Catching goldfish: quality in qualitative research

Focus group study of factors relevant to treatment decisions and experiences among patients with symptomatic peripheral artery disease

BACKGROUND

Clinical guidelines recommend shared decision-making for treatment of peripheral artery disease (PAD), which requires understanding of patient perspectives and preferences. We conducted a focus group study of patients with symptomatic PAD to identify factors important and relevant to treatment choices, and to characterize aspects of the healthcare process that contribute to positive versus negative experiences apart from the specific treatment(s) received.

METHODS

Participants were recruited from an academic medical center over two years using a purposeful sampling approach based on a clinical diagnosis of symptomatic PAD (either claudication or chronic limb threatening ischemia [CLTI]) confirmed by abnormal ankle or toe brachial index. Focus groups were led by a non-physician moderator, consisted of 5-12 participants, and were conducted separately for patients with CLTI and claudication. Audio recordings converted to verbatim transcripts were used for qualitative analysis.

RESULTS

51 patients (26 with CLTI and 25 with claudication) were enrolled and participated in focus groups. Major themes related to the process of care included: decision-making input, provider communication and trust, the timeline from diagnosis to definitive treatment, and compartmentalized care (including different venues of care). Major themes related to the process of care included: decision-making input, provider communication and trust, the timeline from diagnosis to definitive treatment, and compartmentalized care (including different venues of care).

CONCLUSIONS

The results provide insights into patient preferences, perspectives, and experiences related to PAD treatment. These observations can be used to inform patient-centered approaches to shared decision making, communication, and assessment of PAD treatment outcomes.

Morita Therapy for depression (Morita Trial): an embedded qualitative study of acceptability

OBJECTIVE

To explore the views of UK-based recipients of Morita Therapy (MT) on the acceptability of MT.

DESIGN

Qualitative study nested within a pilot randomised controlled trial of MT (a Japanese psychological therapy largely unknown in the UK) versus treatment as usual, using post-treatment semistructured interviews analysed with a framework approach.

SETTING AND PARTICIPANTS

Participants who received MT as part of the Morita Trial, recruited for the trial from General Practice record searches in Devon, UK. Data from 16 participants were purposively sampled for analysis.

RESULTS

We identified five themes which, together, form a model of how different participants viewed and experienced MT. Overall, MT was perceived as acceptable by many participants who emphasised the value of the approach, often in comparison to other treatments they had tried. These participants highlighted how accepting and allowing difficulties as natural phenomena and shifting attention from symptoms to external factors had facilitated symptom reduction and a sense of empowerment. We found that how participants understood and related to the principles of MT, in light of their expectations of treatment, was significantly tied to the extent to which MT was perceived as acceptable. Our findings also highlighted the distinction between MT in principle and practice, with participants noting challenges of engaging with the process of therapy such as fear and discomfort around rest, needing sufficient support from the therapist and others, and the commitment of treatment.

CONCLUSIONS

People in the UK can accept the premise of MT, and consider the approach beneficial and novel. Therefore, proceeding to a large-scale trial of MT is appropriate with minor modifications to our clinical protocol. Participants' expectations and understandings of treatment play a key role in acceptability, and future research may investigate these potential moderators of acceptability in MT.

TRIAL REGISTRATION NUMBERC

ISRCTN17544090; Pre-results.

Universal health coverage necessitates a system approach: an analysis of Community-based Health Planning and Services (CHPS) initiative in Ghana

The 9th Global conference on health promotion (Shanghai 2016) reaffirmed the role of primary health care (PHC) in achieving the 2030 Sustainable Development Agenda. Gaining much international recognition, the community-based health planning and services (CHPS) initiative is considered one of the pragmatic strategy in delivering on the promise of universal health coverage (UHC) through the PHC strategy, in Ghana. Yet, certain key factors threaten its successes - renewing the relevance of this study to present the barriers to and facilitators of the initiative. According to our findings, CHPS contribution particularly in bridging geographical access to health cannot be demeaned. Nevertheless, the full functioning of the initiative is limited by factors centered on the following themes: health governance and leadership, provision of services of quality, financial risk protection strategies targeting public health, information and care continuity, and the right mix of trained health professionals of even distribution across communities. Addressing the challenges of CHPS demand a system-approach. Substantial progress is more likely to emerge with improved leadership especially on the part of Governments to take bold political step to provide adequate financial and material resources. However, much will be achieved when stakeholders including the community work in synergies, to manage competing priorities by focusing on the core values and goals of CHPS.

Generalizability in Qualitative Research: A Tale of Two Traditions

Generalizability in qualitative research has been a controversial topic given that interpretivist scholars have resisted the dominant role and mandate of the positivist tradition within social sciences. Aiming to find universal laws, the positivist paradigm has made generalizability a crucial criterion for evaluating the rigor of quantitative research. This positivist echo has led generalizability to acquire a quantitative meaning, inappropriate for describing qualitative studies. The purpose of qualitative research has, thus, been directed toward providing in-depth explanations and meanings rather than generalizing findings. Through a critical review of empirical and theoretical studies, this commentary seeks to show that in qualitative domains, generalizability is possible provided that, first, generalizability is the main objective of the study; second, due precautions concerning the philosophy and terminology selected are taken. Hence, this commentary contributes to the literature on qualitative research by making suggestions for more consistent and unanimous procedures to adopt in qualitative inquiries.

Patient involvement in qualitative data analysis in a trial of a patient-centred intervention: Reconciling lay knowledge and scientific method

BACKGROUND

We conducted a pilot study of an intervention to facilitate patients' agenda setting in clinical consultations. The primary aim of the study was to test the feasibility of running the randomized controlled trial. A secondary objective was to assess the extent to which patient and public involvement (PPI) could contribute to the process of qualitative data analysis (QDA).

AIMS

To describe a novel approach to including patient partners in QDA; to illustrate the kinds of contribution that patient partners made to QDA in this context; and to propose a characterization of a process by which patient involvement can contribute to knowledge production.

