Theory for Nursing Practice

Theory for Nursing Practice,
1) What methods were put in place to ensure that the subjects were giving true informed
consent?

The population of this study consisted of a total of 20 participants (care givers) of
family members with Heart failure (HF). The population was selected randomly in-
patient hospitals, adult care facilities and cardiology offices. In each of the four
stages, five care givers participated in open ended interviews which lasted for
45minutes-2 hours (Sanford et al, p. 59, 2011).
2) What was the setting for the study?
The investigation setting varied according to each participant location including the
care givers home, in hospitals and offices. The locations were mutually agreed.
3) Was the sample adequate for the research design that was selected?
Qualitative studies often require small sample size to represent the
population(Houser, p133, 2013). In this regard, the 20 participants were adequate for
the investigation. However, there was potential for biasness as all the participants
originated from the same locality i.e. South East America. The biasness could have
resulted from environmental and cultural allied variables. Therefore, different
conclusions could be deducted if the same research is repeated in different locations.
4) Describe the data collection procedure.
Data was collected through open ended interviews which were not structured. The
interviews were conducted at mutually agreed private locations. The interviews were
recorded using an audiotape. Additionally, the researchers kept short notes and

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memos in order to record key points which would require further clarification. Some
of the variables studied included the nonlinear actions involved in decision making
process including support, evaluation, and reflection and seeking input. These
variables were also associated with the participant’s gender, socio economic status
and participant-patient relationship. Demographic data was also collected (Sanford et
al., p.59, 2011).
5) What did the authors say about the reliability and validity of their data collection and
analysis?

The data collection and analysis was reliable. The researchers applied triangulation
method to ensure validity in their research. This method involves use of more than
two approaches to gather data relating on the same topic. This ensures that data is
cross validated through capturing of various dimensions of the same phenomenon
being evaluated. In qualitative study, rigor is defined through use of open data which
scrupulously adhere to specific perspective and increased thoroughness in data
collection. Rigor concept is often applied in qualitative study to ensure that
investigations comply with trustworthiness fundamentals of naturalistic studies.
6) What demographic information was reported?
Demographic information collected included gender, marital status, racial and ethnic
identity, socio-economic status and the participant’s relationship with the HF family
member (Sanford et al., p.60, 2011).
7) What were the variables that were studied?
Some of the variables studied included the nonlinear actions involved in decision
making process including; what support care giver have; how care givers evaluate
decision made; decision reflection and seeking input. These variables were also
associated with the participant’s gender, socio economic status and participant-
patient relationship (Sanford et al., p.55, 2011).
8) How were the data analyzed after collection? Was there any special software used?
Researchers coded data collected line by line and independently after every interview
conducted; focused coding was done later to establish a more salient data
categorization. Core categories identified were analyzed to generate theoretical
categories. As the data was analyzed, pertinent data was theoretically sampled to
refine the categories until fine refinement/saturation was reached. Through these
efforts, theoretical model was completed which described caregivers process of
decision making.

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Special statistical software programs were used. Data collected was transcribed in
verbatim. To ensure reliability, the data accuracy was checked. Data analysis was
done using Nvivo program. Theoretical sampling of the data was also done to refine
categories in the theory until saturation was reached. A theoretical model was
developed to describe the decision making process (Sanford et al., p.60, 2011).
9) Discuss the use of any figures, graphs, and tables. Was the information conveyed in an
understandable and meaningful way?

The researchers use a flow chart diagram to describe the theoretical model of care
givers decision making process (p.61). The flow chart indicates that decision making
process involves actualization of the problem, seeking input support, seeking
validation, making decision choice and evaluation of the decision made.
Table1 on page 59 lists interview questions used for study. The questions include
probes on history of the family member’s illness, their influences, their advice to
other people and how care givers make decisions.
Table 2 on page 60 of the article is a tabulated summary of the frequency
demographic distribution of care givers. From the table, 75% were males, 25% female.
The highest rate of participants was married at 85%, divorcee at 5% and widowed
10%. There was huge disparities between white and African American participants;
75% and 25% respectively. The relationship between patient and care givers results
indicated that 65% were spouses to the HF patients and 35% were HF children.
Graphs, tables and figures capture and summarize data in a way that enhances the
approval of the researcher’s argument. One can grasp the author’s argument at a
glance.
10) Discuss the authors’ conclusions. Do you feel these conclusions are based on the data that
they collected?

The researchers concluded that decision making by care givers of HF family
members was a nonlinear cognitive process which required actualization of the
problem, seeking of input or support, reflecting on the choice made and evaluating
the decision to validate the choice. Based from the data collected, there are factors
that determine decision making ranging from individual attributes to the environment.
Understanding these factors would significantly impact the care giving decision
making and improve the patient’s health.
The conclusions were based on study’s data.

