Introduction and Rationale
Evidence based practice is fundamental to modern nursing care, and can be described as the application of appropriate research findings to practice. There are challenges with integrating research into practice, partly due to a tendency to cling to historic (and arguably, outdated) models of intuitive practice, which are being superceded by evidence based-practice (Rosswurm and Larrabee, 1999). Successfully identifying and applying research to practice can be effected by three central facets of the research, which include the quality of the evidence being used, the clinical area or clinical context into which the research evidence is to be integrated, and the projected processes of implementation (with associated implications for changing practice ) (Kitson et al, 2000; Elliott, 2001). The most important of these factors might be the quality of the evidence, which requires the individual nurse to have the knowledge and critical skill to be able to determine if the research provides a sufficient level of evidence to improve practice (Kitson et al, 2000). According to Reigle (1989), this is linked to patient-centred nursing decision making and client respect, which can be linked to the ethics of nursing practice (Austin, 2001).
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Ultimately, the issue is whether or not the research will benefit patient care, by improving the patient experience and/or clinical outcomes in some way, including through the better use of resources (Crockett et al, 1997). Certain areas of practice can be identified by previous research as requiring exploration and improvement. This paper examines the quality of evidence pertaining to a very topical issue, the compliance with cardiac rehabilitation programmes for clients post myocardial infarction,. There is evidence to suggest that cardiac rehabilitation programmes both benefit patient outcomes and reduce morbidity and mortality, and also therefore contribute to a reduction in resource use consequent to a reduction in serious health consequences of myocardial infarction (Taylor et al, 2006; Davies et al, 2007). The literature debates whether or not this is due purely to the exercise-based rehabilitation, or the reduction in other major risk factors, such as smoking (Taylor et al, 2006; Ferdinandy et al, 2007), but whatever the reason, the links between improved outcomes and cardiac rehabilitation programmes of this type have been established (Dalal et al, 2007).
The NHS Plan (DoH, 2000) also underlines a requirement to improve practice through the judicious application of evidence alongside a reorientation towards patient-centred care which is responsive and inclusive, and takes into account the patient (and carer) perspective. According to some theorists, therefore, application of evidence to practice must take place within a model which combines the evidence from qualitative and quantitative studies, from clinical expertise and from contextual evidence (Rosswurm and Larrabee, 1999), and it is this contextual evidence which must also contain the user perspective. The first stage to this would therefore be to appraise the evidence, both from a point of view of the standards of evidence as defined by the current theoretical and critical literature, and from the point of view of the professional and the service user (Florin and Dixon, 2004). This paper focuses on the critical review of two papers pertinent to this chosen question, which has been an interest of the author due to the very real benefits which can be demonstrated from the adherence to the cardiac rehabilitation programmes available to patients post MI, but which paradoxically are afflicted by poor compliance rates. The author is also motivated by some of the other paradoxes, such as the fact that not only are the poorer socioeconomic groups more affected by coronary heart disease (Wood et al, 2006), but that these are also the groups which display poorer compliance with cardiac rehabilitation programmes (Wyer et al, 2001). This would suggest to this author that there are specific patient needs which may not be met with current care provision, of which this is an important example. The choice of a both a qualitative and a quantitative paper reflects the desire to reflect nursing philosophies as well as the scientific, medical principles which underline evidence-based practice (Thompson, 2000; Johnson et al, 2000; Corben, 1999).
Research Question and Design
Wyer et al (2001) carried out an intervention study, based upon the Theory of Planned Behaviour, to investigate if an intervention based on this theory would affect compliance with (in terms of attendance) cardiac rehabilitation in post MI patients. They clearly outline the Theory of Planned Behaviour (TPB), hence setting the context (and underlying principles of the ‘intervention’ and therefore explaining the hypothesis or research question which underlies their study, that of designing as study to implement and evaluate a TPB founded intervention (Wyer et al, 2001). The determination of the research question in a quantitative study such as this affects the whole study (Thompson, 2000), and in this case, the focus of the study is on the intervention and its effects, with the intervention being the independent variable, and the outcome measures, acceptance, attendance or DNA (did not attend) being the dependent variable. While it is important to assess the research question in terms of its fit with the study (Burns and Grove, 1999), it is also important to look at its usefulness (Stockhausen and Conrick, 2002). Certainly, indicating whether there are theories which explain non-attendance might help to design future studies to improve rates, and this study tests whether an intervention might improve rates, giving it direct clinical significance, although only if sufficiently rigorous (Donovan, 2002).
