Critical Appraisal Skills For Practice

The purpose of this assignment is to critically appraise a research paper which is relevant to practice. My chosen published paper is based on qualitative research, and interprets the feelings and thoughts of older people, after suffering heart failure and how they cope with transition from independence to dependence and for some even death (Waterworth et al, 2010). I intend on using Critical Appraisal Skills Programme (CASP) tool as a framework (see appendix). The tool presents ten questions which can be applied to the qualitative research, broadly examining the assumptions and principles which characterise the paper. Although the questions are not classed as a harden rule the tool acts as a framework or simple guide which aids the reader to make sense of the research (Public Health Resource, 2006) (PHR).

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Critical appraisal skills for practice are vital as it helps the process of identifying and examining a research paper to judge its trustworthiness and value (Burls, 2009). The NMC Code (2008) states a midwife should practice and deliver care which is based on the best available evidence and any information or advice given is also based on the best available evidence.

Qualitative research is defined as a study that searches for answers to certain questions, by collecting evidence with systematically predefined procedures. It is documented that qualitative research produces intangible answers, however once the research is interpreted it gives us a better understanding of complex issues such as reality (Qualitative Research Methods, 2005). Dicicco-Bloom (2006) comments that health service research is usually conducted using questionnaires and highly constructed interviews.

However Mack (2005) states qualitative research is very subjective and often it is very difficult to generalise results. Causing difficulties in determining how many people actually experienced the same feelings of thoughts.

Mack (2005) also documents that often the results are easily influenced by the researcher’s personal mannerisms and characteristic, causing a bias response by the interviewee.

CASP (2006) tool begins with two basic screening questions to determine the aim and methodology used with in the research paper.

1. “Was there a clear statement of the aims of the research?”

An aim is defined as the intention of what the research is about, how it will be accomplished and what they wish to accomplish it (Bryman and Bell, 2006). Rusinova et al (2009) states that although the aim is a thorough explanation often the researcher does not know in advance what he is looking for as the design often materializes as the study commences.

The ultimate aim of the research was identified with clear descriptions. The researcher aimed to explore the experience, deep feelings, thoughts and concerns of older people which had suffered heart failure. The aim was sensible and relevant to practice. The researcher aimed to interpret how the interviewees felt about going from independence to dependence or even facing death (Waterworth et al, 2010).

The aim was relevant to care, as it may possibly indicate changes occurring to older peoples lives over a period of time (Waterworth et al, 2010). Rusinova et al (2009) notes the response from interviewees maybe excessively emotional and may produce an over whelming amount of detail and information, which may result in a lengthy data analysis. Qualitative research is highly dependent on the interviewees experience and feelings, incorrect interpretation or information can cause an inaccuracy in the result, however Golafshani (2003) states qualitative research is now recognised as having a validity and reliability factors.

On reflection to practice there is an opportunity for women to rate their care received during the antenatal, postnatal and intrapartum care. It is my own observation that towards the end of their care women maybe feeling particularly tired, run down and stressed, or even anxious and depressed due to the demands of a newborn baby. Discussing their feelings at that particular time my result in an inaccurate account of their feelings of the total care received. The Royal College of Psychiatrists (2007) states women whom suffer from postnatal depression have feelings of sadness, feel low and irritable. They suffer with tiredness and feelings that they can not enjoy anything or anyone, can’t cope with life and feel anxious. These feelings may effect how they answer questions or rate their care. Turton (2009) states that a person suffering from depression, makes them think and feel irrational which interprets what a person is thinking and distorts reality. Waterworth et al (2010) states at the first and subsequent interviews all participants are screened for depression using a geriatric depression scale, and were invited to have a person with them for support.

2. “Is a qualitative methodology appropriate?”

The researcher used appropriate methodology for the research undertaken, and was consistent with the aims.

Quantitative research is used to distinguish a relationship between one thing and another. Usually the sample groups needs to be very large in order to make a relevant connection. The participants need to be fit into the correct category to part take in the study (Hopkins, 2000). Quantitative research usually is either experimental where by it tests the accuracy or a theory. Or is it is descriptive research the study measures the sample at one time and describes the sample’s demography (Hopkins, 2000).

