¶ … healthcare environment, Palese et al. (2011) argue there is no effective data to support that patients' satisfaction is correlated with a nursing care. Moreover, there is evidence revealing uncertainty in the nursing care environment since there is lack of identification of caring consequences. While the patient's satisfaction has been linked with nurses' caring behaviors, however, there is no empirical evidence to support "the effect of caring on patient's satisfaction." (Palese, Tomietto, Suhonen et al. 2011 p 342). Moreover, there is ongoing scientific debate to ascertain the meaning of caring with reference to a caring context, and working environment to support nurse is caring. Palese et al. (2011) also reveal that there is scanty of studies that focus on the "international cross-cultural nursing studies" (p 342) despite that the European Union has opened its border for free movement of nursing professional to enhance common base and safeguard equal opportunity that will safeguard quality care for every citizen across European countries. b. The authors state independent variables in the problem statement, however, the authors do not clearly identify the dependent variables in the problem statement.

c. Yes, the variables are empirically testable.

d. Yes, the population is specified in the problem statement because the authors identify patient's satisfaction and nursing caring behaviors across six European countries.

e. Yes, the problem is relevant to nursing profession because nurses need to understand the relationship between nursing caring behavior and patient's satisfaction to enhance effectiveness of nursing profession. (Burston, & Stichler, 2010).

f. Statement of purpose

The purpose of the study is to address the following research questions:

"What is the correlation between caring as perceived by patients and patient satisfaction?" (Palese, et al. 2011 p 342).

"Are there differences across various countries on the correlation on caring as perceived by patients and patient satisfaction?" (Palese, et al. 2011 p 342).

"Do caring behaviors affect patient satisfaction?" (Palese, et al. 2011 p 342).

2. Literature Review

a. Yes both independent and dependent variable are adequately reviewed because the authors reviews the literatures that mention patient's satisfaction as evidence of nursing outcome. Moreover, the authors mention demography, patient's expectations, social and cultural aspects in the literature review, which serves as dependent variables.

b. No, the strengths and weakness of the studies reviewed are not included in the review.

c. Yes, the literature provides linkage between variables. For example, patient' satisfaction are linked with demography, patient's expectations, length of stay, care received, social and cultural aspects.

d. Yes, the review includes the data-based and conceptual literature. For example, the concepts such as patient satisfaction, nursing care, treatment regimes, dissatisfied patients, and European countries are mentioned in the literature.

e. No, the authors use both primary and second sources in the review.

f. In the review, some sources are current while some sources are not current. For example, some sources used in the review are dated back as far back as 1998. The dates of the non-current sources in the review are 1998, 2002, 2003, and 2004. However, other sources are current.

g. No, there is no synthesis summary in the literature review.

f. Yes, operational and conceptual definition are clearly identified.

i. Yes, inconsistencies or gaps are identified. For example, the authors reveal that majority of the studies on nursing outcomes are based on administrative data, however, they fail to base on the actual patient's perception. Moreover, the available past studies mainly adopt retrospective study design rather the using the prospective or actual study design. The authors also point out that "measuring the relationship between nursing and nursing outcome has received less attention." (Palese, Tomietto, Suhonen et al. 2011 p 342).

3. Theoretical Framework

a. Yes, the authors clearly identify the theoretical frameworks as patient satisfaction and nursing care.

b. Yes, the theoretical framework is consistence with conceptual definition. For example, the authors identify that nursing caring is correlation with patients satisfaction despite that the studies aim to review the issue. Thus, the authors aim to investigate the "surgical patient satisfaction as an outcome of nurses' caring behaviors": (Palese, Tomietto, Suhonen et al. 2011 p 341).

c. Yes, the theoretical framework is based on a nursing theory. For example self-care theory is a nursing theory that argues that nursing intervention is very critical in enhancing patient's self-care and outcomes.

4. Research Questions / Hypotheses

a....

Yes, the research questions are clearly identified.
b. The research questions are as follows:

"What is the correlation between caring as perceived by patients and patient satisfaction?" (Palese, Tomietto, Suhonen et al. 2011 p 342).

