Concise Appraisal of Qualitative Research Article

Concise Appraisal of Qualitative Research Article

Title Concise Appraisal of Qualitative Research Article Prefered Language style English (U.S.)
Type of document Article Number of pages/words 2 Pages Double Spaced (approx 275 words per page)
Subject area   Nursing Academic Level Undergraduate
Style APA Number of sources/references 4
Order description:
Write a summary and concise appraisal of the study. Use the APA format with title page, 3-4 paragraphs for summary and critique (300-400 words), and the complete reference at the end. Utilize Chapter 14 in your Fain, (2017), book as your guide.
First Paragraph: Write a brief description or summary of the work cited including:•the level of research evidence (based on Melnyk and Fineout- Overholt’s Level of Evidence Scale in Module 1 under Dr. Poole’s video link)•purpose•type of qualitative study•major findings or themes•author’s conclusionsRemember to cite the authors and year in the first sentence of the first paragraph. The summary should be primarily in your own words, with paraphrased segments, except for the purpose of the study which may be word for word.Paragraphs 2 – 3: Analyze the work’s quality using the Critical Appraisal Guidelines: Qualitative Studies section in Fain, (2017) Chapter 14 with additional guidance starting on page 325 for some sections. Answer at least ONE question under each category below:•identified problem for study•purpose and research questions•literature review•sample and sampling procedure/technique including protection of human subjects•methodology•data collection procedures•data analysis: organizing/categorizing/summarizing•scientific integrity: credibility/transferability/dependability/confirmability•results of the study•findings•discussion of findings•evaluation summary including applicability to replicate or apply study findings in your area of practice whether that be a hospital, home health or SNF, etc.Say what is good, but also be critical and find something wrong! Try to be concise and non-repetitive.Last Paragraph: In your own words, discuss how this study relates to evidence-based practice and its implications for or impact upon nursing. Comment on what unique findings or insights that this study provided. If you chose a study outside the United States, how does potentially socialized medicine affect whether the study could be conducted in the United States and if you believe the findings would be the same or different and whyORIGINAL ARTICLE
Educational strategies and challenges in peritoneal dialysis: a
qualitative study of renal nurses’ experiences
Manuela Bergjan and Christiane Schaepe
Aims and objectives. The aim of the study was to explore renal nurses’ experiences, strategies and challenges with regard to the patient education process in
peritoneal dialysis.
Background. Patient education in peritoneal dialysis is essential to developing a
successful home-based peritoneal dialysis program. In this area research is scarce
and there is a particular lack of focus on the perspective of the renal nurse.
Design. Qualitative design formed by thematic qualitative text analysis.
Methods. Five group interviews (n = 20) were used to explore the challenges peritoneal dialysis nurses face and the training strategies they use. The interviews
were analyzed with thematic qualitative content analysis using deductive and
inductive subcategory application.
Results. The findings revealed the education barriers perceived by nurses that patients
may face. They also showed that using assessment tools is important in peritoneal dialysis patient education, as is developing strategies to promote patient self-management.
There is a need for a deeper understanding of affective learning objectives, and existing
teaching activities and materials should be revised to incorporate the patient’s perspective. Patients usually begin having questions about peritoneal dialysis when they return
home and are described as feeling overwhelmed. Adapting existing conditions is considered a major challenge for patients and nurses.
Conclusions. The results provided useful insights into the best approaches to educating peritoneal dialysis patients and served to raise awareness of challenges
experienced by renal nurses. Findings underline the need for nosogogy – an
approach of teaching adults (andragogy) with a chronic disease. Flexibility and
cooperation are competencies that renal nurses must possess.
Relevance to clinical practice. Still psychomotor skills dominate peritoneal dialysis patient training, there is a need of both a deeper understanding of affective
learning objectives and the accurate use of (self-)assessment tools, particularly for
health literacy.
Key words: chronic diseases, content analysis, end-stage renal disease, nephrology
nursing, patient education, peritoneal dialysis
What does this paper contribute
to the wider global clinical
community?
• Findings illustrate the educational barriers that patients face
and highlight the importance to
take in a special kind of adult
education for patients with
chronic diseases.
• A thorough assessment can help
to identify resources and barriers
to learning such as uremia, language barriers and physical limitations.
• Overall, the results of the study
highlight useful strategies of
nurses when ‘doing patient
education at home’.
Accepted for publication: 5 December 2015
Authors: Manuela Bergjan, Dr. phil, RN, Senior Lecturer in Nursing Education, Institute of Health and Nursing Science, Charite –
Universitaetsmedizin Berlin, Berlin; Christiane Schaepe, RN, MPH,
Research associate, Institute of Health and Nursing Science,
Charite – Universitaetsmedizin Berlin, Berlin, Germany
Correspondence: Christiane Schaepe, Research associate, Institute
of Health and Nursing Science, Charite – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Telephone:
+49 30 450 529 098.