METHODS

Six patient and public representatives were supported to contribute to data analysis via a range of modalities. During a series of QDA workshops, experienced research staff role-played consultations and interviews, and provided vignettes. Workshop data and PPI diaries were analysed using thematic discourse analysis.

RESULTS

We characterized a process of thesis, antithesis and synthesis. This PPI group contributed to the rigour and validity of the study findings by challenging their own and the researchers' assumptions, and by testing the emerging hypotheses. By training PPI representatives to undertake qualitative data analysis, we transformed our understanding of doctor-patient consultations.

CONCLUSIONS

This research required changes to our usual research practices but was in keeping with the objective of establishing meaningful patient involvement for a future definitive trial. This work was informed by concepts of critical humility, and a process of knowledge production enabled via the construction of a knowledge space.

Optimising the acceptability and feasibility of novel complex interventions: an iterative, person-based approach to developing the UK Morita therapy outpatient protocol

Background

The aim of this paper is to showcase best practice in intervention development by illustrating a systematic, iterative, person-based approach to optimising intervention acceptability and feasibility, as applied to the cross-cultural adaptation of Morita therapy for depression and anxiety.

Methods

We developed the UK Morita therapy outpatient protocol over four stages integrating literature synthesis and qualitative research. Firstly, we conducted in-depth interviews combining qualitative and cognitive interviewing techniques, utilising vignettes of Morita therapy being delivered and analysed using Framework analysis to investigate potential patients and therapists’ perceptions of Morita therapy. Secondly, we developed qualitative themes into recommendations for optimising Morita therapy and synthesised Morita therapy literature in line with these to develop a draft protocol. Thirdly, we conducted repeat interviews with therapists to investigate their views of the protocol. Finally, we responded to these qualitative themes through protocol modification and tailoring our therapist training programme.

Results

As a consequence of literature describing Morita therapy and participants’ perceptions of the approach, we developed both a therapy protocol and therapist training programme which were fit for purpose in proceeding to a UK-based Morita therapy feasibility study. As per our key qualitative findings and resulting recommendations, we structured our protocol according to the four-phased model of Morita therapy, included detailed guidance and warning points, and supported therapists in managing patients’ expectations of the approach.

Conclusions

Our systematic approach towards optimising intervention acceptability and feasibility prioritises the perspectives of those who will deliver and receive the intervention. Thus, we both showcase best practice in intervention development and demonstrate the application of this process to the careful cross-cultural adaptation of an intervention in which balancing both optimisation of and adherence to the approach are key. This presentation of a generalisable process in a transparent and replicable manner will be of interest to those both developing and evaluating complex interventions in the future.

Electronic supplementary material

The online version of this article (10.1186/s40814-017-0181-4) contains supplementary material, which is available to authorized users.

Barriers and facilitators to disclosing sexual abuse in childhood and adolescence: A systematic review

Children and young people often choose not to disclose sexual abuse, thus preventing access to help and allowing perpetrators to continue undetected. A nuanced understanding of the barriers (and facilitators) to disclosure is therefore of great relevance to practitioners and researchers. The literature was systematically searched for studies related to child and adolescent disclosures of sexual abuse. Thirteen studies were reviewed and assessed for methodological quality. Results of the review illustrate the heterogeneous nature of these empirical studies. Findings demonstrate that young people face a number of different barriers such as limited support, perceived negative consequences and feelings of self-blame, shame and guilt, when choosing to disclose. Being asked or prompted, through provision of developmentally appropriate information, about sexual abuse facilitates disclosure. The review highlights the need for robust, longitudinal studies with more sophisticated methodology to replicate findings. The review identifies the need for developmentally appropriate school-based intervention programmes that facilitate children's disclosure by reducing feelings of responsibility, self-blame, guilt and shame. In addition, prevention programmes should encourage family members, friends and frontline professionals to identify clues of sexual abuse, to explicitly ask children about the possibility of sexual abuse and also to respond supportively should disclosures occur. Facilitating disclosure in this way is key to safeguarding victims and promoting better outcomes for child and adolescent survivors of sexual abuse.

Spirituality/Religiosity: A Cultural and Psychological Resource among Sub-Saharan African Migrant Women with HIV/AIDS in Belgium

Spirituality/religion serves important roles in coping, survival and maintaining overall wellbeing within African cultures and communities, especially when diagnosed with a chronic disease like HIV/AIDS that can have a profound effect on physical and mental health. However, spirituality/religion can be problematic to some patients and cause caregiving difficulties. The objective of this paper was to examine the role of spirituality/religion as a source of strength, resilience and wellbeing among sub-Saharan African (SSA) migrant women with HIV/AIDS. A qualitative study of SSA migrant women was conducted between April 2013 and December 2014. Participants were recruited through purposive sampling and snowball techniques from AIDS Reference Centres and AIDS workshops in Belgium, if they were 18 years and older, French or English speaking, and diagnosed HIV positive more than 3 months beforehand. We conducted semi-structured interviews with patients and did observations during consultations and support groups attendances. Thematic analysis was used to analyse the data. 44 women were interviewed, of whom 42 were Christians and 2 Muslims. None reported religious/spiritual alienation, though at some point in time many had felt the need to question their relationship with God by asking "why me?" A majority reported being more spiritual/religious since being diagnosed HIV positive. Participants believed that prayer, meditation, regular church services and religious activities were the main spiritual/religious resources for achieving connectedness with God. They strongly believed in the power of God in their HIV/AIDS treatment and wellbeing. Spiritual/religious resources including prayer, meditation, church services, religious activities and believing in the power of God helped them cope with HIV/AIDS. These findings highlight the importance of spirituality in physical and mental health and wellbeing among SSA women with HIV/AIDS that should be taken into consideration in providing a caring and healthy environment.

