I’m trying to study for my Nursing course and I need some help to understand this question.
discussion 200 words with i have attach the articles and every thing in the fail please read check.NURS-321 Nursing Research and Evidence-Based Practice
Rubric for Discussion Postings
Requirements
Text word count of 200 words (Note:
citation’s & references not part of the word
count).
Citing’s appear within text.
References appear at end of text.
Appropriate APA format used.
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All of the above mentioned posting
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Points
5
0
0
We have been investigating in depth the methods used for developing research.
Looking back at Ch 7 research articles (on p.127).
Group 2 will look deeply at the Conelius qualitative study article (p.127)
1) Each group should read the other groups article along with their own. Tell me which
article impressed you more, felt more valid, seemed legitimate and why. (Hint: Citations
from within the chapters needed as evidence as to why)
2) Now search online for any research that does not support the results of your groups
research study. Reference the article and cite from it to prove that it does not support
your groups research.
Please use the search engine provided by the Howard Colman Library to assist your
search for evidence. See addition to Home under Miscellaneous.
Critique of a qualitative research study
The research study
The study “A Woman’s Experience: Living With an Implantable Cardioverter Defibrillator” by Jaclyn Conelius, published
in Applied Nursing Research, is critiqued. The article is presented in its entirety and followed by the critique.
A woman’s experience: Living with an implantable cardioverter defibrillator
Jaclyn Conelius, PhD, FNP-BC
Abstract
The implantable cardioverter defibrillators (ICD) have decreased mortality rates from those who are at risk for sudden
cardiac death or who have survived sudden cardiac death and has been shown to be superior to antiarrhythmic medications
(Greenburg et al., 2004). This advance in technology may improve physical health but can impose some challenges to
patients, such as depression, anxiety, fear, and unpredictability. Published research on how ICD affects a woman’s life
experience using phenomenology is limited. Therefore, the purpose of this article is to describe the experiences of women
who have an ICD using Colaizzi’s method of phenomenology since their implant. Analysis of the three interviews resulted
in five themes that described the essence of this experience. The results of this study could not only help clinicians
understand what their patients are experiencing but also it can be used as an education tool.
© 2014 Elsevier Inc. All rights reserved.
Introduction
Implantable cardioverter defibrillators (ICDs) have decreased mortality rates from those who are at risk for sudden cardiac
death or who have survived sudden cardiac death and has been shown to be superior to anti-arrhythmic medications
(Greenburg et al., 2004). ICDs have been supported by many clinical trials and it is now the treatment of choice in primary
and secondary prevention for these patients (Bardy et al., 2005; Bristow et al., 2004; Moss et al., 2002). This mainstay of
treatment has increased steadily from 486,025 implants from 2006 to 2009 to 850,068 from 2010 to 2011 (Hammill et al.,
2010; Kremers et al., 2013). Of these implants approximately 28% were female only.
This advance in technology may improve physical health but can impose some challenges to patients. They include the
adjustments to the device in their everyday living, such as; quality of life issues as well as psychological issues. Through
quantitative research the following have been reported; a fear of physical activity and a fear of shock from the device to
prevent the sudden cardiac arrest (Lampert et al., 2002; Wallace et al., 2002; Whang et al., 2005). Other studies have
reported anxiety, fear, and depression in these patients. Some specific fears included; malfunctioning, unpredictability, and
the inability to control events (Dickerson, 2005; Dunbar, 2005; Eckert & Jones, 2002; Kamphuis et al., 2004; Lemon,
Edelman, & Kirkness, 2004). These quality of life and psychological issues reported in the studies are not reported as
gender specific; therefore, female specific challenges are not well studied. Furthermore, there have been few qualitative
studies based on a patient’s experience of living with an ICD. Previous studies reported themes such as the feeling of
gratitude, safety, belief in the future, adjustment to the device, lifesaving yet changing, fear of receiving a shock,
physical/mental deterioration, confrontation with mortality and conditional acceptance (Dickerson, 2002; Fridlund et al.,
2000; Kamphuis et al., 2004; Morken, Severinsson, & Karlsen, 2009; Tagney, James, & Alberran, 2003).
Based on the available research studies, there is very little reported data specific to females and specifically how an
ICD affects a woman’s lived experience. A lived experience is how a person immediately experiences the world (Husserl,
1970). In order to understand a woman’s lived experience living with an ICD, phenomenology was used. Phenomenology
is a philosophy and a research method used to understand everyday lived experiences. Therefore, the purpose of this study
was to describe what those experiences were, specifically, to describe their thoughts, feelings, and perceptions that they
have experienced since their implant. It is important to gain an understanding and formulate a description of what life is
for a woman who had received an implantable cardioverter defibrillator in order to describe the universal essence of that
experience. Descriptive phenomenology emphasizes describing universal essences, viewing the person as one
representative of the world in which she lives, an assumption of self-reflection, a belief that the consciousness is what
people share and a belief that stripping of previous knowledge (bracketing) helps prevent investigator bias and
interpretation bias (Wojnar & Swanson, 2007). Specifically, Colaizzi’s (1978) descriptive phenomenological method uses
seven steps as a method of analyzing data so that by the end of the study a description of the lived experience could be
reported.
Method
Descriptive phenomenology originated from the philosopher Husserl (1970), who believed that the meaning of a lived
experience may be discovered though one to one interaction between the researcher and the subject. It assumes that for any
human experience, there are distinct structures that make up the phenomenon. Studying the individual experiences
highlights these essential structures. It is an inductive method that describes a phenomenon as it is experienced by an
individual rather than by transforming it into an operationally defined behavior. An important aspect of descriptive
phenomenology, according to Husserl, is the process of bracketing in which he describes as separating the phenomenon
from the world and having the researcher suspend all preconceptions (Wojnar & Swanson, 2007). The goal of descriptive
phenomenology is to provide a universal description of the lived experience as described by the participants of the
phenomenon. Colaizzi’s (1978) method of descriptive phenomenology is the method used for this study. In his method,
interviewing is the selected strategy for collecting data, which is necessary for describing an experience. This method
works well with a small sample size.
Sample.
Ten women were asked to participate, of these, three women agreed to participate from a private cardiology office in the
United States. This convenient sample of women were all Caucasian and their ages ranged from 34 to 50 years old. All
three women had college degrees and have had the device over one year. None of the women were previously diagnosed
with any psychiatric disease.
