Questions about clients’ experiences and concerns: examples of appraisals from different health professions

CHAPTER 11 Questions about clients’ experiences and concerns

examples of appraisals from different health professions

Sally Bennett, John W. Bennett, Craig Lockwood, Sharon Sanders Jemma and Skeat

This chapter is an accompaniment to the previous chapter (Chapter 10) where the steps involved in answering a clinical question about clients’ experiences and concerns were explained. In order to further help you learn how to appraise the evidence for this type of question, this chapter contains a number of worked examples of questions about clients’ experiences and concerns that are relevant to health professions such as the therapies, nursing, medicine and complementary and alternative medicine. The QARI tool for appraising qualitative research that was outlined in Chapter 10 has been used for these examples. Although there are other checklists available for appraising qualitative evidence that have a slightly different focus, there is no consensus about the ideal approach that should be used when appraising qualitative research. The QARI tool has been tested and used extensively. Chapter 1 explained how to access the QARI tool.

As was explained in Chapter 10, when the QARI tool is used, critical appraisal focuses on:

• congruity between philosophical position adopted in the study, study methodology, study methods, representation of the data and the interpretation of the results

• the degree to which the biases of the researcher are made explicit

• the relationship between what the participants are reported to have said and the conclusions drawn in analysis.

Occupational therapy and physiotherapy example

Clinical scenario

You have been working as a therapist in a multidisciplinary stroke rehabilitation unit and want to understand why some clients seem more motivated to participate in rehabilitation than others.

Clinical question

What factors might motivate people who have had a stroke to participate in stroke rehabilitation?

Search terms and databases used to find the evidence

Database: PubMed

Search terms: A simple search using the following text words was used: (stroke rehabilitation) AND motivation AND qualitative.

This search strategy retrieved 16 articles, two of which focussed on stroke rehabilitation and motivation. One article considered motivation from the health professionals’ perspective and the other considered motivation from the perspective of clients. This is the article that you choose to appraise.

Article chosen

Maclean N, Pound P, Wolfe C et al. Qualitative analysis of stroke patients’ motivation for rehabilitation. BMJ 2000; 321:1051–1054.

Structured abstract

Study design: ‘Qualitative study with semi-structured interviews’ is the design stated in the article. However, it is likely to have used a phenomenological approach.

Study question: To explore the attitudes and beliefs of stroke patients identified by professionals as having either ‘high’ or ‘low’ motivation for rehabilitation.

Context: The stroke unit of an inner city teaching hospital.

Participants: 22 patients with stroke who were undergoing rehabilitation—14 with high motivation for rehabilitation and 8 with low motivation.

Data collection method: Semi-structured interviews were used covering the following topics: confidence about making a good recovery, views about relationships with professionals, ideas about important factors in recovery, ideas about the patient’s role in rehabilitation, ideas about the nature and purpose of rehabilitation and feelings about what sort of life is desired after the stroke. Participants were free to structure the conversation within each topic. New topics brought up by the participants were discussed as and when they arose.

Analysis: Transcribed interviews were coded for themes and constant comparison was used. The codes in each interview were then compared with those in each other interview to create broader categories that linked codes across interviews.

Key findings: People with stroke who were identified as having high motivation for rehabilitation were more likely to understand the purpose of rehabilitation than those who were identified as having low motivation. Positive determinants of motivation included: being given information about rehabilitation, positive comparisons with other people with stroke and wanting to leave hospital. Negative determinants of motivation included: overprotection from family members and professionals, lack of information and the provision of mixed messages about rehabilitation to patients and less favourable comparisons with others.

Conclusion: Differences in beliefs were evident between stroke patients who were identified as having low or high motivation for rehabilitation. Environmental factors (behaviour of health professionals, information available, hospital environment and so on) appear to influence motivation in addition to the individual’s personality. Health professionals need to be aware of the ways in which their behaviour affects motivation.

Is the evidence rigorous and sufficiently reported?

1. Is there congruity between the stated philosophical perspective and the research methodology?

The study does not clearly state the philosophical or theoretical premises on which it is based but clearly takes an interpretive perspective in trying to understand motivations for rehabilitation among people with stroke. The methodology is not clearly stated either. The article simply states that it was a qualitative study using semi-structured interviews. It can be seen from reading the methods, however, that a phenomenological perspective has been taken to understand the attitudes and beliefs of people with stroke. Phenomenology seeks to uncover lived experience through spoken and unspoken communication to establish meaning associated with lived experiences as perceived by people and this was clearly undertaken in this study.

