This essay will provide a critical analysis of ‘Experiences of family carers of older people with mental health problems in the care of acute general hospital: a qualitative study’ (Clissett et al 2013). This article has great relevance to my role as a student paediatric nurse, acknowledging the effects that ill health and the hospital environment can have on, not only the patient, but the family/carers around the patient, demonstrating the importance of family centred care.
On completion of analysis, I will demonstrate my understanding of qualitative research and the processes that are involved when collecting and analysing data. Ethical and legal issues will be considered to establish the quality, strengths and limitations of the article. A framework, developed by Caldwell, Henshaw and Taylor (2005) will be used to support my analysis, allowing me to develop a deeper understanding of the research process and appreciate how research can benefit my practice in the future. The NMC Competencies (2010) state that ‘All nurses must appreciate the value of evidence in practice, be able to understand and appraise research, apply relevant theory and research findings to their work, and identify areas for further investigation’ (NMC 2010).
Holloway and Wheeler (2010) suggest that qualitative research focuses on society and how people perceive and interpret their own, individual experiences. Using this approach to analyse family/carer experiences, allows the researchers to gather a range of specific, in-depth perspectives, to develop inductive reasoning. However, in order to do this successfully, Holloway and Wheeler (2002) recommend that research should be related to that of the profession of the authors. Based on the title of the article, the credibility of the authors and the expertise they have, regarding health care and the older generation, I believe they are a reliable source in establishing this research.
The abstract, according to Holloway and Wheeler (2010), should provide a brief overview of the aim, background, the methods, a summary of results and their potential to influence practice. This abstract provides just this. The aim provides a clear outline of what the paper sets out to accomplish, which is rationalised and supported by the background information. The background distinguishes the implications for practice and the importance of working with families when caring for patients with cognitive impairment, ensuring they receive the best possible care.
The design and methods chosen by the authors provides an insight into the strategies used to develop the concepts. With the use of semi-structured interviews and Strauss and Corbin’s framework, the reader can expect to discover legitimate experiences from the participants. The findings reflect this by using quotations from the participants. They proposed that family carers either ‘valued the support of hospital staff and services, or were highly critical of the care provided’ (Clissett et al 2013). These opposing experiences entice the audience to continue reading to discover the reasons for the conflicting views. The conclusion then delivers the key elements family carers of cognitively impaired patients respond to in the hospital environment, thus supplying and enhancing knowledge for nurses, improving practice within this specific field.
Holloway and Wheller (2002) highlight the importance of relating research to clinical practice in order to benefit and enhance health professional’s knowledge and competencies. On consideration of the statistics found in the introduction, they prove great significance to clinical practice, considering over half of 70 year olds have cognitive impairment. However, the term cognitive impairment is such a broad term, that it is hard to categorise at what stage their conditions has an impact on practice, the nurse’s role, the patient and the carers.
The terms delirium and dementia have been cited in the introduction, which leaves the study open and flexible to adverse participant involvement, though this contradicts the title, focusing primarily on cognitive impairment. The Alzheimer’s Society (2013) defines cognitive impairment to be a condition that affects an individual’s ability to think, know and remember. Although these symptoms have the same qualities as dementia, cognitive impairment is not severe enough to be classed as dementia, however, they suggest that this condition could advance to such diagnosis. The Royal College of Psychiatrists (2011) describes delirium to affect the mental state of an individual, causing confusion, due to becoming mentally unwell. So although these all affect mental health, cognitive impairment, dementia and delirium are not classified under the same diagnosis, which leaves the reader to feel unsure of the direction of the paper. This uncertainty is portrayed throughout the paper, identified in the background, aim and design.
Streubert and Carpenter (2011) suggest that, in the background, a justification is needed of how and why the chosen subject is of importance to research and practice. The background has provided rationale for the study, with reference to the challenging environment of acute care and acknowledgment of the positive influences family carer’s have on the dementia patient. It recognises that other relevant studies have been completed with regards to family carer experiences in the acute area, none of which have focused on cognitive impairments. With reference to the statistics in the introduction, this research shows significance to health care practice and can be used in conjunction with the existent related literature, which it has aimed to achieve.
As mentioned previously, the term cognitive impairment is a vague statement, however, using the word ‘explore’ within the aim allows, to an extent, some flexibility. On consideration of the full aim, the main principle is to understand the experiences of individual carers. These experiences cannot be predetermined from the authors, so the aim cannot be truly specific because not every patient is going to be in the exact same situation. However, the design does provide specificity, proposing the research will help professionals ‘understand the world from the perspective of the person with dementia…interpret and evaluate the experience of older people and their carers’ (Clissett et al 2013). Using the word dementia does imply that the focus of the study will be primarily of patients with this disease, which narrows the criteria and spectrum of participants to be involved.
The design indicates that the approach used to develop research was based around ethnography, which is defined by Holloway and Wheeler (2010) to be a way of investigating behaviours and experiences. Triangulation was used to assess the experiences of family carers in hospital. The use of observations and semi structured interviews to individual participants. Flick (2009) encourages this combination when collecting data because it allows researchers to review from different perspectives, deliberating on subjective knowledge and experience, resulting in a detailed analysis, helping to support rigour. However, there is no evidence suggesting that consent has been obtained for the non-participant observations. Green and Thorogood (2009) suggest that gaining consent prior to observational studies can be problematic. Although researchers want to observe participants in a natural environment, they should be informed of the research aims, objectives and contact information should be issued before involvement.