Resisting Evidence: The Study of Evidence-Based Medicine as a Contemporary Social Movement

Evidence-based medicine (EBM) emerged relatively recently to describe the explicit process of applying research evidence to medical practice. The movement was high profile, yet not overly successful: many clinicians do not use up-to-date evidence in their everyday work. This article shows how a social movement perspective can be used to analyse the emergence of EBM and shed light on power struggles between segments of the medical profession. It draws on Blumer's (1951) essay on social movements to demonstrate the continued salience of this approach. The article also presents empirical data from a qualitative study of English and American surgeons to illustrate how EBM provides a focus for segmental conflict within medical practice between `art' and `science', `practice' and `evidence'. Together these data and the social movements perspective provide insight into the dynamics of this struggle and help to explain why clinicians continue to resist EBM.

Morita therapy for depression and anxiety (Morita Trial): study protocol for a pilot randomised controlled trial

BACKGROUND

Morita Therapy, a psychological therapy for common mental health problems, is in sharp contrast to established western psychotherapeutic approaches in teaching that undesired symptoms are natural features of human emotion rather than something to control or eliminate. The approach is widely practiced in Japan, but untested and little known in the UK. A clinical trial of Morita Therapy is required to establish the effectiveness of Morita Therapy for a UK population. However, a number of methodological, procedural and clinical uncertainties associated with such a trial first require addressing.

METHODS/DESIGN

The Morita Trial is a mixed methods study addressing the uncertainties associated with an evaluation of Morita Therapy compared with treatment as usual for depression and anxiety. We will undertake a pilot randomised controlled trial with embedded qualitative study. Sixty participants with major depressive disorder, with or without anxiety disorders, will be recruited predominantly from General Practice record searches and randomised to receive Morita Therapy plus treatment as usual or treatment as usual alone. Morita Therapy will be delivered by accredited psychological therapists. We will collect quantitative data on depressive symptoms, general anxiety, attitudes and quality of life at baseline and four month follow-up to inform future sample size calculations; and rates of recruitment, retention and treatment adherence to assess feasibility. We will undertake qualitative interviews in parallel with the trial, to explore people's views of Morita Therapy. We will conduct separate and integrated analyses on the quantitative and qualitative data.

DISCUSSION

The outcomes of this study will prepare the ground for the design and conduct of a fully-powered evaluation of Morita Therapy plus treatment as usual versus treatment as usual alone, or inform a conclusion that such a trial is not feasible and/or appropriate. We will obtain a more comprehensive understanding of these issues than would be possible from either a quantitative or qualitative approach alone.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17544090 registered on 23 July 2015.

Resisting Prescribed Opioids: A Qualitative Study of Decision Making in Patients Taking Opioids for Chronic Noncancer Pain

BACKGROUND

Opioids are increasingly prescribed for chronic noncancer pain across the developed world. Clinical guidelines for management of these patients focus on over-use. However, research into other types of long-term medication indicates that many patients minimize drug use whenever possible.

OBJECTIVE

To identify the varying influences on patients' decisions about their use of prescribed opioids and explore whether concepts of resistance and minimization of intake apply to these patients.

DESIGN

A multiprofessional team performed a qualitative interview study using the constant-comparative method. Patient's decision making was explored in depth and with a thematic analysis utilizing a published "Model of medicine-taking."

SETTING AND PARTICIPANTS

A purposive sample of 20 participants drawn from two pain clinics in Melbourne, Australia. The sample was biased toward patients interested in nonmedication pain management options.

FINDINGS

Patients' needs to obtain relief from severe pain, maintain function, and minimize side effects could lead to under-use as well as over-use of prescribed opioids. In keeping with the published Model of medicine-taking, resistance to taking opioids was a common and important influence on behavior. In the face of severe chronic pain, many participants used a variety of strategies to evaluate, avoid, reduce, self-regulate, and replace opioids. Furthermore, participants perceived a resistance to opioids within the system and among some healthcare professionals. This sometimes adversely affected their adherence.

CONCLUSIONS

Both patients and doctors exhibit aspects of resistance to the use of prescribed opioids for chronic noncancer pain, suggesting that this shared concern could be the basis of a productive therapeutic alliance to improve communication and shared decision making.

SUMMARY

Clinical guidelines for opioids use for chronic noncancer pain focus on over-use. Our qualitative interview study found that many patients resisted and minimized the use of opioids. Using a published "Model of medicine-taking," we identified various influences on patient decision making. Both patients and doctors had concerns about using opioids for chronic noncancer pain. These could be the basis of a productive therapeutic alliance to improve communication and shared decision making.

Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review

Qualitative methods are progressively being implemented by researchers for exploration within healthcare. However, there has been a longstanding and wide-ranging debate concerning the relative merits of qualitative research within the health care literature. This integrative review aimed to exam the contribution of qualitative research in burns care and subsequent rehabilitation. Studies were identified using an electronic search strategy using the databases PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica database (EMBASE) and Scopus of peer reviewed primary research in English between 2009 to April 2014 using Whittemore and Knafl's integrative review method as a guide for analysis. From the 298 papers identified, 26 research papers met the inclusion criteria. Across all studies there was an average of 22 participants involved in each study with a range of 6-53 participants conducted across 12 nations that focussed on burns prevention, paediatric burns, appropriate acquisition and delivery of burns care, pain and psychosocial implications of burns trauma. Careful and rigorous application of qualitative methodologies promotes and enriches the development of burns knowledge. In particular, the key elements in qualitative methodological process and its publication are critical in disseminating credible and methodologically sound qualitative research.

How to communicate with patients about future illness progression and end of life: a systematic review

Background

Conversation and discourse analytic research has yielded important evidence about skills needed for effective, sensitive communication with patients about illness progression and end of life.

Objectives

To: ▸ Locate and synthesise observational evidence about how people communicate about sensitive future matters;

▸ Inform practice and policy on how to provide opportunities for talk about these matters;

▸ Identify evidence gaps.

