A Critique of a Clinical Nursing - Essay Example

A Critique of a Clinical Nursing Research Study: Decision Making Processes In People With Symptoms Of Acute Myocardial Infarction: Qualitative Study. Introduction: Clinical decision making is an important tool in healthcare delivery. The management offered is a direct derivative of clinical decision making. Sometimes in the clinical practice delays in decision making influences the outcome of care, and it indeed may result in complications or death. Implementation of care in the clinical field is a teamwork of nurses and the physicians when the patients seek care. To be able to do that, the patients must have critical knowledge of symptoms of a specific clinical condition. A critical analysis about a qualitative research study will underpin learning and will bridge the gap between theory and practice and will enable one to understand how a methodology can be evolved to include almost the all the criteria of a clinical problem to reach an answer for the research question. The study, which is being analysed here is about the decision making process in people with myocardial infarction. This work intends to analyse the methodology, data collection, research techniques, and how all of these inculcate into a decision that may be used to modify and improve practice guidelines. Methodology: Since it is a study where patient’s knowledge and ability to make a decision about whether or not to seek care, the choice of the participants were important. The patients, a mixture of rural and urban populations, who had had at least one confirmed myocardial infarction previously, with ability to communicate in English were selected from the patient pools of two district hospitals after obtaining ethical clearance from the appropriate authority. Dependent patients whose clinical decisions are taken by other carers were excluded from the study. These patients included patients with cardiac arrest, patients with severe heart disease, unstable angina, cognitive defects, or admitted in residential care. The information sheet about these individuals were supplied by the nurses, and semi-structured interviews with the patients were audiotaped. Research is basically a systemic enquiry, which is reported in a form that allows the research methods and outcomes to be accessible to others so that people can implement change in practice with dissemination of the inference (Gardner, K., Chapple, A., and Green, J., 1999). This can be done in two ways, by seeking solutions to meaningful questions and nonmeaningful questions. Nonmeaningful questions are not answerable by enquiry alone. As a result, positivist method deals with positive facts and observable phenomenon. This is best suitable for scientific researches where scientific observations or findings are recorded (Giacomini, M.K., Cook, D.J., and for the Evidence-Based Medicine Working Group, 2000). After analysis of these findings, one may not only describe, but also predict and explain the findings on the basis of those analyses. These findings can then be classified and inferred to form descriptive laws that may serve as new findings that can be generalized and propagated. It draws on measurable evidence, so best suitable for quantitative researches (Lidz, C.W., 1999). The other method is naturalistic or phenomenalistic. This is a narrative and qualitative methodology that relies on subjective content implying the researcher’s intention (Sandelowski, M., 2004). The outcomes are descriptions. In our study, thus, the positivist approach is used to collect data via interview, to classify types of incidents, to produce analyses, and to make recommendations based on analysis. However, when patient interviews are concerned as in this study, it requires analysis of the interviews in depth to be able to draw conclusions about the causal factors about the study question in an essentially qualitative way (Barbour, R.S., Featherstone, V.A., and Members of WoReN, 2000). As a result, the data collection tool directly points to development of appropriate questionnaire that carefully takes care of the form and the content applicable to the study population interviewed. In this study, the data collection was simple. The authors asked the patient population to recount their experiences of the heart attack. Since patients’ decision making abilities about seeking care on the face of myocardial infarction is in question here, the design of the interview was very important. It was the patients’ perspectives of experiences with the current and previous heart attack that were probed (Barbour, R.S., Featherstone, V.A., and Members of WoReN, 2000). The rating of the severity of the symptoms in the present attack in light of previous symptomatic experience by the patients themselves were recorded and also whether they themselves thought these symptoms to be that of an acute myocardial infraction was probed. These interviews were audio-taped along with separate interviews of the family members that were present during the attack. The last part might serve as a control comparison of experiences and perspectives (Britten, N. 1995). To validate the reporting times, the data from the ambulance records were corroborated, and timelines were analysed about how much time elapsed between onset of symptoms and seeking care. The question arises, if this is in the interview, then questionnaire may well have a bias, and that may result in an answer sought for, but this has the disadvantage that other important information may remain suppressed or may even be thought by the interviewee as unimportant and not said (Crouch, M. and McKenzie. H., 2006). To eliminate this, the researchers decided to initiate the interview and to allow free talking. In successive sessions, naturally, new information or data would emerge. These were used to develop new codes or themes for a repeat interview. It was observed that many new findings by the patients themselves emerged, like whether they were alone at the time of symptoms, whether symptoms were different from initial attack to start with, how did they differ, whether they thought the present attack to be a heart attack, when they called, whom they called, whether they sought primary physician’s advice, or whether they drove themselves to the hospital. These cycles of interviews continued until about 22 cycles when the observes noted that there were no new information emerging anymore, a situation called saturation of data (Giacomini, M.K., Cook, D.J., and for the Evidence-Based Medicine Working Group, 2000). This method of data collection is dependent on themes or codes that are used to initiate an interview process. Although there were transcripts of these interviews and separate analysis of the data, there is a big question about generalization. To form a research answer, it is important to generalize the question and the responses (Järvinen, M. 2000). In reality, varied patients would be in various situations at the time of attack, and that would generate multifarious interplay of perspectives. Although in this study, there were two different and concomitant analysis process, one by the interviewer and another by another member of the research team, there would