Procedure.
After receiving approval from the university’s institutional review board (IRB), women were recruited from a private
cardiology office in the United States for 4 months. The participant population only included women that had an
implantable cardioverter defibrillator (ICD). Women needed to be 18 years or older, and speak English. Women of all
ethnic backgrounds were eligible to participate. There was no cost to the participant and no compensation provided. Once
the informed consent was signed, they were asked to stay for an interview that day. All women were interviewed privately
in the office and each interview lasted approximately 45 minutes to an hour. They were asked to “describe their
experiences after having received an ICD, specifically, to describe their thoughts, feelings, and perceptions that they had
experienced since their implant?” They were then asked to share as much of those experiences to the point that they did
not have anything else to contribute. The interviews were recorded and then transcribed. The researcher conducted all of
the interviews since the researcher in trained in the method. Interviews were conducted until an accurate description of the
phenomenon had occurred, repetition of data and no new themes where described. This saturation of data did occurs after
the three interviews. After each interview, follow up questions were asked in order to clarify any points the participant
described. The researcher kept a journal to write down any notes needed during the interview.
In order for the description to be pure, the researcher’s prior knowledge was bracketed to capture the essence of the
description without bias (Wojnar & Swanson, 2007). Husserl (1970) introduced the term, and it means to set aside one’s
own assumption and preunderstanding. In order to be true to the method, the researcher reflected and kept a journal of all
assumptions, clinical experiences, understandings and biases to reference during the entire study.
Significant statements and phrases pertaining to a woman’s experience living with an ICD were extracted from each
transcript. These statements were written on separate sheets and coded. Meanings were formulated from the significant
statements. Accordingly, each underlying meaning was coded into a specific category as it reflected an exhaustive
description. Then the significant statements with the formulated meanings where grouped into themes.
To ensure confidentiality, the signed informed consent forms were kept separate from the transcripts. The recorded
tapes and hard copy were in a locked cabinet. Identifying information was deleted and names were never used in any
research reports. Audiotapes were destroyed once the pilot study was completed.
Data analysis.
Each transcript was analyzed using Colaizzi’s (1978) method. The method of data analysis consisted of the following
steps; (1) read all the participants’ descriptions of the phenomenon, (2) extract significant statements that pertain directly
to the phenomenon, (3) formulate meanings for each significant statement, (4) categorizing into clusters of themes and
validation with the original transcript, (5) describing, (6) validate the description by returning to the participant to ask
them how it compares with their experience, and (7) incorporate any changes offered by the participant into the final
description of the essence of the phenomenon.
Rigor.
There were efforts made to limit any potential bias of the researcher. One such effort was to bracket any of the researcher’s
prior perspective and knowledge of the subject (Aher, 1999). To ensure the credibility of the data collected, two of the
women in the study reviewed the description of the lived experiences as suggested by Lincoln and Guba (1985). This was
performed as a validity check of the data. In order to address for auditability, a tape recorder was used and the researcher
reviewed the transcripts and cross-referenced the field noted (Beck, 1993).
Additionally, the transcripts were transcribed verbatim by a secretary in order to ensure they were free of bias. Also, the
data analysis and description of the lived experience were reviewed by an independent judge with phenomenological
experience to ensure intersubjective agreement. All of the themes reported were agreed upon by the judge.
Finally, the researcher validated the description by returning to the participants to ask them how it compared with their
experience and incorporated any changes offered by the participants into the final description of the essence of the
phenomenon. This final description was reviewed by other women with ICDs who were not a part of the study to ensure
fittingness.
Results
At the conclusion of verifying and reviewing the transcripts, there were 46 significant statements extracted that pertained
directly to the phenomenon. From each significant statement formulated meanings were created. These statements were
then formed into five themes (Table 1) that described the essence of these experiences.
TABLE 1
Selected Examples of Significant Statements and their Formulated Meaning for Five Themes
Theme Number
Significant Statement
Formulated Meaning
1
Security blanket: lf it
keeps me alive It’s
worth it.
“I do not have anything to worry about anymore. I used to worry that if
something happened, how soon I can get to a hospital or what
could they do to try to save me.”
The women did not have to worry
anymore about medical
emergencies.
“Actually, I probably do a little more than before. But I can do
everything that I did before. I have not eased up on anything.”
She felt as if nothing has changed.
She does everything she did
prior.
“The children sometimes bump into that side and I am literally guarding
that side all the time.”
She is aware of it and guards it
when others come in contact
with it.
2
A piece of cake: I do
more than before.
3
A constant reminder: I
know it’s there.
Theme Number
Significant Statement
Formulated Meaning
4
Living on the edge: I do
not want it to go
off.
“I do have a little fear of that but so far, it hasn’t happened.”
She has an extreme fear of the
device shocking her.
“I would rather not personally have it but I know medically, I need to
have it, which is a good thing.”
She would rather not have to have
it, but she knows she needs it.
5
Catch 22: I’d rather not
have it.
Theme 1: Security blanket: If it keeps me alive it’s worth it.
Women who had an ICD felt a sense of security with the device. They felt that this device acted as a security blanket. Prior
to their device they had a constant worry about how soon they could get medical treatment and now that they had the
device, that worry was lifted. The feeling of worry was no longer apparent for them. One woman said:
Now I just think this will keep me alive long enough for somebody to make a decision, at least it will give me a
chance. I do not have anything to worry about anymore. I used to worry that if something happened, how soon I
could get to a hospital or what could they do to try to save me.
The women also described how their worry decreased should they require medical treatment while they were with their
family also was decreased. “Now I do not have to worry if I am with my family, I have ICD in my chest to give me
treatment right away.”
Another woman felt that the device just being there saved her life. “If the device can save her life it’s worth it.” The
device prevents the heart from having sustained lethal arrhythmias.
She explained: “I feel like it saved my life, I feel like it keeps my heart beating nice and smooth.”
There was an overall feeling that the device improved their lives. Based on their past medical history, the device was
needed since it is the next step in their medical treatment. All the women were glad they were able to receive the device.
One woman explained:
It could be both ways. I mean, I feel knowing what my family history is, yeah, I am glad I have it. I needed it. It
made me feel that I can go anywhere and do anything because it acts like my insurance policy.
