Written by Raymond H.
Evidence-based practice is a cornerstone of contemporary medical and nursing care (Aveyard & Sharp, 2013) and should be considered the gold standard approach to care. The central tenet of evidence-based practice is that an objective appraisal of published literature can be used to isolate the most effective interventions, which may then be applied in practice, while considering the preferences and considerations of the patient (Hamer & Collinson, 2014). The individual nurse is responsible for ensuring that they adopt an evidence-based approach to care, appraising research relevant to their professional duties and responsibilities (Melnyk & Fineout-Overholt, 2011). As such, critiquing is a key skill that should be developed and practised by all nurses and healthcare professionals alike.
For the purposes of this paper, a critical appraisal was conducted on the paper “Understanding the experience of patients with chronic obstructive pulmonary disease who access specialist palliative care: A qualitative study” by Hayle et al., (2013). In order to critique the selected article, the Caldwell et al., (2005) critiquing framework was employed, to ensure a valid and objective approach to the appraisal process. The results of this critiquing process, including the identifications of strengths and limitations of the article, form the remainder of this paper.
The title of the paper in question provides a clear insight into the content of the paper, noting the approach used (qualitative), the population of interest (patients with chronic obstructive pulmonary disease [COPD]) and the broad aim of the study. The title of an academic paper should be concise and should ideally adhere to the format of identifying the population of interest, intervention (if any), comparisons (if any) and outcomes of interest (O’Brien et al., 2014); this paper follows this format closely. The authors of the paper have a solid publication history and are members of the nursing or palliative care team in a large metropolitan hospital, adding credibility to the research (Tong et al., 2012).
The abstract of a paper provides a key summary of the key elements of the paper, including the aim, design, results, and implications of the findings of the study (Caldwell et al., 2011). This paper utilises a structured abstract, providing clarity in interpreting the key elements of the paper (Grove et al., 2012). The authors successfully provide a suitable justification for the approach used, summarising the key processes used to design and conduct the study, as well as the main findings and their implications.
The rationale for the study is clearly described by the authors, based on a comprehensive and contemporary literature search. The authors identify the epidemiology of COPD and the consequences of the condition, including the palliative care needs of patients. Furthermore, they highlight existing UK policy on palliative care access and service improvement needs for these patients. The literature review uses up-to-date policy and research to justify the need for the present study and the aim of the paper is developed accordingly (Grove et al., 2012). The authors explicitly state the aim of the paper as an in-depth examination of lived experiences of patients with COPD accessing palliative services, simultaneously justifying the qualitative approach and the holistic nature of patient care (Kisely & Kendall, 2011).
When conducting research with patients, ethical approval is essential (Denzin & Lincoln, 2011), and the researchers have sought approval from the local ethics committee. However, a wider discussion of the ethical issues that arose during the research, or were considered prior to data collection, are not discussed in detail. The authors do note that the participants had to complete a written consent document prior to data collection, suggesting that appropriate ethical consideration of capacity and consent was adopted (Denzin & Lincoln, 2011). The general methodological approach is qualitative in nature, consistent with the aim of the research (i.e. exploration of lived experiences). Qualitative studies often rely on a strong philosophical research background in order to justify the means used to collect data and then to analyse and interpret the findings appropriately within the selected paradigm (Marshall & Rossman, 2014). However, the authors of this paper offer no discussion of their philosophical stance, a notable limitation. However, it is not uncommon in published manuscripts that these details are omitted for brevity, which should be considered a possible explanation for the absence of such discussion (Rosenfeld, 2010).
Despite the absence of a philosophical discussion of the research method, the research design and associated processes are discussed and justified appropriately. The general concepts explored in the study are defined in a supplementary appendix and strongly relate to the themes evident in the background literature search, suggesting an appropriate means of identifying relevant topics for analysis. The research design is based on the completion of semi-structured interviews, which is not specifically justified as an approach. However, this is a suitable method, as semi-structured interviews allow for a detailed narrative to be obtained from each patient, with coverage of key topics but the opportunity for patients to expand on their own experiences and provide insight into additional phenomena (Whiting, 2008). Details of the semi-structured interview process are not provided in the body of the manuscript but are shown in a supplementary appendix, illustrating the length, location, and processes of the interviews, which is an essential marker of research transparency (Whiting, 2008). The use of semi-structured interviews, with recorded transcripts, is considered an auditable and therefore valid means of performing qualitative research (Denzin & Lincoln, 2011).
