Critical Appraisal of Evidence on Rehabilitation Needs After Stroke

This paper critically appraises an article by Ekstam et al. (2015) on the combined perceptions of people with stroke and their carers regarding rehabilitation needs 1 year after stroke. The article utilizes a mixed method design and provides insights into the dyadic perspective on rehabilitation needs. The paper discusses the strengths and limitations of the article and its relevance to evidence-based practice.

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Title page
Student Name:
HLSC122 Semester 1, 2018
Assessment 3: Critical appraisal of evidence
Word count:
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Introduction:
Evidence based practice can be defined as the scientific and systematic process
of combining the knowledge and information derived from the authentic and reliable
literature sources in order to be able to implement best practice in the care scenario.
Evidence based practice is a framework that allows the nursing professionals to ensure
optimal safety and efficacy of the care interventions provided to patient and enhances
patient centered- ness of the care program (McKevitt et al., 2011). However, in order for
the nurses to be able to perform adequate evidence based practice, it is crucial for the
nurses to understand the authenticity, reliability and relevance of the literature. Critical
appraisal exercise can be considered as one of the most effective technique for the
nurses to develop the ability or the skills to engage in independent evidence based
practice. This paper will attempt to critically appraise an article by Ekstam et al. (2015)
Body:
Ekstam, L., Johansson, U., Guidetti, S., Eriksson, G., & Ytterberg, C. (2015). The
combined perceptions of people with stroke and their carers regarding
rehabilitation needs 1 year after stroke: a mixed methods study. BMJ open, 5(2),
e006784.
PART A
Authorship:
The author affiliations for each author respectively are:
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1. Division of Occupational Therapy, Department of Neurobiology Care Sciences
and Society, Karolinska Institutet, Huddinge, Sweden
2. Department of Occupational Therapy, Karolinska University Hospital, Stockholm,
Sweden
3. Department of Clinical Research, Uppsala University/County Council of
Gävle, Gävle, Sweden
4. Department of Neuroscience and Rehabilitation Medicine, Uppsala
University, Uppsala, Sweden
5. Department of Clinical Neuroscience, Division of Neurology, Karolinska
University Hospital, Huddinge, Sweden
6. Division of Physiotherapy, Department of Neurobiology Care Sciences and
Society, Karolinska Institutet, Huddinge, Sweden
As the all of the authors are extremely qualified and experienced they can be
considered to have more than enough expertise to have conducted a valid and
relevant research. As all the authors belong to same nation being Sweden and
belonged to similar research domain, the possibility of conflicts is also low.
Research question:
The research question asked by this particular paper is “what is the association
between the dyad’s perception of the person with stroke’s rehabilitation needs,
stroke severity, personal factors (gender, age, and sense of coherence), the use
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of rehabilitation services, amount of informal care and caregiver burden.
Furthermore, the research has also questioned the personal experience of
everyday life changes among persons with stroke and their caregivers and their
strategies for handling these, 1 year after stroke. In justification of the needs for
the study, the authors have explained that the perception of the dyads, the
person coping through the period after stroke and the informal caregiver, with
regards to the rehabilitation needs and plausible associations between such
perceptions and caregiver burden has not been extensively explored in the
previous studies (Ekstam et al., 2015). Furthermore, the authors have also stated
the fact that the combination of a qualitative and quantitative data in this aspect
can help in shedding light on the complex issue in post-stroke rehabilitation and
the dyadic perception.
Research design:
The authors have taken the assistance of a mixed method design which combined both
the quantitative and qualitative data collection and analysis. Now it has to be
mentioned that both quantitative and qualitative data is considered to be viable
research methods independently. Elaborating more on the mixed method
research design, it has to be mentioned that this research design represents an
approach to inquiry and has a much broader perspective (Malina, Nørreklit &
Selto, 2011). For this research design, the study is more focused on the
research question and using all possible measures to explore the variables
bearing direct or indirect link to the research problem. Along with that, it has to be
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mentioned in this context that a mixed method of research study design is
capable of camouflaging the individual issues that persist with any one of the
qualitative or quantitative studies (Lewis, 2015). With respect to the relevancy to
the research study, as the research question is broad and encompasses a
variety of different factors that develop the basic perception of a dyad in the
aspect of stroke rehabilitation, it can be presumed only qualitative or quantitative
data collection could have fallen short of addressing all the confounding factors
associated with the issue. Hence, the choice of mixed method seems relevant to
the needs of the research study and the research aims and objectives.
Research methods:
The research method selected had been mixed and the data analysis method selected
by the authors has been secondary from a prospective observational study of the
rehabilitation process after stroke, named ‘Life After Stroke phase 1’. 349
patients were included in the study and were taken informed consent from to
participate in the study for 3,6, and 12 month follow up. For the informal caregiver
the choice had been wide involving e a partner, a son or daughter or a friend;
which an excellent step for inclusion for the participants. The interviews involved
both open-ended and close ended questions, which provided the participants
with the liberty to share information as per their liking. Lastly, the interviews were
conducted in the comfort of their homes which eliminated the need for the
participants to take the suffering of physically coming to follow ups and avoided
the risk of participants dropping out from follow up (Christensen et al., 2011).
