Joanne K. Singleton

Exploring the Technical Aspects of “Fit” in Qualitative Research

The concept of fit and processes of fitting have been largely ignored in qualitative inquiry. In this article, the authors address the technical significance of fit as an analytic process for both data and concepts in the process of theory construction. The ramifications of violating processes of fit and examples of misfits are discussed. Finally, the procedural components and fit as a method of validation are presented.

Strategies for Learning Evidence-Based Practice:Critically Appraising Clinical Practice Guidelines

Nurse educators have a mandate to educate our students about using an evidence-based practice approach to clinical decision making. At the Lienhard School of Nursing, Pace University, faculty have successfully integrated evidence-based practice into the family nurse practitioner curriculum. This article describes one teaching-learning strategy to help students learn how to critically appraise clinical practice guidelines using the AGREE instrument. There are several steps to the learning exercise: completing preparatory reading, obtaining the guideline that forms the focus of the assignment, working as teams, using the AGREE tool to assess the guidelines validity, and reporting team findings to the entire class. Students have found this learning activity helpful in preparing them for clinical practice.

CARING FOR THEMSELVES: FACILITATORS AND BARRIERS TO WOMEN HOME CARE WORKERS WHO ARE CHRONICALLY ILL FOLLOWING THEIR CARE PLAN

Compliance literature has paid little attention to the ability of patients to carry out their care plan. Indeed, throughout this literature, the voices of patients are disturbingly absent. In this paper, I report a study of compliance issues among women home care workers who were chronically ill. Twenty-nine women participated in five focus groups. They were asked to share perspectives on what helps, what hinders, and how their health care providers were either facilitators or barriers to their care plan. Key findings were identified through a qualitative content analysis. My findings suggest that perspectives on compliance, which do not begin with an understanding of factors affecting compliance within the individuals control, are unrealistic. For these women, following a care plan required being sufficiently motivated and having necessary supports. Supports were identified as good doctor-patient communication, adequate financial resources, time and ability to attend to their care, and spirituality. Yet, even if all supports were in place, if participants did not have a stated motivation (i.e. sufficient reason to follow their care plan), they continued to go through the motions. My study suggests that recognizing the personal context of chronic illness may be what motivates patients to follow their care plan. This finding can be used by providers for patient assessment, and may help to form a foundation for empathic communication.

A qualitative systematic review of internal and external influences on shared decision-making in all health care settings

Review question/objective The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared‐decision making for adult patients and health care providers in all health care settings. The specific questions to be answered are: What are the internal and external influences on shared decision making from the perspective of adult patients in all health care settings? What are the internal and external influences on shared decision making from the perspective of health care providers caring for adult patients in all health care settings? Background Patient‐centered care is emphasized in todays healthcare arena. This emphasis is seen in the works of the International Alliance of Patients’ Organizations (IAOP) who describe patient‐centered healthcare as care that is aimed at addressing the needs and preferences of patients.1 The IAOP presents five principles which are foundational to the achievement of patient‐centered healthcare: respect, choice, policy, access and support, as well as information.1 These five principles are further described as: respect for the patients needs, preferences, values, autonomy, and independence; the right of the patient to have a choice to participate as a partner in making healthcare decisions based on their individual abilities and preferences; meaningful and active involvement in healthcare policy‐making through sharing in decision‐making to ensure that patients are at the center of the policy design; support of a patients access to safe, quality and appropriate services; and the development and offering of age appropriate, linguistically, educationally, and culturally designed information that will enable the individual patient to make decisions about their healthcare needs. Within the description of these five principles the idea of shared decision‐making is clearly evident. The concept of shared decision‐making began to appear in the literature in the 1990s.2 It is defined as a “process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient‐centered care.”3(p.23) The details of the shared decision‐making process are complex and consist of a series of steps including: the recognition that a decision can or must be made; identifying the possible courses of action; listing the pros, cons, and other characteristics of each possibility; comparing the options and identifying one as probably better than the rest; accepting or rejecting options resulting in the final choice; authorization of the final choice; and implementation of that choice.4 Three overall representative decision‐making models are noted in contemporary literature. These three models include: paternalistic, informed decision‐making, and shared decision‐making.5 The paternalistic model is an autocratic style of decision‐making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision‐making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement.5 Finally, the shared decision‐making model is representative of a sharing and a negotiation towards treatment decisions. 5 Thus, these models represent a range with patient non‐participation at one end of the continuum to informed decision making or a high level of patient power at the other end.5 Several shared decision‐making models focus on the process of shared decision‐making previously noted. A discussion of several process models follows below. Charles et al.5 depicts a process model of shared decision‐making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included: the participation of at least two parties, both parties take steps to participate in the process of treatment decision‐making, information sharing occurs as a prerequisite to share in decision‐making, an ultimate decision is made, and both parties agree to the decision. This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker.5,6 This model also depicts the need to take steps to participate in the shared decision‐making process. To take steps means that there is an agreement between and among all involved that shared decision‐making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision‐making and the actuality of shared decision‐making in practice is not strong.5 Research concerning patients and patient preferences on shared decision‐making points to variations depending on age, education, socio‐economic status, culture, and diagnosis. 7‐12 Healthcare providers may also hold preferences for shared decision‐making; however, research in this area is not as comprehensive as is patient focused research.13 Elwyn et al.14 explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision‐making process.14 An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patients preference is different from clinical practice guidelines.15 This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.12 The notion of information sharing as a prerequisite to shared decision‐making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision‐making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision‐making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patients ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.16 Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al.5 portrays shared decision‐making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the “test of a shared decision (as distinct from the decision‐making process) is if both parties agree on the treatment option.”5(p.688) Towle and Godolphin17 developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision‐making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision‐making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include: Develop a partnership with the patient. Establish or review the patients preferences for information. Establish or review the patients preferred role in decision‐making. Ascertain and respond to the patients ideas, concerns, and expectations. Identify choices and evaluate the research evidence. Present evidence, taking into account competencies 2 and 3, in a way that helps the patient to reflect on and assess the impact of alternative decisions with regard to his or her values and lifestyle. Negotiate a decision in partnership with the patient and resolve conflict. Agree on an action plan and complete arrangements for follow‐up.17 Patient competencies include: Define the preferred health care provider‐patient relationship. Find a healthcare provider and establish, develop, and adapt a partnership. Articulate health problems, feelings, beliefs, and expectations in an objective and systematic manner. Communicate in order to understand and share relevant information. Access information. Evaluate information. Negotiate decisions, give feedback, resolve conflict, and agree on an action plan.17 This model illustrates the shared decision‐making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model.5 This model, however, gives greater emphasis to the process of the co‐participation of the healthcare provider and the patient. The co‐participation depicts a mutual partnership