Theme 2: A piece of cake: I do more than before.
The women did not have a decrease in physical functioning or quality of life. Their quality of life remained stable or
improved once the post operative period was over.
One woman explained:
Actually, I probably do a little more than before. But I can do everything that I did before. I have not eased up
on anything. I felt like after the surgery, I was tired for 2 days then I could go on and do everything I used to do;
now I do not even think about it. I just go about my day as usual and even do more because I know I have this
to protect me.
The women felt that the whole process of receiving an ICD was easy. Nothing much changed in their everyday lives.
They live and do everything that they did before with no restrictions.
Another woman shared,
After that, I really have had no change in lifestyle. My life has been as normal as it was before. Physically, I see
no change, or even see an improvement.
Theme 3: A constant reminder. I know it’s there.
The women felt as if they had a constant reminder of the ICD. Their family was aware of the device in their body since
they can see the scar. Some family members would comment on the device if they could feel it when given a hug. This in
turn would remind the women that it was there. The device did affect their body image; it made them more conscious of
the device in their chest.
One woman with school aged children explained:
And it is hard when the kids cuddle up to me and I have to say I can’t have you on my left side anymore. With
four kids, you know the pile up, at least the two youngest ones, they want to lie next to me while watching TV or
when we are praying or reading books or doing anything. I have to remind them that you can’t put your head up
there. The children sometimes bump into that side and I am literally guarding that side all the time.
The most amount of pain that women had experienced was postoperative. After that, it varied when the pain decreased.
The actual incision is “hardly noticeable” in all of the women although the knowledge that the device is in fact in their
chest is a “constant reminder.” The degree at which it reminds them varies depending on body type.
One woman stated: “I am reminded of this all the time, I can feel it, I know it is there. Everyday activities like opening
a jar, it pops and moves. Anytime I use my pectoral muscle, I know it is there, which is a lot of what I do during the day,
like laundry.”
Another woman stated: “The only thing that bothers me a little bit sometimes, it feels like it moves in my chest when I
am in bed. When I lay a certain way it sometimes feels like it is popping out or something.”
Yeah, I mean just being that it is there and it should not be there and it shows itself all the time. I especially
know it’s there in the summer when you were fewer clothes, especially bathing suits. To me it is constant
reminder that I may feel fine, but I am technically sick.
Theme 4: Living on the edge. I do not want it to go off.
All of the women had a common fear that was constantly in their thoughts. They feared that the device would have to do
its job; it would have to “fire.” They did not want this fear to become a reality. They feared that they would be somewhere
in public and the device would have to administer therapy or shock them. The women stated such things as:
I do have a little fear of that but so far, it hasn’t happened. Oh! I don’t want it to go off! I am completely scared it
will go off and no one will know what the heck happened.
The fear of the device firing has a significant impact on these women. The most concerning part, is the wonder on what
it will actually feel like, the uncertainty. These women could not possibly know how it would feel like since none of them
have ever received a shock. They have been told that it feels like an “animal kicking you in the chest.” None of them to
date have yet to experience it. To them that is unimaginable until it becomes a reality.
I am scared. I am afraid it is going to kick off and I was told it would feel like a pair of boots kicking you in the
chest. And I am afraid, but it has never gone off. You know, I am wondering what it would feel like. The doctor
explained it almost like getting kicked in the chest by a horse. Well, that would be a jolt, I guess? I am afraid
that I will be doing something, not feel anything, then all of a sudden boom!
Theme 5: Catch 22: I’d rather not have it.
The women received these ICDs because it was medically necessary for them to have it based on the current guidelines.
They have various cardiac medical conditions that require an implant of a defibrillator. The women understood that it was
essential and yet they would rather not have had to go through it. They would rather not have the heart disease that comes
with needing the device.
I would rather not personally have it but I know it is medically, I need to have it, which is a good thing that I
have it. Mentally it bothers me, mentally; I know I cannot avoid it.
The women felt that the experience was depressing. They were mostly depressed immediately preceding the
implantation. Although, it had decreased over time, there was a constant reminder of the device still there. They needed to
adjust to the device, which was hard for them. They felt as if they had no choice to adjust to this new situation.
One woman explained:
Well, I have adjusted to it, I had no choice. But in another aspect, no, I would rather not be going through this.
Interestingly, no one has ever asked me how I feel about having one before. I just got it and the doctor does not
even ask me about it. I mean it comes and goes, because a lot of things I know are happening are like, it could
get depressing. I do feel anxious at times, then I feel depressed at times, then I am fine at times. So, I guess it
depends on what is going on.
Discussion
Aspects of the five themes that describe the essence of a woman’s experience living with an ICD have been reported in
previous studies, but nowhere is there a study that is an exact comparison to this study. For instance, theme 1 (security
blanket: if it keeps me alive it’s worth it) is similar to the concept in Fridlund et al. (2000), a feeling of gratitude, and a
feeling of safety. The women in this study expressed a feeling of safety and appreciation since they received their ICDs.
This sense of safety and trust in the device is consistent with other studies (Bilge et al., 2006; Dickerson, 2002; Morken et
al., 2009).
Contrary to what is found in the literature, the women in this study reported how they have more energy than before
and noticed an actual increase in physical functioning. Previous studies have identified decreased physical functioning
(Dickerson, 2005; Kamphuis et al., 2004; Williams, Young, Nikoletti, & McRae, 2007) and a decrease in activity levels in
their day-to-day lives (Bolse, Hamilton, Flanangan, Caroll, & Fridlund, 2005; Eckert & Jones, 2002). This contradiction
can be related to the types of studies conducted. Previous studies have used questionnaires while this study focused on
actual descriptions experienced by participants who had undergone the device implant.
Theme 3 (a constant reminder: I know it’s there) described the women “knowing that the device was in their chest,”
and it was a reminder of their condition. They also described how it affected their body image. There were two other
studies that had mentioned this as a concern for women. One study by Walker et al. (2004) reported body image concerns
of women. The women in that study were more concerned on how the device appeared in their chest (i.e. the scar) than
any other aspect. A second study by Tagney et al. (2003), also reported body image concerns in women since it can be
seen in their chest which makes them aware of the device. There were similarities with respect to body image only. They
were not concerned with the constant reminder aspect of the cardiac disease, only a constant reminder of their mortality
(Dickerson, 2002).
