Background
Discuss about the Exacerbations Of Chronic- Obstructive Pulmonary Disease.
Critical appraisal involves systematic inquiry of the article to determine its appropriateness, trust-worthiness as well as relevance for its applicability in healthcare context (Polit, 2016). A detailed critical evaluation of the qualitative study on ‘the experience of patients in recognizing as well as managing COPD exacerbations- at home’ is done. This report carefully analyzes the merits and demerits of the research methods that underpin this study (Marriam-Webster, 2015). According to GOLD (2013), COPD affects 33/ 1,000 persons in the UK in which 26.2% of COPD-patients experience one COPD-exacerbations while 25.5% had more than one episode (Raluy-Callado, 2015). Hence, all the nurses should undertake research critique to provide best possible evidenced care to the patients (Grove, 2015).
This study mainly focuses on the exacerbations of chronic- obstructive pulmonary disease (COPD), affecting about 1 in 3 patients in UK requiring readmissions within 28 days of previous hospitalization. Proper self-managing strategies can minimize hospitalizations and enhance outcomes in COPD (Hinkle, 2014). Patients are the first to recognize alterations in their health-condition and it is highly crucial to understand about COPD-exacerbations, identify deteriorating features and act appropriately (Lewis, 2013). Hence, this study explores the extent to which the COPD-patients understands, recognizes and self-manages their exacerbations.
The previous studies suggest that there is no consensus about the definition for exacerbations as well as how they are identified and understood by COPD-patients. Few studies suggest that the patients have poor understanding of the meaning of exacerbations while other studies confirm that COPD-patients are well-aware of these terms. The meta-synthesis by Harrison (2013) suggests that previous qualitative studies have only examined about the patient’s experience in COPD-exacerbations rather than how they identify exacerbation-symptoms. Few patients report that they feel safe while self-managing exacerbation at home. Though many researchers have published about exacerbation assessment (Sundh, 2013), there is no clear evidence of how COPD-patients recognizes and manages exacerbations (Risør, 2013). This has motivated them to propose this qualitative study to understand how COPD-patients identify and manage COPD-exacerbations.
Objectives/aims are defined as the specific accomplishments that are formulated by the researchers to attain what they have planned to inquire (LoBiondo-Wood 2014). Williams (2014) has stated a clear, concise, acceptable and achievable objective/aim as ‘to explore the current understanding as well as experience of COPD-patients in identifying and managing COPD-exacerbations- at-home’ as given by Moule, (2013).
Objectives
They utilized qualitative design which involves a systematic, highly-interactive and subjective approach used to explore the etiologies, facts, ideas, motivations and personal-life experiences by giving meaning to them (Polit, 2016). Qualitative researches are undertaken to describe and improve the understanding of person’s experiences as discomfort, breathing difficulties, pain, and/or caring (Grossoehme, 2013). According to Yin (2015), qualitative researches are superior to quantitative researches in investigating the emotions of the persons and also in discovering and understanding the person as a whole. This design will help them to perform in-depth analysis ‘to explore the experience in finding-out and managing the COPD-exacerbation by patients at-home’ to find solutions.
In a study, the criteria that specify the patient/population characteristics are known as eligibility or inclusion criteria while the characteristics that the study-population should not possess is termed as exclusion criteria (Gerrish, 2015). According to Polit (2016), the eligibility criteria is defined as the criteria that designates any specific characteristics of the target population through which participants are recruited for the inclusion in a research-study. They have recruited known case of COPD patients (target-population) within their inclusion and exclusion criteria as suggested by Iverson (2014).
Their inclusion/exclusion criteria includes: the patients diagnosed with COPD, >40 years of age, forced expiratory- lung-volume (FEV1) in 1-s; post-bronchodilator <80% and predicted ratio of FEV1 with forced-vital lung-capacity (FVC) of <0.70, history of smoking more than 10 pack years, able to sign in informed consent, MRC- dyspnea scale score ≥2, registered in a general health-practice & as an COPD-exacerbation patients requiring home management and/or hospitalized treatment in the previous year, and/or got referral to any lung-rehabilitation centers, absence of any other pulmonary diseases and cardiac failure (chronic) as given by the New- York cardiac association’s grading system with grade- IV (severe), life- expectancy: above 3 months, ability to clearly understand and write English.
They have recruited those patients who met their eligibility criteria by identifying them in hospital- admission records, lung rehabilitation centers as well as in general health-practice with the help of a respiratory (research) nurse. The patient characteristics in this study that includes: gender (male/ female), age, severity of COPD (GOLD: stage- II, III & IV), duration of COPD symptoms, use of home oxygen, history of previous attendance in any lung-rehabilitation programmes and patient’s living set-up (living with spouse/family and/or living alone), is appropriate.
