Mental Health Nursing

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The objective of this assignment is to critically evaluate the following research article: Bowes, S., Lowes, L., Warner, J., & Gregory, J. W. (2009). Chronic sorrow in parents of children with type 1 diabetes. Journal of Advanced Nursing, 65 (5), pp. 992-1000 (Appendix 1). For the purpose of this essay, the Critical Appraisal Skills Programme (CASP) (Appendix 2) is the critiquing framework used to guide this essay.

Walsh and Wigens (2003) say that critical evaluation allows people to see the validity of a study by assessing all parts of it in depth. Hek (1996) agrees with this and states that when research material is critiqued, it is imperative to highlight the strengths and the weaknesses of the study in order to identify its worth. This essay aims to display that although the study gives a greater insight into the emotions and impact that chronic sorrow has on parents of a child with diabetes, the study has numerous limitations that need to be addressed before the findings could be representable of the current population and then transferred to evidence-based practice.

Whilst a continual process of grieving, such as chronic sorrow, draws attention to concerns about depression, there have been no published studies that have distinguished the difference between chronic sorrow and depression. This particular article was chosen in order to gain more knowledge surrounding the impact that diabetes has on the individual’s family as it is apparent that the emotional needs of the parents are not being met by the healthcare service.

Conducting research-based evidence is fundamental to the use of evidence-based practice (Polit and Beck, 2004) as research is crucial in supplying evidence on the strengths and limitations of clinical interventions. It is also an important device used in nursing to increase the evidence base used in clinical governance, to evaluate the effectiveness of current nursing practice and to effectuate quality services for patients (McSherry and Haddock, 1999). The Nursing and Midwifery Council (NMC, 2008) is in accordance with this as it states that you must ‘you must deliver care based on the best available evidence or best practice’. However, the evidence collated by research does not automatically permit current practice to be changed: the main function of evidence-based practice is to use research in order to improve practice and to guarantee that whatever task is being undertaken is in the best interests of the patient (Aveyard and Sharp, 2009).

The title of the article, as stated above, is brief and clear and offers an indication of what the study compromises of. According to Parahoo (2006), the title of an article can become misleading if it is too short or too long and also it should suggest the purpose of the study being undertaken. However the title suggests that “Chronic Sorrow” is a definite response to a child having ‘type one diabetes’ rather than identifying the prevalence amongst parents. As reported by Cormack (2000), researchers must be duly qualified in order to undertake a research study and it is noted that one of the authors has a PHD, highlighting an educational background and suitable qualifications.

There are four authors who facilitated the study in total, two registered nurses and two doctors’. The credentials and qualifications of each individual are clearly indicated on the front page. It is apparent that all four authors have specialisms in the areas of paediatric diabetes and endocrinology. Throughout the paper, previous studies conducted by the authors are referenced, signifying a large interest surrounding the topic. The fact that the authors reference studies conducted by them proposes that research on topic may be limited and will need further investigation.

The abstract gives a brief summary of the study, highlighting the aim, background, methodology, findings and conclusions. One limitation noted is that the aim appears ambiguous; it states it is a study ‘exploring parent’s longer term experiences of having a child with type one diabetes’ and does not focus on ‘Chronic Sorrow’. This could pose questions regarding the validity of the study as it is misleading. An abstract enables the reader to determine if the article is relevant to their field of practice or development as researchers are mindful of the fact that the majority of people will only read the abstract (Cormack, 2000). The remainder of the abstract offers a summary of method (in-depth interviews), the group (parents) and the overall findings.

The purpose of the introduction is to ascertain the issue and the basis for the study which is something that Polit and Hungler (1999) agree with, stating that the introduction should highlight why the study is significant and how it is applicable. The introduction does not make the limitations apparent which, according to Cormack (2000), should also be evident but they are highlighted further on in the paper. The introduction points out the epidemiology of children with type one diabetes, how it is characterised, the risk of complications and morbidity. Although it stresses the symptoms of type 1 diabetes and the effects it could have on a parent, it does not emphasize the need for the study or the importance of the research. The introduction of the study may have been more useful to the reader if the author had clearly indicated the necessity of the study.