Disciplinary perspectives on evidence-based practice: the more the merrier.

A Google search on June 14, 2007, produced 59,700,000 hits for the term evidence based practice. While this is a popular term today in health care, it is most interesting that the use of this term crosses disciplinary boundaries. With the current trend toward interdisciplinary approaches to our work, the question arises: What does evidence-based practice mean and how is it defined and used by various disciplines?

Effectiveness of school-based family asthma educational programs in quality of life and asthma exacerbations in asthmatic children aged five to 18: a systematic review.

BackgroundAsthma is a common, chronic, non-communicable respiratory disease that affects millions of children worldwide. Asthma exacerbations can range from mild to severe and can have an unfavorable impact on the quality of life of children and their caregivers. Asthma exacerbations often result in absenteeism from school or work, activity intolerance and emergency hospital visits. One strategy to address this health issue in an attempt to improve health outcomes is school-based asthma educational programs. A review of the literature revealed that previous systematic reviews have examined similar topics on the effectiveness of school-based asthma educational programs that have included collaborative efforts between parents and schools. No systematic reviews were found that examined the effectiveness of school-based asthma educational programs that exclusively included children and their caregivers. Research has not been systematically reviewed to determine the effectiveness of a school-based asthma educational program within a familial context. ObjectivesTo identify the best available evidence on the effectiveness of school-based family asthma educational programs that exclusively included both children and caregivers on the quality of life and number of asthma exacerbations of children aged five to 18 years with a clinical diagnosis of asthma. Inclusion criteria Types of participantsChildren aged five to 18 years of any gender, race or ethnicity with a clinical diagnosis of asthma and their caregivers. Types of intervention(s)School-based family asthma educational programs. Types of studiesRandomized controlled trials. OutcomesQuality of life and the number of asthma exacerbations measured by either missed days from school or work, and/or physical activity intolerance, and/or emergency hospital visits. Search strategyThe search strategy aimed to find both published and unpublished studies from inception of the database to August 21, 2015. Methodological qualityQuantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity before inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Data extractionData were extracted from articles included in the review using the standardized data extraction tool from the Joanna Briggs Institute. The data extracted included specific details about the populations, interventions, study methods and outcomes of significance to the review question and its specific objectives. Data synthesisDue to the heterogeneity among the included studies, statistical pooling and meta-analysis was not possible. Results are presented in narrative form. ResultsSix studies examining the intervention were included in this review. All six of the included studies were randomized controlled trials (RCTs). All six studies compared the effects of school-based asthma education to no school-based asthma education/usual care on quality of life and number of asthma exacerbations. Three out of four RCTs showed that children who participated in school-based family asthma educational programs demonstrated a statistically significant improvement in overall quality of life (P < 0.05). All six studies showed improvement in the number of asthma exacerbations that resulted in one or all of the measured outcomes of either missed days from school or work, physical activity intolerance and/or decreased emergency hospital visits. ConclusionSchool-based family asthma educational programs for children that include caregivers can have a positive impact on the quality of life and asthma management of children with asthma. Other outcomes that can be positively affected by school-based family asthma educational programs include absenteeism from school or work, physical activity intolerance and emergency hospital visits as result of asthma exacerbations.