E-mail: christiane.schaepe@charite.de
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 1729–1739, doi: 10.1111/jocn.13191 1729
Introduction
End-stage renal disease is the fifth stage of chronic kidney
disease (CKD) and the prevalence is expected to increase
due to the rise of diabetes mellitus, cardiovascular disease
and obesity, and the aging population (Kaptein et al.
2010). The options available for patients with CKD stage 5
include transplantation, peritoneal dialysis (PD), haemodialysis (HD) or conservative care. While PD patient outcomes
are at least as good as with HD (Lameire & Van Biesen
2010), PD offers several benefits. It allows patients to perform and self-manage their treatment and care in their own
home (Curtin et al. 2008), and it means they are not dependent on healthcare staff and do not have to travel to the
clinic several times a week. It has been shown that PD can
reduce costs e.g. in the UK healthcare system (Baboolal
et al. 2008).
However, although the benefits of PD are abundant and
well documented within NICE guidelines 2011 (NICE 125),
in particular patient education raises multiple demands for
patients and nurses as educators. The biggest is probably to
enable PD patients to handle over 90 percent of their care
by themselves (Hall et al. 2004) while leading a normal life
and dealing with the stress caused by the changes to their
previous routine.
Although adult patients are usually motivated to learn, in
particular their characteristics and possibilities are very
heterogeneous and challenging. Barriers to learning in PD
patients might include cognitive impairments caused by
advanced uremia (Crowley 2003), physical impairments
caused by chronic fatigue and loss of strength, energy (Borras et al. 2006) or motivation (Paudel et al. 2014). Loss of
memory is a source of frustration for both the learner and
the teacher, especially when other barriers to learning are
present (Thomas 2013). Vulnerable patients such as those
with lower educational status, the elderly and those with
multiple comorbidities need more time to acquire self-care
skills and are more likely to develop peritonitis (Borras
et al. 2006). The complex language used in PD therapy can
cause problems in training, and some patients might be
frightened about dialyzing themselves at home (Thomas
2013). Furthermore, in PD patient education it should be
considered, that patients might be suffering from psychological issues related to the loss of self-esteem and selfimage, worrying about the future, and having to make psychological and behavioral changes (Kaptein et al. 2010).
Being dependent on technology for survival is also a psychological burden, and the presence of the abdominal
catheter might disrupt the patient’s body image (Partridge
& Robertson 2011, Tong et al. 2013).
Background
Professional PD patient education is key to addressing these
aspects and responding adequately to the educational challenges. The International Society of Peritoneal Dialysis
(ISPD) recommends that nurses provide the education
(Bernardini et al. 2006). Nurses therefore play an important
role in PD therapy, as patient education is crucial to reducing the occurrence of peritonitis and dropouts, improving
technique survival and other outcomes such as non-adherence and quality of life (Piraino et al. 2011, Schaepe &
Bergjan 2015).
Worldwide there is a wide variation in practices for
PD patient training programs, especially in time and
duration, methods and teaching aids and setting (Schaepe
& Bergjan 2015). However, there is more accordance
about the content of PD training recommended by the
ISPD (Bernardini et al. 2006). Content focused mainly on
technical skills such as aseptic technique, hand washing,
masking, steps in exchange procedures, exit-site care,
complications and troubleshooting. Case and disease management programs have been shown to have positive outcomes for individuals receiving PD (Schaepe & Bergjan
2015).
Current recommendations say that principles of adult
learning are the best basis for effective PD education
programs (Hall et al. 2004, Bernardini et al. 2006, Finkelstein et al. 2011). The study of Hall et al. (2004) showed
that applying adult learning theory and educational principles improves some but not all patient outcomes. In part,
the study focused on the learners’ needs and used different
strategies for different levels of learning in the cognitive,
psychomotor and affective domains of learning. It also
provided tools to engage learners according to their perceptual style (Hall et al. 2004). An important aspect to
consider is that the learner in PD therapy is a patient with
a long term condition who requires a special teaching
method.
Ballerini and Paris (2006) proposed the term nosogogy to
describe the science of teaching adults (andragogy) who
have a chronic disease (derived from the ancient Greek
word ‘nosos’, meaning ‘disease’). There are differences
between andragogy and nosogogy. Adult patients with a
long term condition ‘will be asked to adhere to multiple life
requirements’, because PD therapy influences all aspects of
life such as habits, relationships or work. They strive to be
less dependent on health professionals, but often have less
learning resources as healthy adults. Patients cannot choose
their learning contents and objectives. They learn what
nurses expect them to and what they need to know, in
© 2016 John Wiley & Sons Ltd
1730 Journal of Clinical Nursing, 25, 1729–1739
M Bergjan and C Schaepe
order to be able to perform the therapy (Ballerini & Paris
2006: 124–125).