The setting and sample is introduced through reflection of a similar, larger study, which causes the reader to become disengaged with the prominent study. The setting and sample is not explained until the end of the second paragraph. The analysis of the larger study, I feel, is not necessary in this section. If the authors feel it has relevance to their study, I believe it should be mentioned in the background.
During the sampling stage, ethics were considered. Under section 32 of the Mental Capacity Act (2005) they have taken ethical steps to retrieve consent from participants. Section 32 of the mental capacity act (2005) states that if an approved research project is being conducted and the participant lacks capacity to consent, anyone that is involved for caring for the patient or is interested in the patients welfare and is willing to be consulted by the research under the section, can consent. Due to the context of the paper, any carers involved in the process are eligible to consent for themselves and their family member, if they are not competent in doing so. However, cited at the end of the setting and sampling section, it discloses that out of the 34 participants, 15 of them had one or more mental health problems of their own, which poses the question, did they have the capacity to consent?
Holstein and Gubrium (2003) confirm that the interview process shapes the information received for data collection and analysis. The authors have completed the interviews at the participant’s homes. Allowing them to be in their own environment may have resulted in a more in depth, accurate interview because they felt comfortable and in control of the process, making the situation less daunting. However the interviews lasted between 20 minutes and 2 hours which could suggest that some carers were more open and honest about their experience.
The use of semi structured interviews encourages participants to reveal their own personal experiences, yet still enables the researcher to guide the interview in the right direction. The use of grounded theory supports this notion. Grounded theory was used as an approach to interview. Willis (2007) states that grounded theorist initiate the interview process by using general and broad questions. As the interview progresses, the questions then become structured around the individual participant. All of the interviews were audio recorded. Silverman (2003) suggest that the use of tapes allows the researchers to relive the interviews, comprehend the right information, providing in-depth and systematic analysis. However, the interviews were not returned to the participants for checking, which Clissett et al. (2013) provides no rationale for. This could be due to the fact that once the interviewees had time to reflect on their experiences, their perspectives could have changed, affecting the results.
Bradbury-Jones (2007) specifies rigour to determine whether the qualitative research is methodical and thorough, however, focusing too much on the reliability of the data during data collection can deter creativity and development of the study. Holloway and Wheeler (2002) identify that researchers may find it difficult to agree to the validity and trustworthiness of research, which may show reflection in the broad spectrum of agreement in this paper (68-98%). These discrepancies are not due to preconceived, biased opinions of care in the trust, because none of the researchers involved had a clinical role at the hospitals.
A theoretical approach was taken during data analysis. Charmaz (2003) suggest that using the theoretical approach allows grounded theorists to: ‘(i) gain rich data (ii) fill out theoretical categories (iii) discover variations within the theoretical categories, and (iv) define gaps within and between categories’ (Charmaz 2003). Applying this approach to the experiences of carers allows themes to emerge and develop, which are represented in the results.
The word ‘disruption’ was a key theme established in the results. Clissett et al (2013) explained that disruption was chosen because of its varied meaning. However, they contradict themselves by giving a patronising definition of the word, when the term is subjective to each participant. Positive and negative accounts of care and coping strategies were all established in the results, which were supported by quotations from the interviews. Although these provide a greater insight in to the results, they were too long and repetitive.
The non-participant observations were touched upon to support the findings, suggesting that the ‘hospital processes were perceived as disruptive….the department was seen as a chaotic place’ (Clissett et al 2013). The use of the words ‘perceived’ and ‘seen’ demonstrates that the researchers are not just interpreting what the interviewees had said, but they are commenting from an outsider’s perspective.
In the discussion there are again, many references to other studies, which seemed unnecessary. However, some were deemed to be relevant, with reference to the studies that suggest long visitations can affect the health and mood of the carers, which could have contributed to the negative experiences. The overall discussion of the primary study is comprehensive, but I feel the bullet pointed summary, sums up the key points in a clear manner, rather than the main discussion itself.
One significant limitation identified was the lack of participants. They state that data saturation occurred, however I don’t believe with this number, that any sufficient claims can be made. One way of rectifying this could have been to broaden the spectrum for data collection. Only two hospitals were involved, which were within the same trust. If more hospitals were considered around England, then this would have made the sample and results more rigorous. Time lapses and relationships between carers were also a problem when completing the research. However if interviews took place sooner, due to their situation and vulnerability, it may have been viewed as invasive and disrespectful.
The conclusion identifies the key attributes that need to be adopted by nurses in order to improve family centred care. The importance of triadic nursing has been highlighted throughout, recognising the involvement of family carers and how their expertise can be used to benefit the care of the patient. All of the suggestions to improve care are transferable and achievable within practice. I believe the conclusion to be beneficial to all nurses, regardless of the field or area they work in. Communication is fundamental when working with any patient and family, so although this paper has primarily focused on patients with mental health conditions, the findings can be used in every aspect of nursing.
I believe this paper will have an impact on my personal education and practice. As a paediatric nurse, The Nursing and Midwifery Council (2013) state that we should ‘Acknowledge the role of siblings, other family members and friends in the lives of children and young people and the effect that illness or disability may have on them. Work positively with siblings and friends for the benefit of the child/young person’ (NMC 2013). Clissett et al (2013) have produced a paper that is specific for one area; however I believe the results prove to be transferable in all health professions.
Nicola Gentles Adult Nursing BSc (Hons) student
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