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The following questions pertain to: Schwarz, K., Mion, P., Hudock, D., &Litman, G. (2008).
Telemonitoring of heart failure patients and their caregivers: A pilot randomized controlled study.
Progress in Cardiovascular Nursing, 23(1), 18–26.
11) What methods were put in place to ensure that the subjects were giving true informed
consent?

The physicians provided a written permission to their patients to be identified and get
enrolled for the study. Potential participants about the research and obtained verbal
permission for PI to contact them before they were discharged from the hospital. The PI
obtained oral consent from the patients. Patients also provided their contacts during
discharge. Care givers and patients provided HIPAA authorization and written informed
consents during the first interview (10 days after discharge).
12) What was the setting for the study?
The setting was at 537 bed tertiary teaching hospital located in Northern Ohio. Ten days
after discharge, interviews were conducted and 90 days after discharge. Interview
investigation setting varied according to each participant location but were generally
mutually private location (patients home) agreed upon but data collection and all other study
methodologies were conducted at the teaching hospital in Northern Ohio.
13) Was the sample adequate for the research design that was selected?
In quantitative study, sufficient sample size is the least number of subjects required to
statistically evaluate/indicate if variations actually exists. Before sample size calculations,
researchers should establish what they consider statistically significant for the proposed
investigation; then a sample size is estimated. Elements which influence sample size are put
into consideration. These include effect of the sample size, sample homogeneity , risk error
and anticipated study attrition.
In this framework, study sample was adequate for the study. A hundred and two patients
randomized into two groups for 84 days. The study design was well structured and
executed.
14) Describe the data collection procedure.
Approval was obtained by the researchers. Physicians and cardiologists provided written
permission to their patients who potentially matched screening eligibility. HF manager
identified potential participants during routine rounds. The potential participants were
informed study particulars and care managers obtained verbal consent; the PI was informed.
PI explained further the study particulars to both the HF and care giver and issued the
potential participants a letter of explanation. Eligible patients gave their telephone and

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contact numbers after discharge. Randomization of participants to usual hospital they were
admitted by drawing from an already prepared envelops which was sealed.
After discharge, participants were interviewed ten days immediately and 90 days after
discharge by RN. After the first interview, participants received telemonitoring facilities
which were removed 90days later. The data collector (RN) placed a weight scale in the
patients home which were connected via the homestead’s telephone line to a computerized
monitoring system at the hospital. Therefore, most of the data pertaining to physiological
status of the patient was collected by the computerized system. Additionally, the manager
of the HF care and APN monitored the device and recorded the information. The physician
recorded the number of hospital visits and ED visits(Schwarz et al., p.21, 2008).

15) How did the authors addressthe reliability and validity of their data collection and analysis of
the instruments used?

The data collection and analysis was reliable. The researchers conducted periodical checks
throughout the investigation and ensured they maintained more than 90% of the
agreement(Schwarz et al., p.20, 2008).
Hospital readmission in this study referred to unplanned hospital within 90 days after
discharge. Days of re-admission referred to days between the discharge and readmission.
Functional status was evaluated using IADL’s baseline. The ADL tool consisted of eating,
bathing, toileting, movements/transfers and incontinence. The scores for the tool ranged
from 0 (Totally independent – 2 (Totally dependent). The IADL scale is very reproducible with
co-efficient of 0.96 and 0.87 inter-rater reliability . ADL &IADL ranges are 0-26; and have
been shown to be feasible and valid by Spector and Fleishman.
Depressive symptomatology was evaluated by Center for epidemiological studies
Depression Scale (CES-D). Twenty items were rated using 4 point Likert scale; ranging from
0( “rarely”) -3(“most/ all the time”). It represented the CES-D psychometric excellent
properties.
Quality of life was recorded using 18 items from Minnesota Living With HF questionnaire
(MLWHF). The 18 items were rated using 6 point Likert Scale where 0=no and 5=very much.
Cronbach’s coefficient at time 1&2 was 0.91. Rector & Cohn identified MLWHF as a valid self-
assessment on therapeutic strategies.
Care giver mastery was given using Philadelphia Geriatric Center Caregiving Appraisal
Scale (PGCCAS) at baseline and at 90 days. The six items assessed included uncertainty of