"Are there differences across various countries on the correlation on caring as perceived by patients and patient satisfaction?" (Palese, Tomietto, Suhonen et al. 2011 p 342).

"Do caring behaviors affect patient satisfaction?" (Palese, Tomietto, Suhonen et al. 2011 p 342).

c. Yes, the research question clearly relate to the research problems. For example, one of the research question intends to investigation the relationship between patient's satisfaction and caring.

d. Yes, the research questions expresses the relationships between variables identified in the studies. For example, research questions mention patients, caring, and patient satisfactions.

e. Yes, the literature review supports the research questions.

f. The research questions are used appropriately because they intend to address the research problem.

5. Design

a. The study uses the multicenter correlational design that involves surgical patients across six countries: Czech Republic, Cyprus, Finland, Greece, Italy and Hungary.

b. Yes, the design control is relevant to the internal validity because the authors ensure that the participation in each county is based on the pre-existing cooperation among the countries. Moreover, the authors select participating wards and hospitals based on proximity, availability and convenience.

c. Yes, the authors take external validity into consideration. For example, the selection of wards and hospital is based on convenience of partner access to the premises.

Part II

a. The authors select 1,565 patients in autumn 2009 using the PSS (Patient Satisfaction Scale) and CBI (Caring Behaviors Inventory). The study uses the descriptive statistics, correlation analysis and multiple regression for the data analysis. The analysis aim to investigate the relationship between patients satisfaction and caring behaviors. The study uses the probability of a = 0.01 and power 95% with assumed difference of ± 0.5 and standard deviation of 0.9.

b. The authors use the eligible procedure as basis of bias. For example, the authors use the eligible analysis to select the sample to be used for the study. The authors also send the total of 1,971 and 1,565 eligible questionnaire were returned. However, 1,562 (84.2%) were eligible for analysis.

c. The sample represents the sample population because the authors select the sample from the surgical patients in need of general surgery such as abdominal, and gastroenterical surgery . The sample was selected to measure the patients' surgical satisfaction with reference to nursing caring behaviors.

d. The eligible criteria are clearly identified because the authors only select patients undergoing surgical operations and not selecting all patients.

e. Yes, the sample is adequate because the authors need 223 questionnaire for each country, which is 1,338 for all countries.. After the questionnaire were distributed and returned, 1,565 questionnaire were eligible for data analysis.

f. The authors determine the same size by selecting 223 questionnaire for each country. Since the study covers six European countries, the sample size is 223 x 6 =1,338.

g. There is no clear indication that the right of the samples were insured. Nevertheless, the authors assured the subjects that failure to participate in the study will not affect their surgical caring outcomes.

7. Data Collection

a. Yes, the data collection instrument are clearly identified because the patients are to return the questionnaire in a sealed envelope and place it in box that is clearly identified in the hospital ward after receiving the PSS and CBI-24 in the background data sheet

b. Yes, the method is appropriate for the problem the authors are studying.

c. Yes, the study adopts similar data collection procedure for all subject because the subject are to return the questionnaires in a sealed envelope and place it in box that is clearly identified in the hospital ward.

d. The instruments are valid and reliable on the ground that the study selects the instrument based on their conceptual theoretical frameworks.

e. The study tests validity and reliability of the instrument by assuring that the instrument is based on the " Watson's Transpersonal Caring Theory. The instrument was selected because of its conceptual-theoretical basis clarity, its consistent language, and its comprehensible instructions. It has also been reported that it requires the shortest length of time to complete " (Palese, Tomietto, Suhonen et al. 2011 pp 343-344).

For example, CBI-24 instrument contain factors such as:

assurance to human presence,

Security and patients' needs;

Skill and knowledge, respectful to other.

The instrument also uses the a "a 6-point Likert scale (1 = never, 6 = always)" to ascertain reliability and validity. (Palese, et al. 2011 344).

8. Data Analysis

a. Yes, the level of measurement is used for the statistics. For example, the study uses the SPSS for the analysis to enhance accuracy of data. The study also uses both inferential and descriptive statistical method to enhance accuracy of the data analysis.

b. The descriptive statistics used are the means, percentages, and standard deviations frequencies.

c. The inferential statistics reported "examined the relations between the variables of interest, using…