Rough Draft Qualitative Research Critique and Ethical Considerations
Write a critical appraisal that demonstrates comprehension of the two qualitative research studies listed below.
Must use the following “Research Critique Guidelines” document to organize your essay. Successful completion of this assignment requires that you provide rationale, include examples, and reference content from the studies in your responses.
Use your practice problem and the two qualitative, peer-reviewed research articles you choose.
***Practice Problem that needs to be included*** PICOT: In mental health patients with substance use disorders (P), does treatment, (I) as compared to non-treatment, (C), reduce readmissions, (O) within 90 days? (T).
In a 1,0001,250 word essay, summarize the two qualitative studies, using the nursing research guide template and explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study. APA format.
Research Critique Guidelines Part I
Use this document to organize your essay. Successful completion of this assignment requires that you provide a rationale, include examples, and reference content from the studies in your responses.
Qualitative Studies
Background of Study
1. Summary of studies. Include problem, significance to nursing, purpose, objective, and research question.
How do these two articles support the nurse practice issue you chose?
1. Discuss how these two articles will be used to answer your PICOT question.
2. Describe how the interventions and comparison groups in the articles compare to those identified in your PICOT question.
Method of Study:
1. State the methods of the two articles you are comparing and describe how they are different.
2. Consider the methods you identified in your chosen articles and state one benefit and one limitation of each method.
Results of Study
1. Summarize the key findings of each study in one or two comprehensive paragraphs.
2. What are the implications of the two studies in nursing practice?
Ethical Considerations
1. Discuss two ethical consideration in conducting research.
2. Describe how the researchers in the two articles you choose took these ethical considerations into account while performing their research.
2019. Grand Canyon University. All Rights Reserved.
2 1AntonySM, etal. BMJ Open 2018;8:e018200. doi:10.1136/bmjopen-2017-018200
Open access
Qualitative study of perspectives
concerning recent rehospitalisations
among a high-risk cohort of veteran
patients in Connecticut, USA
Sheila M Antony,1 Lauretta E Grau,1,2 Rebecca S Brienza1,3
To cite: AntonySM, GrauLE,
BrienzaRS. Qualitative study of
perspectives concerning recent
rehospitalisations among a high-
risk cohort of veteran patients
in Connecticut, USA. BMJ Open
2018;8:e018200. doi:10.1136/
bmjopen-2017-018200
Prepublication history for
this paper is available online.
To view these files, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2017-
018200).
Received 13 June 2017
Revised 27 April 2018
Accepted 4 May 2018
1VA Connecticut Healthcare
System, West Haven,
Connecticut, USA
2Yale School of Public Health,
New Haven, Connecticut, USA
3Section of General Internal
Medicine, Yale School of
Medicine, New Haven,
Connecticut, USA
Correspondence to
DrLauretta EGrau;
lauretta. [emailprotected] yale. edu
Research
AbstrACt
Objectives Veterans Affairs (VA) patients are at risk for
rehospitalisation due to their lower socioeconomic status,
older age, poor social support or multiple comorbidities.
The study explored inpatients perceptions about
factors contributing to their rehospitalisation and their
recommendations to reduce this risk.
Design Thematic qualitative data analysis of interviews
with 18 VA inpatients.
setting VA Connecticut Healthcare System, West Haven
Hospital medical inpatient units.
Participants All were aged 18+ years, rehospitalised
within 30 days of most recent discharge, medically stable
and competent to provide consent.
Measurements Interviews assessed inpatients health
status after last discharge, reason for rehospitalisation,
access to and support from primary care providers (PCP),
medication management, home support systems and
history of substance use or mental health disorders.
results The mean age was 71.6 years (11.1 SD); all
were Caucasian, living on limited budgets, and many had
serious medical conditions or histories of mental health
disorders. Participants considered structural barriers to
accessing PCP and limited PCP involvement in medical
decision-making as contributing to their rehospitalisation,
although most believed that rehospitalisation had
been inevitable. Peridischarge themes included beliefs
about premature discharge, inadequate understanding
of postdischarge plans and insufficiently coordinated
postdischarge services. Most highly valued their
VA healthcare but recommended increasing PCPs
involvement and reducing structural barriers to accessing
primary and specialty care.
