Lynne Lohfeld

Revisiting the Quantitative-Qualitative Debate: Implications for Mixed-Methods Research

Health care research includes many studies that combine quantitative and qualitative methods. In this paper, we revisit the quantitative-qualitative debate and review the arguments for and against using mixed-methods. In addition, we discuss the implications stemming from our view, that the paradigms upon which the methods are based have a different view of reality and therefore a different view of the phenomenon under study. Because the two paradigms do not study the same phenomena, quantitative and qualitative methods cannot be combined for cross-validation or triangulation purposes. However, they can be combined for complementary purposes. Future standards for mixed-methods research should clearly reflect this recommendation.

Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial

Abstract Objective To assess whether a multifaceted intervention can reduce the number of prescriptions for antimicrobials for suspected urinary tract infections in residents of nursing homes. Design Cluster randomised controlled trial. Setting 24 nursing homes in Ontario, Canada, and Idaho, United States. Participants 12 nursing homes allocated to a multifaceted intervention and 12 allocated to usual care. Outcomes were measured in 4217 residents. Interventions Diagnostic and treatment algorithm for urinary tract infections implemented at the nursing home level using a multifaceted approach—small group interactive sessions for nurses, videotapes, written material, outreach visits, and one on one interviews with physicians. Main outcome measures Number of antimicrobials prescribed for suspected urinary tract infections, total use of antimicrobials, admissions to hospital, and deaths. Results Fewer courses of antimicrobials for suspected urinary tract infections per 1000 resident days were prescribed in the intervention nursing homes than in the usual care homes (1.17 v 1.59 courses; weighted mean difference −0.49, 95% confidence intervals −0.93 to −0.06). Antimicrobials for suspected urinary tract infection represented 28.4% of all courses of drugs prescribed in the intervention nursing homes compared with 38.6% prescribed in the usual care homes (weighted mean difference −9.6%, −16.9% to −2.4%). The difference in total antimicrobial use per 1000 resident days between intervention and usual care groups was not significantly different (3.52 v 3.93; weighted mean difference −0.37, −1.17 to 0.44). No significant difference was found in admissions to hospital or mortality between the study arms. Conclusion A multifaceted intervention using algorithms can reduce the number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes.

Organization specific predictors of job satisfaction: findings from a Canadian multi-site quality of work life cross-sectional survey

BackgroundOrganizational features can affect how staff view their quality of work life. Determining staff perceptions about quality of work life is an important consideration for employers interested in improving employee job satisfaction. The purpose of this study was to identify organization specific predictors of job satisfaction within a health care system that consisted of six independent health care organizations.Methods5,486 full, part and causal time (non-physician) staff on active payroll within six organizations (2 community hospitals, 1 community hospital/long-term care facility, 1 long-term care facility, 1 tertiary care/community health centre, and 1 visiting nursing agency) located in five communities in Central West Ontario, Canada were asked to complete a 65-item quality of work life survey. The self-administered questionnaires collected staff perceptions of: co-worker and supervisor support; teamwork and communication; job demands and decision authority; organization characteristics; patient/resident care; compensation and benefits; staff training and development; and impressions of the organization. Socio-demographic data were also collected.ResultsDepending on the organization, between 15 and 30 (of the 40 potential predictor) variables were found to be statistically associated with job satisfaction (univariate analyses). Logistic regression analyses identified the best predictors of job satisfaction and these are presented for each of the six organizations and for all organizations combined.ConclusionsThe findings indicate that job satisfaction is a multidimensional construct and although there appear to be some commonalities across organizations, some predictors of job satisfaction appear to be organization and context specific.

Caregiving at the end of life: perspectives from spousal caregivers and care recipients

OBJECTIVE The purpose of this study is to examine the perspectives of both the spousal caregiver and care recipient on the caregiving experience in home-based palliative care. METHODS A qualitative research strategy involving home-based face-to-face interviews with older palliative care patients and their spousal caregivers was used to examine the caregiving experience. RESULTS Ten spousal caregivers and care recipient dyads participated in the study. Most informal caregivers viewed caregiving as an extension of the family relationship where caregiving responsibilities evolved over time. Spousal caregivers identified many negative reactions to caregiving, such as fatigue or weariness, depression, anger and sadness, financial stresses, and lack of time. Care recipients acknowledged the emotional and financial strain and expressed concern for their spouses. Both caregivers and care recipients were appreciative of home care services although they identified the need for additional services. They also identified difficulties in communication with formal providers and poor coordination of care among the various services. Both caregivers and care recipients disclosed some challenges with informal supports, but on the whole felt that their presence was positive. Additional positive aspects of caregiving reported by spouses included strengthened relationship with their spouse and discovering emotional strength and physical abilities in managing care. SIGNIFICANCE OF RESULTS Health care and social service professionals need to recognize and understand both caregiver and care recipient perspectives if they are to successfully meet the needs of both members of the dyad.

Extrinsic and intrinsic determinants of quality of work life

The objective of this research was to test whether extrinsic, intrinsic or “prior” traits best predict satisfaction with quality of work life (QWL) in health care. Extrinsic traits are salaries and other tangible benefits; intrinsic traits include skill levels, autonomy and challenge. Prior traits are those of the individuals involved, such as their gender or employment status. A survey of employees was conducted in seven different health‐care settings located in the south central region of Ontario, Canada. A total of 65 questions were gathered into scales measuring such factors as co‐worker support, supervisor support and teamwork and communication. These were factor‐analyzed into intrinsic and extrinsic variables, and regressed against a satisfaction scale, with socio‐demographic variables included. Based on the results, the following conclusions can be drawn: objectively identifiable traits of an organization – pay, benefits and supervisor style – play the major role in determining QWL satisfaction. Decision‐makers with an interest in improving QWL in a health‐care institution can focus on these traits and pay correspondingly less attention to enhancing staff autonomy or discretion.