The effectiveness of structured interdisciplinary collaboration for adult home hospice patients on patient satisfaction and hospital admissions and re-admission: a systematic review protocol

Background Patient satisfaction and hospital re‐admission rates are the two major outcomes for measuring quality of healthcare delivery. Interdisciplinary collaboration, a concept that describes coordination of care between multiple healthcare professionals and patients and families to deliver the highest quality of care across settings, is fundamental to improving patient outcomes. Home hospice care is palliative in nature and is a critical segment of patient care. To date, no systematic review has been undertaken to determine the effectiveness of structured interdisciplinary collaboration in the home hospice setting in relation to patient satisfaction and hospital readmission. Objective The aim of the review was to synthesize the best available evidence on the effectiveness of structured interdisciplinary collaboration on patient satisfaction and hospital admission and re‐admission rates for adults receiving home hospice services. Inclusion criteria Types of participants Adults, male and female (18 years old or older), receiving home hospice services or transitioning from hospital to home hospice services Types of intervention(s)/phenomena of interest The studies that evaluate interdisciplinary collaboration among the hospice team providing home hospice services in the home care settings Types of studies In this review, randomized controlled trials and quasi‐experimental studies were considered for inclusion. Types of outcomes Patient satisfaction and all cause hospital admissions and re‐admission rates. Search strategy Published and unpublished literature in the English language was sought from the inception of the databases through August 15, 2014. The databases searched included: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Nursing & Allied Health Source, Health Source: Nursing/Academic Edition and ProQuest Health Management. A search of grey literature and any relevant homecare/hospice websites was also performed. Results There were no studies located that met the inclusion requirements of this review. There were no text or opinion pieces that were specific to structured interdisciplinary collaboration among the hospice team in home care settings on patient satisfaction and hospital readmission. Conclusion There is currently no evidence available to determine the effectiveness of structured interdisciplinary collaboration among hospice teams in home care settings in regard to patient satisfaction and hospital readmission. Implications for practice No conclusive recommendations can be made regarding the effectiveness of structured interdisciplinary collaboration among home hospice teams in home care settings in regard to patient satisfaction and hospital readmission. Implications for research Quantitative and qualitative research studies are urgently required to determine the effectiveness of structured interdisciplinary collaboration among home hospice teams in home care settings in regard to patient satisfaction and hospital readmission.

A systematic review on the effectiveness of continuity of care and its role in patient satisfaction and decreased hospital readmissions in the adult patient receiving home care services.

Background Continuity of care, a concept that in its broadest terms describes patient and provider coordination across time and settings, has evidenced a positive correlation with patient satisfaction and hospital readmission rates. Home health care, where patients receive care from a variety of healthcare practitioners, is one area where these measures are being investigated to determine the effectiveness of continuity of care. Objective To examine and synthesize the best available evidence related to the effectiveness of continuity of care interventions and their impact on patient satisfaction and all‐cause hospital readmissions rates in the adult patient who is receiving home care services. Inclusion Criteria Types of participants Male and female aged 18 years or older receiving home care services, regardless of diagnosis, stage or severity of disease, co‐morbidities, or previous treatment received. Types of intervention All types and models of interventions for continuity of care delivered by nurses to patients receiving home care services were considered for inclusion in the review. Types of outcomes Patient satisfaction and hospital readmissions. Types of studies In this review randomised controlled trials were considered for inclusion. In their absence, other research designs, such as non‐randomised controlled trials, quasi‐experimental studies, and before and after studies were considered for inclusion. Search Strategy Published and unpublished literature in the English language was sought from the inception of the databases through November 1, 2011.The databases searched included: Academic Search Premier, CINAHL ERIC, Health Reference Center Academic, MEDLINE via PubMed, ProQuest Nursing and Allied Health Source, ProQuest Health Management, Cochrane Central Register of Controlled Trials, EMBASE, Health Source Nursing Academic, PsycINFO and Bio‐Med. A search of the grey literature and virtual hand searching of relevant journals was also performed. Methodological quality Two reviewers evaluated the included studies for methodological quality using standardised critical appraisal instruments from the Joanna Briggs Institute. Data Collection Data were extracted using standardised data extraction instruments from the Joanna Briggs Institute. Data synthesis Statistical pooling via meta‐analysis was not possible. The results are presented in narrative form. Results Two randomised controlled trails and two quasi‐experimental studies were included in this review. In one randomised controlled trial, 66% of patients rated their overall satisfaction with care as very good or excellent as compared with 63% of those receiving usual care at 24 months (p=0.31). Another randomised controlled trial reported no statistically significant difference between groups (p value not reported). In one quasi‐experimental study there was higher satisfaction rate amongst intervention patients with a mean difference of 16.88 (95%CI[16.32, 17.43] compared with 14.65 (95%CI[13.61, 15.68] in the control group (p=0.001). In one randomised controlled trial there was no statistically significant difference between intervention and control groups in hospital admission rates per 1000 at year two (700 vs. 740; p=0.66). Another randomised controlled trial showed no difference in readmissions at 90 days between groups (36% vs. 35%; no p value reported). In one quasi‐experimental study, the mean number of hospital readmissions per patient was higher in the intervention group compared to the control group (0.75; 95% CI[ 0.47, 1.03] vs. 0.66; 95% CI[ 0.40, 0.91]; p=0.599), In another quasi‐experimental study, a statistically significant higher number of intervention group patients in the intervention group were discharged and remained at home (34 or 82.9%), compared to the control group (20 or 51.3%) (p<0.05). Conclusions Home care interventions that include nurses and advanced practice nurses with specialised training in the care of the population served as the direct provider along with collaboration with an interdisciplinary team in a high‐risk patient populations contributed to reduced hospital readmission rates. The outcomes of the included studies suggest that consistently scheduled home care services promote patient satisfaction. Implications for practice This review concluded that the utilisation of an advanced practice nurse with specialised training in a specific disease process in collaboration with a multidisciplinary team can affect readmission rates and patient satisfaction. Implications for research Further research is needed that captures a diverse patient population in terms of age and illness and the role that an advanced practice nurse can play.