Conclusions Increased PCP involvement in medical
decision-making about rehospitalisation, expanded clinic
hours, reduced travel distances, improved communications
to patients and their families about predischarge and
postdischarge plans and proactive postdischarge outreach
to high-risk patients may reduce rehospitalisation risk.
IntrODuCtIOn
The issue of hospital readmission has come
to national attention, and although the
link between readmissions and quality of
care is controversial, readmissions lead to
increased cost, and interventions to reduce
readmissions have been correlated with
reduced mortality.1 Overall cost for 30-day
readmissions within the Veterans Affairs (VA)
is estimated at US$6000 to US$8000 for an
average medical admission,2 although some
studies suggest higher rates of readmission
within the Department of Veterans Affairs
health system than in non-VA hospitals.3 4 In
addition to overall costs associated with read-
missions, rehospitalised patients are more
likely to suffer from chronic comorbidities
and impaired functional status that place
them at increased risk of death.5 6 Systems
level factors such as hospital size have been
found to be negatively associated with the
patient outcomes of rehospitalisation and
death.7
VA patients may be at higher risk for rehos-
pitalisation due to their lower socioeconomic
status, older age, poor social support and
multiple comorbidities.811 Among seriously
ill veterans receiving palliative care, a recent
strengths and limitations of this study
Collecting data on Veterans Affairs (VA) patients
perspectives about their recent rehospitalisation
can identify important contextual factors that are not
typically or easily assessed in quantitative studies
and may suggest other issues to target in interven-
tions to reduce rehospitalisation risk.
Inpatients recommendations about how to reduce
rehospitalisation risk may uncover structural/sys-
tems issues not recognised by providers or other
hospital staff that may be important to target in in-
terventions to reduce rehospitalisation risk.
Although saturation was achieved, the non-probabi-
listic sampling strategy and small sample size limits
the potential generalisability and should be verified
in a larger, quantitative study.
The study sample included mostly Caucasian males
from one VA hospital in the Northeast, and it is pos-
sible that other themes exist among non-Caucasian
or female patients orin other regions of the USA.
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qualitative study found that issues with self-care and
poor support systems may contribute to readmissions.12
Chronic disease, distance from the VA and age are also
associated with increased readmission risk in veterans.8 9
Studies of transitions of care suggest that difficulty navi-
gating the healthcare system, disempowerment to make
health decisions and complex psychosocial factors may
contribute to readmissions.13 Studies of non-VA patients
who are readmitted within 30 days of last discharge reveal
that patients often have difficulty in understanding
their discharge plans, issues with self-care and difficulty
resolving these barriers.14 15 Functional impairment14 16 17
and polypharmacy18 are associated with preventable post-
operative complications (eg, infection, thromboem-
boli)19 and, among bariatric surgical patients, have higher
presurgical basal metabolic index scores.20
The VA system has sought to reduce readmission risk,
primarily via identification of risk factors in quantitative
studiesboth within3 21 and beyond the VA system2 14 22
and testing interventions to reduce readmissions.10 2325
For example, rehospitalisation rates were reduced by
implementing nursing-led interventions to improve
delivery of discharge instructions in patients following
hip replacement and pharmacist-led interventions to
provide postdischarge medication reconciliation.23 25 And
improved contact with primary care correlated with fewer
readmissions among older veterans.10 Yet rehospitalisa-
tion rates remain high.
To date, few studies have examined veterans percep-
tions regarding the readmission experience.12 13 The
current study was undertaken in response to VA interest
in exploring patients perceptions about factors that
possibly contributed to their recent rehospitalisation and
how to potentially reduce the likelihood of readmission.
Identification of the unique challenges and perspectives
of these patients may inform future healthcare policies
and guide development of interventions aimed at further
reducing readmission risk, enhancing quality of health-
care and improving transitions of care.
MethODs
setting
The VA Connecticut (VACT) healthcare system comprises
six community-based outpatient clinics (CBOCs), an
ambulatory care centre and the 216-bed main hospital
and ambulatory care clinics at West Haven and serves
57 884 patients.26 The study was conducted on the inpa-
tient medicine units at the main hospital, which is staffed
by Yale internal medicine residents, full-time hospitalists
and rotating primary care and subspecialty attending
providers from the West Haven VA.
