Critique of Care of older people with dementia in nursing

Introduction
This assignment will critically appraise a qualitative research report from the Nursing Standard titled: Care of older people with dementia in an acute hospital setting.(Fiona Cowell, 2009) (Appendix 1). The critiquing frameworks by Polit and Beck (2010) and Roe (1998) will be used to facilitate understanding of the quality of the study. On a personal level, as a third year student nurse it has been witnessed how some healthcare professionals have difficulty relating to patients with dementia; through lack of understanding and education in dementia care. According to the Alzheimer’s society (2010) there are approximately 750,000 people with dementia in the UK.
The reason for nursing research is to generate knowledge about nursing education, nursing administration, health care services, characteristic of nurses and nursing roles, in which the finding from these studies indirectly affect nursing practice and thus add to nursing body of knowledge (Burns and Grove, 2006)
This part should be in refs section not in main body of essay. If it’s a direct quote it should be in inverted commas including page number of book where it came from
Introduction to the study
According to Gerrish and Lacey (2006) the introduction must convince the reader that the proposed study is important and it should identify how the study will add to previous work and build on theory. For the purpose of this research paper Cowell (2009) has decided to write the introduction separate from the main abstract.
Cowell clearly explains why the study needs to be investigated within the introduction and convinces the reader that the best way to investigate this research would be to use a qualitative approach, to address this gap in knowledge.
Title
According to Parahoo (2006) titles that are too long or short can be confusing or misleading. The title should suggest the research problem/purpose of the study. The title in Cowell’s (2009) study is unambiguous, concise, and highlights with clarity the content of the research study.
Literature Review
A Literature review is to give an objective account of what has been previously been written on the topic (Moule and Goodman, 2009).
In this research the literature review provided a list of data bases that were used to search for relevant articles on dementia between 1980 and 2004, with a list of keywords used within the search.
The articles investigated a range of different subjects however there was limited evidence that these had achieved a demonstrable change in practice due to study limitations and sample size.
The literature review only comments on a (How many is a few, state number)few, out of forty seven articles. In one of the articles mentioned in the review none of the patients had been diagnosed with dementia. Holloway and Wheeler (2010) state that in qualitative studies the discussion of literature tends to be more limited than in other types of research.
The articles that the researches choose to comment on helps to convince the reader that views of nurses on dementia care are limited and that care of dementia patient in acute hospitals needed to be addressed.
Overall the literature review provides detailed references, keywords and information on how Cowell went about the search, but the study fails to provide recent research material in conjunction with the study title. Moule and Goodman (2006) advise researchers to use up to date studies, that is, certainly not more than ten years old and preferable not more than five years old. The reason why Cowell hasn’t used any up to date studies may be because she might not want readers to be influenced by any previous material and that dementia has become a focus of political agendas, which enables the researcher to identify gaps that can be addressed.

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Methodology
Cowell has used a qualitative approach to this study and has decided to use naturalistic paradigm. Naturalistic researchers tend to look in detail at a specific group of people or a particular situation (Walsh and Wigens, 2003). This approach tries to gain an awareness and appreciation of how particular individuals or groups of people view and experience the world (Moule and Goodmand, 2009).
Qualitative research is a form of social inquiry that focuses on the way people make sense of their experiences and the world in which they live (Holloway and wheeler, 2010). In contrast, quantitative research seeks to test a hypothesis or answer research questions based on a framework (LoBlondo-Wood and Haber, 2006).
The Cowell tells the reader in the abstract that she will use an ethnographic approach. Ethnography means a “portrait of people” and involves writing about people and culture (Moule and Goodman, 2009).
These approaches use observational and interview data collection methods, which is what the researcher has used within this research article.
The aim of ethnographers is to learn from (rather than to study) members of a group to understand their world view as they perceive and live it and social norms of a particular group, such as nurses (Polit and Beck, 2010).
Overall the researcher has used the best approach to find out the experiences of patients and nurses in relation to care delivered to, and received by, older people with dementia.
Data Sampling
Data was collected during 2005- 2006 from three older peoples’ wards. The researcher mentions that ethnographic observations and interviews were used, and that a total of 125 hours of observation were completed in two five-hour blocks between 7am-8pm. Field notes where transcribed and eighteen interviews were audio taped.
No rationale was given for how the decision about the type of interviews that were going to be used. According to Moule and Goodman, (2009) it should have been clearly presented and justified.
How the data was collected in relation to the methodology used was reasonably explained but limitations to the study for example, small sample size, using patients that had servere dementia who may have had cognitive impairment. Which overall might have had influences on the results. Gerrish and Lacey (2010) say that sample size is not an intrinsic feature of the analysis in qualitative research.
Data Analysis
Data was transcribed and verbatim as soon as possible following the data collection. This method also has implications in that the researcher may have to transcribe the interview (“write out what is said”) (Moule and Goodman, 2009).