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caregiver, caregiver’s reassurance that he is giving right care, feeling of satisfaction that
they are doing the right care, care giver decision making process and perception. The six
items were rated on 5 point Likert Scale where 1=never and 5= nearly always. The study
reliability and validity was measured using Cronbach’s coefficients ranging from 0.61- 0, 73
at time 1 and time 2 respectively.
Informal social support was measured using tangible subscale from Modified Inventory of
Socially Supportive behaviors Scale (MISSB). It used 9 items using 4point Likert scale
where 1=never and 4=very often, To measure reliability and validity Cronbach’s coefficient of
0.71-0.92 were used.
16) What limitations did the authors face in data collection? How could these have been
lessened or minimized?
One of the major weaknesses of random controlled trials is the limited external validity. In
this context, the findings were limited to patient classified in NYHA AS II; III&IV. Replication
of the study could yield different conclusions using less ill participants. Using a large cohort
could reduce biasness due to sampling.
Secondly, there was reduced and unwillingness to record vital findings such as specific
number of hospital visits. This could have introduced bias. Researchers should ensure they
participate in data collection. Further studies should introduce control over usual care
provider; and should integrate EHM (Schwarz et al., p.25, 2008).
There lacked a formalized monitoring system put in place to determine whether patients
complied to medication. Again, there were variations during medication prescription and
administration which could have led to study biasness. Future studies should put
standardized procedure on subjects medication prescription and processes in order to
reduce study heterogeneity.
17) What demographic information was reported by the authors?
Demographic information collected included gender, education background, age, racial and
ethnic identity, , and socio-economic status, perceived health status of the participant and
care givers (Schwarz et al., p.21, 2008).
18) What were the variables that were studied?
The variables used included the hospital readmission, emergency visits, days to
readmission were used to evaluate readmission risk. Additionally, physiologic health status
was assessed. These included but not limited to blood pressure, patients weight, the apical

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pulse and oxygen concentration. Functional status, informal support, cost of care and
depressive symptomatology was also evaluated (Schwarz et al., p.21, 2008).

19) Were there any inferential tests used in the analysis of data in this study? If so, what were
they?

Descriptive analysis and comparative statistical tools were used to analyze data collected
using SPSS Inc. version 13. Descriptive analysis included measures of central tendencies
(mean, median and mode), frequencies and measures of dispersion. Inferential tests used
includes Using Pearson correlation of co-efficient, the variables association was
evaluated(Schwarz et al., p.22, 2008).
20) Discuss the use of any figures, graphs, and tables. Was the information conveyed in an
understandable and meaningful way?

The researchers use a flow chart diagram to describe the alogarithm of cohorts who were to
be selected for eligibility(Schwarz et al., p.20, 2008).
Table 1 on page 22 of the article is a tabulated summary of the participants and care givers
attributes as indexed during hospital visits. From the table, 43% were females for IG and 31%
for control group; p=0.07. The highest rate of participants was married at 71% and 55% for
control group;p=0.56. NYHA class II, III & IV subjects were 24%, 45% and 31% respectively
for intervention group and 18%, 51% and 31% consecutively; p=0.74. Commodities p=0.14
current medication p=0.79. About 64% of participants were spouses of HF, 13% were
children and 10% were other distant relations (not specified).
Table 2 (p.23) summarizes the ED visits, cost of care and hospital readmission frequencies.
IG hospital readmission was 0.32 whereas the control group was recorded 0.33; p=0.9; ED
visits for IG was 0.34 and control group 0.39; p=0.73 and cost of care for IG was 12,017 and
control group 6,673; p=0.28
Table 3 (Schwarz et al., p.24, 2008) summarizes other variables including the depressive
symptomatology, quality of life and days of admission by group. Depressive symptoms
value at baseline was 8.7 in Intervention group (IG) and 6.8 for control group(p=0.32). At 90
days after discharge IG depressive symptoms changed whereas the control group
depressive symptom maintained at 6.6 (p=0.44). Days to re-admission, IG group had
lengthier days at 31.3 whereas the control group were shorter recorded at 24 (p=0.96). The
patients quality of life was influenced by care giver mastery(p=0.05 at baseline; p=0.38 90
days after discharge).

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Graphs, tables and figures capture and summarize data in a way that enhances the approval
of the researcher’s argument (Creswell, p. 36, 2009). One can grasp the author’s argument at
a glance because the information is presented in a neat and meaningful way.

References
Creswell, J. (2009). Research design: qualitative, quantitative and mixed method approaches
(3 rd ed.)Thousand Oaks, CA: sage publications
Houser, J. 2013. Nursing research: Reading, using, and creating evidence (3rd ed.). Sudbury,
MA: Jones & Bartlett.
Schwarz, K., Mion, P., Hudock, D., & Litman, G. (2008). Telemonitoring of heart failure
patients and their caregivers: A pilot randomized controlled study. Progress in
Cardiovascular Nursing, 23(1), 18–26.
Sanford, J., Townsend-Rocchicciolli, J., Horigan, A., & Hall, P. (2011). A process of decision
making by caregivers of family members with heart failure. Research & Theory for
Nursing Practice, 25(1), 55–70.

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