2. Is there congruity between the research methodology and the research question or objectives?

The objective of the research was to explore the attitudes and beliefs of stroke patients who were identified by professionals as having either ‘high’ or ‘low’ motivation for rehabilitation. Therefore the objectives are congruent with the phenomenogical methodology.

3. Is there congruity between the research methodology and the methods used to collect data?

Data collection relied upon health professionals identifying ‘high’ and ‘low’ motivation patients and therefore used purposeful sampling. Semi-structured interviews were employed and these were then transcribed. This is appropriate to the methodology of a phenomenological approach.

4. Is there congruity between the research methodology and the representation and analysis of data?

Analysis of the data was conducted using a process of constant comparison. Data were first coded and care taken to ensure that the codes captured the respondents’ meanings. The codes in each interview were then compared with those in each other interview to create broader categories that linked codes across interviews (constant comparison). These methods of analysis are congruent with the methodology (phenomenology). The study did not involve any reflective validation by the research participants. The representation of the data is also congruent with the methodology. It draws on quotes from participants to validate the identified themes.

5. Is there congruity between the research methodology and the interpretation of results?

The results have been interpreted appropriately as they have been used to inform the researchers of the experiences and perceptions of people who have had a stroke. The focus on establishing meaning based on experience is appropriate for a phenomenological study.

6. Is there a statement locating the researcher culturally or theoretically?

The beliefs and values of the researchers are not described.

7. Is the influence of the researcher on the research, and vice versa, addressed?

The influence of the researcher was not clearly addressed. The primary author interviewed all participants but there was no indication in the report that the researcher had reflected on the influence that their role, position, values or beliefs might have had on the interview process with the participants.

8. Are participants and their voices adequately represented?

Quotes were used to illustrate most themes; however, a few themes were not validated through the use of quotes. Further it was clear that different participants’ voices were represented (indicated by participant number for each quote used).

9. Is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body?

No specific statement about obtaining ethical approval is evident in the report; however, it does state that participants agreed to participate.

10. Do conclusions drawn in the research article appear to flow from the analysis, or interpretation, of the data?

The researcher’s conclusions are clearly drawn from the key themes identified and inform the strategies for interacting with stroke patients that may increase motivation for rehabilitation.

What are the main findings?

People with stroke who were identified as having high motivation for rehabilitation were more likely to understand the purpose of rehabilitation than those who were identified as having low motivation. Positive determinants of motivation included: information about rehabilitation, positive comparisons with other people with stroke and wanting to leave hospital. Negative determinants of motivation included: overprotection from family members and professionals, lack of information and the provision of mixed messages about rehabilitation to patients and less favourable comparisons with others.

How might we use this evidence to inform practice?

This study emphasises the need for health professionals to look past an individual client’s personality to environmental factors and health professional behaviours that may influence the motivation of people who have had a stroke to participate in rehabilitation. In particular, overprotection from family members and professionals and providing clients with insufficient information and/or mixed messages about rehabilitation may contribute to a reduced level of motivation. There are aspects of the methods and reporting of this study that could have been improved and this, in turn, would have strengthened your confidence in the findings of the study.

Podiatry example

Clinical scenario

You are a member of a recently established multidisciplinary team of health professionals who are involved in the management of clients who have diabetic foot complications. During a case conference, you begin a discussion about a client who has developed a new ulcer on the plantar surface of her foot after a recent digital amputation. The client has a pair of therapeutic shoes but refuses to wear them. Though you have spoken to her about the importance of appropriate footwear, she does not regularly wear any type of footwear that can accommodate pressure deflective devices or that provides sufficient protection to her feet. Recognising that many of the clients who are seen by the team seem not to wear their prescribed footwear or to follow footwear advice, the endocrinologist asks if you have any suggestions about how to tackle this problem. Before coming up with any strategies, you say that first you would like to gain an understanding of people’s attitudes to, beliefs about and experiences with prescribed footwear. You think this understanding may help you come up with strategies that may improve clients’ concordance with footwear advice. You agree to present your findings at the next case conference.

Clinical question

What are people’s experience with prescribed footwear and what factors determine whether they will follow footwear advice?

