Critical Appraisal of Burton and Lincoln et als Studies - Coursework Example

Critical Appraisal of Burton and Lincoln et al’s Studies Introduction: Over the past two decades or so, significant researches have been carried out to assess the effectiveness and efficiency of the stroke rehabilitation services. In these researches, an eye has always been kept on the difficulties that the professionals face in these services. Researchers have attempted to approach the evaluation of the services from both the perspectives of the professionals and the patients. In the jobs of stroke rehabilitation, professionals’ evaluation of their competency is as crucial as the understanding of the patients’ outlook on the meaning of living with stroke. Both of Burton and Lincoln et al’ studies attempt to investigate the significant aspects of rehabilitation service from different perspectives. Clarity of the Statement of Aim: Though in his study Burton has a clearly stated aim of study, Lincoln et al, to some extent, has failed to state the aim of their study line in their research papers. They stated that the purpose of their study is “to evaluate a specialist multi-professional team in a community setting” (Lincoln et al, 2004:41).They failed to articulate persuasively the terms of evaluation around which their investigation would be carried out. According to the introduction of their paper, their research appeared to be the comparative evaluation of the stroke rehabilitation services, but they did not explicitly identify areas within which the comparison would be performed. Sometimes they made a thorough comparison between the hospital-based rehabilitation services and the multi-professional community stroke team. They significantly deviated from their aim to make a pure evaluation and their research ultimately landed on the comparison between the community stroke team and the individual routine care of the stroke patients. In spite of this deviation, though not as crucial as to devastate their credit, from the purpose of the study, they became successful to uphold a comparative assessment of the competency of the multi-professional community stroke team. However, in the paper, “Living with stroke: a phenomenological study” Christopher R. Burton’s study revolved around a unified purpose with clearly stated terms of investigation. He is completely successful to uphold the significance of the subject of his study. Especially his success lies in the fact that he further designates the outline of his investigation from the patients’ perspective. Study is potential enough to exert fair influence on the shape of the stroke rehabilitation services because his study aims to evaluate the contemporary stroke rehabilitation service from the perspective of patients. The study provides the professionals in this field with opportunity to evaluate the effectiveness of the jobs from the patients’ perspectives. In addition, it made a string appeal to include the stroke patients’ perception in order to make the jobs more acceptable. As he says, “Recovery from stroke involved restructuring and adaptation in all aspects of an individual's life….tasks and activities that had previously been taken for granted presented new challenges, requiring appraisal, considerable effort and learning, and re-appraisal” (Burton, 2000: 301). If Lincoln et al’s study is compared with Burton’s in term of the influences that these studies exert on the rehabilitation services; it will be found that the Burton’s study is more impressive to sway the contemporary rehabilitating ideas and concepts. Appropriateness of Methodology As it is stated earlier that Lincoln et al did not give any clear statement of the perspective of their evaluation, their methodology is also inflicted with the same dualism. The word, “Evaluation” is explicitly present in the title of the paper. However, neither the title, nor the paper explicitly mentioned the perspective from the stroke rehabilitation service would be evaluated. There dual use of both of the quantitative and the qualitative method of their study indicates that they qualitatively assessed and evaluated the patients’ evaluations that were collected in an objective and quantitative way. It appears that it is a bit flawed to grasp the subjective comments and opinions of the patients in an objective questionnaire. In addition, it is evident that the study was intended to “evaluate a specialist multi-professional team in a community setting” (Lincoln et al, 2004: 41), the questionnaire regarding the “satisfaction with the care” does not allow the patient to state their points of dissatisfaction or causes of dissatisfaction, whereas such findings might make the paper more complete as an evaluation study. After all, the use of Barthel Index, Extended ADL, General Health Questionnaire 12, and Euroquol thermometer form denote the appropriateness of the attempt of Lincoln et al to assess the patients’ condition, therefore, to evaluate the stroke rehabilitation services. On the other hand, Burton’s study shows a cautious handling of the qualitative method for his study. His paper explicitly denotes the subjectivity of his research in the first place. The subjectivity of Burton’s paper lies in the fact that “an understanding of the `meaning' of life with stroke was sought” (Burton, 2000: 303) in the study. However, the flaw within Burton’s study is that he totally ignored a researcher’s objective evaluation of the patients’ condition. Due to the lack of proper knowledge of stroke, patients’ perspective