Qualitative research is the best possible method in collecting such data. The longitudinal approach enabled the researcher to distinguish a change in feelings and experiences other time. The research describes an event in its most natural setting, and is a subjective way of looking at life and how it is lived which is vital to health care and how it is delievered (Lowhorn, 2007).

The third to the tenth questions within the CASP (2006) tool are classed as detailed questions.

3. “Was the research design appropriate to address the aims of the research?”

A research design is defined as a structure, something that holds the study together. It includes how the data is collected and analysed, methods and time lines (Agency for Healthcare research and quality, 2005). King (2009) States a good research design provides reassurance you are gaining the best validated results. Waterworth et al (2010) includes a detailed research design.

4. “Was the recruitment strategy appropriate to the aims of the research?”

The recruitment of interviewees consisted of 25 older people aged between 70 and 90 years of age with “New York Heart Classification levels 11-1V”. The New York Heart Association assessed the participants once before interview selection (Waterworth, 2010). Using a scale to assess heart failure stage the interviewees were given a class 1 for mild heart failure to IV for severe. There was a mixture of males and females taken from three general practices, including a heart failure clinic and four other wards and invited via a phone call or letter (Waterworth, 2010).

It can not be said that these 25 people represent the population on a whole, neither can it that the results may indicate a popular result as the group sample contained males and females, all at different stages, ages and classes of heart failure. Waterworth et al (2010) did acknowledge that some of the interviewees were ready die and others were not quite at this stage.

In general people aged between 70 and 90 maybe going through a transition of independence to dependence regardless of heart failure, and it is not uncommon for people of this age to be single, due to the loss of their partner due to age, resulting in different abilities to coping or reasons to carry on with life. This in its self may contribute to the feelings and experiences of the participants. Rudkin (1994) states that old age and increasing dependency is very common, and Hunt et al (2003) states older people do engage in a considerable amount of worrying when it comes to coping with aging and death. It may complicate analysis of data when trying relating transition from independence to dependence and heart failure, when in reality this transition occurs with many adults of that age anyway.

5. “Were the data collected in a way that addressed the research issue?”

The study was conducted between December 2006 and February 2008 with semi-structured interviews every 3-4 months. Interviews took place within the participant’s home or the residential care home they were staying lasting between 35 – 90 minutes. Semi-structured interviews are thought to aid in the flow of conversation, leaving room for two way communication and are seen as less intrusive to the interviewee. They are also seen as more flexible; allowing new questions to be explored during the interview (British Medical Journal, 1995) (BMJ). Farrell (2009) states there is no real guideline to how long a study should go on for, but change in feelings, experinces and thoughts can take years to emergeMacdowell (2001) documents that the best place to conduct a study and asks interviewees questions are in a familiar place such as their own home. This aids the participant into relaxing. This is not only convenient to the participants but also puts them at ease, as personal objects and surroundings may jog their memory (Macdowell, 2001). The length in which the interviews last can be key in the value of data collected. The interviews are not classed as a casual chats and in order to collect sufficient data the participant needs to concentrate. Interviews which last too long can cause a lack in concentration and data may be affected causing an incorrect in the interpretation and analysis (Macdowell, 2001).

Waterworth et al (2010) used a longitudinal design approach with a general inductive style. Longitudinal research is defined as a study which is done over a period of time, allowing data collection points in stages thus monitoring changes over time (Yurek et al, 2008). Molly et al (2007) remarks that once the first initial questions are asked the researchers periodically returns to the interviewees and re-addresses previous questions.

Weel (2005) states longitudinal research can help practice based research, however a mechanism tool should be put in place to track when participants leave the study or die. Matton (2007) remarks on the enormous opportunities and progression longitudinal qualitative research has however, it also comes with disadvantages and limitations. For instance when the researcher returns to address previous questions, the interviewee is asked to recall feelings and experiences. Retrospectively answering questions can limit or alter answers, either due to lack of memory or deterioration of the participant (Matton, 2007).