Recertifying as a doctor in Canada: international medical graduates and the journey from entry to adaptation

Objective  Globalisation and severe doctor shortages in many countries have resulted in increased numbers of international medical graduates (IMGs) in medical training programmes in major recipient countries such as Canada. Much of the literature on IMGs is written from the perspective of the doctor workforce. Less is known about the recertification training experiences of IMGs in recipient countries. This study aims to describe the recertification training experiences of IMGs in Canada in order to help medical training programmes understand how to facilitate the integration of IMGs into recipient medical communities.

Elder Abuse and Oppression: Voices of Marginalized Elders

The voices of elderly people from marginalized groups are rarely solicited, and the relationship between elder maltreatment and belonging to an oppressed group has not been adequately investigated. This article reviews the literature on oppression and elder abuse and describes findings from the secondary analysis of data from focus group discussions on elder abuse held with marginalized older adults and (quasi)professionals caring for them in two Canadian cities. Participants identified that increased vulnerability to elder abuse was related to oppression experienced as a consequence of ageism, sexism, ableism/ disability, racism, heterosexism/homophobia, classism, and various intersecting types of oppression.

Stress processes in caring for an end-of-life family member: Application of a theoretical model

Objectives: Family caregivers play a vital role in maintaining the lives of individuals with advanced illness living in the community. However, the responsibility of caregiving for an end-of-life family member can have profound consequences on the psychological, physical and financial well-being of the caregiver. While the literature has identified caregiver stress or strain as a complex process with multiple contributing factors, few comprehensive studies exist. This study examined a wide range of theory-driven variables contributing to family caregiver stress. Method: Data variables from interviews with primary family caregivers were mapped onto the factors within the Stress Process Model theoretical framework. A hierarchical multiple linear regression analysis was used to determine the strongest predictors of caregiver strain as measured by a validated composite index, the Caregiver Strain Index. Results: The study included 132 family caregivers across south-central/western Ontario, Canada. About half of these caregivers experienced high strain, the extent of which was predicted by lower perceived program accessibility, lower functional social support, greater weekly amount of time caregivers committed to the care recipient, younger caregiver age and poorer caregiver self-perceived health. Conclusion: This study examined the influence of a multitude of factors in the Stress Process Model on family caregiver strain, finding stress to be a multidimensional construct. Perceived program accessibility was the strongest predictor of caregiver strain, more so than intensity of care, highlighting the importance of the availability of community resources to support the family caregiving role.

Renowned physicians' perceptions of expert diagnostic practice.

Purpose To further the development of a substantive theory of expert diagnostic practice, the authors explored the ways in which exceptional physicians, nominated by their peers, conceptualized their own diagnostic expertise specifically and diagnostic excellence generally. Method In this grounded theory, interview-based study, physicians at six North American research sites were nominated by their peers as exceptional diagnosticians and exceptional professionals and invited to participate in the study. A saturation sample included 34 participants, 20 exceptional diagnosticians, and 14 exceptional professionals. Using a constant comparative approach, the authors conducted one-on-one interviews with participants, transcribed the audiotapes of those interviews, and analyzed them for emergent themes. They developed a stable thematic structure and applied it to the entire data set. Results Four interconnected themes emerged that inform the community’s understanding of how physicians conceptualize expert diagnostic practice: (1) possession of extensive knowledge built through purposeful, continuous engagement in clinical practice, (2) possession of the skills to effectively gather patient stories, (3) reflective integration of that knowledge and those patient stories during diagnosis, and (4) continuous learning through clinical practice. Conclusions Exploring these results within the context of current discourses in medical education brings to the forefront two key features of physicians’ construction of diagnostic excellence: (1) the integrated nature of the medical competencies that underpin the diagnostic process and (2) the optimally adaptive nature of the diagnostic process. These findings can inform the development of practical and effective pedagogical strategies to guide trainees, clinicians, and medical educators who strive for excellence.

Development of the Volunteer Peer Educator Role in a Community Cardiovascular Health Awareness Program (CHAP): A Process Evaluation in Two Communities

Volunteers can support the delivery and sustainability of programs promoting chronic disease awareness to improve health at the community level. This paper describes the development of the peer education component of the Cardiovascular Health Awareness Program (CHAP) and assessment of the volunteer peer educator role in a community-wide demonstration project in two mid-sized Ontario communities. A case study approach was used incorporating process learning, a volunteer survey and debriefing discussions with volunteers. A post-program questionnaire was administered to 48 volunteers. Five debriefing discussions were conducted with 27 volunteers using a semi-structured interview guide. Discussions were audio-recorded and transcribed. Analysis used an editing approach to identify themes, taking into account the community-specific context. Volunteers reported an overall positive experience and identified rewarding aspects of their involvement. They felt well prepared but appreciated ongoing training and support and requested more refresher training. Understanding of program objectives increased volunteer satisfaction. Volunteers continued to develop their role during the program; however, organizational and logistical factors sometimes limited skill acquisition and contributions. The prospect of greater involvement in providing tailored health education resources addressing modifiable risk factors was acceptable to most volunteers. Continued refinement of strategies to recruit, train, retain and support volunteers strengthened the peer education component of CHAP. The experience and contributions of volunteers were influenced by the wider context of program delivery. Process evaluation allowed program planners to anticipate challenges, strengthen support for volunteer activities, and expand the peer educator role. This learning can inform similar peer-led health promotion initiatives.