The common concern as described in theme 4 (Living on the Edge: I do not want my device going off) was the fear of
the device having to shock them as well as the uncertainty of when, where, and who would be around for support. This
was foremost in their thoughts. There have been common themes of fear of the device going off or shocking them in the
literature reviewed. Dickerson (2002, 2005) reported that uncertainty of when and where shocks can be triggered was a
prevailing concern of the male and female participants. Also, participants in Albarran, Tagney, and James (2004) study
reported a feeling of uncertainty regarding the device firing.
The prevailing concern in theme 5 (catch 22: I’d rather not have it.) is the conflict women have after receiving a device.
These women knew that they medically needed the device yet would have rather not have gone through with it. Dickerson
(2005) reported the theme of conditional acceptance that touches on the same concept. Also, a greater acceptance of the
new situation was reported in previous studies (Carroll & Hamilton, 2005; Kamphuis et al., 2004).
The women in this study offered specific experiences of living with an ICD which is not completely seen in any
previous study as stated previously. Moreover, there were some similar aspects identified in other studies such as receiving
a shock and feeling of safety but most were not specific to women (Bilge et al., 2006; Dickerson, 2002, 2005; Morken et
al., 2009). This study was able to describe the essence of women who are living with an ICD. As stated previously, the
majority of the patients who receive ICD s are male and all of the samples in previous studies have been predominantly
male. This study is specific to women and allows special insight to women who are living with cardiac disease and more
specifically cardiac disease requiring a medical device.
Clinical implications and future research
This study can have an impact on clinical practice as a whole by helping clinicians understand what their patients are
experiencing. The women in this study stated that they experienced a lot of uncertainty regarding the need for the device
and its functionality. This uncertainty can be reduced or eliminated by educating the patients with respect to how the
device operates. An increase in education pre and post operatively on device functionality would benefit patients by
relieving some of that uncertainty. These concerns are not being addressed properly in the healthcare system. This study
can help clinicians gain the understanding of the experience these women are having and perhaps pay closer attention to
these issues when they are seen in outpatient settings.
Furthermore, this study can also advocate for support groups for women. Support groups would allow these patients to
converse with other women with the same health condition. There are multiple studies in the literature regarding the use of
support groups in heart failure patients, however, there are very few studies involving patients with ICDs. Support groups
can expose women to different types of resources in order to cope better, decrease anxiety and answer any questions that
arise (Myers & James, 2008). Also, it would give them a security knowing that they would be able to have each other as a
support system.
The women in this study were similar in that they were Caucasian from affluent areas with numerous resources
available to them (Smeulders et al., 2010). An additional study involving women of various ethnical backgrounds and ages
would allow capture of a wider range of experiences. Also, since the women have an outstanding fear of the device
firing/shocking them, a noteworthy follow-up study would be to describe their experience post firing/shock. These studies
would help clinicians understand what their patients are experiencing. lt would allow them to be more empathetic and
identify the gaps in knowledge. The results would become a valuable teaching tool to help educate patients regarding their
device function.
The critique
This is a critical appraisal of the article, “A Woman’s Experience: Living With an Implantable Cardioverter Defibrillator”
(Conelius, 2015) to determine its usefulness and applicability for nursing practice.
Abstract
The purpose of the abstract is to provide a clear overview of the study and summarize the main features of the findings and
recommendations. The abstract should accurately represent the remainder of the article. Conelius (2015) summarized the
research in the following narrative:
The implantable cardioverter defibrillators (ICD) have decreased mortality rates from those who are at risk for
sudden cardiac death or who have survived sudden cardiac death and has been shown to be superior to
antiarrhythmic medications (Greenburg et al., 2004). This advance in technology may improve physical health
but can impose some challenges to patients, such as depression, anxiety, fear, and unpredictability. Published
research on how an ICD affects a woman’s life experience using phenomenology is limited. Therefore, the
purpose of this article is to describe the experiences of women who have an ICD using Colaizzi’s method of
phenomenology since their implant. Analysis of the three interviews resulted in five themes that described the
essence of this experience. The results of this study could not only help clinicians understand what their
patients are experiencing but also it can be used as an education tool.
Introduction/review of literature
All research requires the investigator to review the literature. This is the point at which gaps are identified with regard to
what is known about a particular topic and what is not known.
In qualitative research, the literature review is generally brief, because there is not a great deal known about the topic;
nor is there an existing body of research studies. This essentially means that the researcher needs to have an understanding
of the substantive body of knowledge on the topic and a clear perspective of what areas still need to be explored. A clear
rationale for why the research is needed should be established. The researcher must be clear that a gap in nursing
knowledge was identified, there is a clear need for the study, and the selected research method is
appropriate. Bracketing what is known about the phenomenon is one way to prevent bias and keep what is known about
the topic separate, prior to data collection and analysis (see Chapter 6). Conelius (2015) discusses bracketing in the data
collection section of her research on women and implantable cardiac defibrillators. The background information provided
in her introduction establishes a need for a qualitative study. Conelius (2015) emphasizes the fact that to date much of the
research has been quantitative. She further notes that qualitative studies to date have not been gender specific, emphasizing
the need for a study related to women’s experiences.