The ISPD’s recommendations for PD patient education
(Bernardini et al. 2006) are mostly based on theory and
opinion and little empirical research has been done since
then (Bernardini et al. 2006). Evidence-based PD patient
training is therefore lacking, and there is a recognized need
to promote PD by stimulating relevant education and
research (Lameire & Van Biesen 2010). Furthermore, previous studies on educational interventions in kidney disease
have been classed as suboptimal (Mason et al. 2008).
Thus, qualitative research is needed to provide a deeper
understanding of this complex nursing task. The perspectives
of PD nurses on their experiences of PD education, the
strategies they apply and the challenges they face can provide
valuable insight into their knowledge and expertise. This
could help develop future PD curricula and educational
interventions for other chronic diseases. This study therefore
aimed to explore PD nurses’ experiences, strategies and challenges with regard to the patient education process.
Methods
Participants and setting
This study used a qualitative research approach to meet its
aims. The underlying theoretical framework of qualitative
content analysis is communication theory (Watzlawick
et al. 1967), which benefits are acknowledged for nursing
research and education by Graneheim and Lundman
(2004). The communication act between researcher and
participants goes on during describing, structuring or interpreting the texts based on interviews. The researcher must
‘let the text talk’ and can get valuable insights into participants’ knowledge and expertise in PD patient education.
The participants all had experience of PD patient and
nurse education. To get a broad perspective, they were
recruited from nephrology wards in a university hospital
(n = 3, group interview 1), from Baxter Germany (n = 9,
group interview 2 and 3) and from dialysis clinics (n = 8,
group interview 4 and 5). The hospital participants were
selected on the basis of their positive responses to study
information provided in their workplace. The participants
from the dialysis clinics and from Baxter Germany were
asked if, given their long experience of PD education, they
would like to participate voluntarily. It is their ordinary
task to train patients, which takes place either at the clinic
or occasionally at the patient’s home. The interviews were
pilot-tested with four participants. Two researchers were
always present during the interviews, which each lasted
around 90 minutes. Notes were taken directly after the interviews to record key statements made by the participants.
Data collection
Five semi-structured group interviews (n = 20) were conducted with the PD nurses between May and June 2013.
An interview guide provided direction for the interview,
which used open-ended questions to elicit information. The
main topics addressed in the interview guide were: the participants’ strategies for teaching patients; the educational
challenges that patients face when learning new skills; the
challenges that trainers face when educating patients; positive and negative learning conditions; strategies for training
PD trainers. This last theme will be presented elsewhere.
Ethical consideration
The study was granted permission to collect data and
received approval from the data protection supervisor and
from the staff council representatives of the participants’
employers. Due to the reason that no patients were
involved in the study, it was not mandatory to seek ethical
approval from a research ethic committee. However, we
followed the Ethical Principles for Medical Research
Involving Human Subjects, which were adopted in the Declaration of Helsinki (World Medical Association 2013). It
was emphasized that participation was voluntary. All participants received oral and written information on the aim
of the study and on the data security procedure. Written
informed consent, including consent to audiotaping, was
obtained from all participants via the signing of a consent
form prior to each session. To ensure privacy and the quality of the data, the interviews took place in a quiet room,
away from the participants’ place of work.
Data analysis
All interviews were taped and transcribed verbatim. Identifying information, such as name and place of work, was
replaced with code numbers. Analysis was done with the
software MAXQDA 11 VERBI Software GmbH, Berlin, Germany and carried out by both authors. Two data coders
were involved in each step of analysis and consulted with
one another to reach consensus where necessary. The interviews were analyzed with thematic qualitative text analysis
using deductive category and inductive subcategory application (Kuckartz 2014). This is illustrated in Fig. 1. The first
step involved reading the transcripts several times to obtain
a sense of the whole and to become immersed in the data.
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 1729–1739 1731
Original article Educational strategies and challenges in PD
Next, a categorization matrix (see Table 1) was developed
by choosing nine main categories (‘wh-questions’) based on
the common components of the education process used in,
e.g. the ASSURE model (Bastable 2003) and the ISPD
guidelines for PD patient training (Bernardini et al. 2006).
