SCIE research briefing 12: Involving individual older patients and their carers in the discharge process from acute to community care: implications for intermediate care
Critical appraisals
Bull M.J., Roberts J. (2001). Components of a proper hospital discharge for elders. Journal of Advanced Nursing, 35 (4), 571-581.
The aim of this study was clearly defined as identifying key people’s perspectives on what the components are of effective discharge planning for elderly adults, and what factors impede the discharge planning process. A qualitative approach was appropriate for obtaining the perspectives of the people involved in discharge planning, including health professionals, patients and carers. The choice of this study design was not justified, however. The study used snowball sampling to identify relevant health professionals from two wards of a hospital and a community team, and convenience sampling to identify elderly patients and carers who complied with stated criteria. Numbers who were approached, but declined to take part in the study, were not given. The sample consisted of 21 health professionals, 2 older patients and 1 carer.
The data were collected from semi-structured interviews. The questions put to the different groups in the sample were all described. The interviews were taped and transcribed, and the content verified by the participants. Efforts were made to ensure the reliability and validity of the findings. For example, triangulation was achieved by using a qualitative ethnographic methodology, in which data from interviews, observation and documents were compared and used to verify and supplement the findings. The relationship between researcher and participants was not considered, however. Ethical approval for the study was obtained, and the study was explained to participants and their consent obtained. There was only a general description of how the data were analyzed, and no detail on how data were selected for the reported findings.
There is a full thematic discussion of the findings, but greater use of quotations could have been made: only a few quotations were used to support the findings. The findings were very clearly discussed with reference to the aims of the study, however, and they were considered in the context of existing literature on the topic. The practical implications of the study’s findings were discussed, and there was also brief discussion of the limitations of the study, such as its small scale. Suggestions for future work were given.
This is a good study which provides some important preliminary findings on discharge planning from the perspective of both professionals and service users. However, the paper would have benefited from much more detail on the data analysis, and more explicit use of the data to support its findings.
This critical appraisal was conducted using the following tools:
CASP collaboration for qualitative methodologies (2002). 10 questions to help you make sense of qualitative research.
Available from: http://www.phru.nhs.uk/casp/qualitat.htm
[Accessed 1 February 2005].
Clegg A. (2003). Older South Asian patient and carer perceptions of culturally sensitive care in a community hospital setting. Journal of Clinical Nursing, 12 (2), 283-290.
This study had a clearly defined research question: how do older south Asian patients and their relatives describe culturally sensitive care. A qualitative approach was appropriate for obtaining the views of this group about their experiences of community care. The choice of study design was described and fully justified. The study recruited appropriate individuals, who complied with stated criteria, but numbers who were approached, and declined to take part in the study, were not given. The sample consisted of 4 older patients and 3 relatives.
The data were collected from a series of informal, unstructured interviews. Data from the first interviews were used to develop a more formalized interview structure and basic topic guide for subsequent interviews. The interviews were taped and transcribed, and the content validated by a number of translators and reviewers. This was important for validation because some of the interviews were in Urdu and were translated for the transcription. The relationship between researcher and participants was considered, especially from a cultural perspective; ethical approval for the study was obtained, and the study was explained to participants and their consent obtained. Coding and data analysis followed grounded theory, but there was no detail on how data were selected for the reported findings. However, the study did achieve a measure of triangulation by using a second, south Asian reviewer to examine and validate the categories identified by the first reviewer.
There was a full thematic discussion of the findings, but greater use of quotations could have been made: only two or three quotations were used to support the findings in each category. The findings were very clearly discussed with reference to both the aims of the study and existing literature on the topic. The practical implications of the study’s findings were discussed, and there was also a full discussion of the limitations of the study, such as its small scale, and the problems of cross-cultural research, including the language barrier. Suggestions for future work were given.
This is a good study which provides some important findings on the experiences and preferences of a particular ethnic minority in relation to their care. However, the paper would have benefited from more detail on some aspects of the data analysis, and more explicit use of data to support the findings.
This critical appraisal was conducted using the following tools:
CASP collaboration for qualitative methodologies (2002). 10 questions to help you make sense of qualitative research.
Available from: http://www.phru.nhs.uk/casp/qualitat.htm
[Accessed 1 February 2005].
