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In this Discussion, you will conduct a literature review of your topic area, focusing on a research study that uses one of the qualitative approaches covered this week. To prepare for this Discussion: Review the reading materials about the different approaches in this week’s Learning Resources.Conduct your own literature search to find a published study that represents one of the Week 3 approaches. Remember, you may have to broaden your search terms to find an appropriate study.Review the following resources before proceeding with your own article review Document: R8360 Guidelines for Reading and Evaluating Qualitative Research Articles (PDF) Document: Example of How to Read and Evaluate a Qualitative Research Article (PDF) **************************************************My Topic: What are the specific problems and characteristic of different types of offender Reentry Programs Targeting Recidivism in the United States? (Please find an article on this topic to evaluate) Contribute a 3-paragraph Discussion post in which you respond to the following: Summarize the characteristics of the approach of the research article you chose during your literature search.Summarize the research article, including the citation and sufficient information for your classmates and Instructor to locate the article.Present a short critique of that article based on the “R8360 Guidelines for Reading and Evaluating Qualitative Research Articles” document. *Locate and review two of the articles a classmate critiqued. Then, review the critique itself. Respond to your classmate and provide constructive feedback on his or her critique.
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BMC Geriatrics
BioMed Central
Open Access
Research article
Pneumonia care and the nursing home: a qualitative descriptive
study of resident and family member perspectives
Soo Chan Carusone1, Mark Loeb1,2 and Lynne Lohfeld*1,3
Address: 1Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada, 2Department of Pathology and
Molecular Medicine, McMaster University, Canada and 3Program for Educational Research and Development, McMaster University, Canada
Email: Soo Chan Carusone – [email protected]; Mark Loeb – [email protected]; Lynne Lohfeld* – [email protected]
* Corresponding author
Published: 23 January 2006
BMC Geriatrics 2006, 6:2
doi:10.1186/1471-2318-6-2
Received: 19 September 2005
Accepted: 23 January 2006
This article is available from: http://www.biomedcentral.com/1471-2318/6/2
© 2006 Carusone et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background: Nursing home residents are frequently sent to hospital for diagnostic tests or to
receive acute health care services. These transfers are both costly and for some, associated with
increased risks. Although improved technology allows long-term care facilities to deliver more
complex health care on site, if this is to become a trend then residents and family members must
see the value of such care. This qualitative study examined resident and family member perspectives
on in situ care for pneumonia.
Methods: A qualitative descriptive study design was used. Participants were residents and family
members of residents treated for pneumonia drawn from a larger randomized controlled trial of a
clinical pathway to manage nursing home-acquired pneumonia on-site. A total of 14 in-depth
interviews were conducted. Interview data were analyzed using the editing style, described by
Miller and Crabtree, to identify key themes.
Results: Both residents and family members preferred that pneumonia be treated in the nursing
home, where possible. They both felt that caring and attention are key aspects of care which are
more easily accessible in the nursing home setting. However, residents felt that staff or doctors
should make the decision whether to hospitalize them, whereas family members wanted to be
consulted or involved in the decision-making process.
Conclusion: These findings suggest that interventions to reduce hospitalization of nursing home
residents with pneumonia are consistent with resident and family member preferences.
Background
The demand for long-term care in facilities is increasing in
response to changing demographics and social values. As
of 2000, an estimated 46 percent of Americans 65 years
old will spend time in a nursing home before they die. By
2020, the total number of older adults using nursing
home care in the United States is expected to more than
double [1].
The functional dependence and clinical complexity of
health problems that long-term care facility (LTCF) residents have are also increasing. In 1997, the United States’
National Nursing Home Survey found that 75% of elderly
nursing home residents needed help with three or more
activities of daily living (bathing, dressing, eating, transfer
from bed to chair, toileting), and that 44% had difficulty
with both bowel and bladder continence [2]. Although
Page 1 of 9
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BMC Geriatrics 2006, 6:2
http://www.biomedcentral.com/1471-2318/6/2
Table 1: Inclusion and exclusion criteria of the clinical trial*
Inclusion Criteria
Exclusion Criteria
Have 2 or more of the following signs or symptoms:
• New or increased cough
• New or increased sputum production
• Fever (>38°C)
• Pleuritic chest pain
• New or increased findings on chest examination
1. Residents not expected to live longer than 30 d (from enrolment)
2. Residents who have had a previous anaphylactic or allergic reaction to
quinolones
3. Residents who have not provided consent
4. Residents with advanced directives stating that they are not to be
transferred to hospital for treatment
*This qualitative descriptive study was nested within a much larger multi-centred clinical trial.
many LTCF residents are currently transferred to hospital
for diagnostic tests or to receive acute medical services, fiscal pressures, improved technology, and complications
associated with hospitalization suggest that more medical
care should be provided in nursing homes.