Design

Systematic review of conversation/discourse analytic studies of recorded interactions in English, using a bespoke appraisal approach and aggregative synthesis.

Results

19 publications met the inclusion criteria. We summarised findings in terms of eight practices: ‘fishing questions’—open questions seeking patients’ perspectives (5/19); indirect references to difficult topics (6/19); linking to what a patient has already said—or noticeably not said (7/19); hypothetical questions (12/19); framing difficult matters as universal or general (4/19); conveying sensitivity via means other than words, for example, hesitancy, touch (4/19); encouraging further talk using means other than words, for example, long silences (2/19); and steering talk from difficult/negative to more optimistic aspects (3/19).

Conclusions

Practices vary in how strongly they encourage patients to engage in talk about matters such as illness progression and dying. Fishing questions and indirect talk make it particularly easy to avoid engaging—this may be appropriate in some circumstances. Hypothetical questions are more effective in encouraging on-topic talk, as is linking questions to patients’ cues. Shifting towards more ‘optimistic’ aspects helps maintain hope but closes off further talk about difficulties: practitioners may want to delay doing so. There are substantial gaps in evidence.

Quantitative and qualitative methods in medical education research: AMEE Guide No 90: Part I

Medical educators need to understand and conduct medical education research in order to make informed decisions based on the best evidence, rather than rely on their own hunches. The purpose of this Guide is to provide medical educators, especially those who are new to medical education research, with a basic understanding of how quantitative and qualitative methods contribute to the medical education evidence base through their different inquiry approaches and also how to select the most appropriate inquiry approach to answer their research questions.

Using the framework method for the analysis of qualitative data in multi-disciplinary health research

BACKGROUND

The Framework Method is becoming an increasingly popular approach to the management and analysis of qualitative data in health research. However, there is confusion about its potential application and limitations.

DISCUSSION

The article discusses when it is appropriate to adopt the Framework Method and explains the procedure for using it in multi-disciplinary health research teams, or those that involve clinicians, patients and lay people. The stages of the method are illustrated using examples from a published study.

SUMMARY

Used effectively, with the leadership of an experienced qualitative researcher, the Framework Method is a systematic and flexible approach to analysing qualitative data and is appropriate for use in research teams even where not all members have previous experience of conducting qualitative research.

Using the framework method for the analysis of qualitative data in multi-disciplinary health research

BACKGROUND

The Framework Method is becoming an increasingly popular approach to the management and analysis of qualitative data in health research. However, there is confusion about its potential application and limitations.

DISCUSSION

The article discusses when it is appropriate to adopt the Framework Method and explains the procedure for using it in multi-disciplinary health research teams, or those that involve clinicians, patients and lay people. The stages of the method are illustrated using examples from a published study.

SUMMARY

Used effectively, with the leadership of an experienced qualitative researcher, the Framework Method is a systematic and flexible approach to analysing qualitative data and is appropriate for use in research teams even where not all members have previous experience of conducting qualitative research.

Academic impact of qualitative studies in healthcare: bibliometric analysis

CONTEXT

Although qualitative studies are becoming more appreciated in healthcare, the number of publications of quality studies remains low. Little is known about the frequency and characteristics of citation in qualitative studies.

OBJECTIVE

To compare the academic impact of qualitative studies to that of two quantitative studies: systematic reviews and randomized controlled trials.

METHODS

Publications in BMJ between 1997 and 2006 (BMJ's median impact factor was 7.04 during this period) employing qualitative methods were matched to two quantitative studies appearing the same year using PubMed. Using Web of Science, citations within a 24-month publication period were determined. Additionally, three hypotheses were examined: qualitative studies are 1) infrequently cited in original articles or reviews; 2) rarely cited by authors in non-English-speaking countries; and 3) more frequently cited in non-medical disciplines (e.g., psychology or sociology).

RESULTS

A total of 121 qualitative studies, 270 systematic reviews, and 515 randomised controlled trials were retrieved. Qualitative studies were cited a total of 1,089 times, with a median of 7.00 times (range, 0-34) for each study. Matched systematic reviews and randomized controlled trials were cited 2,411 times and 1,600 times, respectively. With respect to citing documents, original articles and reviews exceeded 60% for each study design. Relative to quantitative studies, qualitative studies were cited more often by authors in English-speaking countries. With respect to subject area, medical disciplines were more frequently cited than non-medical disciplines for all three study designs (>80%).

CONCLUSION

The median number of citations for qualitative studies was almost the same as the median of BMJ's impact factor during the survey period. For a suitable evaluation of qualitative studies in healthcare, it will be necessary to develop a reporting framework and include explicit discussions of clinical implications when reporting findings. Coordination between researchers and editors will be needed to achieve this goal.

Students' educational needs for clinical reasoning in first clerkships

Developing clinical reasoning skills early in medical education is important. However, research to uncover students' educational needs for learning clinical reasoning during clerkships is limited. The aim of our study was to investigate these needs. Focus group discussions with an independent moderator were conducted. Students were included directly after 10 weeks of clerkships. The (verbatim) transcripts were coded manually and discussed by the authors until consensus was reached. Saturation was reached after three focus groups, including 18 students in total. Statistical analysis indicated our sample matched the approached group of 61 students. After a consistency and redundancy check in ATLAS.ti, 79 codes could be identified. These could be grouped into seven key themes: (1) transition to the clinical phase, (2) teaching methods, (3) learning climate, (4) students' motivation, (5) teacher, (6) patient and (7) strategies in clinical reasoning. Students can adequately describe their needs; of the seven key themes relevant to clinical reasoning five are in line with literature. The remaining two (patient factors and the need for strategy for clinical reasoning) have not been identified before.

Perceived barriers to participating in continuing education: the views of newly registered community pharmacists

Objective

The main aim of this study was to explore newly registered community pharmacists' attitudes to the current provision of continuing education (CE) and to identify key factors that act as motivators and barriers to participation in CE.