of their condition might be flawed. If Burton evaluated the patient’s condition objectively with Barthel Index, Extended ADL, General Health Questionnaire 12, and Euroquol thermometer form, and compared them with the patients’ finding, a more accurate depiction of the patients’ evaluation of the living with stroke might be possible. Appropriateness of Research Design In their papers Lincoln et al, though they did not mentioned explicitly, did use a proper research design that is complete concordance with their aim of study. Evaluation of a multi-professional community stroke team necessarily insisted on the inclusion of a long-term observation of the two types of patients who took routine care and community stroke-team care. However, some of the features of the research design of Lincoln et al appear to be superfluous to some extent. They excluded the patients “who lived outside the geographical area of the study or had been treated by the community stroke team in the previous two years” (Lincoln et al, 2004: 42). However, they did not specify the exact reasons why these students should be kept out of the study. Their decision to exclude the patients who did not take the treatment within two years can be validated, whereas their decision to exclude the patients outside the area of the study is not in concordance with the aim to evaluate the community stroke team. Anyway, Burton’s research design is completely harmonious with the aim of the study, as it explicitly elicited that “the philosophical framework adopted in the study was phenomenology, as an understanding of the `meaning' of life with stroke was sought” (Burton, 2000: 303). The research aim of Burton’s study is such that it claimed a close observation over the patients for significantly long time. Therefore, the number limit of the participants, though it is small, can be considered as reasonable. Due to the long duration of the study, “A decision was taken therefore to limit the number of informants with a view to undertaking more in-depth and long-term study” (Burton, 2000: 303). Sampling of the Patients Lincoln et al convincingly explained the motto of the recruitment of the participants for their study. Patients that referred to Nottingham Community Stroke Team were considered as the participant of Lincoln et al’s study. They chose a particular area from which the patients within particular age range were chosen as the participants. With biographical details, including age and sex patients were randomized and allocated with computer-technology and were divided into two groups -routine care group and community team cared group- with the proportion of 60:40. The routine care group received rehabilitation treatment from any source available to them other than the service of the community rehabilitation team-services. The another group of the patients received the care of the community stroke team. Especially it was maintained that the patients would be treated at their home until their wellbeing. In order to keep an in-details records of the care-giving, “the intervention given to patients was recorded so that it was known which team members saw patients and the time allocated by each member of the team” (Lincoln et al, 2004: 42). On the other hand, Burton’s study included a very limited number of participants. Total eight people including two who refused consent were included in the study. Though the number of the participants was decided to keep within a small limit in order to reduce the duration of the study, a group of eight participants is too small in number to keep the credibility of the finding intact and to uphold the real picture. All of the participants of Burton’s study were the patients of the “rehabilitation unit of a district general hospital in the north-west of England with a diagnosis of first stroke” (Burton, 2000: 303). In Burton’s study, the biographical details, including age and sexes, of the patients were recorded. Data collection Procedures In Lincoln et al’s paper, the setting for the data collection was justified as the patients, the agent of the patients, patients’ home, and family members. Mainly the data were collected through a questionnaire including Barthel Index, Extended ADL, General Health Questionnaire 12, and Euroquol thermometer form. In order to codify the outcomes of the six months treatment of the of both of the group, Lincoln et al used the above-mentioned instruments. However, the issue why they use the questionnaire-by-post method has not been mentioned in the paper. More than one data format have been used in the study. The formats that have been used in the study were clear and, widely used in this field. Also Lincoln et al did not describe the saturation of data explicitly, but they discussed the atypical cases. For Burton, the setting of the data collection for his study was justified as the patients, hospitals, homes of the patients. Burton’s study clearly stated that the data were collected through both of formal and informal interviews. Total 73 interviews were taken. Most of the initial interviews were informal and unstructured in order to ensure the maximum free expression of the patients. In these informal and unstructured interviews, the patients were asked to tell the story of their stroke. Consequently, the following interviews were advanced with the issues that were raised in their earlier ones. At monthly intervals, the interviews were taken for about one year and on an average, every interview took about 35 minutes. Burton asserts, The principles of