Crawford M., Rutter D., Manley C., Weaver T., Bhui K., Fulop N. et al (2002). Systematic review of involving patients in the planning and development of health care. British Medical Journal, 325 (7375), 1263-1267.
The review had a clearly defined aim: to examine the effects of involving patients in the planning and development of their health care. A definition of involvement was provided. No particular study design was appropriate to this question, so the authors were correct in not limiting their search to one study design only, and so included all study designs. The search found 42 relevant papers.
The reviewers did try to identify all relevant studies. The search included a full range of electronic databases, hand searches of reference lists of papers, contact with experts and service user organizations, and a hand search of grey literature. The searches used MeSH and free text searching. The terms and combination of terms used were likely to identify most if not all relevant studies. The reviewers applied clear inclusion and exclusion criteria. Two reviewers evaluated studies for inclusion and, where there was disagreement, this was resolved by consultation with a third reviewer. All included studies were then classified by study design, context of involvement, method of involvement, and whether there was a reported outcome. The majority were case reports, for which no quality assessment exists, so there was no appraisal of the included studies.
There was no formal meta-analysis. This was not practical because the included studies covered a number of distinct study designs, different methods of patient involvement, different services, and the majority were case studies. The authors therefore decided to write a narrative review. The review demonstrated that there is very little literature on the effect of patient involvement on the quality or effectiveness of services: most studies do not investigate outcomes of patient involvement, and the ones that do are case studies.
The results of the study were not generalizable to the local population. The majority of the studies were from the UK, but they were case studies, which have very low external validity. The study considered outcomes ranging from patient satisfaction, through further user involvement, to actual changes in services. The outcomes also involved changes being made to services, but not whether the changes had a positive effect on clinical or related outcomes.
This is a good systematic review, which is methodologically sound. The results are not generalizable, however. This is because the majority of the studies identified were case studies, and the range of different study designs precluded meta-analysis, with the result that there is no precision to the findings.
This critical appraisal was conducted using the following tools:
CASP appraisal skills programme (2002). 10 questions to help you make sense of reviews.
Available from: http://www.phru.nhs.uk/casp/reviews.htm
[Accessed 1 February 2005].
Huby G., Stewart J., Tierney A., Rogers W. (2004). Planning older people's discharge from acute hospital care: linking risk management and patient participation in decision-making. Health, Risk and Society, 6 (2), 115-132.
This study had a clearly defined aim: to explore older patients’ participation in discharge decision making from the perspective of patients and their professional carers. A qualitative approach was appropriate for obtaining information about the views and experiences of this group. The choice of study design was not justified by the authors. The study recruited appropriate individuals. Numbers who were approached, and declined to take part in the study or were unable to give consent, were given. The interviewed sample consisted of 22 older patients.
The data were collected from a series of semi-structured interviews over a 5-month period. The setting for data collection was described. There was no information about how the data were recorded, however. Triangulation of the data was achieved by additional interviews with professionals, and observation of consultations and meetings, and by the frequent comparison of interview styles, content and settings between the researchers. The relationship between researcher and participants was explicitly considered; ethical approval for the study was obtained, and the study was explained to participants and their consent obtained. There is no information about the coding and analysis of the data, or how data were selected for the reported findings.
Two very detailed case studies with extensive transcripts from the interviews, including both interviewer questions and participant responses, were used by the authors to demonstrate their findings. Data from some other participants were then presented briefly to support some of the same points, as well as some additional ones. The findings were very clearly discussed with reference to both the aims of the study and the limited literature on the topic. The practical implications of the study’s findings were discussed, but there is no discussion of the limitations of the study, such as its small scale and non-generalisability, and no suggestions were made for future work.
This is a good study in terms of recruitment, reflexivity and presentation of some of the data, but there are also weaknesses. There are important omissions from the paper concerning data collection, and an absence of detail on the process of data analysis. The findings of 2 or the 22 participants are used to great effect, but the remaining participants do not appear to provide any meaningful data at all. It is therefore difficult to evaluate if the two case studies are representative of the views of the sample as a whole.
This critical appraisal was conducted using the following tools:
CASP collaboration for qualitative methodologies (2002). 10 questions to help you make sense of qualitative research.