Patient and public involvement
The study was not a randomised controlled trial. The
research question was based on patients preference
not to be readmitted frequently and the VACT priority
to potentially reduce readmissions within 30 days of
the last hospitalisation. Neither patients nor the public
were involved in the study design. The study goal was to
understand the reasons for readmission from patients
perspectives and determine whether we could develop
interventions to prevent or reduce readmission. Our
initial assumption was that patients would have important
insights due to their recent readmission, and the open-
ended interviews allowed participants to shape the
discussion according to their own priorities. In addition,
patients were not involved in the recruitment or conduct
of the study due to patient privacy issues, the uniqueness
of the study population (ie, inpatient, readmitted) and
the specialised skills required for conducting qualitative
interviews. We did not ask participants permission to
contact them after the study due to privacy and HIPAA
concerns. The study results will be disseminated through
the literature. We will also attempt to distribute the results
through regular publications for veterans.
Participant eligibility and recruitment
Purposive sampling was used to recruit VA patients who
were (1) 18+ years of age, (2) rehospitalised to internal
medicine within 30 days of last discharge, (3) medically
stable and (4) mentally competent to provide consent.
Potential participants were identified via retrospective
chart review and discussion with the patients ward nurse
to confirm eligibility criteria. Participants were then
consented and interviewed during their hospitalisation.
Interviews were audiotaped and lasted 2030 min. Written
consent was obtained from all participants.
Data collection and analysis
An interview guide, previously used in a non-VA setting,27
was adapted to include VA-specific questions regarding
pharmacy services, telephone triage, inpatient and
primary care services and probes to contextualise factors
surrounding rehospitalisation. Key domains included
perceived postdischarge health status, factors believed
to be associated with readmission, medication manage-
ment, access to and support from primary care, home
support systems, resources (eg, housing, transportation)
and history of substance use or mental health disorders.
Basic demographic information (ie, age, ethnicity, sex)
was also recorded. The interviews occurred between
September 2013 and October 2014 and were conducted
by internal medicine residents with training on qualita-
tive interviewing skills.
All interviews were audiotaped, transcribed verbatim
and subsequently deidentified. Interviews continued until
data saturation was achieved as determined during regu-
larly scheduled research team meetings. Codebook devel-
opment and data analysis followed an iterative process
and were grounded in the text. The coding and analytic
team (SA, LG) met weekly throughout the process of
codebook development, coding and analysis. A total of
32 codes were created based on the content expressed
during the interviews. Both team members held postgrad-
uate degrees in clinical fields and were experienced in
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qualitative research methods; one (SA) had interviewed
some participants and was able to bring that experience
to the analytic discussion. Both independently coded all
transcripts, and any coding discrepancies were resolved by
consensus during the weekly meetings. The teams epis-
temological position was constructionist and used prag-
matism as the interpretive framework. Using ATLAS. ti
(V.7.1.7) and thematic analysis,28 29 we identified common
patterns across the dataset, grouped them into themes,
and sought negative instances where the data did not
fit the existing themes. Reports of all quotes subsumed
under each code were generated and discussed iteratively
to identify themes that transcended individual codes. The
analyses were reviewed by the research team iteratively
during the entire coding and analytic period of the study.
results
Four major themes were identified. The first related to
participants thoughts about what they valued in their
healthcare and providers. Two themes concerned factors
that may have contributed to their rehospitalisation, the
first primarily identifying factors most closely associated
with the actual readmission and the second with factors
related to difficulties surrounding discharge and postdis-
charge services. The final theme concerned their recom-
mendations to reduce rehospitalisation risk.
sample characteristics
Table 1 describes the study sample. Of the 18 participants,
there were 17 men and 1 woman, proportions that reflect
the overall VACT patient population.30 All were Cauca-
sian; this is also consistent with the overall racial compo-
sition of the West Haven VA patient population. Most
were elderly (mean age 71.6; SD 11.1 years), reported
being financially secure although often living on limited
budgets; approximately half lived with family members
or spouses. Many had pre-existing chronic or serious
medical conditions (eg, diabetes, pulmonary or cardio-
vascular disease, neurological disorders, cancer) or histo-
ries of affective disorders (eg, depression, post-traumatic
stress disorder, anxiety); a few had alcohol or substance
use disorders.