The research design is experimental, and although the authors do not evaluate their design or methodology within this paper in any way, it does seem suitable to the research question. They define it as a rancomised control trial, but there are elements of an RCT which are not present here (Duffy, 2005). However, as Donovan (2002) suggests, “the reliability of an experimental design may be considered as the extent to which an observation is reproducible and characteristic of the association between the variables being tested” (p 2), and although basic quantitative principles are adhered to in this study, there are some significant issues in relation to validity which are not addressed within this paper.
Cooper et al (2005) carried out a qualitative study, with the aim “to elicit patients’ beliefs about the role of the cardiac rehabilitation course following myocardial infarction” (p 87). They clearly outline the context of the study, and this relates well to the research question (Thompson, 2000). Cooper et al (2005) also refer to psychological theories, in this case Leventhal’s self regulatory model (p 88) which in this study explores rationales for attendance/non attendance at cardiac rehabilitation programmes. The research design is appropriate to the question, being a qualitative design addressing an exploratory question about perceptions and experience rather than measurable outcomes (Silverman, 2004, Forchuk, 1993). The specific focus of the study on patient beliefs prior to attending any cardiac rehabilitation (Cooper et al, 2005) also demonstrates its usefulness because it may point to areas of patient need, such as education, to change their beliefs and potentially affect attendance and compliance. The methodology is reasonably clear, but could have been explained in more detail, as the rather brief summary of ‘interpretive phenomenological analysis’ (p 88) may not be sufficient for those less well-versed in research theories (Corben, 1999).
Wyer et al (2001) started with an initial sample of 113 participants, with a response rate of 88%, and 13 subsequent exclusions from the group, resulting in a final sample of 87 participants. Although this is a quantitative study, there has been no statistical determination of optimal sample size, which affects transferability (Donovan, 2002; Thompson, 2000; Burns and Grove, 1999), and no indication that it is a representative sample (Stoner and Rutledge, 2005; Russell and Gregory, 2003). However, it is a strength that the experimental and control groups were matched for age, gender and living distance from the programme (Wyer et al, 2001), and there isindication of how this relates to the fact that they were randomly assigned and there is mention of blinding of participants or researchers (Donovan, 2002). The demographic variables were statistically evaluated between the two samples, and no statistical significance was identified, which strengthens the sample used.
Cooper et al (2005) clearly define their inclusion and exclusion criteria for their sample, which seem suitable for the study design (Thompson, 2000), and define theirs as a purposive sample with some limitations, although they could have given more of a clear rationale for this sampling approach (Corben, 1999), and also outline some demographic characteristics. Purposive sampling is suitable for qualitative studies of this nature, and the sample described is suggestive of trustworthiness (Russell and Gregory, 2003).
Data Collection and Analysis and Presentation of Results
The study conducted by Wyer et al (2001) involved the distribution of two letters to the experiemental group, which consisted of the intervention, and the authors outline what was in these letters and how it related to the Theory of Planned Behaviour. This level of transparency is very useful for transferability and for replication of the study (Daggett et al, 2005). “Acceptance and attendance figures were collected for participants and for those who declined to take part in the research study”, along with compliance rates for the programme collected weekly (Wyer et al, 2001 p 156). These data collection methods match the RCT design (Russell and Gregory, 2003), because they provide statistics on the outcome measures being tested. The authors used SPSS to analyse the data, and state which version, and which statistical tests were used, but do not explain these tests or explain how/why these were appropriate for the sample and results. This could have been explained and the data collection methods and analysis tools tested using a pilot study, which was not carried out (Thompson, 2000).