Two further categories were chosen that were based on the
nursing didactics described by Fichtmuller and Walter €
(2007). They use the term ‘critical action problems’ (CAPs)
to describe the challenges and uncertainness that arise in
clinical learning contexts and to which learners can respond
by engaging in training that will adapt their skills. Our
assumption is that the learning activities developed by PD
nurses in CAP situations will be beneficial to managing
challenges in PD patient education.
The two researchers agreed on the definition of the mutually exclusive main categories, example quotes and coding
rules. They coded independently and deductively according
to the wh-questions and CAPs, and reviewed their work
jointly. A second step involved inductively generating subcategories. To improve the presentation, the CAP categories
were assigned to the respective wh-question categories.
Results
This section presents the main findings of the interviews.
CAPs will be presented together with the wh-questions
based on the components of the education process. For the
purposes of readability, some of the main and the subcategories are presented under the same heading (non-professional actors, learning content and objectives, teaching
activities and instructional materials and learning environment). This is illustrated in Table 1.
Non-professional actors
Patients
Peritoneal dialysis nurses use the patients’ learning background as a resource in training. All interviewees emphasized the importance of tailoring the training to fit the
individual. However, they also said it was hard to assess a
patient’s ability and readiness to learn:
Then, I don’t know, I go away, but how will he get on? (…) I’d
like to have more time, be able to go back and follow up two or
three weeks later. (group interview 2)
A thorough assessment can help identify barriers to learning early on. Barriers mentioned often in the interviews
were uremia, language barriers, physical limitations in
elderly patients and the course of the long term condition
itself:
With the first patient, I ran through the whole program before I
realized that he couldn’t take it in – he’s just too preoccupied with
his disease. (group interview 4)
Figure 1 The basic process of thematic qualitative text analysis (Kuckartz 2014: 70).
© 2016 John Wiley & Sons Ltd
1732 Journal of Clinical Nursing, 25, 1729–1739
M Bergjan and C Schaepe
Peers
Experienced PD patients are occasionally used for peer support. They help with decision-making in the pre-dialysis
phase, at clinic information sessions, and during home visits:
We take in experienced patients to visit experienced dialysis patients
at home. It’s a really successful approach. (group interview 4)
Providing space for patients to engage in mutual
exchange is considered beneficial because it responds to
their need to meet and interact with their peers:
When I hear my patients counseling the new ones, it’s clear they’re
the experts. They’re much better at it than I am. (group interview 4)
Relatives
Relatives participate in training when they are needed as
interpreters or want to support the patient. However, they
are not always interested in being involved and can even
disrupt the training:
Sometimes you have these helping husbands – they come in with
the video camera: “I’ll record everything, darling, and play it back
for you later (…).” That kind of thing is obviously disruptive.
(group interview 3)
Learning content and objectives
This section presents the findings on training content and
on the psychomotor, cognitive and affective objectives (domains of learning). The PD nurses emphasized that practical skills, especially those related the bag exchange, have to
be taught and should take priority over theory-based topics:
The bag change is the most important goal. He needs to be able to
flush out the fluid from his abdomen and refill it with fresh solution
– and he has to be able to do it hygienically. (group interview 3)
Why should I teach a 77-year-old man the basics of anatomy? That’s
nonsense. It’s of no interest to him at all. (group interview 4)
Table 1 Main topical categories and example subcategories of the content analysis presented in the article
Deductive main categories*(2) Inductive subcategories*(4)
Heading in the article* Wh-questions Definition Example of subcategories Example quote (7)
Who? Learners and their
characteristic traits
Uremic patients ‘They’re often so uremic
that they just don’t get it’
Non-professional actors
From whom? Educators (professionals,
non-professionals)
Patient as teacher ‘We take the new patient to
visit an experienced
patient at home (…)’
With whom? People who assist trainers, or
another learner
Relatives ‘I had a Greek patient (…)
and his daughter assisted
with his training’
What for? Learning objectives & outcomes Affective learning objective ‘They’re really frightened,
and I believe our job is
to remove that fear’
Learning content
and objectives
What? Content of the training program Bag exchange as an
essential topic
‘The bag change is the
most important goal.
He needs to be able to
flush out the fluid from
his abdomen and refill it
with fresh solution’
With what? Teaching and learning aids Visual media, pictures,
pictograms, icons
‘I think pictures, useful
pictures, are ideal.
Simple things with
not much text’
Teaching activities
and instructional materials
How? Teaching and learning methods Simulation ‘I made a fake patient
stomach out of a plastic
infusion bag (…)’
Where? Place where learning occurs,
and the conditions of that place
Conditions at home ‘I would prefer training at
home, to train them in
their own environment’
Learning environment
*(2), (4), (7): numbers of steps in the content analysis see in Fig. 1.