The participants were selected from a specific location and their inclusion was based on the fulfillment of key criteria. This is known as purposive sampling and is often used as a means of ensuring that the researchers are able to obtain data from the group whose experiences are the focus of the research (Teddlie & Yu, 2007). In this instance, it is an appropriate strategy, as patients with COPD accessing palliative care services are a distinct group. Both inpatient and outpatient services were considered, presumably as a means of expanding the available number of patients for participation. Furthermore, the authors ensured objectivity in the research method by excluding patients known to the researchers in a clinical capacity, while ensuring that patient capacity to participate was assessed and used to guide the selection process (Dobson, 2008). Overall, the sampling process may provide limitations on the generalizability of the findings to other locations or patient groups (Gibbs et al., 2007), but it is an appropriate process for the present study aim. However, it should be recognised that the sampling strategy may have led to bias when selecting patients, as patients with extreme views on service quality or their own experiences may have been more likely to share their opinions (Gibbs et al., 2007). Furthermore, the most unwell patients, who were physically unable to participate, may have different insights into service use, which would not have been explored in this study (Dobson, 2008).
The data analysis process was guided by hermeneutic phenomenology, as an appropriate approach for this study based on the need to analyse individual patients’ lived experiences, which phenomenology is an established approach (Ajjawi & Higgs, 2007). This data analysis method has been explored and validated in other research contexts, providing support for the use of the technique in this paper (Ajjawi & Higgs, 2007). The approach is well-structured and is suitably designed to allow for the identification and synthesis of the lived experiences of a patient group, consistent with the aim of the paper. The use of multiple researchers in analysing data also reduces the risk of individual researchers introducing bias into the analytical process, increasing the reliability of the data analysis approach (Caldwell et al., 2011).
However, the role of the researcher is important to consider when adopting any qualitative study, as researchers may influence the data collected and the analysis process (Caldwell et al., 2005). The authors fail to provide an overview of the role of the researcher in this study, marking one limitation of the theoretical basis of the paper. It can be argued that appreciation of the role of the author as a source of social desirability bias has been presented, which is an important point to note (van de Mortel, 2008). It must be noted that the authors of the study felt that their influence would be minimised as they were not in direct clinical contact with any patient, which may apply to their clinical role but not necessarily their position as a researcher. Therefore, this point may have required further comment in the paper to clarify the reflection of the authors.
The results of the paper are based on the analytical approach described and are presented as a series of key themes or topic areas in which the authors provide a summary of the findings from all participants (n=8), supporting these summaries with direct quotations from the interview transcripts. This is a commonly used approach to presenting qualitative data sets that are thematic in nature and is therefore justified (Bazeley, 2009). The use of quotations allows the reader to relate the assertions of the researchers back to the original transcripts, thereby increasing the credibility of the research process (Bazeley, 2009). The main themes identified in the literature included: physical impact, psychosocial impact, spiritual impact and perceptions of palliative care services. All of the themes are appropriate and relevant to the research aim, while each theme is explored in sufficient detail to suggest that they are appropriate outcomes of the research process. It may have been useful for the reader if the themes and sub-themes were identified in a tabulated format to supplement the narrative presentation, while also providing a clear link between themes and the original transcript data (Grbich, 2012).
The discussion section provides an overview of the main study findings and attempts to place these findings within the wider context of patient care and associated literature. The discussion section is adequately referenced, with contemporary sources used to support he points raised by the authors. Indeed, the discussion section should be richly referenced to demonstrate that the authors have considered their findings in relation to previous studies or knowledge gaps (Caldwell et al., 2011). The authors achieve this successfully while maintaining their thematic approach to the research question.
The authors of the paper also provide a detailed overview of the strengths and weaknesses of their paper, which is recommended as a means of self-appraisal in the literature (Caldwell et al., 2005). The authors rightly reflect that the external validity of the findings is limited due to the small-scale and localised geographical nature of the study process (Silverman, 2016). Furthermore, the authors have generally considered other limitations (noted above), suggesting an honest and reflective account of the research process (Silverman, 2016).
The conclusion of the paper focuses on the implications of the study for service design and future research. It is important to note that the authors state that the value of their research lies in providing an overview of the experiences of patients and therefore may be limited in guiding service design without future studies being conducted. Indeed, this form of study is often hypothesis-generating, rather than directly linked to practical measures that may be used to improve services (Daly et al., 2007). However, the suggestions and conclusions drawn by the authors are reasonable and realistic, relating to their findings closely. Finally, the suggested future research directions successfully build on the findings of the present study, while exposing knowledge gaps and the need for specific types of study in this population.
Overall, this study adheres to many of the standard requirements of a well-conducted qualitative research process, including the isolation of a suitable data collection and analysis approach, as well as interpretation of the findings in relation to a qualitative perspective. However, the small sample size and limited geographical location of the study reduce the transferability of the research and the implications for practice. Furthermore, the lack of a philosophical paradigm reduces the theoretical strength of the research. The implications of the research are considered in light of these limitations and are suitably comprehensive to suggest that further studies may integrate these findings to explore gaps in the knowledge base.
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