Method

Eight focus groups of newly registered pharmacists were set up. All focus groups were tape-recorded and transcribed verbatim. The results presented in this paper focus specifically on the barriers to participation in CE.

Setting

Four geographical areas of England.

Key findings

The main barrier identified by the pharmacists was competing demands on their time, both in and out of work. Participants felt disillusioned with further study, describing this stage of their lives as a “honeymoon period” in which they sought to make adjustments in both their professional and personal lives. They also felt disillusioned with the reality of community pharmacy and offered this as an explanation for their lack of involvement in CE. In addition, many pharmacists believed themselves to be at the peak of their pharmaceutical knowledge, thus not requiring CE. Rather, it was felt that they needed to develop their skills in other areas such as communication skills or applying pharmaceutical knowledge in practice. It was suggested that this could only be remedied through working with and learning from more experienced pharmacists, rather than undertaking formal CE activities.

Conclusion

Non-participation in CE may be seen to result from a complex web of factors which do not easily map on to policies to increase participation of newly registered pharmacists in CE activities. Nevertheless, if newly registered community pharmacists are to achieve the continuity of learning necessary for continuing professional development, education providers will need to address their specific learning needs in the period following registration.

[Quality control and assessment of qualitative interview in health care research]

It is not finally concluded how to standardize the use of qualitative research in the world. Qualitative researchers disagree with each other about this issue. As we know, there have been a large number of articles written in different ways about qualitative research due to the "flexibility", one of its features. Qualitative research is quite different from quantitative research which is easy to control its quality and quality assessment. A series of criteria has been set up for quantitative research. However qualitative research needs to be improved in these aspects, in which qualitative interviews are mostly used at home and abroad at present. Hence, it becomes an important and urgent issue for qualitative researchers to standardly control and assess the quality of qualitative interview.

Opting in and opting out: a grounded theory of nursing’s contribution to inpatient rehabilitation

Aim: To develop a grounded theory of nursing’s contribution to patient rehabilitation from the perspective of nurses working in inpatient rehabilitation.

Design: Grounded theory method, informed by the theoretical perspective of symbolic interactionism, was used to guide data collection and analysis, and the development of a grounded theory.

Setting: Five inpatient rehabilitation units in Australia.

Participants: Thirty-five registered and 18 enrolled nurses participated in audio-taped interviews and/or were observed during periods of their everyday practice.

Findings: The analysis revealed a situation whereby nurses made decisions about when to ‘opt in’ and when to ‘opt out’ of inpatient rehabilitation. This occurred on two levels: with their interaction with patients and allied health professionals, and when faced with negative system issues that impacted on their ability to contribute to patient rehabilitation. The primary contribution nurses made to inpatient rehabilitation was working directly with patients, enabling them to self-care. Nurses coached patients when their decisions about ‘opting in’ and ‘opting out’ were based on assessment of the person in their particular context. In contrast, the nurses mostly distanced themselves from system-based problems, ‘opting out’ of addressing them. They did this not to make their working lives easier, but more manageable.

Conclusion: System-based problems impacted negatively on the nurses’ ability to deliver comprehensive rehabilitation care. As a consequence, some nurses felt unable to influence the care and they withdrew professionally to make their work lives more manageable.

Understanding the challenges of service change - learning from acute pain services in the UK

OBJECTIVES

To explore organizational difficulties faced when implementing national policy recommendations in local contexts.

DESIGN

Qualitative case study involving semi-structured interviews with health professionals and managers working in and around acute pain services.

SETTING

Three UK acute hospital organizations.

MAIN OUTCOME MEASURES

Identification of the content, context and process factors impacting on the implementation of the national policy recommendations on acute pain services; insights into and deeper understanding of the generic obstacles to change facing service improvements.

RESULTS

The process of implementing policy recommendations and improving services in each of the three organizations was undermined by multiple factors relating to: doubts and disagreements about the nature of the change; challenging local organizational contexts; and the beliefs, attitudes and responses of health professionals and managers. The impact of these factors was compounded by the interaction between them.

CONCLUSIONS

Local implementation of national policies aimed at service improvement can be undermined by multiple interacting factors. Particularly important are the pre-existing local organizational contexts and histories, and the deeply-ingrained attitudes, beliefs and assumptions of diverse staff groups. Without close attention to all of these underlying issues and how they interact in individual organizations against the background of local and national contexts, more resources or further structural change are unlikely to deliver the intended improvements in patient care.

Evaluative criteria for qualitative research in health care: controversies and recommendations

PURPOSE

We wanted to review and synthesize published criteria for good qualitative research and develop a cogent set of evaluative criteria.

METHODS

We identified published journal articles discussing criteria for rigorous research using standard search strategies then examined reference sections of relevant journal articles to identify books and book chapters on this topic. A cross-publication content analysis allowed us to identify criteria and understand the beliefs that shape them.

RESULTS

Seven criteria for good qualitative research emerged: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability. General agreement was observed across publications on the first 4 quality dimensions. On the last 3, important divergent perspectives were observed in how these criteria should be applied to qualitative research, with differences based on the paradigm embraced by the authors.

CONCLUSION

Qualitative research is not a unified field. Most manuscript and grant reviewers are not qualitative experts and are likely to embrace a generic set of criteria rather than those relevant to the particular qualitative approach proposed or reported. Reviewers and researchers need to be aware of this tendency and educate health care researchers about the criteria appropriate for evaluating qualitative research from within the theoretical and methodological framework from which it emerges.

How residents learn: qualitative evidence for the pivotal role of clinical activities

OBJECTIVES

Medical councils worldwide have outlined new standards for postgraduate medical education. This means that residency programmes will have to integrate modern educational views into the clinical workplace. Postgraduate medical education is often characterised as a process of learning from experience. However, empirical evidence regarding the learning processes of residents in the clinical workplace is lacking. This qualitative study sought insight into the intricate process of how residents learn in the clinical workplace.