Participants could be generally classified into four
patient types based on their description of events,
behaviours and attitudes: (1) loners, (2) hardcore,
Table 1 Sample characteristics (N=18)
Age (years) Mean 71.6 (SD 11.1)
Range=5790
<59 (2) 6069 (8) 7079 (3) 8089 (3) >=90 (2)
Male 94% (17)
White, non-Hispanic 100% (18)
Living situation 7 subjects live independently
6 live with family (non-spouse)
4 live with a spouse
1 lives in a nursing facility
Homecare 10 reported having home services
Medication management 9 reported needing assistance
4 from family member
5 from nurses or nursing facility
8 were independent in medication management
1 did not take medications
Patient type
Loner I deal with my own problems by myself. Ive always kept issues to myself. (Male, 65 years)
Well, Im kind of a lonie, you know? I keep to myself.(Male, 64 years)
Hardcore I dont go for a hangnail or anything like that. The only time I go over [to the clinic] is when [the
doctor] says, Its time for your checkup and they do a little blood work, stuff like that. Im not the
type of person to go, Im hardcore. (Male, 57 years)
I tough it out and just, theres no reason to call a doctor because you stub your toe. (Male,
64 years)
Resilient Because I know the different medical complications that I have that make thingsthey muddy the
waters a bit. So I know how to tweak them around. (Female, 59 years)
Im pretty independent on whats going on and everything so. (Male, 60 years)
Passive/accepting I take what they give me. I dont judgeI figure they know what theyre doin. (Male, 74 years)
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(3) engaged or (4) passive/accepting. Loners can
be described as independently managing their lives
(including medical problems) with little or no outside
input. Hardcore patients tended to minimise medical
problems and delay seeking healthcare services. The
engaged patients tended to actively participate in active
discussions about their health with their providers.
Passive/accepting patients tended to unquestioningly
accept medical decisions made by their providers or
families. The first three patient types took an active
interest in the medical decision-making process, and
the fourth and smallest group tended to accept any
medical decisions made by their providers or family.
Quotes that exemplify each of these patient types are
provided in table 1. The patient types did not neatly
map onto the themes, but were thought to influence
decision-making processes and activities at times.
healthcare values and priorities
Most participants were very satisfied with their healthcare
and described their VA providers as (a) caring person,
(an) excellent team of doctors, (a) wonderful person
and pays attention. As one male patient aged 69 years
noted, I think the veterans get a better support system
than most [patients] do.
But [my primary care provider] really does pay a lot
of attention. And, to the details. To the minor details
that you wouldn’t think of. (male, 90 years)
The valued qualities were sometimes explicitly identi-
fied or could be inferred from negative statements about
their care. Trust was an important quality that participants
highly valued, particularly in their primary care provider
(PCP).
Because the only one that I want, the only person
I want to see when it comes to my health, that are
people who I trust. Okay and I know that my primary
doctor, I trust, okay. Shes very, very good and shes
always concerned about me when I walk through that
door and she always has a good word to say to me.
(Male, 57 years)
And like I told you, I have a lot of faith in [my PCP].
So whatever she says, I go along. (Male, 90 years)
Respectful and attentive attitudes were other commonly
valued qualities.
[The PCP is] very good, shell pick up stuff and shell
call me and check with me and find out whats good
and I like that too. (Male, 69 years)
The driver was very disrespectful to me and I says,
I dont want you to go and pick on this driver but
you get a hold of all your drivers and you sit down
with them and they have to respect the veteran who is
handicapped. (Male, 57 years)
Participants also valued providers who communicated
and listened well and were thoroughly knowledgeable
about their case. They appreciated clear and consistent
explanations about their medical care, especially in cases
involving multiple specialties during their inpatient care.
Well, I always feel better after I talk to my primary
care doctor because he knows everything about me.