Implantable cardioverter defibrillators (ICDs) have decreased mortality rates from those who are at risk for
sudden cardiac death or who have survived sudden cardiac death and has been shown to be superior to antiarrhythmic medications (Greenburg et al., 2004). ICDs have been supported by many clinical trials and it is now
the treatment of choice in primary and secondary prevention for these patients (Bardy et al., 2005; Bristow et
al., 2004; Moss et al., 2002). This mainstay of treatment has increased steadily from 486,025 implants from
2006 to 2009 to 850,068 from 2010 to 2011 (Hammill et al., 2010; Kremers et al., 2013). Of these implants
approximately 28% were female only. (Conelius, 2015)
This advance in technology may improve physical health but can impose some challenges to patients. They
include the adjustments to the device in their everyday living, such as; quality of life issues as well as
psychological issues. Through quantitative research the following have been reported; a fear of physical activity
and a fear of shock from the device to prevent the sudden cardiac arrest (Lampert et al., 2002; Wallace et al.,
2002; Whang et al., 2005). Other studies have reported anxiety, fear, and depression in these patients. Some
specific fears included; malfunctioning, unpredictability, and the inability to control events (Dickerson,
2005; Dunbar, 2005; Eckert & Jones, 2002; Kamphuis et al., 2004; Lemon, Edelman, & Kirkness, 2004). These
quality of life and psychological issues reported in the studies are not reported as gender specific; therefore,
female specific challenges are not well studied. Furthermore, there have been few qualitative studies based on
a patient’s experience of living with an ICD. Previous studies reported themes such as the feeling of gratitude,
safety, belief in the future, adjustment to the device, lifesaving yet changing, fear of receiving a shock,
physical/mental deterioration, confrontation with mortality and conditional acceptance (Dickerson,
2002; Fridlund et al., 2000; Kamphuis et al., 2004; Morken, Severinsson, & Karlsen, 2009; Tagney, James, &
Alberran, 2003). Based on the available research studies, there is very little reported data specific to females
and specifically how an ICD affects a woman’s lived experience. (Conelius, 2015)
Phenomenology is a philosophy and a research method used to understand everyday lived experiences and is an
appropriate methodology for the phenomena of interest. The subjective experience of women with an ICD is central to
study and key to developing interventions to help these women cope. Conelius (2015) clearly articulates the focus of the
study and makes a clear case for why a qualitative design is appropriate.
When critiquing the literature review of a qualitative study, it is important to remember that this component of the
study must be critiqued within the context of the qualitative methodology selected. In phenomenological studies, the
literature review may be delayed until the data analysis is complete in order to minimize bias. Conelius (2015) does not
indicate that the review was delayed.
Philosophical underpinnings
In addition to making a case for the study and qualitative approach, it is also important to give the reader perspective on
the philosophical traditions of the method selected. Conelius (2015) describes the philosophical underpinnings of
phenomenology and then relates the traditions to the method used in the study. In most published studies, the author is
most concerned about sharing the findings of the study. This limits the space for in-depth literature reviews or discussion
of the method used. Conelius (2015) discusses the work of Husserl (1970) as being an integral component of her
philosophical grounding of phenomenology as method. She then connects this fundamental work to the method developed
by Colaizzi (1978).
A lived experience is how a person immediately experiences the world (Husserl, 1970). In order to understand
a woman’s lived experience living with an ICD, phenomenology was used. Phenomenology is a philosophy and
a research method used to understand everyday lived experiences. Descriptive phenomenology emphasizes
describing universal essences, viewing the person as one representative of the world in which she lives, an
assumption of self-reflection, a belief that the consciousness is what people share and a belief that stripping of
previous knowledge (bracketing) helps prevent investigator bias and interpretation bias (Wojnar & Swanson,
2007). Specifically, Colaizzi’s (1978) descriptive phenomenological method uses seven steps as a method of
analyzing data so that by the end of the study a description of the lived experience could be reported.
(Conelius, 2015)
The specific qualitative research approach selected helps determine the focus of the research and the manner in which
sampling, data collection, and analysis are undertaken. The qualitative research example provided here used
phenomenology as method. Research studies using a qualitative approach other than phenomenology should be critiqued
relative to the philosophical underpinnings of the method.
Purpose
The author explained why the study was important and the significant contribution the study would make to nursing’s
body of knowledge. The background information justified the use of a qualitative approach as well as why
phenomenology was used.
The researcher states that “The purpose of this study was to describe a woman’s experience living with an ICD. More
specifically to describe their thoughts, feelings and perceptions that they have experienced since their implant” (Conelius,
2015). The purpose is clearly articulated, first in the abstract and then in the introduction of the study. Conelius (2015)
makes it clear that there is a gap in nursing knowledge related to ICDs and the experience of women living with an ICD.
Ethical considerations
Addressing the ethical aspect of a research report involves being able to know whether participants were told what the
research entailed, how their autonomy and confidentiality were protected, and what arrangements were made to avoid
harm. In qualitative research the data collection tools generally include interview and participant observation, making
anonymity impossible. Because the interviews are open-ended, the possibility of disclosing personal information or
uncomfortable experiences related to the topic may occur. Consent must be a process of continuous negotiation (Oye et al.,
2016).
The study by Conelius (2015) was approved by the Institutional Review Board. The author clearly states how the
participants were protected. “To ensure confidentiality the signed informed consent forms were kept separate from the
transcripts. The recorded tapes and hard copy were in a locked cabinet. Identifying information was deleted and names
were never used in any research reports. Audiotapes were destroyed once the pilot study was completed” (Conelius, 2015).
Participants were fully informed about the nature of the research and were protected from harm; their autonomy and
confidentiality were protected.
Conelius (2015) also made clear to the participants that they had the right to withdraw from the research at any time.
This is true for any research; however, in a qualitative investigation, ethical issues may arise at any point in the study
(Hegney & Chan, 2010). Conelius (2015) clearly articulated the ethical rigor of this study.
Sample
In qualitative research, participants are recruited because of their life experience with the phenomena of interest. This is
referred to as purposeful sampling. The goal is to ensure rich, thick data about the phenomenon of interest. Data are
generally collected until no new material is emerging and data saturation has been reached. Cleary and colleagues (2014)
discuss sampling in qualitative research in relationship to sample size. Qualitative studies generally have a small sample.
Following the steps for sampling in qualitative research, Conelius (2015) offers the following information related to
participant selection:
After receiving approval from the university’s institutional review board (IRB), women were recruited from a
private cardiology office in the United States for 4 months. The participant population only included women that
had an implantable cardioverter defibrillator (ICD). Women needed to be 18 years or older, and speak English.
Women of all ethnic backgrounds were eligible to participate. There was no cost to the participant and no
compensation provided. Once the informed consent was signed, they were asked to stay for an interview that
day. (Conelius, 2015)
In qualitative research, purposive sampling is the approach of choice. Participants must have experience with the
phenomenon of interest and be appropriate to inform the research. In this case, Conelius (2015) needed women with an
ICD. Her selection process supports a qualitative sampling paradigm that is appropriate for phenomenology.
Data generation
The data generation approach should be sufficiently described so that it is clear to the reader why a particular strategy was
selected.
