Qualitative studies - critical appraisal case study

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Introduction

This study shines a light on a neglected area (discharge to residential care for the elderly), and changing demographic factors (an aging population, smaller families), social changes (greater mobility, more women in the work force), and economic pressures. The article is not a systematic review but incorporates wide reading. A study like this seems to have ethical dimensions (authors discuss the risk of "exhausting the subjects"), but there is no evidence of ethics approval. There is no evidence of blinding: the observers are colleagues and staff. Is this what they mean by "modified action research"?

Critical appraisal of a qualitative study

• Reed J, Morgan D. Discharging older people from hospital to care homes: implications for nursing. J Adv Nurs. 1999;29(4):819-25.

Screening questions

Was there a clear statement of the aims of the research?

Yes: a clear aim is identified: to explore experiences of older people discharged from hospital into nursing and residential care, and identify possible forms of support.

• Is a qualitative methodology appropriate?

Yes: a qualitative methodology is appropriate as the study considers the experiences of the subjects through their own eyes and those of staff.

Sampling strategy

• Where the sample was selected from and why?
  • The sample were identified from hospital records for an acute Trust in the north-east of England, which was the study setting. The samples were dischargees from hospital, nominated family members and hospital and residential home nursing staff.
  • Who was selected and why?

They were selected to provide as wide a range of experiences as possible.

• How were they selected and why?
  • purposive sample of 20 older adults discharged from hospital. Of an original sample of 48, 19 were excluded because of frailty or cognitive impairment; others declined to take part, had left the area or died. The subjects nominated seventeen family members. Twenty four staff were interviewed, plus six written responses submitted, although the report states that this amounts to a total of 29 respondents.
  • Was the sample size justified?

No justification of sample size offered, and there is no indication if there was data saturation.

• Is it clear why some participants chose not to take part?

It is not clear why three patients did not participate. Staff responses were reported to be reduced as a consequence of work commitments, and the report indicates a range of efforts which were made to increase staff responses.

• Was the sampling strategy appropriate to address the aims?

Overall, the sampling strategy was compromised by problems in sampling appropriate staff and a high attrition rate among eligible patients.

Data collection: is it clear

• Where the setting of the data collection was, and why that setting was chosen. There is a clear description of the setting, but it is unclear why this setting was chosen.
• How the data were collected and why?

Patients and family were interviewed individually, while staff were interviewed in focus groups, with one individual interview and six responses to a questionnaire. It is unclear why focus groups were the method of choice for staff, and other methods were used with this group on an ad hoc basis.

How the data were recorded and why?

Semi-structured interview schedules were used: no description of data recording method. d. If the methods were modified during the process and why? The methods of collection of staff data were modified to increase the sample size. Were the data collected in a way that addresses the research issue? Overall, data collection methods addressed the research question.

Data analysis - is it clear

a. How the analysis was done? There is no discussion of how data analysis was undertaken. b. Was the data analysis sufficiently rigorous? It is not possible to tell if the analysis was sufficiently rigorous. There are questions about the validity and reliability of the analysis.

Research partnership relations

Is it clear:

a. Whether researchers critically examined their own role, potential bias and influence?

The study claimed to be an action research approach, working in collaboration with staff. However this seems to be tokenistic, with no indication of how the research team worked with staff to address the findings. Patients and families appeared to be used as ‘response fodder’ with little or no feedback.

b. Where the data were collected and why that setting was chosen?

There is no discussion of why the particular research setting was chosen.

c. How the research was explained to the participants?

There is no description of how the research was explained to participants, and it was unclear on what basis patients were given an opportunity to refuse to take part. There is no discussion of the ethics of interviewing older people about their experiences.

Has the relationship between researchers and participants been adequately considered?

Overall, there is inadequate discussion of the research relationships.

Findings

The findings are presented clearly, but the findings from the different groups of respondents address different themes, and there is little effort to bring these together.

Justification of data interpretation

a. Is there sufficient data presented to support the findings?

There is not sufficient data presented as direct quotations to justify the findings. This is particularly the case for the patient group, in which quotations are brief and infrequent.

b. Do the researchers explain how the data presented in the paper were selected from the original sample?

The researchers do not explain how the quotations presented were selected.

Transferability

The setting is described adequately to enable judgements of transferability; however this may be compromised because of threats to validity. In particular, the response rate was under 50% and the study is limited to the cognitively intact: i.e. it excludes any with dementia or confusion.

Relevance & usefulness

a. In terms of addressing the research aim?

The study is relevant to the aim.

b. In terms of contributing something new to understanding / new insight / different perspective?

The study offers new insights.

c. In terms of suggesting further research

The study offers potential for further research.

d. In terms of impacting on policy / practice?

There are policy and practice implications.

How relevant is the research? How important are these findings to practice?

Overall

Overall, and given the reservations about internal validity, the study is relevant and useful to people being discharged into care. It has important implications for practice.

The study puts a neglected area (discharge to residential care) in context, especially as changing demographic factors (an aging population, smaller families), social changes (greater mobility, more women in the work force), and economic pressures (the run down of NHS long term beds) make for increasing use of this option to care for the frail elderly. There is evidence of wide reading, but not of a systematic nature. A study like this seems to have ethical dimensions (on page 822 the authors discuss the risk of "exhausting the subjects"), but there is no evidence of Ethics Committee approval. There is no evidence of blinding: the observers are colleagues and staff. Is this what they mean by "modified action research"?

The main finding is that older people are passive in the process of selecting and moving to care homes and staff need to be more pro-active in eliciting their views and preferences.

References

• Barnett-Page E. Methods for the synthesis of qualitative research: a critical review. London, Evidence for Policy and Practice Information and Coordinating (EPPI) Centre, 2009.
• Centre for Reviews and Dissemination. Systematic reviews: CRD’s guidance for undertaking reviews in health care. University of York; 2009.
• Dixon-Woods M, Agarwal S, Young B, Jones D, Sutton A. Integrative approaches to qualitative and quantitative evidence. London: 2004.
• Finlayson KW, Dixon A. Qualitative metasynthesis: a guide for the novice. Nurse Researcher. 2008;15(2):59-71.
• Finfgeld DL. Meta-synthesis: the state of the art - so far. Qualitative Health Research. 2003;13:893-904.
• Mason J. Qualitative researching. London: Sage, 2007.
• Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358(9280):483-8.