Critical Analysis of Two Articles about PEG Feeding - Essay Example

? Critical Analysis of Two Articles about PEG Feeding CONTENTS Introduction The research process Research question and hypothesis in the two articlesBackground Literature review Design and sample Methodology Results Conclusion Bibliography Introduction This analysis explores two research papers on Percutaneous endoscopic gastrostomy (PEG) feeding: Paper 1: Brotherton, A, Abbott, J and Aggett, P 2006 ‘The impact of percutaneous endoscopic gastrostomy feeding upon daily life in adults’, Journal of Human Nutrition and Dietetics, vol. 19, pp. 356-67. Paper 2: Brotherton, A and Abbott, J 2009 ‘Clinical decision making and the provision of information in PEG feeding: an exploration of patients and their carers’ perceptions’. Journal of Human Nutrition and Dietetics, vol. 22, pp. 302–309. The aim of this analysis is to assess these two articles and how well they follow general research standards and the use of (appropriate) methods. As a core requirement in the presentation of a scientific argument a paper has to begin by introducing the topic chosen in terms of a “research question" and a “hypothesis” (a “preliminary”, i.e. ahead of the actual research, answer to the question). It should then proceed by clearly stating the aim of the research and how the authors propose too “explore the problem” by comparing to other “literary source and concept”. Importantly, such published articles need to define the “setting” and/or the “sample” and qualify these and the literature in terms of a particular set of “methods” to be used and deemed appropriate, be they person-oriented and qualitative, or of a more quantitative nature, or a mix of the two groups. Following the method, is the “results-section”, an analysis and discussion of the data collected. Finally, conclusions and recommendations are made, and including discussion how the study has tested the research question. Limitations of one’s findings should also be noted (Rees, 2003). The Research Process Research, the search for knowledge and problem-solving, is a process of adding to knowledge (Ellen, 1984). By this understanding, research is an ongoing process. There are, however, certain procedures to be followed and standards to be adhered to, be they of an “inductive” (experimental: “arriving at a theory based on facts”) or “deductive” (“facts are organized to match theory”) nature. Based on this division, one arrives at a “positivistic” and “relativistic stance”, resulting in a contrast of “explanation” (deduction, positivism) and “understanding” (induction, relativism) (Bowling, 2002, pp. 117-32; Alexander, 1983; Gellner, 1985). “The contrast has been exemplified by the different emphases placed upon structure and upon process; upon positivist, empiricist observation as against intellectual inference and propositions about deep structures of society; by notions of detachment and objectivity opposed by more subjectivist views; by assumptions of validity and certainty of generalisation set off against those of ambiguity, uncertainty of findings. Such contrasts are not unilineal; they often overlap” (Firth, 1992, p. 215). Firth’s last sentence is revealing. Contrasts between a quantitative and qualitative approach are often being set up but they do not refer to real differences in the end. It is, as another anthropologist notes, rather “a matter of degree” since both dimensions (induction and deduction) are indispensable for an understanding of other people and their worlds (Geertz, 1974). The alleged contrast is as straw man argument. Research question and hypothesis in the two articles 1. Brotherton, Abbott and Aggett’s (2006) article is about how percutaneous endoscopic gastrostomy (PEG) feeding relates to the daily lives of adult patients. The authors aim was to explore that question (research question) from two perspectives, that of patients and carers. Their research question assumes (hypothesis) that the two parties hold different notions and models regarding the condition. Their research was of a qualitative nature and follows the standards of research presentation (Bowling, 2002; Rees, 2003). 2. In 2009 Brotherton, one of the authors of the previous article, and Abbott published their study of PEG patients and their carers, their perceptions of information given them concerning their condition and their involvement in clinical decision making. The assumption informing this focus is that knowing about how patient and carers perceive of clinical information relates to their involvement in the decision making process. Their research method is again qualitative and adequate in terms of their person-oriented research of perceptions, the research question and the hypothesis (Bowling, 2002; Rees, 2003). Background To begin with Brotherton, Abbott and Aggett (2006) provided important background information regarding the history of home enteral tube feeding in the community in the UK with a focus on 2000 and 2002. They highlighted that the condition or disease underlying Gastrostomy feeding has a major impact on physical activity, with 51% of patients housebound and bed bound in 1996-2000 and at the end of 2002 84% of all adults were fed by Gastrostomy (ibid: 355-56). Their background information included figures and percentages as well as a discussion of these that appears very relevant (Rees, 2003). Overall mortality in adults after one year of PEG feeding was recorded as 34%. This percentage varies, however, a great deal with regard to some groups of patients where the percentage is much higher, 63% in the case of motor neurone disease, 47% in oesophageal cancer and 38% in head and neck cancer (Brotherton, Abbott and Aggett, 2006: 356). Mortality may also be much lower than the average percentage with 14% for multiple sclerosis patients and 12% in the case of cystic fibrosis (ibid: 356). This may, the authors emphasize, imply