Conelius (2015) clearly articulates that the data generation method supports a qualitative paradigm and allows for
discovery, description, and understanding of the participants’ lived experience. The researcher uses open-ended
questioning and asks each individual to exhaust their ideas and describe their experiences. She also completes three indepth interviews with each participant, allowing for clarification of responses as well as an opportunity for the participants
to add experiences that may have been omitted at the first interview. Recording and transcribing the interview verbatim
helps maintain authenticity of the data. The following excerpts from the article illustrate these points:
All women were interviewed privately in the office and each interview lasted approximately 45 minutes to an
hour. They were asked to “describe their experiences after having received an ICD, specifically, to describe
their thoughts, feelings, and perceptions that they had experienced since their implant?” They were then asked
to share as much of those experiences to the point that they did not have anything else to contribute. The
interviews were recorded and then transcribed. The researcher conducted the interviews since the researcher
was trained in the method. Interviews were conducted until an accurate description of the phenomenon had
occurred, repetition of data and no new themes where described. This saturation of data did occur after the
three interviews. (Conelius, 2015)
The researcher kept a journal to write down any notes needed during the interview. “In order for the description
to be pure, the researcher’s prior knowledge was bracketed to capture the essence of the description without
bias (Wojnar & Swanson, 2007). Husserl (1970) introduced the term, and it means to set aside one’s own
assumption and preunderstanding. In order to be true to the method, the researcher reflected and kept a
journal of all assumptions, clinical experiences, understandings and biases to reference during the entire study.
Significant statements and phrases pertaining to a woman’s experience living with an ICD were extracted from
each transcript. These statements were written on separate sheets and coded. Meanings were formulated from
the significant statements. Accordingly, each underlying meaning was coded into a specific category as it
reflected an exhaustive description. Then the significant statements with the formulated meanings where
grouped into themes.” (Conelius, 2015)
Data generation was appropriate for this study and followed the steps described by Colaizzi (1978).
Data analysis
The process of data analysis is fundamental to determining the credibility of qualitative research findings. Data analysis
involves the transformation of raw data into a final description or narrative, identifying common thematic elements found
in the raw data. The description should enable a reviewer to confirm the processes of concurrent data collection and
analysis as well as steps in coding and identifying themes.
Data analysis followed the method described by Colaizzi (1978). The author developed a table to allow the reader to
follow the line of thinking and establish thematic elements. The reader can clearly follow the researcher’s stated processes.
Further, Conelius (2015) followed clear processes to establish authenticity and trustworthiness of the data. The findings
reported demonstrate the participants’ realities. During data analysis the researcher made every effort to eliminate potential
bias. Bracketing, verbatim transcription of taped interviews, and an independent reviewer were used to establish
intersubjective agreement.
Authenticity and trustworthiness
Critical to the meaning of the findings is the researcher’s ability to demonstrate that the data were authentic and
trustworthy or valid. Rigor ensures there is a correlation between the steps of the research process and the actual study.
Procedural rigor relates to accuracy of data collection and analysis. Rigor or trustworthiness is a means of demonstrating
the credibility and integrity of the qualitative research process (Cope, 2014). A study’s rigor may be established if the
reviewer is able to audit the actions and development of the researcher. It is at this point that the review of literature
becomes critical and should be systematically related to the findings. This was addressed by the author, and every effort
was clearly employed to reduce any bias or misinterpretation of findings.
Conelius (2015) was able to demonstrate rigor with regard to data analysis in multiple ways. She stated:
There were efforts made to limit any potential bias of the researcher. One such effort was to bracket any of the
researcher’s prior perspective and knowledge of the subject (Aher, 1999). To ensure the credibility of the data
collected, two of the women in the study reviewed the description of the lived experiences as suggested
by Lincoln and Guba (1985).
This was performed as a validity check of the data. In order to address for auditability, a tape recorder was
used and the research was reviewed the transcripts and cross-referenced the field noted (Beck, 1993).
Additionally, the transcripts were transcribed verbatim by a secretary in order to ensure they were free of
bias. The data analysis and description of the lived experience were reviewed by an independent judge with
phenomenological experience to ensure intersubjective agreement. All of the themes reported were agreed
upon by the judge. Finally, the researcher validated the description by returning to the participants to ask
them how it compared with their experience and incorporated any changes offered by the participants into the
final description of the essence of the phenomenon were created.
Conelius (2015) provided clear evidence of rigor for the reader. Bracketing, having participants read the final
description and thematic elements, taping and transcribing interviews verbatim, and using an independent judge to
establish intersubjective agreement are key elements in a well done qualitative study. The author also left an audit trail
illustrated in table format. This table establishes the researcher’s line of thinking. Examples of how raw data lead to the
identification of thematic elements were provided and further establish rigor for this study.
Findings, conclusions, implications, and recommendations
Findings from a qualitative study generally are discussed in a narrative format that tells the story of the experience through
an exhaustive description and thematic elements. Conelius (2015) summarized conclusions, implications, and
recommendations from the study. The findings were also compared to prior research studies. In qualitative research, this is
the area that must include a comprehensive incorporation of current research on the topic. According to Conelius (2015):
Aspects of the five themes that describe the essence of a woman’s experience living with an ICD have been
reported in previous studies, but nowhere is there a study that is an exact comparison to this study. For
instance, theme 1 (security blanket: if it keeps me alive it’s worth It) is similar to the concept in Fridlund et al.
(2000), a feeling of gratitude, and a feeling of safety. The women in this study expressed a feeling of safety and
appreciation since they received their ICDs. This sense of safety and trust in the device is consistent with
other studies. (Bilge et al., 2006; Dickerson, 2002; Morken et al., 2009)
Contrary to what is found in the literature, the women in this study reported how they have more energy than
before and noticed an actual increase in physical functioning. Previous studies have identified decreased
physical functioning (Dickerson, 2005; Kamphuis et al., 2004; Williams, Young, Nikoletti, & McRae, 2007) and a
decrease in activity levels in their day-to-day lives (Bolse, Hamilton, Flanangan, Caroll, & Fridlund, 2005; Eckert
& Jones, 2002). This contradiction can be related to the types of studies conducted. Previous studies have
used questionnaires while this study focused on actual descriptions experienced by participants who had
undergone the device implant. Theme 3 (a constant reminder: I know it’s there) described the women “knowing
that the device was in their chest,” and it was a reminder of their condition. They also described how it affected
their body image. There were two other studies that had mentioned this as a concern for women. One study
by Walker et al. (2004) reported body image concerns of women. The women in that study were more
concerned on how the device appeared in their chest (i.e., the scar) than any other aspect. A second study
by Tangney et al. (2003), also reported body image concerns in women since it can be seen in their chest
which makes them aware of the device. There were similarities with respect to body image only. They were not
concerned with the constant reminder aspect of the cardiac disease, only a constant reminder of their mortality.