He knows the meds Im on, he knows about my histo-
ry. (Male, 64 years)
I mean she was easy to talk to. She, you would tell
her your deepest secrets and everything that you
wouldnt tell nobody else. You just felt comfortable
with her, just her personality, her attitude. (Male, 60
years)
[The inpatient medical team will] listen to you for
10 min and then, okay, Ill get back to you this after-
noon and they never do. (Male, 64 years)
Continuity of care was another important issue for
participants. For complicated medical problems involving
multiple providers or a hospitalisation, some partici-
pants questioned the extent of communication between
providers and regretted the limited involvement of their
PCP during their hospitalisation.
If Im in a hospital, I think my primary doctor should
be one of the first people to come here. (Male, 90
years)
So, it just seems like theres so many people on your
case that things get kinda mixed up between the peo-
ple I like their 1-on-1, I like the 1-on-1 rather than
a team of doctors. (Male, 64 years)
[The] bigger question I have is whether the doctors
who prescribe them are talking to each other. (Male,
69 years)
themes linked to the readmissions event
Perceptions about the readmission situation included
three themes: (1) logistical/structural barriers to
accessing their PCP, (2) limited involvement of PCPs
in the medical decision-making process and (3) the
perceived inevitability of the readmission.
Logistical/structural barriers
Logistical/structural barriers were the most frequently
cited problem and mainly concerned challenges to
connecting with their PCP in a timely fashion. Partici-
pants reported often feeling worse after clinic hours or
on weekends when the possibility of speaking to a clinic
provider was reduced. Beliefs about limited clinic hours
and heavily booked outpatient schedules were other
perceived barriers to accessing primary care services.
What happens sometimes, things happen on the
weekendYou cant get nobody. (Male, 82 years)
I went over there to see [the PCP] and they told me
I couldnt see him. I could only see him by appoint-
ment. And they wanted to give me an appointment
in, like, a month and a half. (Male, 64 years)
When you get hurt, you get hurt. And if it comes
down to it, theyre not open, theyre only open from
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7:00, 7:30 in the morning till 4:00 in the, then you
have to go to the Emergency Room. (Male, 57 years)
For others, the lack of specialty services at the CBOCs
necessitated travelling long distances to the central
clinic. Perceived transportation difficulties or ineffi-
ciencies may have caused patients to attempt handling
their medical problems at home. This phenomenon was
more likely to occur among loner or hardcore patient
types.
I have to depend on somebody to give me a ride and
both my brothers that give me a ride down here,
theyre both working so they cant just bring me down
any time they want. (Male, 64 years)
So I set up a ride with the VA Transport and thats
a pain in the ass because if they got ten people in
there, I cant go in there with my walker and my leg
wrapped up. I tried it once and it was devastating.
(Male, 57 years)
Limited PCPinvolvement in the medical decision to return to the
hospital
Some participants considered the decision to seek
urgent care without input from the PCPthe person
ostensibly the most knowledgeable about and most
trusted by the patientwas due to these logistical/
structural barriers or tendencies to ignore symptoms
(especially for the loner and hardcore patients) until
there seemed to be no option but to go to the emer-
gency department.
It happened on a weekend and I had no choice but to
go to the Emergency Room Well, like this last time.
I started getting pains in my stomach and naturally,
my daughter and my son said, “You better go”. (Male,
82 years)
Well, like sometimes I let it go too long [and so go
to the Emergency Room]. I dont get to where Im
supposed to be till, its not too late but its late. (Male,
60 years)
Perceived inevitability of the rehospitalisation
Perhaps the most surprising issue was that most patients
believed that their readmission was inevitable because
they had a chronic, degenerative or terminal illness. Only
two participants believed that their readmission could
have been prevented. One attributed his kidney failure
to what he believed to be inadequate monitoring of his
lab data, and the other was convinced that he had been
discharged too soon.
I was following [the doctors] orders to take MiraLax
twice a day and still I wound up here. I dont get it.
(Male, 82 years)
I dont think [the doctor] couldve done anything
Because it was my heart hadnt ever done anything
like that before. So theres no way any doctor would
have known. (Male, 76 years)
Discharge-associated themes
Several themes that may have contributed to participants
readmission concerned the discharge process and postdis-
charge services. These included beliefs about premature
discharge, inadequate or poorly understood information
about postdischarge plans or poorly coordinated postdis-
charge services.
Perceived premature discharge
Participants noted persistent symptoms or insufficient
rehabilitation as contributing to their rehospitalisation.