that patients with a disease that is rapidly progressing suffer since they may receive PEG feeding too late for a nutritional benefit to be achieved. Against the background of an increase in PEG feeding they provided a solid rationale for their evaluation of PEG feeding and the patient’s perspective in their article and their subsequent data collection. This background information led therefore on to an evaluation of the quality of life (QoL) of the sick in the following section, whether PEG feeding is “in the patient’s best interest” (ibid: 356). In 2009 Brotherton and Abbott note as background information to their topic of perceptions and involvement in decision making that official Government health policy required that health professionals assure the involvement of patients in decision regarding their condition and care. This asks that patients be provided with information to make adequate decisions and is to impact positively health communication and therapeutic efficacy. How this policy is to be realized and given the many complexities of the issue, however remains, unclear. That there is a need to tackle the issue is reported by the literature. So as to provide proper background to their own study (to contextualize it in the literature, Rees, 2003) they cite one study in 1997 that showed how patients were uncertain about the decision taken of PEG tube feeding. The problem of inadequate information given was also highlighted in a 1999-study (ibid: 302). Subsequent studies in 1999 and 2007 (Van Rosendaal et al., 1999; Brotherton et al., 2007) are also cited by them that have focused on the same problem and poor prognosis information as well as inadequate communication between health care personnel and patients/carers. One study cited (Mitchell and Lawson, 1999) showed that sometimes decision-makers themselves may be unsure whether the enteral feeding decision is the right one to make and in many cases patients reported having received insufficient information regarding the pros and cons of PEG (ibid: 303). “…the reality in clinical practice for decisions relating to PEG placement is that patient involvement in decision making is inconsistent and limited” (ibid: 303). This reality is further complicated by various legal and nutritional requirements, such as the Mental Capacity Act, 2005 (Department for Constitutional Affairs, 2007) and nutritional guidelines of support contained in NICE (2006). The withdrawal or enforcement of feeding also involve numerous legal and ethical issues (ibid: 303). In all this, an additional complexity that has remained and pertains to “the patient’s perspective”, they note (ibid: 303). Thus, Brotherton and Abbott focus on the perceptions of patients and carers regarding the kind and quality of information provided about PEG tube feeding and their involvement in decisions regarding PEG placement (ibid: 303). Literature review 1. Having outlined the problem and given relevant background information, Brotherton, Abbott and Aggett (2006) then analysed relevant literary sources and the concept of QoL that is central to answering the research question. Their review reflects “the state of the art” regarding knowledge of the QoL, having both physical, psychological and social dimensions. Still one has to distinguish between QoL and disease processes and outcomes (ibid: 356). They reviewed appropriately various studies with comparisons to “regular” population groups. Findings varied. Some studies focused specifically on levels of QoL and found them often to be lower among sick as compared to healthy individuals. Others stressed an association between a reduced QoL and malnutrition, the relationship between symptoms and QoL, the psychological impact of being fed by a tube, the impact on daily life. Longitudinal and follow-up studies are also cited as giving important statistical information (percentages), especially on mortality outcomes. PEG-use and its relation to/impact on QoL (ibid: 357). Reviewing past findings, they noted that these studies are all limited, however, by not having specifically-designed, systematic and valid measures to assess QoL in PEG patients (ibid: 357). This lack or omission was the background for their study which used a specifically-designed tool, interviewing, a qualitative method, to assess the experiences of PEG feeding as they divide among patients and their carers. They considered their tool a more adequate, systematic and meaningful approach. In pointing out past omissions and introducing their own approach, they were observing a truly scientific argument (Bowling, 2002; Rees, 2003). In 2009 Brotherton and Abbott followed a slightly different presentation format whereby they contextualized their topic in the existing literature in their Introduction. This is a perfectly legitimate choice where the issues particularly relevant to solving the identified research problem are highlighted: perceptions, information, decision-making, health-communication and participation. Design and sample: Having provided a literature review and introduced their methodology, Brotherton, Abbott and Aggett (2006) proceeded by describing their sample which, they note, is based on a cross-section of PEG patients and carers and a sample, “purposive sampling”, that included a wide range of diseases among patients. For sampling purposes, patients were derived from one NHS hospital in the Northwest of England. A rather inclusive sample, they stressed (ibid: 357). They also ensured to qualify their sample further recording ages and gender as well as diagnoses, feeding regimes and length of time of PEG feeding and relationships of patients to carers. Although a wide range of diseases amongst patients were appropriately selected, it would have been more appropriate to collect samples from more than one NHS hospital in order to be able to make generalisation more applicable. Brotherton and Abbott (2009), used the same sampling technique adopted by Botherton et al. in 2006, a cross-sectional sample of 16 patients and 27 carers. As previously, they derived their sample from an NHS hospital in the North West of England. The data, they note, were collected their data in 2003 and 2004. Methodology After this clear discussion of their sample, Brotherton, Abbott and Aggett (2006) proceeded to describe their methodology; structured interviewing regarding the perception of patients and carers in PEG feeding. They list the specific interview questions in a table (table. 