outcome – testing the improvement in the depression score – had been achieved by nurse-led corroborative care.

Data Collection Methods

The Patient Health Questionnaire (PHQ-9) enabled the researchers to quantitatively measure the level of depression over time using a Lickert-type measurement scale, while the SF-36 questionnaire was instrumental in measuring the health, wellbeing and lifestyles of the patients. The GP Management Plan enabled coordination between GPs-led care and nurse-led collaborative care. The steps taken to protect the rights of subjects are adequate because the patients’ confidentiality was guaranteed through the use of a unique ID number assigned by the patient’s practice, implying that no personal details reached the research team (Morgan et al., 2009). The purpose of the study was also well explained to the subjects and a consent form was also dispatched to seek their willingness to participate.

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Data Analysis Procedures

The data analysis procedures, namely t-tests, x2 tests, linear mixed models, and regression analysis, among others, are appropriate because this study involved studying the intervention group as well as the control group. Consequently, these techniques are not only effective in measuring changes between both groups over a period of time, but they can also be used to compare baseline data and the data received during the various stages of the intervention period (Burns & Grove, 2005). This implies that the procedures are appropriate for answering the research question and testing the hypothesis because they offer empirical evidence as to whether they have been a reduction of prevalence following intervention.


One of the major strengths of this study is that it uses previously tried data gathering instruments to collect data from the field, thus enhancing validity and reliability, while the other major strength is that the sample is representative of the target population. The scientific merit of this study, however, can be limited by the fact that it deals with human subjects who may be having other medical conditions, thus altering the findings. The other limitation is that patients may drop out of the study process, thereby altering the composition of the sample. The study findings are valid since they reinforce the findings of other studies done in the U.S. about the efficacy of nurse-led collaborative care. The findings are practical for use in nursing practice and education since the study not only followed the scientific method, but the intervention measures posted positive outcomes for nurse-led collaborative care (Burns & Grove, 2005).


In nursing practice, the implications of this study demands a change of policy towards using nursing-led collaborative care in the management of patients with depression and T2DM or CHD. Procedures of treatment, plans of care and evaluation of care for this group of patients also need to be drastically changed to allow for practice interventions, therefore reduce complex and increasing chronic disease burden. In education, patients need to have continued education on how they can manage the stressors that leads to depression as well as their lifestyle habits. This type of education can be provided informally or in community settings. Nurses also need to undergo formal training on how to provide care to this group of patients. Further research is needed to come up with ways through which instances of co-morbid depression can be reduced by up to 80 percent in patients suffering from T2DM or CHD.


This analysis has demonstrated how quantitative research can be of significant importance to the nursing practice, particularly in coming up with a relevant body of knowledge that could be intrinsically used to improve the practice as well as expand care to patients.

Reference List

Burns, N., & Grove, S.K. (2005). The practice of nursing research: Conduct, critique, and utilization, 5th Ed. St. Louis, Missouri: Elsevier Saunders

Length, R.V. (2001). Some practical guidelines for effective sample-size determination. Web.

Morgan, M., Dunbar, J., Reddy, P., Coates, M., & Leahy, R. (2009). The trueblue study: Is practice-led collaborative care effective in the management of depression for patients with heart disease or diabetes. BMC Family Practice, 10(46), 1-8.

Nicoli, L.H., & Beyea, S.C. (n.d.). Selecting research instruments to measure reliability and validity of nursing research studies. Web.

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StatSoft. (n.d.). Elementary concepts in statistics. Web.

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