(Dickerson, 2002)
The common concern as described in theme 4 (Living on the Edge: I do not want my device going off) was the
fear of the device having to shock them as well as the uncertainty of when, where, and who would be around
for support. This was foremost in their thoughts. There have been common themes of fear of the device going
off or shocking them in the literature reviewed. Dickerson (2002, 2005) reported that uncertainty of when and
where shocks can be triggered was a prevailing concern of the male and female participants. Also, participants
in Albarran, Tagney, and James’ (2004) study reported a feeling of uncertainty regarding the device firing. The
prevailing concern in theme 5 (catch 22: I’d rather not have it.) Is the conflict women have after receiving a
device. These women knew that they medically needed the device yet would have rather not have gone
through with it. Dickerson (2005) reported the theme of conditional acceptance that touches on the same
concept. Also, a greater acceptance of the new situation was reported in previous studies. (Carroll & Hamilton,
2005; Kamphuis et al., 2004)
The women in this study offered specific experiences of living with an ICD which is not completely seen in any
previous study. Moreover, there were some similar aspects identified in other studies such as receiving a shock
and feeling of safety but most were not specific to women. (Bilge et al., 2006; Dickerson, 2002, 2005; Morken
et al., 2009)
This study was able to describe the essence of women who are living with an ICD. The study remained true to
qualitative research design. The focus on women was important, as there have been no gender specific studies to date.
Capturing the fear and uncertainty for women with an ICD can have an impact on clinical practice and patient education.
The author emphasized that these concerns are not being addressed properly in the healthcare system. This study can help
clinicians gain an understanding of the experience these women are having and perhaps pay closer attention to these issues
when they are seen in outpatient settings (Conelius, 2015).
The research may also be helpful in the establishment of support groups for women with ICDs. “Support groups can
expose women to different types of resources in order to cope better, decrease anxiety, and answer any questions that
arise” (Myers & James, 2008). “Since the women have an outstanding fear of the device firing/shocking them, a
noteworthy follow-up study would be to describe their experience post firing/shock” (Conelius, 2015). By capturing the
experiences of women with ICDs, the potential for better sensitivity toward the patient experience exists. This may be
critical to overall quality of life and extends beyond the actual purpose and operation of the device. Conelius (2015) has
made an important contribution to the understanding of women’s experiences with an ICD.
The critical appraisal of a qualitative study involves an in-depth review of each step of the research process. The
example of a qualitative critique in this chapter provides a foundation for the development of critiquing skills in qualitative
research.
Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional
research articles for practice in reviewing and critiquing.
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Critique of a quantitative research study
The research study
The study “Symptoms as the Main Predictors of Caregivers’ Perception of the Suffering of Patients with Primary Malignant
Brain Tumors” by Renata Zelenikova and colleagues, published in Cancer Nursing, is critiqued. The article is presented in
its entirety and followed by the critique.
Symptoms as the main predictors of caregivers’ perception of the suffering of patients with
primary malignant brain tumors
Renáta Zeleníková, PhD
Dianxu Ren, MD, PhD
Richard Schulz, PhD
Barbara Given, PhD
Paula R. Sherwood, PhD
Key words
Brain neoplasms
Caregivers
Neurobehavioral
manifestations
Background: The perception of suffering causes distress. Little is known about what predicts the perception of suffering
in caregivers. Objective: The aims of this study were to determine the predictors of caregivers’ perceptions of the suffering
of patients with a primary malignant brain tumor and to find to what extent perceived suffering predicts the caregivers’
burden and depression. Methods: Data were obtained as part of a descriptive longitudinal study of adult family caregivers
of persons with a primary malignant brain tumor. Recruitment took place in outpatient neuro-oncology and neurosurgery
clinics. Caregiver perception of care recipient suffering was measured by 1 item on a scale from 1 to 6. Results: The sample
of caregiver interviews 4 months after recipients were diagnosed consisted of 86 dyads. While controlling for age, years of
education, tumor type, being a spousal caregiver, spiritual well-being, and anxiety, perception of overall suffering was
predicted by such symptoms as difficulty understanding, difficulty remembering, difficulty concentrating, feeling of distress,
weakness, and pain. Caregivers’ perception of the patient’s degree of suffering was the main predictor of caregiver burden
due to schedule 4 months following diagnosis. Conclusions: Care recipient symptoms play an important role in caregivers’
perception of the care recipients’ suffering. Perception of care recipient suffering may influence caregiver
burden. Implications for Practice: Identifying specific predictors of overall suffering provides meaningful information for
healthcare providers in the field of neuro-oncology and neurosurgery.
In the nursing and healthcare literature, suffering is commonly described in terms of an awareness of the impact of a
deteriorating physical state on an individual : the construction of events such as pain or loss as threats to the individual self ;
a visceral awareness of the self’s vulnerability to being broken or diminished at any time and in many ways ; and the
experience of having to endure, undergo, or submit to an evil of some sort. Suffering is an intensely personal
experience whose presence and extent can be known only to the sufferer, something unsharable that, paradoxically,
involves asking the question “why.” Researchers in diverse settings consistently have concluded that suffering exists across
dimensions of physical, psychological and emotional, social and interpersonal, and spiritual and existential well-being. For
our purposes, suffering is a broad construct defined as a state of severe distress associated with events that threaten the
intactness of the person as a complex physical, social, psychological, and spiritual being and that is subjective and unique
to the individual.