1) which makes for a concrete insight and a good overview. This tabulation makes for a clear presentation and demonstrates the specific and systematic, as well as practical, nature of their research (Rees, 2003). Being well-organized, their description of the questions to be asked demonstrated their value in, as they note, generating the data needed showing, “benefits and practical difficulties of living with a PEG” (ibid: 357). Their theory-methodology-data were clearly interconnected, (Bowling, 2002; Rees, 2003). In connection with describing their methodology, they also note their “procedure” (invitation to participants by phone and written consent) and, importantly, obtaining “ethical approval” (Rees, 2003) and place of interviewing and related details and circumstances of interviewing (=data collection). They took great care in describing their interview and style (non-judgmental, not biased, reflexivity and awareness of the interviewer’s position in the research process). This attests to the highest standards in the description of use of their qualitative methodology (Bowling, 2002). Brotherton and Abbott (2009) chose a very similar methodology and sampling technique in their 2009-study. They selected 16 patients and 27 carers to be interviewed in a semi-structured manner. The same procedure of transcribing verbatim interview data and using a thematic analysis was adopted in 2009. In their cross-sectional sampling they also ensured that the patients represented a wide range of disease categories. In the case of patients and carers, semi-structured interviewing included questions regarding how PEG tube feeding information received was perceived (as appropriate and adequate or not) and what the patient and the carers thought of their involvement in the decision-making process (ibid: 304). They also provided a brief list asking for a number of yes/no-answers to questions concerning choice, information and satisfaction with PEG feeding (ibid: 304). Viewed as a whole and given their general person-oriented theme, the two research articles (2006, 2009) very appropriately choose a qualitative methodology (semi-structured interviewing) to explore the question and a study design and sampling technique, whereby a section of an adult population is sampled. According to Bowling (2002, p. 2) a person-oriented research question and hypothesis call for a qualitative approach and thus the choice of method and sampling is very suitable. Also in terms of the research process as such, the presentations in their “abstract” in 2006 and 2009 are entirely consistent and adhere to accepted scientific standards (Rees, 2003). Results Following the information provided appropriately on the setting, sample and methods, Brotherton, Abbott and Aggett (2006) arrived, via a section on the form of data analysis (giving us added insight in their presentation of the data) at the presentation of data, its analysis and discussion (ibid: 359 ff). The data presentation begins with a presentation of “demographic and clinical data” (referring to 24 patients and carers, 34 interviews) –presented in a table (table 2, p. 360). Next was the presentation of the results of interviewing. These are organised in terms of, first, the “structured questions” on feeding regimen (benefits and disadvantages of PEG feeding –these are presented in another table, “table 3”). A summary of the responses of carers and patients are given in a table”. Next the results regarding “Quality of life (QoL)” was provided. These bring out “acceptability” and lack of such in the context of QoL (as perceived by both patients and carers) and are structured in terms of 9 domains with verbatim quotes and feelings voiced by both patients and carers: “relief of pressure to eat at mealtimes”, “disturbed sleep”. ”restricted ability to go out/take holidays”, “restricted choice of clothes/leakage of feed onto clothes”, ”difficulties finding a place to feed; “missing being able to eat and drink”, “social occasions”, “negative attitudes of others towards PEG feeding”, “the burden placed on family members”. In their discussion (ibid: 363 ff.) they point out that most patients and carers primarily expressed negative impacts and feelings concerning PEG feeding. This also has a parallel in the literature (e.g., Rickman, 1998). Another finding was the considerable discomfort that many patients experience because of PEG feeding (nausea, diarrhoea, vomiting), leaking, infection. These results also compare well with the literature. Their findings call, however, attention to the great prevalence of leaking and infection. These are, therefore, two areas that require increased attention, “the need to manage the feed and the symptoms resulting from feeding effectively… this is often very challenging in practice because of the presence of underlying disease. “ (ibid: 364). At the same time, adding increased authority to their study, is their finding concerning “feed delivery” which also relates to an important area defined by the BAPEN report ‘Trends in artificial nutrition support in the UK during 1996–2000’ (Elia et al., 2001). The inclusive sample they used made it possible to obtain at a great variety of responses vis-a-vis various disease (mild-severe). Nevertheless, they were aware of certain limitations of their study, such as data depth (a problem of semi-structured