Pneumonia and other lower respiratory tract infections
(LRIs) are a major cause of morbidity and mortality
among nursing home residents. They are also the leading
reason for their hospitalization. One Canadian study
found that nearly one-third of all LTCF residents with
pneumonia were hospitalized [3]. Recent research suggests that residents with pneumonia at a low- to mediumlevel mortality risk may be managed safely in a LTCF for
less cost [4,5].
Some researchers have argued that the provision of health
care cannot be decontextualized from the environment in
which it is provided. As such, the locus of care is an important issue. There are also a variety of perspectives to understand in relation to this issue – specifically that of older
adults, their families, friends, and health care providers
[6]. Although the decision about where and when LTCF
residents should receive care is no longer solely in their
control, it is important to understand their preferences for
care.
Few studies have examined the care preferences of LTCF
residents and their families and most of this work has
been done with the use of surveys to assess the views of
well people in response to hypothetical situations. Two
such studies have found that nursing home residents generally prefer hospital-based care [7,8]. Kleinman [9], however, suggests that generic models of health-related
behaviors are very different from responses to specific illness episodes experienced by a person, and that the latter
are essential to understanding help-seeking behaviors for
sickness. The objective of this study was to learn if LTCF
care for pneumonia is consistent with resident and family
preferences using a qualitative descriptive study design.
Methods
This study was part of a multi-centred randomized controlled clinical trial that tested the effectiveness and utility
of using a protocol for treating nursing home-acquired
pneumonia. The protocol listed signs and symptoms of
pneumonia and directed staff to follow a treatment pathway that included criteria for deciding the appropriate
locus of care (LTCF vs. hospital). Twenty nursing homes
in southern Ontario were matched by size and one member in each pair was randomly allocated to use the clinical
pathway. The other facility continued to follow normal
care practices to diagnose and treat pneumonia. From
November 2003 to June 2004, research nurses
approached primary decision makers (residents or family
members of residents who were deemed incapable of
making informed decisions regarding their care) to participate in the qualitative study.
Sampling and recruitment
Inclusion and exclusion criteria for the clinical trial are
summarized in Table 1. After 30 days of follow up in the
clinical trial study, residents with pneumonia and family
members were invited by a clinical trial study nurse to participate in the qualitative study. Our aim was to enrol
information-rich participants, or people who can best
describe the experience under study (purposeful sampling) [10]. As a result, study nurses were asked to only
invite residents they deemed capable of remembering and
discussing care provided for a recent case of pneumonia
(residents), or family members who were most directly
involved in decision-making for residents unable to speak
about their own care. Residents and family members who
indicated they were willing to participate in this study
gave consent to have their names released to the
researcher (SCC) who then explained the study to them
prior to obtaining informed consent. Although our goal
was to recruit individuals until saturation of the main
themes was achieved, we were limited by the number of
eligible participants enrolled in the clinical trial during
the data collection period. However, a strong consensus
among participants’ views on the major topics raised during data collection was achieved.
Data collection
Data were collected by the researcher (SCC) in one-time,
individual, semi-structured interviews with residents (n =
6) and family members (n = 8). All of the resident inter-
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BMC Geriatrics 2006, 6:2
Table 2: Interview guide for residents
Diagnosis
Thinking back to when you were sick, what sort of symptoms did you
have?
Who first told you that you had pneumonia?
How did you feel when they told you that you had pneumonia?
Have you had pneumonia before?
Treatment
What sort of treatment did you receive?
How often did you see the doctor?
What could have made the care that you received better?
Quality of Care
To you, what is the most important aspect of care?
What makes you feel like you are being well taken care of?
Preferences for care
If you had a choice, where would you have preferred to receive care
(in the nursing home or in the hospital)?
