A Critical Appraisal of a Published Piece of Research Related to Practice

For this assignment the author has been asked to critically appraise a published piece of research related to practice. For the purposes of this work, a case study entitled “Patient Dignity in an Acute Hospital Setting,” by Dr. Lesley Baillie (2008) has been used. In justifying Baillie’s credibility as an author and as an experienced researcher, the author established she is a reader in healthcare at the University of Bedfordshire for the Institute for Health Research and she has been a trained acute nurse for the past 32 years. She is an author in her own right and has contributed to a number of other publications. Baillie completed her PhD on Patient Dignity in 2007. Between 2007–2009 Dr.Baillie was a consultant to the Royal College of Nursing’s ‘Dignity at the Heart of Everything we do’ campaign (Johnson, 2011).

In order to maintain some structure to the essay, the author chose to use the “Critical Appraisal Skills Programme” (CASP). CASP is an assessment tool that has been developed for those unfamiliar with qualitative research (PHRU, 2006). The programme aims to develop skills and make sense of research evidence, which in turn enables us as professionals to put knowledge into practice. The aim of a critical appraisal is to extract the following information; is it of any interest? Why and how was it done? What has it found? What were the implications and what else was of interest? (Crombie,1996). Critical appraisal is the process of assessing and interpreting evidence by systematically considering validity, results and relevance (www.evidence-based-medicine.co.uk, 2010).

The author Baillie (2008) sets out in the abstract her objectives for the case study. There are very clear and precise aims to the study which all relate to patient dignity i.e. what dignity means to patient’s, the threats and how patient dignity can be promoted in an acute hospital environment. The relevance of this case study was to investigate how a patient’s dignity is affected by situations that they are not in complete control of, which can ultimately result in how the patient’s outcome is determined.

Following the (DoH, 2010)) Essence of Care report and the National Service Framework (NSF) for Older People report (DoH, 2001b) which emphasised that older people’s dignity should be respected, it became an important issue within the National Health Service (NHS) for the subject to be researched. It is only from research that we can obtain information and knowledge in order to provide an understanding of nursing practice, its affects on patients and their carers and the use of resources (Parahoo, 2006).

Dignity is a very subjective issue and for this reason qualitative research as opposed to quantitative research was the appropriate method of study for this case study. Qualitative research is a method used for the understanding and motivations of the research subjects and is often associated with the search for reasons rather than causes (Porter, as cited in Cormack, 2000).

Parahoo (2006) states that qualitative research is an umbrella that covers varied approaches, which subscribe to the notion that phenomena can realistically be understood by studying the meaning that people give to them and the context in which they happen.

With qualitative research there is no definitive answer to the subject being examined. Every person’s interpretation will be distinctive to that particular phenomenon, in this case dignity. Therefore every researchers interpretation of the answers will be unique. Unlike quantitative research it is difficult to establish validity and reliability. The absence of similar conditions and unstructured interviews in dynamic encounters between an active interpreting subject and an active interpreting researcher will always result in diverse outcomes (Carter, Porter as cited in Cormack 2000).

In respect of this study, Baillie’s (2008) choice of qualitative research was the appropriate method to embrace, as Creswell’s (1998) definition of qualitative research states

“Qualitative research is an inquiry process of understanding based on distinct methodological traditions of inquiry that explore a social or human problem. The researcher builds a complex holistic picture, analyses words, reports detailed views of informants and conducts the study in a natural setting.”

Baillie’s (2008) research design was a qualitative, triangulated single case study. This was an appropriate method of research as it incorporated interviews with patients and health care professionals and their personal interpretation of dignity both on the ward and in the home following discharge, Baillie (2008) also conducted participant observations with patients and nurses in the acute hospital setting. Parahoo (2006) points out that in qualitative studies researchers should actively seek diversity and ‘negative’ cases in order to present phenomena in all their different facets and from different perspectives. This in turn creates more questions, which can be further investigated because of the flexible nature of qualitative enquiry (Parahoo, 2006).

There are a number of advantages and disadvantages to participant observations depending on whether these observations are covert or overt. In Baillie’s (2008) case study all observations were overt. The benefits of this method are that all participants are aware of the reason for the research and have given their consent to the research taking place. It also allows the researcher to ‘observe’ the participants in the natural setting. A problem with overt observation is the effect on behaviour of the participants due to the presence of the researcher; For example, they may give an answer that they feel the researcher wants to hear, rather than the answer they want to give (Britten, 2006).