Available from: http://www.phru.nhs.uk/casp/qualitat.htm
[Accessed 1 February 2005].
Jewell S. (1996). Elderly patients' participation in discharge decision making: 1. British Journal of Nursing, 5 (15), 914-916 and 929-932.
This study aimed to explore primary nurses’ perceptions of older patients’ participation and their own practice in relation to discharge planning. A qualitative approach was appropriate for obtaining the views of this group. The choice of study design was justified. The study recruited appropriate individuals. The sample was self-selecting and convenient, so numbers who were approached, and declined to take part in the study, were not given. The interviewed sample consisted of 9 primary nurses from two units for frail elderly people.
The data were collected from two unstructured group discussions. The interviews were recorded, although there was no reference by the authors to the transcription of these data. A basic topic guide was used to identify the themes for the discussion. The relationship between researcher and participants was not considered, and there was no explicit reference to the consent of the participants. The data were subject to content analysis, but no other details about analysis, coding or validity were given.
There was a full thematic presentation of the findings of the interviews, which were supported by substantial numbers of quotations. The findings were also very clearly discussed with reference to both the aims of the study and the limited literature on the topic. However, there was no conclusion, and no discussion of the practical implications of the study’s findings or the limitations of the study, such as its small scale and non-generalisability, and no suggestions for future work.
This is an original study with insights into professional perceptions of the participation of elderly patients in their discharge planning. There are weaknesses of methodology and presentation, however: for example the absence of detail about data analysis and the form of the data; a very brief discussion section; the absence of any conclusion; and no discussion of the study’s limitations.
This critical appraisal was conducted using the following tools:
CASP collaboration for qualitative methodologies (2002). 10 questions to help you make sense of qualitative research.
Available from: http://www.phru.nhs.uk/casp/qualitat.htm
[Accessed 1 February 2005].
Roberts K. (2002). Exploring participation: older people on discharge from hospital. Journal of Advanced Nursing, 40 (4), 413-420.
This study employed both a qualitative and a quantitative approach. The aim of the study was clearly defined: to explore the views and experiences of older users (aged 70 or over) of health and social services in relation to decision making about their care. A qualitative approach was appropriate for seeking the views of older people about their care, and the survey was appropriate for obtaining demographic data and binary data on the discharge process and service provision post-discharge. The choice of study designs was not justified by the authors, however. The study recruited appropriate individuals. The response rate was given and explained, but was low (50%). The survey sample was 260, of which 30 also took part in qualitative interviews. The sampling for the interviews was purposive.
Data were collected by a validated survey instrument (questionnaire) with closed and open questions, and by semi-structured interviews, which aimed to build on the responses from the survey. A degree of triangulation was therefore achieved by this method. The content of both the survey and the interviews was described and explained. The interviews were taped and transcribed, and their setting was described and justified. Data saturation was reached. The relationship between researcher and participants was not considered, but both ethical approval and the informed consent of participants was obtained. There was only a very brief and general description of how both the quantitative and qualitative data were analyzed.
There was a full report and discussion of the findings for both the survey and the interviews. The number of participants who gave each coded response was given. The findings were very clearly discussed with reference to the aims of the study. The implications of the findings were fully discussed, reference was made to existing research, recommendations for future research were given, and the principal limitations of the study were acknowledged, especially concerning the sampling process. The findings were therefore not representative and are not generalisable.
This is a good quality study which offers some interesting insights into the role older patients want or are willing to play in their own discharge and care. Methods of recruitment, and data collection and presentation are all appropriate. The weaknesses of the study are the low response rate of the survey and the non-random sampling of the interviewees, although this latter issue is addressed by the authors. The paper would have benefited greatly from a fuller explanation of the data analysis process.
This critical appraisal was conducted using the following tools:
CASP collaboration for qualitative methodologies (2002). 10 questions to help you make sense of qualitative research.
Available from: http://www.phru.nhs.uk/casp/qualitat.htm
[Accessed 1 February 2005].
Crombie I. K. (1997). Appraising surveys. In: The Pocket Guide to Critical Appraisal. A Handbook for Health Care Professionals. London, BMJ Publishing Group. pp. 30-36.