Would you like to be asked where you would like to receive
treatment? Or, would you prefer the doctor or nurses to make the
decision on their own?
Differences between hospital and nursing home
What sort of differences do you see between the care that you would
receive here versus the care that you would receive in the hospital?
What would make you think that you have to go to hospital?
views were performed in one of four nursing homes. Family member interviews were performed in nursing homes,
at coffee shops, or by telephone. Interviews lasted
between 20 and 90 minutes, depending on the participants’ ability to express themselves. All but one interview
was tape recorded and transcribed verbatim for accuracy.
Data were collected in the one non-taped interview by
extensive note taking during and immediately after the
interview. Interviews focused on four themes: participants’ experience with a recent case of pneumonia, preferred locus of care for pneumonia (hospital or nursing
home), perceived differences between LTCF- and hospitalbased care, and what constitutes ‘good care’. Preliminary
analysis of the first four transcripts revealed an important
but unanticipated theme: participants’ desired involvement in treatment decision-making. This topic was therefore included in subsequent interviews. The interview
guides for the resident and family member interviews
were similar. The only differences were that resident interviews probed for more information about the actual care
that residents received, and family member interviews
addressed both family members’ actual preferences as
well as their views on the preferences and experiences of
the residents they spoke about (See Table 2 for the final
version of the resident interview guide).
Rigour and credibility
Numerous steps were taken to ensure that the findings
were faithful to the participants’ descriptions and interpre-
http://www.biomedcentral.com/1471-2318/6/2
tations (credible), and that the research process could be
followed by another researcher (rigorous). All interviews
were conducted by the same person (SCC) to ensure continuity across interviews (reduce bias). Following the recommendations of Miller and Crabtree [11], the researcher
made reflective journal entries throughout the study. Two
types of triangulation were used in this study. Data were
collected from both LTCF residents and from residents’
family members (multiple sources of data), and two
researchers independently coded transcripts and compared their findings (multiple researchers). A third
researcher, with extensive clinical and research experience,
was consulted at all stages of the study (peer review).
Ethical considerations
Informed consent was received from all participants prior
to conducting an interview. Individuals were assured that
their care would not be affected in any way by their decision about participating in the study. None of the study
nurses or researchers worked for a nursing home enrolled
in the study, and did not provide care outside of the study.
This study was approved by the research ethics board at St
Joseph’s Hospital in Hamilton, Ontario, Canada.
Data analysis
Following standard practice, audiotapes produced during
each interview were transformed into verbatim written
accounts (transcripts) by a professional typist. The
researcher (SCC) then compared the written and audiotaped versions of each interview in order to correct transcription errors. Data from earlier transcripts were
analyzed concurrently with ongoing data collection
[10,12] in order to ensure that emerging themes could be
further pursued in later interviews. Analysis followed a
five-phase process [12]. In phase one (description), transcripts were read in their entirety without coding the data
and reflexive journaling was used to gain an overview or
overall sense of the views of study participants. Phases two
and three (organizing and connecting data) involved
more detailed transcript review to identify key phrases
and words, and then pattern coding [13] or clustering
them into themes, followed by data reduction and linking
across clusters. In phase four (corroborating/legitimating), two researchers (SCC & LL) individually coded the
transcripts and compared their findings to reach consensus about disconfirming evidence and alternative explanations. Phase five (representing the account) involved
highlighting results with supporting quotes (linking findings to the data), and interpreting the findings in light of
relevant literature.
Presenting results
Following standard procedures for reporting interview
data [14], exemplars, or typical statements made by participants, are presented initalics to support conclusions
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Table 3: Participant characteristics
ID (relationship)
Sex*
Age*
Hospitalized*
Barthel*a
R1
R2
R3
R4
R5
R6
FM1 (son)
FM2 (daughter)
FM3 (son)
FM4 (daughter-in-law)
FM5 (son)
FM6 (wife)
FM7 (son)
FM8 (wife)
Female
Female
Female
Female
Female
Female
Female
Female
Female
Female
Male
Male
Female
Male
76
84
93
86
84
83
96
88
98
93
88
88
84
92
Yes
No
No
No
Yes
No
Yes
No
No
No
No
No
No
No
6
9
14
17
0
7
3
8
3
12
0
0
0
10
* Characteristics of resident
a Modified Barthel Index: 0 indicates complete dependence and 20, complete independence.
drawn by the researchers. The views of LTCF residents and
family members are presented separately to aid comparisons across these two groups in the discussion section of
this paper. Participants are identified by a letter (“R” = resident, “FM” = family member”) and a number based on
the sequence in which interviews were conducted. For
example, “R4” is the fourth resident we interviewed. Minimal editing was done to preserve authenticity while
ensuring readability [15]. Ellipses (…) were used where
irrelevant information was deleted from a quote. Where
necessary, clarifying information was added to a participant’s words in square brackets ([ ]).