Waterworth et al (2010) used an inductive approach in order to condense varied data and put into a concise summary format. This is thought to help establish clear links and also reflect on repetitively reported feelings by the participants, and also provide convenient and resourceful way of analysing qualitative data (Thomas, 2003). The final summary is purely based on the information and data collected; nonetheless the researcher may interpret the data collected incorrectly and draw incorrect meanings or experiences (Thomas, 2003). Thomas (2006) States that all inductive approach research requires a demand of deeper thinking in general inductive approach is less complex than using other approaches to qualitative data analysis

6. “Has the relationship between researcher and participants been adequately considered?”

7. “Have ethical issues been taken into consideration?”

Waterworth et al (2010) does state that the study was approved by the “">New">Zealand Northern Regional Ethical Committee”. Ethics in Health Research (2006), comments that Ethical issues in qualitative research are frequently more subtle than ethical issues in survey or experimental research. One aspect would be to gain Informed consent from participants. Waterworth et al (2010) includes a statement where it is documented that informed consent was gained from participants prior to any interviews. By which they signed consent forms and again asked prior to interviews if they still wished to part take in the study. The study was explained via a telephone call and by post by means of an information pack.

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Ethics in Health Research (2006), also states the participants must be made aware of any risks or benefits of the study, what it entails and details of questions, if however the questions are not known at this time the participants have to be made aware of this.

The NMC Code (2008) states midwives must gain informed consent prior to treatment or care. The Royal college of Nursing (2005) (RCN) states informed consent is defined as an agreement for a person to under go treatment receive care or participate in research, after an adequate explanation of risks and benefits to the person.

Qualitative research aims to seek deep feelings; questions recalling feelings of sensitive topics may cause stress and anxiety to the participant. Richards et al (2000) suggests the best way to avoid such probing questions that may potentially cause distress is that the study is scientifically sound and conducted by a person of expertise and that the study is of a beneficial nature.

There is no reference to confidentiality within the script. NMC Code (2008) defines confidentiality as an essential role in professional practice, which protects a human right. Someone whom discloses information to another has the right to have that information kept in confidence unless you believe someone is at risk of harm (NMC, 2008).

8. “Was the data analysis sufficiently rigorous?”

Waterworth et al (2010) states data gathered was transcribed verbatim and then entered into NVivo 8 for analysis. Transcribed verbatim is defined as a common means of data collection, every word uttered and sighed is recorded during an interview (Halcomb, 2006). It is thought transcribed verbatim is fundamental to the examination and interpretation of verbal data. Wellard (2001), comments that the procedure of transcription may disclose or obscure certain information, however agrees it is a common process of data collection and analysis.

NVivo 8 is defined as a frequently used qualitative analysis software package, used for the analysis of interviews, enhancing the process and at a much quicker pace, and seen as a highly sophisticated essential tool, to use when interpreting data (Auld et al, 2007).

Field Methods (2004) States NVivo 8 is known to be among one of the best qualitative data analysis programs, it allows a researcher to compare chunks of text or data with codes or labels. Giving the ability to introduce a broad range of resource materials and make it easier for researchers to tag with remarks and observations, this includes video and audio recordings (Macer, 2008).

9. “Is there a clear statement of findings?”

The findings in the study conducted by Waterworth et al (2010) were not explicit or

10. “How valuable is the research?”


Checklist for a qualitative research paper

Did the article describe an important clinical problem examined via a clearly formulated question?

Was the qualitative approach appropriate?

How were the setting and the subjects selected?

What was the researcher’s perspective and has this been taken into account?

What methods did the researcher use for collecting data-and are these described in enough detail?

What methods did the researcher use to analyse the data-and what quality control measures were implemented?

Are the results credible and if so are they clinically important?

What conclusions were drawn and are they justified by the results?

Are the findings of the study transferable to other clinical settings?

taking an increasingly active role in

research in order to develop new knowledge and to

create a larger evidence base to inform their



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