Grieving the Loss of Self: Challenges in Type 2 Diabetes Mellitus Self-Management

The aim of this study was to understand and describe the experience of diabetes self-management among patients not meeting glycemic control (A1C > 9). Type 2 diabetes mellitus (T2DM) is a complex chronic disease process. Diabetes self-management is equally complex and critical to patient outcomes and quality of life. The components for self-management include: knowledge, skills/abilities, and support. Few studies have reported on the experiences of self-management for patients with T2DM to reach and sustain glycemic control. This study used a qualitative descriptive design. Semistructured interviews were conducted with 13 patients receiving care at a diabetic clinic at a major health-care system in New York City. An interview guide was developed based on diabetes self-management which guided the interviews. All data were analyzed using qualitative content analysis. Initially, three themes that describe each component of diabetes mellitus self-management (DMSM) and impact the patients’ reaching the desired outcome were identified: acceptance of knowledge, motivation for skills and abilities, and variability and vulnerability of support. Further analysis of the three themes led to the identification of an overarching, theme: loss of self. This overarching theme helped to explain the stages of grief illustrated across the themes in the participants DMSM experiences. The participants in this study identified loss of self, and the accompanying grief and grieving process related to the loss of self in response to their T2DM diagnosis. Participants were “stuck” in a stage of loss of self, which presented challenges to acceptance of their diagnosis, barriers to DMSM, and optimizing glycemic control.

Evidence-Based Practice Beliefs and Implementation in Doctor of Nursing Practice Students

BACKGROUND Doctors of Nursing Practice focus on leadership in evidence-based practice (EBP). EBP is influenced by ones beliefs in and implementation of EBP. Little is known to date about the EBP beliefs and implementation of Doctor of Nursing Practice students and outcomes of Doctor of Nursing Practice education. AIMS Guided by the Advancing Research and Clinical practice through close Collaboration (ARCC) Model, the Evidence-Based Practice Beliefs (EBPB) and Implementation (EBPI) tools were used to assess the impact of EBP as a program pillar, curricular thread, and content area on EBPB and EBPI of Doctor of Nursing Practice-Family Nurse Practitioner students. METHODS Five cohorts who completed the same curriculum were studied. Fifty-four of the 89 students across the five cohorts began and completed the study. RESULTS Paired t-test for group effects showed statistical significance from pre- to post-measure in students overall EBPB, t = 4.4 (52), p < .001, and EBPI, t = 8.4 (52), p < .001. A large effect size of .75 standard deviation (SD) gain above the mean for EBPB, and a very large effect size of 1 SD gain above the mean for EBPI were observed. Repeated measures ANOVA showed that all cohorts made gains across the curriculum. Effect sizes for EBPB ranged from .25 to 1 SD above the mean, and .75 to 1.5 for EBPI. LINKING EVIDENCE TO ACTION DNP students who are educated to be EBP leaders must have a curriculum that supports them in the knowledge and skill-set needed to translate evidence into practice. The ARCC Model can guide faculty in EBP curriculum development. EBPB and EBPI are valid and reliable measures to assess for gains across a curriculum. Through educational outcomes, educators can assess desired student outcomes for EBP across a curriculum and can build an evidence base for ongoing curriculum development.