These criteria should be identified before sample recruitment as proper selection of inclusion and exclusion criteria can enhance the external & internal validity of the study-findings, improve study- feasibility, minimize the study’s cost and reduce ethical constraints (Polit, 2016). Specifically, proper recruitment criteria will fairly enhance the homogeneity of the population selected that enables control of extraneous variables as well as increases the likelihood to obtain an unbiased interpretation of study-results (McDonagh, 2013).
Methods
Williams (2014) has used purposeful (judgmental) sampling which is a non-probability sampling in which they have selected the samples based on personal judgment by which ones will be most informative (Polit, 2016). Though, this sampling technique can induce subjectivity in sample selection by reducing chance of being selected for the study, it is one of the best sampling techniques in qualitative study that involves volunteer informants which can supplement the study.
Their purposeful selection of COPD-patients will help them to attain their objectives as this method has enabled the researchers to select the samples based on their personal judgment voluntarily to meet their study preferences to explore their experiences in identifying and handling the COPD-exacerbation at-home.
Data collection is defined as the process of gathering data to address the study problem (LoBiondo-Wood 2014). They have used semi-structured interview schedule that focused on the topics as experience, identification and management of COPD-exacerbation by COPD-patients at-home which lasted from 20 to 55 minutes by encouraging the participants to respond within their topic, as advised by Polit (2016). They have audio-taped their field notes immediately after their interview in-order to provide the interview’s context that also aids in their data analysis. The questions in their interview schedule proves that they have collected data regarding the experience, identification as well as management of COPD-exacerbations which suggests that their data collection tool is based on their objective to be explored.
The advantages of semi-structured interviews include: enables interviewer to prepare and appear competent at the interview because of prior preparation; allows freedom to the informants to tell-out their own views; provides valuable, reliable with comparable qualitative-data; promotes 2-way communication by allowing interviewee to question the interviewer (functioning like an extension-tool); provides not just the answers but also the reasons for it and it also allows the informants to discuss sensitive-issues (Polit, 2016). The disadvantages include: the interviewer should be skilled; necessitate sufficient participants to draw comparisons; requires effective preparation (no prescriptive or leading questions); skill in analyzing collected data; time consuming; resource intensive and able to ensure confidentiality (Yin, 2016).
They could have used focused-group interview as an alternate in which a group of 4 or more members can be gathered for a discussion conducted by the researcher with a written question set (Polit, 2016). They are carefully planned sessions that helps to gather rich informations from the participants. This also helps the participants (homogeneous group) to express their views easily in a similar background.
Data Collection
Qualitative analysis involves organizing and interpreting the narrative data to discover underlying facts, themes, and patterns of relationships (Yin, 2016, THS. 2015). The researchers have audio-taped the collected data, transcribed verbatim and then anonymised their transcripts by importing into a qualitative software-data programme (NVIVO-10) to enable storing, organizing and analyzing the data. They have analyzed using grounded-theory approach and by constant-comparative measure with open-type, axial-type and selective-coding as well as memo-writing in-order to trace-out the existing theoretical linkages and conceptual details from the collected data.
Appropriate methods should be selected in qualitative analysis as it involves organizing data, providing structure and eliciting meaning from data to frame themes, concepts and theories (Yin, 2016). Unlike quantitative, qualitative analysis is labor-intensity process that necessitates creativity, hard-work and conceptual sensitivity. Absence of standard analytical rules, enormous work requirement and reducing data for reporting purpose challenges qualitative analysis (Polit, 2016).
The researchers mentioned that they ensured rigour in their coding process by allowing 2 interviews to be encoded by a well-experienced qualitative-researcher in their department (but external to their study). Additionally, all the research team-members met at regular intervals to discuss about the process of data-analysis and data-interpretation. These processes have helped them to achieve transparency as well as credibility of study-findings (Yin, 2016).
The study-findings suggest that COPD-patients have identified their exacerbations based on their visible (objective/measurable) symptoms that include cough producing sputum as well as invisible (subjective) features as sensations in chest along with bodily knowledge. Majority of COPD-patients appeared to use both visible and invisible approaches in recognizing COPD-exacerbations based on their previous experience. Patients were also found to use self-management strategies at the exacerbation time that includes intake of self-medications as antibiotics & steroids and monitoring their improvement and they contact health-professionals only when they were unable to manage by their own.
These findings can be transferred into newly diagnosed patient settings where educating them with visible and invisible symptoms will make them free from acute exacerbations. Further researches have to be conducted to quantify the patient-experiences by clarifying the current COPD-exacerbation’s definition and informing clinical measures to enable earlier identification & management of COPD-exacerbation, specifically in the tele-monitoring interventions.
References
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