interviewing, they suggest), possible bias of an interviewer also being a dietician (ibid: 364). They also point out that there is a significant differences concerning the perceptions of PEG feeding and QoL (“acceptability”) as voiced by patients and carers. As this is such an important area, further research and the development of measures on PEG and QoL is required, as this study shows. The discussion implies therefore some clear emphases on the future development of QoL tools (Rees, 2003 on “conclusions and recommendations”). Their recommendations (based on their findings) also highlight the importance of increased support for family and carers (Brotherton, Abbott and Aggett, 2006: 365). They cite a number of studies that add support to their findings and recommendations (Verhoef & Van Rosendaal, 2001). They conclude their article by stressing implications for clinical practice”. These follow from their findings and concern the diversity of responses and attend to the individual patients and carers and their needs and the implications of PEG feeding for the person’s life in terms of increased support (clinically, emotionally, socially). Accordingly, they attach a “questionnaire” on the “implications of living with PEG feeding” to be filled in by patients and their carers. Before presenting their results in the 2009-article - similar to the section on data analysis in the 2006-research article - Brotherton and Abbott inform of the tools and manner of data collection and recording, taping, transcription, the use of software, the recording of reflections and emotions of the participants. As previously in 2006, ethical considerations were appropriately made and approval by the local research ethics committee as well as the consent of the participants obtained. This process is critical for such research. As to results, the findings are that 11 of the 17 patients interviewed reported no involvement in the decision-making process and 10 out of the 17 patients noted that inadequate information had been given. Carers felt having more of a say in the decision making process. The responses are presented in a table (“table 1”, p. 305) and included, in the case of patients, “poor communication between health care professionals and patients/carers”, “lack or inadequate/inappropriate information”, “attitudes of health care professionals” (often lacking empathy and being paternalistic), “exclusion” (many patient feel excluded from the decision-making process). The responses of the carers had little overlap with those given by patients. However, in terms of “lacking information” and “the rigid and authoritarian attitudes of health care professionals” there was some agreement. Otherwise, the carers focussed on inadequate nutritional intake, weight loss and requirements as well as the perceived benefits of regular PEG tube feeding and perceived lack of feeding alternatives (ibid: 306 ff.). “There was also recognition that PEG feeding had been a ‘lifeline’ as ‘it has saved his life’ “(ibid: 307). In their discussion of their findings (ibid: 307) they stress that they have found an expressed need among patients and carers of appropriate information to base their decisions on. They also note the importance of shared decision-making as a precondition for improved health communication and participation in decision-making. This finding was backed up with other published the literature (e.g., Murray et al., 2007). As they stress, “The key challenge facing clinicians is to be able to determine each individual’s preferred style, taking account of any differences that may exist as the seriousness and complexity of the decision increases or diminishes” (ibid: 307). In terms of clinical practice this seems to a very important finding in that is coupled with the need for adequate information and involvement. Moreover, there is a constant need for updating and evaluating decisions made (ibid: 308). They were appropriately aware that their study had its limitations; in particular since it only explored perceptions and did not attempt to use the data to build models for PEG placement decision making and other practically useful models for clinicians. Certain shared decision making models are already available (ibid: 308) such as the framework of Makoul & Clayman (2006). Conclusion The results of the data analysis and test find expression in the Results section in the two research articles. Conclusions are made and recommendations regarding future research or interventions were provided. In other words, the conclusions also note in which sense they are/are not in agreement with the research questions. The data collected highlighted further research questions and new questions or answers to one’s research question. In summary, comparing the two research articles, one notes that they are both well-structured and in agreement with Colin Rees’ Framework for Research (Rees, 2003). The use of literature to contextualize their arguments and results were of the highest standards and very convincing. While the two articles vary in length, the 2006 article 13 pages compared to 8 pages of the 2009-publication, they adhered to the same high standards for research and its presentation. They were both qualitatively oriented in their use of theory and methods. They both included clear tables and verbatim quotes from their interview data highlighting perceptions and their diversities on the part of both patients and carers. When discussing their results, they also showed detailed awareness of the limitations of their findings. This awareness speaks in their favour and that of adequate research standards (Rees, 2003). Bibliography Alexander, J 1983 Theoretical Logic in Sociology. Vol.1: Positivism, Presuppositions, and Current Controversies. Berkeley: University of California Press. Bowling A 2009. Research methods in health. 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