METHODS

We carried out a qualitative study using focus groups. A grounded theory approach was used to analyse the transcribed tape recordings. A total of 51 obstetrics and gynaecology residents from teaching hospitals and affiliated general hospitals participated in 7 focus group discussions. Participants discussed how they learn and what factors influence their learning.

RESULTS

An underlying theoretical framework emerged from the data, which clarified what happens when residents learn by doing in the clinical workplace. This framework shows that work-related activities are the starting point for learning. The subsequent processes of 'interpretation' and 'construction of meaning' lead to refinement and expansion of residents' knowledge and skills. Interaction plays an important role in the learning process. This is in line with both cognitivist and sociocultural views on learning.

CONCLUSIONS

The presented theoretical framework of residents' learning provides much needed empirical evidence for the actual learning processes of residents in the clinical workplace. The insights it offers can be used to exploit the full educational potential of the clinical workplace.

Exploring improvisation in nursing

Improvisation has long been considered a function of music, dance, and the theatre arts. An exploration of the definitions and characteristics of this concept in relation to the art and practice of nursing provide an opportunity to illuminate related qualities within the field of nursing. Nursing has always demonstrated improvisation because it is often required to meet the needs of patients in a rapidly changing environment. However, little has been done to identify improvisation in the practice of nursing or to teach improvisation as a nursing knowledge-based skill. This article strives to explore the concept of improvisation in nursing, to describe the characteristics of improvisation as applied to nursing, and to utilize case studies to illustrate various manifestations of improvisation in nursing practice.

Knowledge-based quality management and clinical pathways

OBJECTIVES

Although 65% of the hospitals in Taiwan claim to be applying the clinical pathway concept, most hospitals do not implement this concept effectively. The purpose of this study was to determine the reasons for the improper or inappropriate application of the clinical pathway design in hospitals.

METHODS

This study differs from other studies in clinical pathway design and application in that it seeks to resolve misunderstandings of the clinical pathway analysis that may have been generated by the responses to survey questionnaires. Therefore, in-depth interviews and Senge's system archetype have been used to ascertain the reasons why the use of a clinical pathway design has been ineffective. We also used the 4 dimensions of knowledge-based management proposed by Drucker to set up the knowledge-based clinical pathway. Thirteen experts used the Delphi method to construct 20 knowledge-based clinical pathway guidelines.

CONCLUSIONS

The application of knowledge- and management-based clinical pathway designs is recommended.

Residents' responses to medical error: coping, learning, and change

PURPOSE

To explore the significant emotional challenges facing resident physicians in the setting of medical mishaps, as well as their approaches to coping with these difficult experiences.

METHOD

Twenty-six resident physicians were randomly selected from a single teaching hospital and participated in in-depth qualitative interviews. Transcripts were analyzed iteratively and themes identified.

RESULTS

Residents expressed intense emotional responses to error events. Poor patient outcomes and greater perceived personal responsibility were associated with more intense reactions and greater personal anguish. For the great majority of residents, their ability to cope with these events was dependent on a combination of reassurance and opportunities for learning. Interactions with medical colleagues and supervisory physicians were critical to this coping process.

CONCLUSIONS

Medical mishaps have a profound impact on resident physicians by eliciting intense emotional responses. It is critical that resident training programs recognize the personal and professional significance of these experiences for young physicians. Moreover, resident education must support the development of constructive coping skills by facilitating candid discussion and learning subsequent to these events.

Making words count: the value of qualitative research

In the current climate of evidence-based practice, physiotherapy is urged to prove its worth via rigorous scientific research. However, there are concerns that limited methodologies are used to explore complex therapeutic issues, and that the profession relies too heavily on quantitative research studies to provide its evidence base. Qualitative research methods are able to explore the complexity of human behaviour and generate deeper understanding of illness behaviours and therapeutic interactions. Nevertheless, there is still a sense of distrust of qualitative research, related to the challenge of evaluating both the quality and usefulness of findings derived through qualitative methods. This discussion paper explores these issues. It examines some of the most frequently used techniques aimed at ensuring quality and value in qualitative research, such as sampling, triangulation, multiple coding, respondent validation and the use of audit trails, as well as addressing reflexivity. Because of the pluralistic and interactive nature of qualitative inquiry, the criteria used to judge quality need to be appropriate to each piece of research and should provide evidence to help readers to evaluate the calibre of the study and its relevance to their own area of work.

Action Research: a valuable research technique for service delivery development

The evaluation of healthcare practice and service delivery is fraught with difficulties. Service development and/or delivery occurs within socially dynamic settings which are in a continual state of change. Service development also often involves large elements of improvisation. The action research approach is useful for health service research, as it supports collaboration between researchers and practitioners, and not only allows but makes explicit that the action researcher has both roles within the setting being studied. This paper discusses action research methodology and offers insight into principles that favor its use for service delivery development. This includes consideration of the interactive variables within studies of health care systems and the importance of evaluating relationships between stakeholders to understand how these factors or variables, which cannot be controlled for, are responsible for successful development of the service. Action research facilitates change and helps bridge the theory-practice gap. With the current dynamic changes within both the pharmacy profession and national health services, researchers may find the action research technique of value when considering new roles and innovative ways of engaging in collaborative, multi-disciplinary working to improve delivery of patient care.

Development of the specialist menopause pharmacist (SMP) role within a research framework

OBJECTIVE

To determine the potential contribution of a new healthcare practice model, the specialist menopause pharmacist (SMP) role.