Results
Participants
Participants included six residents and eight family members. All of the residents were females between the ages of
76 and 93 years (mean age = 84 years). Residents varied
greatly in their functional status, as measured by a modified-Barthel Index used to rate status on 10 daily functions
for a summary score that ranges from 0 (full dependence)
to 20 (full independence) points. Four of the residents
were extremely dependent (Barthel Index < 10, range: 0 to 9) and two were moderately independent (Barthel Index 10–20). Two residents had been hospitalized for pneumonia while enrolled in the clinical trial. Half of the family members were female (2 wives and 2 daughters or daughters-in-law) and the other four were sons of LTCF residents. The seven residents they spoke about (5 of them female) ranged in age from 84 to 96 years (mean age = 91 years) and scored very low on the Barthel Index (0–12). One of the residents they spoke about had been hospitalized for pneumonia and died upon return to the LTCF. All the participants were recruited from five nursing homes (2 for-profit, 3 not-for-profit) with 100–250 beds (see Table 3 for a summary of participant characteristics). Participants readily spoke about the four topics raised in the interviews. Both residents and family members preferred that care be provided in the nursing home (when possible), although for slightly different reasons. They also had different views on how decisions about locus of care should be made. Preferred locus of care Both residents and family members largely preferred that pneumonia be treated in the nursing home. This appears to be a function of both their beliefs about pneumonia and how they define good care. Both groups of participants believed that hospital care is clearly necessary for some conditions (e.g. fainting, broken bones, operations, and heart problems) but not for pneumonia ('I don't want to go to hospital [for pneumonia]. If you need an operation, that's different' [R3, page 5]). Residents: Although all residents in the study had been diagnosed with pneumonia or a LRI, and two of them had even been hospitalized for this condition, they were generally not very concerned by such a diagnosis. Some residents referred to their illness simply as a 'cold' or the 'flu' and seemed to have had trouble believing it was pneumonia ('I thought, "Oh, no, I haven't got pneumonia!" I was just surprised that I had it, or that I was supposed to have it.' [R5: page 1]). They generally felt that pneumonia could be cared for in the nursing home ('I don't want to be in the hospital again... I know they have taken people from here to the hospital. I guess when they get pretty bad... [but] I don't think they could get any better treatment then we get here.' [R2, page 7]). Family members: Family members were more concerned than residents about the diagnosis of pneumonia, recognizing that it could be a serious illness in the elderly. Page 4 of 9 (page number not for citation purposes) BMC Geriatrics 2006, 6:2 However, many of them still felt that it can usually be managed on-site: 'In the elderly, [pneumonia] is quite a serious thing. If it's caught early, which it is usually in the nursing home, I think it's better to be treated here. With the antibiotics that they have now, and the [fact that the] nurse came in every day and checked her every day [for] the oxygen level, the care was terrific.' [FM4, page 2] Despite preferring on-site care for pneumonia, some family members acknowledged that they were not sure what level of acute care a LTCF could provide: 'I think [my mother] would get better care [in the nursing home] than she probably would in the hospital, except she would not be very ill. Because when she is very ill, I don't think they would be able to look after her [here]. They haven't got the facilities. I don't think they're geared to do that.' [FM2, page 5] In some cases, family members acknowledged that even if their loved one was very sick, it was not necessarily desirable to provide care in hospital: 'Let's be honest about it. He's 88. He's been on the verge of death several times. The man has no quality of life at all; zero... Why are we going to use hospital resources when all we really want to do is make him comfortable in his last hours or months or years, or whatever he's got left? I don't think hospital intervention is going to improve his quality of life at all.' [FM5, page 2] Defining good qua ... Purchase answer to see full attachment

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