Ethical Considerations
Nurse researchers have a professional responsibility to design research that uphold sound ethical principles and protect human rights (Speziale and Carpenter, 2007). I.e. informed consent, gaining access, confidentiality, anonymity and avoid harm.
Cowell has appeared to adhere to the guidelines and adequately safeguard the rights of the participants due to the incorporation of these four principles into her research design.
Ethical approval was also gained from the local NHS research ethics committee and the NHS Trust involved within the study. All participants gave verbal consent before each period.
Results
The researcher used two subs headings within the findings/results she listed them as Patient experience of care and Nursing Staff experiences of care delivery.
Within the findings section the researcher used some direct quotes from both the patients and nursing staff, which the reader found biased and unreliable. This is due to the small size of the patients involved in the study and the severity of the patients dementia. According to the Alzheimer’s society (2010) Memory loss is likely to be very severe in the later stages of dementia. A more trustworthy result would (in the readers opinion) have been obtained if the researcher had included patients in the study who were in the early and moderate stages of dementia; who could have articulated their feelings more clearly.
The strengths of the results was that all the patients were diagnosed with dementia before they were admitted to the wards and Mini-mental examinations where carried out, which results ranged from 0-7 that indicated server dementia.
The researcher also never comments on any organisation or environmental factors that could of influenced the results or have an impact on the patient’s feelings/experiences.
Discussion
The discussion is clearly separate from the actual findings which make it much easier for the reader to read and understand Cowells work. The findings are well discussed within this article and the researcher relates back to her literature review and background information.
The major findings within the article were interpreted, discussed and backed up by references. Cowell does discuss that little is known about acute hospital care from the perspective of people with dementia.
Cowell never mentioned the different types of dementia the patient had been diagnosed with or if cognitive skills were impaired.
Normans (2003) process was used within this article, which is a process that encourages the researcher to take account of his or her influence on the study. The researcher does state to the reader that this could have influenced the data results.
LoBlondo-Wood and Haber (2006) suggest that the research may influence the participants if the researcher observers the participants to collect data.
The researcher decided to use two different methods of collecting data. This is known as triangulation collection. Triangulation is thought to improve the validity of a study, by drawing on multiple reference points to address research questions (Moule and Goodman, 2009).
Researchers using triangulation in data collection are hoping to overcome potential biases of using a single data collection method.
Brewer and Hunter, 1989 says that no one method is perfect, though using a combination of methods can, it is argued, limit the potential deficits and biases of one-particular method.
So with the researcher using both the interviews and observations she has enhanced the reliability, validity and trustworthiness of this research study and its overall quality.
No recommendations of further research were discussed within this article.
Study Limitations
The researcher does mention study limitations in a separate column in which she comments that the study was on a small scale and conducted in one acute hospital. Therefore the findings are not generalised, but may be transferable.
As the work has been interpreted by the researcher she does say openly that the article is biased.
The researcher also says she never returned to the other participants to check data, as she believed it would be a burden to them, and may have limited value. (REF about going back to participants)
She failed to mention the Hawthorne effect could have affected the participant’s behaviour or performance, which could have impacted subsequently on the dependant variable (Moule and Goodman, 2009).
Relevance of the study to practice
The issues that Cowell (2009) identifies have also been seen over the years on clinical placements that prove Health Care Professionals need further education on dementia care. This will help patients in the future receive more patient focused care/individual care and not personalised dementia care.
The author does not think it would be hard to change practice due to the evidence within this study that nursing staff have a lack of knowledge and education in delivering nursing care to dementia patients. With most staff wanting to gain more understanding in dealing with patients with dementia the only factor that may be challenging would be resources, cost and time management in the ward area for staff to do the training.
Also by having Nursing journals available in ward areas would help staff attitudes for further training and using evidenced based research in practice.
other factors, such as staffing issues in the wards are affecting patient care, which with the right staffing would improve patient focused care but further research would be needed to prove this.
The comments within Cowdells (2009) article and experience on clinical placement have made the author realise he acts as an advocate for dementia patients and that in the future he will make sure everything is done in the patient’s best interest, instead of the nursing staff convenience.
The use of evidence based studies is the best way to improve quality of care and improve patient experiences is essential (ref).
Evaluation
Cowell (2009) study has been subjected to critique using the Polit and Beck (2010) and Roe (1998) framework, which has helped to gain a more understanding of dementia care.
Cowells article is presented well and flows; which makes it easy to read and understand.
Cowell (2009) chose a good method and approach but there were flaws within her data sampling, which was addressed within the article; this could have posed a threat to validity and reliability.
By critiquing this article it has helped the author to increase his knowledge on reading research articles, understanding the terminology and appraising nursing research. It has also made the author more aware of how dementia patients feel in acute hospital settings and how he can, as a future staff nurse, make a change on how care is delivered to patients with dementia.