METHOD

Post pilot, the SMP's remit was proposed as combining clinical practice (service delivery) and research studies, with emphasis on strengthening liaison between the secondary and primary care sectors. Action research, a qualitative research technique, was selected to document role development in the first year. Here the pharmacist-researcher's focus was a local situation where the effects of a particular change, involving people who were part of the situation, were assessed. The change factor was the introduction of the pharmacist to the multi-disciplinary specialist team. The pharmacist-researcher did not attempt to hold anything constant but observed the changes occurring in a systematic manner. Analysis of on-going collaborative professional activity generated the hypothesis that the role was of use in enhancing patient care. Using triangulation and focusing on the descriptive phrase 'of use', it was then possible to study SMP implemented 'actions' that would be accepted as being 'useful' SMP functions. The aim was to test for reliability and obtain data with greater range and accuracy. The three studies undertaken included a controlled, questionnaire study asking for patients' views on the pharmacist service, auditing health professionals usage of the pharmacist operated telephone help-line, and assessing the impact of structured on-site training on community pharmacists.

MAIN OUTCOME MEASURE

Overall impact and achievements over 3 years, against a background where the SMP role continued to develop during the study.

RESULTS

Action research methodology engendered reflective practice, enabling the SMP to be both the service delivery provider (the intervention) and the researcher. This pharmacist practice model is accepted both by patients and health professional colleagues. The remit combines clinical practice with on-going research studies. In the UK setting, the SMP can undertake numerous liaison activities between secondary and primary care sectors to facilitate enhanced delivery of menopause patient care.

CONCLUSION

Using an action research approach, and combining qualitative and quantitative methods to complement data collection, it was possible to assess the specialist pharmacist role in depth.

The development of evidence-based nursing interventions: methodological considerations

BACKGROUND

The call for evidence-based practice presents numerous challenges to nurses who are responsible for developing interventions and expanding the associated knowledge base. The challenge is compounded because there is limited literature concerning development of interventions and their evidence base.

AIM

The purpose of this article is to present a model that has been successfully used to guide the process of developing and testing complex nursing interventions, especially those in which the experience of the client plays an important role.

DISCUSSION

The model consists of four stages: problem definition, accumulation of building blocks for intervention design, intervention design and intervention validation. Each stage is described and examples from research studies are presented. Specific attention is given to the manner in which the model allows for the accumulation of empirical evidence and theory development during the development process.

CONCLUSIONS

Use of the model could facilitate effective communication among nurses, researchers and educators when discussing the development and testing of nursing interventions.

Health visiting: the public health role

BACKGROUND

United Kingdom (UK) government policy advocates the development of a family-centred public health role for health visitors. Studies have suggested that barriers and constraints exist to hinder the development of a public health role. However, few of these have considered the issues from a practitioner perspective.

AIM

The aim of the study was to examine the constraints on developing a family-centred public health role in a health visiting service.

METHODS

An exploratory study was carried out using focus groups with 27 health visitors in one primary health care trust in North West England. Data were transcribed and analysed to identify themes.

FINDINGS

Elements of practice that contributed to public health were identified, along with constraints on the development of a family-centred public health role. Three themes were generated from the health visitor focus group discussions as a framework for addressing the constraints: connecting to public health, clarifying the role and changing practice.

CONCLUSIONS

The study sets out the challenge faced in developing the public health roles of practitioners. Leadership is essential for clarifying the public health role, developing networks between public health and practitioners, and supporting change in practice. Despite the limitations of the study, its findings, together with evidence from previous literature, suggest that there are common issues that face health visiting services in the UK as they seek to develop the public health role.

The impact of the establishment of a midwife managed unit on women in a rural setting in England

OBJECTIVE

to determine what impact the changes from consultant-led care to midwife-led care in a local maternity service have had on women using that service.

DESIGN

case study, data were collected by postal questionnaire, semi-structured, tape-recorded interviews, observations and scrutiny of records.

SETTING

a small town in rural England.

PARTICIPANTS

all pregnant women eligible for a midwife-managed unit (MMU) birth in a small rural town in England.

FINDINGS

the women using the MMU were satisfied with the care they received and the MMU style of care. Women giving birth at the MMU and at home required less pain relief and were more likely to have an intact perineum than a similar group of women giving birth in hospital. Continuity of carer did not appear to be an issue for women as long as they felt supported by a known team of midwives. Transfer for complications during the birthing process was a cause for anxiety and stress for women and their partners. Women, whilst satisfied with the MMU, would prefer the consultant-led maternity hospital to be re-established in the town. The home-birth rate rose by 28% when the consultant unit closed.

IMPLICATIONS FOR PRACTICE

while the establishment of a midwife-managed unit has provided increased choice for a minority of women, the removal of the consultant unit in the town has disadvantaged the majority of pregnant women. While guidelines are needed when establishing these units the application of restrictive inclusion and exclusion criteria can sometimes force women to make less appropriate birth choices.

Reframing the evaluation of qualitative health research: reflections on a review of appraisal guidelines in the health sciences

In this article, we explore the form of evaluation put forward by guidelines used in the health sciences for appraising qualitative research and we begin to articulate an alternative posture. Most guidelines are derivative of the modes of assessment developed by clinical epidemiologists as part of the promotion of evidence-based medicine (EBM). They are predominantly proceduralist in orientation, equating quality with the proper execution of research techniques. We argue that this form of judgment assumes a fixed relationship between research practice and knowledge generated, and tends to over-simplify and standardize the complex and non-formulaic nature of qualitative inquiry. A concern with methods as objects of judgment in and of themselves restricts the reader's field of vision to the research process and diverts attention away from the analytic content of the research. We propose an alternative 'substantive' perspective that focuses on the analysis put forward, and regards methods as resources for engaging with and understanding the substantive findings and topic of inquiry. An important challenge is to find a way to embody such a form of judgment in practical assessment tools.

Assessing qualitative research in rehabilitation: guidelines from the society for research in rehabilitation

There are numerous contested issues in qualitative research, and its findings are difficult to condense. Thus, short, qualitative research abstracts are difficult both to compile and evaluate. The Society for Research in Rehabilitation has produced guidelines that aim to illuminate and inform the development and judging of such abstracts. These draw on an extensive Health Technology Assessment review of qualitative methods in health services research.