For some, their strongly expressed desire to return home
may have played an important role in early discharge and
their ultimate readmission. For example, it was unclear in
the case of one participant whether he had shared with
his providers that he continued to be symptomatic at the
time of his first discharge. In another case resulting in
readmission after falling at home, it was unclear whether
the patient would have received training on using his
walker had he not left the hospital against medical advice.
I come down with C. diff. They kept me in the hos-
pital for approximately a week and a half. They sent
me home, even though I still had C. diff. They never
tested me andI was at home. I had a problem with
diarrhea and so on and so forth. (Male, 64 years)
My congestive heart failure was so bad that they start-
ed treating that. And treated that for about 9 weeks.
And then sorta had fully recovered, but I hadn’t. I was
too weak. And I left the hospital 1 day, and when I got
home, I realized I shouldn’t be home, so I came back.
(Male, 74 years)
Response to question about the readmission: I
needed more (inpatient) physical therapy, rehab.
(Male, 65 years)
Insufficient or poorly understood information about postdischarge
plans
Several participants thought that insufficient or unclear
information at the time of discharge may have contrib-
uted to their readmission. It is possible that some (eg,
passive/accepting or hardcore patient types) may not
have asked questions to clarify any confusion concerning
the discharge plans.
I know exactly what I can eat, how to prepare my
foods, and a little bit more than I did the very first
time they released me. (Male, 64 years)
Theres about 15 pills that I have to take and God
knows what they are and for what theyre used for,
because nobody has explained what they are used for.
(Male, 87 years)
Inadequate postdischarge services
Finally, some complained that their postdischarge treat-
ment was either poorly coordinated, inadequate to
address their postdischarge service needs or not covered
by their insurance.
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[VA staff] told me, “You go home and take care of
your treatment at home. Okay? When you get there,
your nurse will be waiting for you. They’ll come ev-
ery day to do it for you. Put in the machine and get
it ready”. They lied. Nobody showed up. (Male, 64
years)
Yes, they set me up for a visiting nurse or visiting phys-
ical therapist but it lasted for about 3 days each, which
didnt accomplish much. (Male, 69 years)
Patient recommendations about how to reduce readmission
risk
Most participants were pleased with their VA healthcare
but recommended several ways to further improve care
and reduce risk of rehospitalisation. These included
increasing involvement of PCPs, reducing transporta-
tion and distance barriers to primary and specialty care,
expanding predischarge services and improving coordi-
nation of postdischarge services.
Improve access to PCP and to expedite more urgent cases
Most participants had great respect and trust for the
primary care providers, and many suggestions concerned
ways in which to reduce challenges to interacting
with them both within and outside the hospital. These
included requiring a call-back within 24 hours for urgent
complaints or being able to rush the system in cases
where quicker scheduling of services or procedures are
required.
I wish I could talk directly [to the primary care team],
pick up the phone and you gotta go through like with
the Veterans ServiceEverything goes to an answer-
ing machine. (Male, 57 years)
Instead of, maybe have two or three appointments
or testings or something set up real close together to
find out, to get a good grip on whats going on and
then you know is it something that we need to really
move with or is it something we can kind of put the
brakes on and slow down a bit. (Male, 60 years)
I mean youve got a 48 hours I think system for noti-
fication or for where they got to return the informa-
tion back and, if anything, I would like to see some
way where theres a red button that you could hit
that would be an emergency; in other words if I got
a problem that needs to be addressed right away, is
there something in the system, the computer or tele-
phone where that can happen. (Male, 68 years)
And now [because of delays in scheduling the proce-
dure], theyre looking at removing the complete bile
duct system, so they kind of went from a minor surgery
to a very complex, major surgery. (Male, 60 years)
Reduce barriers associated with long distances or limited
transportation services
Recommendations to reduce challenges to accessing
primary and specialty outpatient services involved
arranging for efficient and courteous transportation
services and reducing travel distances for such services.
the transportation with the VA is a very poor system
when it comes to handicapped persons like myself.
They have to come up with something better for us
because we are handicapped. (Male, 57 years)
They never asked me, Do you need money for trans-
portation?Like at some places, they got the cashier
downstairs and I see some guys get money for trans-
portation. (Male, 82 years)
Improv