Serious disease can result in serious suffering. Analogous to the association of pain with suffering is the association of
cancer with death. Another major factor in the association of cancer with suffering is the recognition of the drastic effects
of cancer treatments. Even with a good prognosis, the effects of surgery, chemotherapy, and radiation therapy are distressing
and can be devastating. Suffering of patients with primary malignant brain tumors (PMBTs) can be particularly notable
across the cancer trajectory encompassing initial diagnosis, treatment, remission, and even long-term survival. In addition,
patients with PMBT can have cognitive deficits including difficulty speaking, difficulty remembering, or difficulty
concentrating. These neurologic deficits can drastically interfere with daily life and function. Persons diagnosed with a
PMBT are faced with a unique and challenging set of circumstances that affect not only them but also those close to
them. Caregivers of persons with a PMBT must deal with both oncological and neurologic issues. They are charged with
caring for a person with a potentially terminal diagnosis who is undergoing active cancer treatment and may have cognitive
and neuropsychiatric sequelae. Suffering typically occurs in an interpersonal context and is shaped by and affects others
1
2
3
4
5
1
6
5
5
7,8
9
5
10
11
exposed to it.12 Predictors of caregivers’ perceptions of suffering in persons diagnosed with PMBT are not established in part
because of a lack of valid and reliable instruments to measure the caregiver’s perception of the care recipient suffering.
The main purpose of this study was to determine the predictors of caregivers’ perceptions of the suffering of patients
with PMBT. We predicted that care recipients’ symptoms would be the main predictors of caregivers’ perceptions of the
suffering while controlling for tumor type and caregivers’ characteristics (age, years of education, being a spousal caregiver,
spiritual well being, and anxiety).
Theoretical framework
The study framework was derived from the work of Schulz and colleagues13 and reflected perceived suffering, caregiver
compassion, and caregiver helping and health; this framework guided identifying potential predictors of caregivers’
perceptions of the suffering of patients with PMBT and to find out to what extent caregivers’ perceptions of the patients’
suffering predicted the burden borne by caregivers and caregiver depression. Although the framework emphasizes the
directional effects of perceived suffering on compassion, 1 of the framework components depicts perceived suffering as
directly linked to psychiatric and physical morbidity. Therefore, we hypothesized that perceived suffering can impact
caregiver burden and caregiver depression.
Being exposed to the suffering of others is an important and unique source of distress. 12 Research in dementia patient
populations indicates that perceived suffering can contribute to care giver depression and caregiver burden. 7,12 Similarly,
descriptive findings in a longitudinal study in 1330 older married couples enrolled in the Cardiovascular Health
Study confirmed that exposure to spousal suffering is an independent and unique source of distress in couples and contributes
to psychiatric and physical morbidity.14
Psychobehavioral responses of caregivers that include depression, burden, anxiety, and positive responses to care have
been studied previously, mostly in patients’ population with dementia or oncology disease. Caregiver burden and depression
may be considered as a general distress response for caregivers. 15 Caregiver burden is a multidimensional concept and
represents the impact of providing care on different areas of the caregiver’s life (schedule, self-esteem, health, finances,
feeling of abandonment), psychosocial reaction resulting from an imbalance of care demands relative to caregivers’ personal
time, social roles, physical and emotional states, financial resources, and on formal care resources given the other multiple
roles they fulfill.15
Depression is 1 of the most important potential adverse consequences for caregivers because it is common, associated
with poor quality of life, and is a risk factor for other adverse outcomes including functional decline and
mortality.16 Caregiver depression is a complex process, mediated by cultural factors (as measured by the ethnicity of the
patient), patient characteristics, and caregiver characteristics.16 Positive aspects of caregiving may decrease feelings of being
burdened and subsequently lead to a more positive effect of health outcomes.
Measuring suffering
Research methods for approaching human suffering are often qualitative and are based on interviews with people who are
assumed to have experienced suffering.17 Some authors believe that attempting to measure suffering is reductionist and futile
because of its personal and unsharable nature.7 While suffering is personal and potentially ultimately incommunicable, from
a practical standpoint, that is, in order to design suitable interventions to relieve suffering, measures that approximately
capture a communicable core of suffering are needed. According to Monin and Schulz,18 both the experience of suffering
and the perception of suffering by others can be measured. Ultimately, measures of suffering should focus on the patient’s
experience, the patient’s direct and indirect expressions of suffering, caregiver perceptions of the patient’s degree of
suffering, and caregiver perceptions of whether the patient’s expression of suffering is an accurate reflection of his/her actual
degree of suffering.13
Measuring suffering via caregiver perceptions of suffering is useful and important, especially for patients with impaired
cognitive status because this patient population may not be able to report suffering. To better understand the perceived
suffering, we examined caregivers’ anxiety and spirituality. Caregivers can play a role in relieving the suffering of their
loved one by sharing the experiences, or if the suffering cannot be relieved, then caregivers can help their loved one to bear
it through their companionship and compassion. To help caregivers cope with caregiving distress, researchers need to
identify how caregivers perceive the suffering of their patients and the predictors of these perceptions.
Aim
The main aim of this study was to determine the predictors of caregivers’ perceptions of the suffering of patients with
PMBTs. The secondary aim was to find out to what extent caregivers’ perceptions of the care recipients’ suffering predicted
the care givers’ burden and depression.
Methods
Design and setting
Data were obtained as part of a descriptive longitudinal study of adult family caregivers of persons with PMBT (R01
CA118711). Care recipient and caregiver dyads were recruited from suburban neurosurgery and neuro-oncology clinics in
Western Pennsylvania. Recruitment took place in outpatient neuro-oncology and neurosurgery clinics from October 2005
through June 2011. Data were collected from persons with a PMBT and their family caregivers. Interviews with caregivers
were conducted in person or via telephone. Data were collected at 3 timepoints over the disease trajectory—right after
diagnosis and 4 and 8 months after diagnosis. Data for this analysis are from the second timepoint—4 months after diagnosis
to focus on a time of illness progression. Approval from the institutional review board at the University of Pittsburgh and
informed consent from participants were obtained prior to data collection. Both the patient and caregiver had to consent to
enroll in the study.
Participants
Caregivers were queried regarding sociodemographic characteristics, personal characteristics, and psychological responses,
and care recipients were queried regarding the tumor grade, functional and neurologic ability, and symptom status. Care
recipients were required to be older than 21 years, newly diagnosed (within 1 month of recruitment) with a PMBT verified
by a pathology report. After the death of the care recipient, the corresponding caregiver was given the option of continuing
to participate in the study. Caregivers were required to be older than 21 years, nonprofessional (ie, not paid caregivers), not
a primary caregiver for anyone else (excluding children aged
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