grounded theory methodology were used to elicit and clarify meaning from interview transcripts. The strength of grounded theory relates to the process of the constant comparing of emerging concepts within the data to guide further data generation and comparison. Emergent concepts are thus grounded or embedded in the data. (Burton, 2000: 303) Format of the data of Burton’s study was clear, as it used tape-recorders to record the interviews that were taken maintaining privacy and confidentiality. In order to avoid the saturation of the data, “All interviews were transcribed verbatim as soon as possible after each interview. Audio-cassettes were kept to enable further clarification of the transcript if required” (Burton, 2000: 304). Reflexivity of the Studies Both of Lincoln et al and Burton’s studies showed reflexivity of the collected data in their research. In Lincoln et al’s study the data were kept in the questionnaire forms and analyzed. Burton preserved the research records in both Audiocassettes and verbatim transcripts. None of Burton and Lincoln et al considered and evaluated their relationship with the patients. But the progression of both of the two researches showed their reasonable concern with the formulation of the research questions. Lincoln et al cautiously approached the caregiver and patient relationship. They made no attempt that might influence the content of the service for group A. But for Group B exclusive attempts to provide the best service were taken by Lincoln et al. As Lincoln at al says, “This team provided coordinated multidisciplinary rehabilitation in the community. The team exclusively treated stroke patients and therefore provided a specialist service” (Lincoln et al, 2004: 42). It was decided that two members of the team would pay an initial assessment visit to the Patients of these group at home. On a regular basis the patient were being discussed in the team meeting in order to assess the condition of the patients and accordingly these patients were treated by the allocated therapists. No significant changes were made in the procedure of their research. In addition, in order to avoid the bias an independent assessor was employed to assist the disabled patients and “the outcome assessment was administered by a bilingual co-worker for patients who did not speak English” (Lincoln et al, 2004: 43). Burton did not consider relationship between researcher and participants adequately. Ethical Issues in the Studies In their paper Lincoln et al significantly deals with the ethical aspects of their research papers. The ethical maintenance was important for the paper to retrieve free and unbiased opinions of the patients. At six months after receiving routine care and treatment for the community stroke team, the patients’ consent was sought by post. However, Lincoln et al did not explicitly mention what type privacy maintained regarding the patients’ opinions about their caregivers. In addition, they did not take any step to inform the patients’ of the privacy of their opinion. Indeed, their procedure to deal with the patients by post was meant to maintain the privacy of the patients. Also Lincoln et al assert, “Ethical approval was granted by the Local Research Ethics Committee” (Lincoln et al, 2004: 42). A serious flaw within the ethical aspect of Lincoln et al’s paper is that the consent of the patients was sought after the six months treatment. Such postponed demand of consent might have two effects: first, the patients were deprived of mulling over the various aspects of the study; the patients might face a moral pressure that might affect their opinion with unwanted positive bias. In his paper, Burton also showed a significant handling of the ethical issues of the study. The study received ethical approval from the local research ethics committee. Unlike Lincoln et al’s study, Burton sought the patients’ consent at the very beginning of the research, as he says, “Consent was obtained prior to inclusion, and for audio-taping of interviews” (Burton, 2000: 303). As according to the purpose of Burton’s study, the direct evaluation of the patients should play a crucial role in the research, the ethical approval of the study claimed the participants were mentally healthy and did not have any dysphasia, “had no history of clinical depression preceding their stroke, had no evidence of cognitive impairment, and had no significant medical history at the time of their stroke likely to influence their recovery” (Burton, 2000: 303). Data Analysis Lincoln et al did not speak much about the process of analyzing the data of their research. Indeed though they did not discuss it directly, the procedure of the collection of the data performed the analysis needed for the research. For example, the use of the Barthel Index, Extended ADL, General Health Questionnaire 12, and Euroquol thermometer form was intended to retrieve some particular sets of data that could be handled to work out the result without much analysis. The whole data analysis of the research was based on the comparison of the two groups: routine care group and the stroke team group, as Lincoln et al asserted the base line of the analysis, “The two groups were compared on baseline variables…..This showed that patients in the intervention and the control group were comparable on age and gender. Patients who were followed-up were compared with those who failed to complete the outcome assessments” (Lincoln et al, 2004: 43). But Burton spoke a lot about the process of the data analysis. Burton’s data analysis