The results are presented in textual form supported by numerical/statistical data, and as a graph which demonstrates the comparisons between the percentage of participants in the experimental and control groups who demonstrated the three measured variables of acceptance, attendance and DNAs. Presenting data in graphical form makes it more accessible and understandable to the reader (Thompson, 2000), but in this case, the reader must also understand the textual explication of the statistical process, which could be rather dense for the novice reader/researcher. The sequential statistical analysis carried out to test differences between gender, distance and age are at least described, which is a strength (Robinson, 2001; Daggett et al, 2005).
Cooper et al (2005) carried out face to face, in depth, semi-structured interviews, which were audio-recorded and transcribed ‘in full’. The use of this kind of interview in exploratory, qualitative research is an accepted approach to data collection, made stronger by audio taping (Denzin and Lincoln, 2005). However, the transcription is not described as verbatim, and it is not said who transcribed the data, so the nature of the transcription, the researcher’s relationship with this process, is not made clear (Corben, 1999). The researcher’s did not carry out member checking, which could enhance the trustworthiness of the findings (Russell and Gregory, 2003).
Data analysis is described in a summary by Cooper et al (2005), and includes a description of how themes were arrived at, which is good (Emden and Sandelowski, 1998), but given the range of qualitative methodologies available within this paradigm, which include models for thematic analysis, it is a weakness that no recognised structure or model is cited or employed here (Corben, 1999). There is good transparency here, however, which would aid in replication of the study, but the authors have also not made use of any of the qualitative data analysis software available, or have not cited that they used this (Thompson, 2000).
The results are presented as Key Themes (Cooper et al, 2005) which are described, and quotes from the data are included, which enhances trustworthiness (Forchuk and Roberts, 1993). The themes are summarised in a table, and also presented within a framework which is described and discussed within the paper. The authors acknowledge their inability to establish links between participants’ beliefs, any expressions of intention to attend cardiac rehabilitation, and actual attendance behaviour (Cooper et al, 2005). This demonstrates some of the limitations of this study.
Wyer et al (2001) were able to demonstrate that their intervention, consisting of two letters based on the TPB, was effective in increasing attendance rates in their study sample.
Cooper et al (2005) ultimately conclude that “prior to course attendance some patients hold erroneous beliefs about the course content, especially the exercise component” (p 87). This suggests that the exercise element was the most off-putting for many participants. There were also co-existent cardiac misunderstandings (Cooper et al, 2005).
Conclusion and Implications for Practice
Both of these studies offer some guidance for practice in relation to improving compliance with cardiac rehabilitation programmes for patients following an MI. The Wyer et al (2001) study provides strongly conclusive results which suggest that the use of this kind of intervention would increase compliance with rehabilitation programmes and, subsequently, reduce the demand on cardiac and other services from ongoing morbidity in cardiac disease. However, there are some limitations to this study, not the least of which is a lack of clarity over the RCT design in the paper, and a small sample size which is not statistically calculated. It may be necessary to replicate this study in a larger, more representative population. Cooper et al’s (2005) study provides some insight into the beliefs which prevent patients from attending, many of which are due to erroneous understanding about the programme and its relevance for them. Therefore, this could prompt nurses to pay more attention to the kinds of information given to these patients, and to check their understanding and conceptions of the programme, a relatively simple change in practice. While there may be some nurses who would argue that a single, small, qualitative study cannot really constitute evidence for practice, the benefit for patients might be significant and the change in practice is relatively small and carries few risks for the clients.
Given that the morbidity and mortality experienced by patients following an MI can be drastically reduced by attendance at targeted cardiac rehabilitation programmes (Taylor, 2004; Taylor et al, 2006), this author believes that any evidence which supports even minor changes in practice has benefits for the patients, the healthcare providers and the resources of the NHS which are in such constant demand. However, these studies do not constitute evidence weighty or reliable enough for radical changes in practice, but they do indicate ways in which practice might be changed. However, this author also believes that these studies point to underlying, inherent issues related to the quality of nursing and other healthcare for these patients at this crucial period, and believes that nurses can, and should make changes to practice based on critically appraised research such as this. While targeted interventions would be a large scale change, improving the quality of information giving and checking understanding should be part of cardiac nursing care for all patients.
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