Search terms and databases used to find the evidence

Database: You know that this question is best answered by a qualitative study. Your hospital librarian suggested that CINAHL is a probably a good database for you to start your search in.

Search terms: (footwear OR shoes) AND (complian^∗ OR adheren^∗ OR concordan^∗)

This search retrieves 50 titles. There are three studies that have examined people’s experiences with prescribed footwear or investigated factors associated with a person’s decision to follow footwear advice. You think that it will be important that you review them all for your presentation. To begin with, you select the following study which gives client and health professional views on the use of therapeutic footwear.

Article chosen

Johnson M, Newton P, Goyder E. Patient and professional perspectives on prescribed therapeutic footwear for people with diabetes: a vignette study. Pat Educ Couns 2006; 64:167–172.

Structured abstract

Study design: Qualitative analysis of semi-structured interviews using the framework approach.

Study question: The purpose of the study was to explore the experiences and views of people involved in prescribing and wearing footwear designed to reduce diabetes-related complications.

Context: Diabetes foot clinics, North Sheffield, UK.

Participants: 15 health professionals with experience in delivering care to people with diabetes-related foot complications and 15 clients from two diabetes foot clinics who had been prescribed footwear designed to reduce diabetes-related complications.

Data collection method: Participants were interviewed using a vignette depicting the experiences of a fictitious client with diabetes-related foot complications. Prompts were used after each vignette section to explore participant views.

Analysis: Interviews were taped and analysed using the framework approach.

Key findings: There was incongruence between clients and health professionals in terms of the expectations and reality of preventive behaviour. Health professionals, while advocating preventive measures in order to limit morbidity, are aware of how difficult this can be for clients. For clients, the reality of wearing prescribed footwear conflicted with personal and social norms. Both clients and health professionals expressed concerns about shoe fit when foot shape, size and structure are constantly changing.

Is the evidence rigorous and sufficiently reported?

1. Is there congruity between the stated philosophical perspective and the research methodology?

The study does not clearly state the philosophical or theoretical premises on which it is based but clearly takes an interpretive perspective in trying to understand the experiences and views of people involved in prescribing and wearing footwear that is designed to reduce diabetes-related complications. The methodology is not clearly stated either. It simply states that it was a qualitative study that used semi-structured interviews and vignettes. One can see from reading the methods, however, that a phenomenological perspective has been taken. Phenomenology seeks to uncover lived experience through spoken and unspoken communication to establish meaning associated with lived experiences as perceived by people and this was clearly undertaken in this study.

2. Is there congruity between the research methodology and the research question or objectives?

The purpose of the study was to explore the experiences and views of people who are involved in prescribing and wearing footwear designed to reduce diabetes-related complications. Therefore the objectives are congruent with the phenomenological methodology.

3. Is there congruity between the research methodology and the methods used to collect data?

Purposive sampling was used to identify health professionals and clients. Different types of health professionals (consultants, general practitioners, nurses, orthotists, podiatrists and a dietitian) with experience in delivering care to people with diabetes-related foot complications were interviewed. The clients who agreed to participate had long-term experience with foot care services and were from diverse socio-economic circumstances. The researchers believed these clients would provide a broad spectrum of beliefs and attitudes to prescribed footwear.

In this study, one-on-one interviews with health professionals and clients were conducted using vignettes. A piloted vignette which depicts the experiences of a fictitious client with diabetes-related foot complications was used. Prompts were used after each vignette section to explore participant views. Responses were then followed up as necessary to increase the clarity and depth of information. The researchers discuss why vignettes were used and why face-to-face interviews were conducted (as opposed to focus groups) with participants. These are appropriate to the methodology of a phenomenological approach.

4. Is there congruity between the research methodology and the representation and analysis of data?

The interviews were taped and analysed using the framework approach. In this method, after becoming familiar with the data, investigators classified the data according to key themes and concepts. In this study, two researchers carried out this process with a sample of transcripts before applying the framework to the remaining data. The validity of the interpretations does not appear to have been examined. These methods of analysis are congruent with the methodology (phenomenology). The representation of the data is also congruent with the methodology. It draws on quotes from different participants to validate the identified themes.

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Tags: Evidence-Based Practice Across the Health Professions

Mar 21, 2017 | Posted by admin in MEDICAL ASSISSTANT | Comments Off

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