The nursing contribution to qualitative research in palliative care 1990-1999: a critical evaluation

BACKGROUND

Qualitative research plays an important part in providing evidence for practice in nursing, and is gaining greater acceptance within medicine. However, questions remain about what criteria are most appropriate for evaluating qualitative research. To date, little systematic evaluation of qualitative research in palliative care has been conducted.

AIMS

This paper is based on a larger study in which we conducted a critical review of qualitative research in palliative care from nursing, medicine, specialist palliative care, sociology, death studies, medical anthropology, and gerontology journals published between 1990 and 1999. The aim of this paper is to present an account of the strengths and weaknesses of qualitative palliative care research in nursing, using data from this review.

METHODS

In the larger study, 138 papers from 50 journals were reviewed critically using a tool developed to assess both content and quality; in one part of this tool reviewers recorded open-ended comments on the strengths and weaknesses of each paper. In this paper, we present a thematic analysis of reviewers' comments on a subgroup of 67 nursing papers from the main review, together with an analysis of comments on 29 papers from a comparison group of death studies, medical anthropology, and sociology journals. Patterns of positive and negative evaluation are identified and used to generate an account of strengths and weaknesses in qualitative palliative care research in nursing.

FINDINGS

Over 40% of the subgroup of papers from nursing journals received positive comments on topic and quality of writing; around 30% received positive comments on contribution to understanding, practical value, and conceptual or theoretical issues. Less than 20% received positive comments on other critical dimensions. Over 40% of nursing papers received negative comments on the link between data, analysis, and findings, other aspects of method and theoretical and conceptual issues. A higher proportion of papers in the comparison group received positive comments on conceptual and theoretical issues and contribution to understanding.

CONCLUSIONS

Nearly half the nursing papers reviewed were judged to be well written or to have a well-chosen topic. However, more than 40% of papers drew negative comments about key methods-related issues. Arguably therefore efforts to improve the quality of research evidence should focus on this area.

Methodologies analysing individual practice in health care: a systematic review

AIM OF THE REVIEW

The aim of the systematic review was to identify, explore and evaluate the current level of knowledge of methodologies used in comparative analyses of the individual practice of doctors, nurses and midwives.

RATIONALE

The question of how roles and responsibilities might be shared differently between professional groups in order to promote improved, cost-effective health care requires a systematic analysis of existing roles and practice. To do this effectively, knowledge of the methodologies available for such an analysis is essential.

METHODS

A systematic review of the literature published since 1989 comparing the practice of doctors, nurses and midwives was undertaken.

FINDINGS

The findings are presented in tabular format and include the following categories of published methodologies: experimental/quasi-experimental; descriptive/nonexperimental and qualitative studies. The discussion centres on a critique of quantitative methodologies used to analyse individual practice in relation to role substitution and diversification. The potential contribution of qualitative methodologies in the analysis of individual practice is discussed.

CONCLUSIONS

The authors conclude that the current level of knowledge is biased towards quantitative research. It is argued that the assessment of health care roles and responsibilities would be well served by a more balanced approach that recognizes the strengths of both quantitative and qualitative work.

Enhancing the rigor of grounded theory: incorporating reflexivity and relationality

Some proponents of the grounded theory method appear to treat interview and participant observation data as though they mirror informants' realities. Others claim that grounded theory incorporates reflexivity. It is claimed in this article that the principal texts on grounded theory do not attend to the effects of interactions between researchers and participants in interview and participant observation contexts. Descriptions of the effects of interactions on interview data and attention to relationships between interviewers and interviewees are necessary for attending to the rigor of grounded theory findings. Therefore, it is argued that reflexivity and relationality, which are defined as attending to the effects of researcher-participant interactions on the construction of data and to power and trust relationships between researchers and participants, should be incorporated into grounded theory.

'Self-care' and its relevance to developing demand management strategies: a review of qualitative research

The promotion of self-care has been recognized as an important aspect of managing demand for health care more effectively. Self-care is increasingly being seen by policy makers as a hidden health care resource to be viewed in the context of health care provided by the formal health care sector. Quantitative studies are important for understanding the effectiveness of interventions in terms of the impact they may have on health service utilization. However, questions remain about the reasons people may or may not adopt self-care, the mechanisms for change and the way in which social context may affect the way in which people respond to self-care interventions. Qualitative research that has focused on people's self-care practices provide insights into these aspects. The qualitative studies reviewed here suggest that a number of factors need to be considered when devising health care interventions for managing demand better. These include an assessment of the meaning of the disease to the person so that self-care information can be designed in a way that fits people's prior beliefs and lifestyles. Timing and the stage in a person's illness career are also important factors to consider when designing effective self-care interventions. Social interaction and the impact of significant others may affect whether or not a self-care regime is followed, and autonomy and control are also relevant to designing acceptable self-care strategies. Incorporating these aspects of self-care as a dynamic and interactive process is important for both devising and assessing the impact of interventions aimed at the better management of demand.

The appropriate uses of qualitative methods in health economics

Ontology, epistemology and methodology are not subjects frequently discussed in health economics, yet they are of great relevance to the question of how, or whether, to use qualitative methods as a means of examining certain issues. The paper discusses the nature of enquiry in health economics and then details the nature of qualitative methods and the constructivist philosophy with which they are most commonly associated. The paper continues by examining different areas in the study of economics: neo-classical positive economics, alternative approaches to explanatory economics and normative welfare economics. For each area the philosophical approach is outlined as are the areas of research interest. Appropriate roles for qualitative methods within these philosophical approaches are then suggested. The paper concludes by warning that health economists should not use qualitative methods naively. They must be aware of the potential difficulties: both of inadvertently ending up outside the intended research philosophy and of conducting research which is accepted by neither economists nor qualitative researchers. If, however, health economists are aware of ontological, epistemological and methodological issues, they can make an informed decision about the appropriateness of qualitative methods in their research and thereby potentially enhance their ability to answer the questions in which they are interested.