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Hence, the research methods utilized were targeted, analytical and extremely
relevant.
For the data collection and analysis, the use of likert scale and ANOVA test provided
excellent measures for the data to be systematically analyzed. As interview and
medical records were both involved in the data collection process, the data
collected had been extensive and relevant (Ekstam et al., 2015). However, the
inclusion of the open ended questionnaire and use of set answers on a statement
about rehabilitation needs only provided generalized information and data had
not been rich enough to make comparisons between the partners in the dyads.
Results:
The research question for the study had been to question the exact perception of the
partners within dyad regarding the rehabilitation needs and to the different factors
associated with the rehabilitation needs including the caregiver burden. The
results of the study indicated 52% of the dyads perceived that need for
rehabilitation in a stroke patient are met after 10 months after the stroke event.
This indicates the fact that people with rehabilitation needs being met had
suffered a less severe stroke and fewer stroke related difficulties with more
strategies for solving everyday problems (Ekstam et al., 2015). The findings also
indicated the perception of rehabilitation needs, 1 year after stroke, differs
between dyads in relation to stroke severity and major life events. In dyads
where rehabilitation needs were met, the persons with stroke had a higher SOC
than those in dyads with discordant views. Caregiver burden was also rated
lower in dyads with met rehabilitation needs with some having social advantages
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after the stroke. Hence the research question was met as it clearly provided the
perception of the caregivers regarding the rehabilitation needs and to what extent
their perceive it to be met (Gosman‐Hedström & Dahlin‐Ivanoff, 2012). The study
re-affirmed the previous literature studies on rehabilitation needs, with the only
unique contribution being the dyadic perspective.
PART B:
There are certain barriers and limitations of any literature to be able to be
implemented in the practice scenario. These barriers involve quality of the research
evidence, transferability of the study, clinical applicability and even patient values. This
research has undoubtedly provided a clear idea on the dyadic perspective on the
rehabilitation needs, there are certain barriers (Zohrabi, 2013). First and foremost, the
population size had been small for the study and the results may vary in a larger setting.
The qualitative data collected had also been generalized, lacking richness and can be
attributed to personal biases. On a more specific note the questions about the perceived
rehabilitation did not define what rehabilitation encompasses, rather the participants
only responded to their best understanding and knowledge of rehabilitation. Hence, the
results are based on the informal caregivers’ idea of rehabilitation which can differ from
different elements of rehabilitation after stroke (Tistad et al., 2012). Hence, this study
can be fertile ground for further research to emphasize on dyadic perspective, but due
to the barriers identified it cannot be implemented in practice.
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Conclusion:
Evidence based practice has become of the greatest pillars of health care
delivery in the present scenario and as a result, it has become one of most critical
requirements of the nursing professionals to adhere to with respect to the care planning
and implementation. This had been an excellent opportunity for me to understand
critical appraisal of articles and how to identify the strengths and limitations of an article,
and lastly whether or not it can be implemented in evidence based practice. It can be
hoped that this experience will help me perform evidence based practice effectively in
the future practice.
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References
Christensen, L. B., Johnson, B., Turner, L. A., & Christensen, L. B. (2011). Research
methods, design, and analysis.
Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative,
and mixed methods approaches. Sage publications.
Ekstam, L., Johansson, U., Guidetti, S., Eriksson, G., & Ytterberg, C. (2015). The
combined perceptions of people with stroke and their carers regarding
rehabilitation needs 1 year after stroke: a mixed methods study. BMJ open, 5(2),
e006784
Gosman‐Hedström, G., & Dahlin‐Ivanoff, S. (2012). ‘Mastering an unpredictable
everyday life after stroke’–older women’s experiences of caring and living with
their partners. Scandinavian journal of caring sciences, 26(3), 587-597.
Lewis, S. (2015). Qualitative inquiry and research design: Choosing among five
approaches. Health promotion practice, 16(4), 473-475.
Malina, M. A., Nørreklit, H. S., & Selto, F. H. (2011). Lessons learned: advantages and
disadvantages of mixed method research. Qualitative Research in Accounting &
Management, 8(1), 59-71.
McKevitt, C., Fudge, N., Redfern, J., Sheldenkar, A., Crichton, S., Rudd, A. R., ... &
Rothwell, P. M. (2011). Self-reported long-term needs after stroke. Stroke, 42(5),
1398-1403.
Tistad, M., Koch, L., Sjöstrand, C., Tham, K., & Ytterberg, C. (2013). What aspects of
rehabilitation provision contribute to self‐reported met needs for rehabilitation one
year after stroke–amount, place, operator or timing?. Health Expectations, 16(3).
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Tistad, M., Tham, K., von Koch, L., & Ytterberg, C. (2012). Unfulfilled rehabilitation
needs and dissatisfaction with care 12 months after a stroke: an explorative
observational study. BMC neurology, 12(1), 40.
Zohrabi, M. (2013). Mixed method research: Instruments, validity, reliability and
reporting findings. Theory and Practice in Language Studies, 3(2), 254.
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