appeared a dynamic process of evaluation that continued with the progress of data collection. As Burton says, “The data were analyzed continuously throughout the duration of the study. This included documenting key reflections alongside interview transcriptions, so that data could be revisited in later interviews and contextual features explored.” (Burton, 2000: 304) Consequently, the data was collected from the original source and appeared to be sufficient to support the finings. In his analysis the points such as immersion, naïve interpretation of the initial sense of patients’ stories played a crucial role in the analysis. Data codes were organized into a matrix of themes and sub-themes according to the content analysis. Here Burton comments, “The content of the log journal was reviewed alongside each stage of the data analysis to ensure that the original context of the data was maintained” (Burton, 2000: 304). Findings of the Research Lincoln et al explicitly described the findings of their research in their paper. With a thorough analysis of the evidence, they came to a conclusion that there was no significant difference between the outcomes of the two groups of patients except the emotional support and the reduced strain of the caregivers under the supervision of the community stroke team. In addition, no significant difference between the two groups’ independence in personal activities was revealed on using a Mann–Whitney U-test. The researchers attempted to establish the credibility of their findings upon arguing it with the findings of the other research. As they contextualized the findings of their evaluation in the following lines: Rehabilitation by a community stroke team produced equivalent outcomes to routine services in terms of independence in ADL and mood…However, the CST service provided greater emotional support for patients, had benefits for carers in terms of both satisfaction, and reduced strain. (Lincoln et al, 2004: 44) The striking finding of the study that they denoted is the facilities provided by the CST is complementary to hospital outpatient services and social services OT. This lack of difference is supported by the previous studies of Forster and Young, Walker et al, Roderick et al and Gladman et al. Finally Lincoln et al were aware of the lacking and limitations of their study, they said, “There are limitations to the study, which need to be taken into account when interpreting the data” (Lincoln et al, 2004: 45). Consequently, they described the impact of the lacking on the findings of the study. Anyway though Burton discussed and described the findings of his study regarding some points like Issues in physical recovery, Initial personal experiences of stroke, Early recovery, Slowing down, New challenges, Issues in emotional recovery, Uncertainty, Hope, Loss of control, Anger/frustration, Changing roles, Isolation, Reflections on previous life (Burton) he did not tell anything in his methodology whether the points were in focus of the interviews with the patients. But the credibility of Burton’s findings lies in the fact that Burton attempted to support his points referring to a number of studies and authors such as Hafsteinsdottir and Grypdonck (1997), Koch (1994), Doolittle (1991). Value of the Research The purpose of Lincoln et al’s study confined its contribution to the assessment of the Nottingham Community Stroke Team. It does not contribute much to the general knowledge of the community stroke-rehabilitation team. The studies, “Living with stroke: a phenomenological study” by Christopher R. Burton and “Evaluation of a multi-professional community stroke team: a randomized controlled trial” by Lincoln et al are the significant attempts to evaluate the competency of the professionals in the stroke rehabilitation services. Lincoln et al’s study is helpful enough to take a deep insight into the rehabilitating performance of the multi-professional community stroke team, whereas in his research paper Burton study explores into the ontological significance of the patients’ perception of their living with stroke. He also examines how the patients’ perception influences the outlines of the rehabilitation. Bibliography Burton, C. R. (2000) ‘Living with stroke: a phenomenological study’, Journal of Advanced Nursing, 32(2), 301±309 Doolittle N. (1991). ‘Clinical ethnography of lacunar stroke: implications for acute care’, Journal of Neuroscience Nursing 23, 235±240 Forster A, Young J. (1992) ‘Specialist nurse support for patients with stroke in the community: a randomized controlled trial’. BMJ; 7: 135–39 Gladman JR, Lincoln N, Barer DH. (1993) ‘A randomized controlled trial of domiciliary and hospital based rehabilitation for stroke patients after discharge from hospital’, J Neurol Neurosurg Psychiatry; 56: 960–66 Hafsteinsdoattir T.B. & Grypdonck M. (1997) ‘Being a stroke patient: a review of the literature’, Journal of Advanced Nursing 26, 580±588 Koch T. (1994), ‘Establishing rigor in qualitative research: the decision trail’, Journal of Advanced Nursing 19, 976±986 Lincoln et al, (2004), ‘Evaluation of a multi-professional community stroke team: a randomized controlled trial’, Clinical Rehabilitation; 18: 40–47 Roderick P, Low J, Day R et al. (2001) ‘Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day-hospital care’, Age Ageing; 30: 303–10 Walker MF, Gladman JRF, Lincoln NB, Siemonsma P, Whiteley T. (1999) ‘Occupational therapy for stroke patients not admitted to hospital: a randomized controlled trial’. Lancet; 354: 278–80 Read More