The participants were a convenience sample of seventeen parents, ten of which were mothers and seven were fathers. Convenience sampling, also known as nonprobability sampling, is a technique where participants are selected due to their proximity and availability to the researcher. This method suffers from some critical weakness as it is not representative of the entire population and there is no way to estimate the potential bias, which therefore poses the question of validity of the study (Polit and Beck, 2009). Huberman and Miles (2002) propose that a smaller sample is size is better in qualitative studies as it focuses on the quality of the information received rather than the quantity of information received. The age range of the children in the sample was 9-23 years; this age range is quite large and would suggest that some of the parents have been dealing with their child having diabetes longer than others, consequently signifying the levels of acceptance would be different for each parent. Also participants were recruited from one health service centre in wales which could imply that the study is only relevant to that specific area and, once again, not typical of the entire population.

As stated above, one of the more significant weaknesses of the study is the size of the sample. The authors use phrases such as ‘many parents’ and ‘mothers were far more likely than fathers to talk about their emotions’. Sweeping statements like this give the view that the findings are applied to large amount of participants when in fact they are actually applicable to seventeen parents. This, in turn, emphasizes the need for further exploration with additional participants and the applicability to the wider population.

It states that Mothers and Fathers were interviewed separately to enable comparative data between paternal and maternal responses to the questions but the study also allowed two parents from separate families to be interviewed together. What the researcher fails to do is clarify whether it was a mother and a father, two mothers or two fathers being interviewed. As the responses and emotions displayed could have been influenced by the other participant in the room (Borbasi et al, 2008) the author’s ability to collect comparative data is compromised.

The interviews focus on the parent’s experience of caring for a child with diabetes for 7-10 years, the authors used semi-structured interviews all which started with the initial question ‘Describe your experience of having a child with type one diabetes’. Semi structured interviews typically have a topic of conversation that they want to follow but it is steered by the participant, it is often described as a ‘guided conversation’ (Walsh and Wigens, 2003). One major drawback of this approach is that the reliability of the data collected is substandard as it is difficult to compare responses between participants as they may not have been asked identical questions and, as an outcome, can produce inadequate data (Polit and Beck, 2009).

However, Klenke (2008) argues that semi structured interviews create a positive rapport between the interviewer and interviewee, which permits more in-depth information being shared aiding for better data collection. Streubert and Carpenter (2011) similarly report that that unstructured interviews give the opportunity for participants to go explore a greater depth to the answers they give and also, as generalisation of results is not the purpose of the study as it is in qualitative research, there is no need to select participants randomly. The researcher admits that ‘only minimal prompting was needed’ as parents elaborated on anticipated topics which points to the suggestion that participants were not asked corresponding questions. This then argues the validity of the data and how it is unable to be applied to the rest of the population. The findings of the paper may have been more persuasive if the researcher had used structured interviews instead of semi-structured interviews as it allows the participant to answer in-depth questions in a longer process and would add to the reliability of the data.

Ethics is an important part of research and studies need to be scrutinised and approved before publishing. The study was sanctioned by the appropriate ethics committees. The article states that participants gave written consent preceding the telephone interview and were given the option to withdraw at any point. The interviews were transcribed precisely and pseudonyms were used to ensure their confidentiality. The authors describe the methods used in some detail allowing for replication of the study in its broad sense at a later date. However, it does not state that copies of the transcript were shown or distributed to the participants to verify the information being recorded which stresses another issue of validity as information could have been interpreted differently to what was originally intended. Taylor et al (2006) claim that ‘member checks’ should be undertaken during qualitative research to verify the data collected. ‘Member Checks’ are where participants of the study audit parts of the study to ensure the researcher has presented their contributions in the way it was intended.

Another major drawback of the study is that it fails to address the issue of culture. Cultural perspectives can shape people’s reactions to grief. As a result of this, responses to grief within a culture vary from one person to the next; this is especially so in societies that are made up of various cultural backgrounds. McCubbin et al (1993) draw focus to the fact that healthcare professionals need to be able to recognise how cultural diversity affects grief and how it affects their method of dealing with childhood illness which is something the researchers have failed to do.

The article is clearly presented and has incorporated information that is interesting and relates to practice. Although the article was published in a peer-reviewed journal, many limitations were highlighted which reduces the articles credibility and applicability to the wider population. The findings are thought-provoking and enhance the understanding of chronic sorrow but the limitations need to be taken into account and addressed in order for the study to be more reliable. Further research that may enable the study to be more persuasive in regards to evidence-based practice is to conduct the research with a larger sample group which includes evidence of cultural diversity and conducts interviews that are structured.

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