The recruitment strategy for this case study was appropriate to the aims of the research. All participants were volunteers, although purposely selected, as they were either an inpatient on the surgical ward aged between thirty-four and ninety-two, fifteen men and nine women all from diverse socio-economic backgrounds, or a healthcare professional working on the ward or within the hospital. By purposely selecting the participants, Baillie was able to gain the most wide-ranging actions and answers to her semi-structured questions. This enabled her at a later stage to analyse her research more objectively when producing her findings for the research.

In addition, they could all verbally communicate and speak English. The twenty-six registered nurses and healthcare assistants were observed in practice thirteen of which were interviewed following observation.

Six senior nurses were purposely selected for interview. There were also twelve patients that had stayed on the ward for at least two days who were interviewed following discharge. It was noted that although there were only twenty-two beds on the surgical ward the study was carried out on twenty-four patients, it is unclear why this ambiguity occurred. Prior to the study being carried out, Baillie (2008) gained ethical approval from The Local Research Ethics Committee and the study was registered with the hospital’s Research and Development Office, adhering to governance requirements (DoH, 2005). All participants involved in the case study gave written consent and were advised there was no obligation to take part. For the purpose of this study overt observation was considered to have been best practice as the participants were aware of the ongoing research.

The data for this case study was collected during 2005 by one researcher. This ensured the researcher maintained a consistent approach to the data collected. The research was concerned with patient dignity in an acute hospital setting and therefore Baillie (2008) was justified in her selection of suitable candidates who were all inpatients on the surgical ward. The data was collected by patient observations and interviews whilst on the ward and post discharge in the home. Data for the health care professionals was gathered by interviews immediately following observations of them in practice. Senior nurses were purposively selected for interviews,

“As they could offer insight into factors influencing dignity from a wider hospital perspective” (Ballie, 2008).

The interviews were semi-structured, which consisted of open-ended questions allowing both the researcher and the patients to respond to the area being explored (Britten, 2006). The researcher would ask an opening question, ‘What does the term dignity mean to you?’ Exploring their thoughts and feelings about the subject would follow this up. The advantage to semi-structured questions is that they can be asked in what appears to be general conversation, which encourages two-way conversation and therefore the researcher can gain additional information. A disadvantage can be that, questions may be slightly different for each participant dependant on how the ‘conversation’ evolves.

Patton (1987) outlined that in qualitative interviews questions should be clear to the interviewee, open-ended, neutral and sensitive. He then went on to suggest various types of questions that should be asked. These included experiences or behaviour, values, on knowledge, on feelings, on opinions and demographical or background details.

Baillie in her (2008) case study considered the relationship between herself and the participants and how she could create the most natural and relaxed conditions, ensuring the participants acted ordinarily and without oppression. By wearing a nurse’s uniform in the ward environment, she was able to develop relationships both with the patients and the staff whilst working shifts and prior to any collection of data. Baillie (2008) in recognition of researcher bias maintained a researcher’s diary with reflective observations. Reflexivity is an important self- evaluating tool, as it identifies the researcher’s own values, prejudice’s and behaviour in any given situation and the interpretation of responses (Parahoo 2006). Following her earlier findings, Baillie (2008) later discussed them with the participants to verify they were credible.

The Data collected throughout the study was analysed manually using a framework approach, which is primarily used in health care settings. It is a process, which is flexible in allowing analysis during and also at the conclusion of data collection. By listening to audiotapes and reading transcripts of field notes, the researcher was able to absorb the data and become aware of key ideas and recurrent themes (Ritchie and Spencer, 1994). The author then reduced the data to ‘significant statements’ relating to dignity, coded these statements into a coded framework that enabled her to construct meaningful charts. Using the framework approach for this case study ensured the data analysis was sufficiently rigorous (Ritchie and Spencer, 1994).

Baillie’s (2008) case study concludes with a clear statement of findings. Patient dignity is of paramount importance when in an acute hospital setting. The study has credibility due to a number of reasons. These include the author’s background in relation to the setting of the research, the relevance of the study, the framework of the research together with other factors suggested by (Brewer, 1994).

An area of improvement within Baillie’s (2008) study could have been the incorporation of non-English speaking ethnic minorities from different religious cultures and also lowering the age limit from thirty-four to eighteen. This would have better represented our multicultural society and generated a more diverse set of answers and recommendations to come out of the study. Baillie (2008) in her conclusion does acknowledge this fact and recommends further studies should be carried out in different acute settings such as a city hospital with a multicultural population.

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