be scope for discrepancies. This study used the discussion to solve discrepancies, and they used 20% of the transcripts for emerging similar concepts and different themes, yet there seems to be a gap here. Events can be generalized, but not perspectives or feelings (Erickson, P.I. and Kaplan, C.P., 2000). It is a feeling of impending danger that promotes a patient to seek care as soon as possible often remaining unaware about the real risks that may perpetuate out of a myocardial infarction. However, the detailed coding, repeated interviews, dual theme analysis, and validations of data from other sources, all attempt to reduce this gap as much as possible, and this is acceptable in a qualitative research where the goal is to provide an understanding the background of the factors that influence decision making process in people with symptoms of heart attack that may be transmitted in practice to all the patients in this category so they are able to take a rapid decision to seek help (Pope, C., Royen, P.V., and Baker, R., 2002). Apart from these, the only other limitation of this study was that the study population had very few female candidates. This study has a clear and relevant discussion section. Analysis of the data and findings underpins the multiple contexts, picture of multiple realities, and situational perspectives of the patients to explain the patients’ accounts of myocardial infarction. Decision making about seeking medical help is a complex process that hints towards the main themes that influence decision making. These are how symptoms are perceived, the perspectives of risks of myocardial infarction, previous experience of myocardial infarction, individual psychological or emotional factors, patients’ beliefs about NHS and expectation about care, and the context of the symptomatic experiences (Pattenden, J., Watt, I., Lewin, R.J.P., and Stanford, N., 2002). This section honestly admits the limitations of a qualitative study in its inability to synthesise findings that can lead to a generalized protocol to be applicable to other people. Given the fact that data were collected until a saturation point emerged, and in each step, the emerging new themes were incorporated in the interview process, and these were analysed in order to find similarities, this study definitely highlights issues that are relevant to an attack of myocardial infarction. This opens up the scope for its applicability in clinical practice. These themes may be used to inform and educate people who are at risk of developing myocardial infraction in near future so the decision time may be altered in the population. Although this study included population from a wide range of socioeconomic background, this had inadequate female presentation, and in contrast to the authors’ expectation, a real generalization is possible with a larger number of study population, and it is expected by authors themselves that these varied themes are not all inclusive, and new themes may arise (Sofaer, S., 2002). Decision to seek help is a complex interaction of knowledge guiding recognition and evaluation of symptoms and other factors related to previous experience, beliefs, emotions, and contextual perspectives of the event. The main problem is that myocardial infarction may present with a various array of symptoms in subsequent attacks, and the patients may fail to recognise it. This situation brings the population back to square one, they may be educated that future infarctions may well be different from the previous and the perspective remains unpredictable, and with age, the frequency of atypical symptoms increases. Since many factors play roles in the process of decision making to seek help, and there is still possibility that other hitherto unknown factors may emerge in other larger studies, no single determinant will have absolute generalized principality (Donovan, J. et al., 2002). However, despite these limitations, in practice, there may be interventions based on these findings to reduce delay to seek help after an attack, but it must be individualised for any patient so that exploration of factors involved in each patient may guide the practitioner to develop an effective coping strategy when an acute myocardial infarction happens. Such interventions may be carried out with the patients, families, and other caregivers at discharge from the hospital to help not only individual decision making process but also the influence of other people may be sought to help a decision making. In the primary care setting, this may be applicable to the patients with risk of developing a myocardial infarction. This study clearly identifies the facts that simply educating patients on appraisal of symptoms of myocardial infarction would not suffice to influence a rapid reporting to seek care and that the decision making is a complex process involving interplay of many factors that may be hitherto unknown by the caring staff. To promote a speedy decision making process in such a situation, an individualistic approach is to be taken, and the care staff may play a significant role in improving awareness in the population. It is worthwhile to mention here that staff knowledge about critiquing research article is an important tool to understand the existing and emerging knowledge, and only an analytic capability to comprehend the findings and limitations of a study would enable the staff to implement a finding in the practice to facilitate care. Care is not medicine alone, care involves all round facilitation of wellbeing on the face of an illness, as a result that demands a continuous update of knowledge. For example, it was a well known fact that although appraisal of symptoms by the patients is difficult, individual sociodemographic and clinical factors influence time of seeking care. This fact is not of any practical use unless some generalizations are made about what the staff needs to do to influence decision making so that the staff may consider these revelations to design interventions to promote prompt action by people having an acute attack of myocardial infarction. This, in turn, may enhance the effectiveness of service to reduce mortality and morbidity from myocardial infarction. As a result, the choice of this study for critiquing a research method is one of the best in that analysis of all the factors and dissemination of knowledge derived out of that will improve practice as in relevant in improving the outcome. Reference List Barbour, R.S., Featherstone, V.A., and Members of WoReN, (2000). Acquiring Qualitative Skills For Primary Care Research. Review And Reflections On A Three-Stage Workshop. Part 1: Using Interviews To Generate Data. Family Practice; 17: pp. 76 - 82. Barbour, R.S., Featherstone, V.A., and Members of WoReN, (2000). Acquiring Qualitative Skills For Primary Care Research. Review And Reflections On A Three-Stage Workshop. Part 2: Analysing Interview Data. Family Practice; 17: pp. 83 - 89. Britten, N. (1995). Qualitative Research: Qualitative interviews in medical research. British Medical Journal; 311: 251. Crouch, M. and McKenzie. H., (2006). The Logic Of Small Samples In Interview-Based Qualitative Research. 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