You are a community nurse working with Vera, an 88 year old female. She lives in her own home and has done so for 35 years but her two daughters are often present. You know the family well as you have been coming in for over a year to dress Vera’s venous leg ulcer and to help manage her chronic pain from osteoporosis. Twice in the last year she has fallen and she recently fell again sustaining severe bruising to her face and left side. Both the family and (independently) Vera have suggested to you that she is finding it difficult to cope and that a spell in a nursing or residential home might be a possible solution. On your last visit, Vera’s daughter stated that she is planning to broach the subject with her mother and wondered what factors Vera is likely to be considering and what areas of concern the family should expect Vera to raise when they discuss the future with her. You explain that you do not have much experience in this area, and that you would like to discuss it at the next visit after you have had time to reflect and examine the experiences of others.

You formulate the question, In elderly people living at home, what are the likely issues they will be considering when deciding to seek out long-term care services?

Searching terms and evidence source
You decide to search the CINAHL (Cumulated Index of Nursing and Allied Health Literature) database to identify qualitative studies that have considered this topic. Qualitative studies often address questions about how people experience and feel about things that are happening in their lives. Using the subject headings “long term care” AND “decision making” (exploded), you come up with 117 citations. Adding the subject heading “qualitative studies” narrows the list to 10 citations, which includes the following study: Forbes S, Hoffart, N. Elder’s decision making regarding the use of long-term care services: a precarious balance. Qualitative Health Research 1998, 8:736-50.

Read the article and decide:

• Is the evidence from this randomised trial valid?
• If valid, is this evidence important?
• If valid and important, can you apply this evidence in caring for your patient?

Completed Qualitative Research Worksheet for Evidence-Based Nursing

Citation

Forbes S, Hoffart, N. Elder’s decision making regarding the use of long-term care services: a precarious balance.
Qualitative Health Research 1998, 8:736-50.

Are the results of this study valid?

Are the aims of the study clearly stated?

Yes. “To explore factors that influenced decision making regarding the use and non-use of long-term care services.”

Is a qualitative methodology appropriate?

Yes. The authors sought to focus on elder beliefs, attitudes, and values by describing elders’ perspectives of decision-making processes using a naturalistic research design.

Is the study’s sampling strategy appropriate to address the aims?

Yes. They showed evidence of reflexivity in sampling (i.e., sampling procedures changed in response to the emerging needs of the study) and purposive techniques to select information-rich informants.

Are the study’s data collection strategies appropriate?

Yes. They used semi-structured interviews to obtain accounts of elders, and collected data until they reached theoretical saturation (process of collecting data to a point where no new themes are generated).

Is there a rigorous process of data analysis evident?

Yes. The research team used techniques of constant comparison, negative case analysis, explicit coding definitions and subject-verification. One negative case highlighted by the authors is not really described in any detail.

Do the researchers consider the effects on the study of the relationship between themselves and the informants?

No. This is an important omission because qualitative data collection techniques such as interview and observation have enormous potential to influence the accounts or behaviour of study participants. For discussion in the context of appraising qualitative research see Giacomini and Cook (forthcoming).

Are the findings clear and easy to understand?

Yes. The results are contained in 2 sections: beliefs, attitudes and values; and the decision making process.

1. Beliefs, such as:
   1. Money is necessary to remain independent.
   2. Nursing homes are where people go to die.
   3. It is hard to give up your independence and depend on someone else.
   4. Receiving help means you are less of a person.
2. Attitudes: acceptance (passive and active), non-acceptance of change/fight, perseverance, self-responsibility, and reciprocity.
3. Values: independence, sense of self, security, work ethic, privacy, quality of life, and trust.
   The decision making process: this is based around key decision points such as health need, supervision needs, required levels of formal or informal support, and affordability. The decision process can be visualised as a scale that requires balancing, with the attitudes, values, and beliefs of the individual acting as determinants of this ‘balancing act’.

Do the researchers justify the data interpretation used in the analysis?

Yes. The quotations used are reinforced by the use of contextual information and vignettes.

Are the results of this study important?

How relevant and useful is the article to your patient/clinical problem/clinical scenario or to you as a practitioner?

The article is very relevant and provides useful results. Perhaps if combined with survey data examining the probabilities that elderly people in this situation would align themselves with such beliefs and attitudes, the usefulness could be enhanced.

How important are the findings to your practice? (do they directly address the aims? Add new policy/ practice insights or suggest specific further research?)

The findings do directly address the research aims and also my clinical question; therefore they are important.

Can I apply these valid, important findings to my patient or their family?

Are the findings of this study logically transferable to other groups of patients?

Yes. The study was well conducted and the analysis put forward appears cogent.

Is my patient so different from those in the study that the findings can’t help?

No. There are real similarities between the types of individuals described in the study and my patient and her family. The use of demographic data and descriptive vignettes of some of the individuals makes the process of deciding whether or not they are similar much easier. One important difference, however, is the fact that the study was conducted in the United States with its differing health care and social security systems. Conceivably there might be differences in the weighting associated with some of the decision points (such as affordability) in UK patients.

Do the patient and/or family have a clear assessment of their values and preferences?

No. I need to assess these with Vera and her family (independently and as a family) and to use them as a framework to structure my feedback of the appraisal of this paper.

Are the suggested course of action and its consequences acceptable to the patient and/or family and you?

Not known at this stage, but I shall endeavour to make sure that any unacceptability or agreement is built into my plan of care in relation to the decisions Vera and her family must make.

Comments

The appraisal questions are derived from:

• The Critical Appraisal Skills Programme: Making sense of evidence about effective health care. Oxford: CASP, 1998.
• Popay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qualitative Health Research 1998;8:341-51
• Giacomini MK, Cook DJ. A user’s guide to qualitative research in health care: part 1: are the results of the study valid? Evidence Based Medicine Working Group, McMaster University, Hamilton, Ontario CA. (forthcoming)

Appraised By

Carl Thompson RN, PhD.