Rough Draft Qualitative Research Critique and Ethical Considerations
Introduction to Nursing Research NRS – 433V – 0502
Background of Study
In the older population, 65 years and over, the most common cause of hospitalization is congestive heart failure (CHF). Currently more than 1 in 3 adults, roughly 5.8 million, in the United States (U.S.) have been diagnosed with heart failure and about 1 in 9 deaths were contributed to this cardiovascular disease (CDC, 2016). In older adults with CHF, the presence of comorbidities and weakness is associated with a decreased of quality of life (QoL), 92% increased risk for emergency room visits, and a 65% increased risk for hospitalizations (Lemay, Li, Benzaquen, Khoury, & Azad, 2016).
There is an increase in the care needs of patients with CHF as the disease progresses. CHF diagnosis follows a gradual, although non-direct course, where by the mortality of the patient is unexpected or progress to end-stage CHF over time (Lemay, Li, Benzaquen, Khoury, & Azad, 2016). It has been shown that quality gaps and decreased patient safety often result from fragmented care caused by the lack of coordination and integration amongst services (Browne, Macdonald, & May, 2014). Most of hospital admissions are due to the lack of self-care help, medication managing, and following a dietary regimen. Patient-level obstacles to self-care include regimen complexity, undesirable medication effects, and inadequate knowledge, tools and support (Holden, et al., 2015).
The objective of the study was to determine both patients’ and caregivers’ perspectives and experiences with CHF and to explore the barriers to high-quality care. To enable optimal CHF management, the focus included adherence to the Guidelines Applied in Practice (GAP) Tool for educating patient with CHF, better communication in self-care, addressing advance directives, case coordination at the time of discharge, and transitional care planning (Lemay, Li, Benzaquen, Khoury, & Azad, 2016).
Is there enough evidence that these poor experiences be dramatically improved by simple organizational and process changes, rather than complex clinical mechanisms (Lemay, Li, Benzaquen, Khoury, & Azad, 2016)?
Method of Study
The study used both quantitative and qualitative methods at the Ottawa Hospital, Geriatric Medical Unit (GMC) during a three-month period from June 2015 to September 2015.
The qualitative part of the project, patients and their caregivers were interviewed with semi-structured questionnaires, which took place in person during the hospitalization and two weeks later over the phone post discharge. Additional data were gathered by using assessment tools, adherence to the GAP Tool, and data analysis was done using Fischer exact test for categorical variables and Mann-Whitney testing for continuous variables (Lemay, Li, Benzaquen, Khoury, & Azad, 2016).
In the quantitative data research was gathered through chart review, gathering all information that was relevant to the studying including: age, ethnicity, educational level, marital status, gender, mental and physical function, morbidities, and advance directives. Medications that were administered upon admission and on discharge. Lab and imagining results were recorded.
The small sample size of the 36, 19 consented to participate in the study and 18 caregivers, eligible CHF patient admitted during the three-month period did raise question of the generalizability of the research. The limitations were interview time-period, simplified questions, and language barriers. Because of the limitation of the study, the interviews were made short and simplified specific questions. However, even though there were limitation, the literature review includes adequate information to build a logical argument, and the sample size was acceptable for the quality improvement project.
Results of the study
Analysis focused on evaluating three domains with qualitative data: service utilization, self-care teaching/communication, and End-of-Life (EoL) care.
Participants reported barriers to function and self-care as fatigue, dyspnea, and edema. Only a small marginal of patients had community support in place to assist them. Most were living alone or relying on family members for help them remains as independent as possible. Six patients (31%) reported having asymptomatic CHF, five patients (26%) had a cardiologist involved in their care (Lemay, Li, Benzaquen, Khoury, & Azad, 2016, p.196). Participants reported having challenges with making follow up appointments with their primary care physician (PCP), which lead to emergency room visits or readmissions.
All the participants, except for three, communicated great with the GMU team. The three that were unhappy felt as though information was only provided to family and when information was provided, it was too quick and this made the patient unhappy with the services. Most of the participants did not recall receiving information on CHF management (medications, diet, exercise). They were not sure why they were being weighted daily or doing exercise. The participants also did not recall receiving information on the life expectancy and prognosis.
End of Life discussions rarely occurred with the hospital care team. Most participants were comfortable to discuss EoL care and dying, but the concept of palliative care was new to most of the participants. They wanted more information on CHF, besides a handbook that was given, with their families present.
Of the 18 caregivers, 14 (73%) were directly involved with providing daily patient care (Lemay, Li, Benzaquen, Khoury, & Azad, 2016). They reported rarely being included in discussions with the GMU team. There was a concern about diet recommendations not being carried over to the retirement home upon discharge. Caregivers did not appreciate being given too many written pamphlets. Seven (37%) of the caregivers had concerns about the current discharge plan since the patients (68%) had poor experiences with hospital readmission and emergency room visits. Premature discharges and lack of care coordination created resistance and uncertainty with the current discharge plan (Lemay, Li, Benzaquen, Khoury, & Azad, 2016).
The study was funded by a grant received from the Ottawa Hospital Department of Medicine, Ottawa, Ontario, Canada. Patients information was obtained from chart reviews and electronic medical records (EMR) and additional information was obtained from assessment tools: function, cognition, mobility, balance, morbidity, and depression as well as adherence to the GAP Tool, there was no conflict of interest disclosures declare by the authors. There were no ethical considerations regarding the treatment or lack of. The patients in the study were typical of hospitalized patients with CHF.
This study found that the quality of care, from the perspective of HF patient/caregiver experiences and preferences, was not optimal. The survey identified many care gaps both within
GMU and with the DC summary hand-off. These results will provide the ‘current state’ and starting point for a major quality assurance program. The first step in this program is to perform
a root cause analysis to determine the source of these quality gaps. The second step is an organization change to move the DC summary implementation via a cardio-geriatric clinic to
GMU to provide direct performance feedback. The root cause analysis and this direct DC summary implementation feedback will provide input to drive the necessary process re-engineering. In this and similar cardio-geriatric settings, the key is to provide a clinical framework that allows the cardiologist, geriatrician, PCP, patient, and caregiver to actively work
together as a team to develop the optimal DC plan.
Browne, S., Macdonald, S., & May, C. (2014). Patient, carer and professional perspectives on barriers and facilitators to quality care in advanced heart failure. PLOS ONE A Peer-Reviewed, Open Access Journal, 9, 3. doi:e93288
CDC, C. (2016). Heart Failure Fact Sheet. Division for Heart Disease and Stroke Prevention, 1.
Holden, R. J., Schubert, C. C., Eiland, E. C., Storrow, A. B., Miller, K. F., & Collins, S. P. (2015). Self-care Barriers Reported by Emergency Department Patients With Acute Heart Failure: A Sociotechnical Systems-Based Approach. Annals of Emergency Medicine, 66, 1 – 12.
Lemay, G., Li, J., Benzaquen, M., Khoury, L., & Azad, N. (2016). Perspectives from Geriatric In-patients with Heart Failure, and their Caregivers, on Gaps in Care Quality. Canadian Geriatrics Journal, 19(4), 195 – 201. doi:10.5770/cgj.19.257