Critical Appraisal of a Qualitative Study on COPD Exacerbations

This report provides a critical appraisal of a qualitative research study investigating the experiences of patients in recognizing and managing COPD exacerbations at home. The study, which employed a qualitative design using semi-structured interviews and grounded theory analysis, aimed to explore how COPD patients identify and self-manage exacerbations. The report analyzes the study's background, objectives, sampling methods (purposeful sampling of COPD patients), data collection techniques (semi-structured interviews), and data analysis approach (grounded theory with NVIVO-10). The findings suggest that patients utilize both visible and subjective symptoms to identify exacerbations and employ self-management strategies. The report also highlights the study's strengths, limitations, and implications for healthcare practice, emphasizing the importance of patient education regarding exacerbation recognition and management. The critique evaluates the rigor and trustworthiness of the research, referencing relevant literature and considering the study's contribution to evidence-based practice in COPD management.

Critique
Research Critique
Critical appraisal involves systematic inquiry of the article to determine its
appropriateness, trust-worthiness as well as relevance for its applicability in healthcare
context (Polit, 2016). A detailed critical evaluation of the qualitative study on ‘the
experience of patients in recognizing as well as managing COPD exacerbations- at
home’ is done. This report carefully analyzes the merits and demerits of the research
methods that underpin this study (Marriam-Webster, 2015). According to GOLD (2013),
COPD affects 33/ 1,000 persons in the UK in which 26.2% of COPD-patients
experience one COPD-exacerbations while 25.5% had more than one episode (Raluy-
Callado, 2015). Hence, all the nurses should undertake research critique to provide best
possible evidenced care to the patients (Grove, 2015).
Background of the study
This study mainly focuses on the exacerbations of chronic- obstructive
pulmonary disease (COPD), affecting about 1 in 3 patients in UK requiring readmissions
within 28 days of previous hospitalization. Proper self-managing strategies can minimize
hospitalizations and enhance outcomes in COPD (Hinkle, 2014). Patients are the first to
recognize alterations in their health-condition and it is highly crucial to understand about
COPD-exacerbations, identify deteriorating features and act appropriately (Lewis,
2013). Hence, this study explores the extent to which the COPD-patients understands,
recognizes and self-manages their exacerbations.
The previous studies suggest that there is no consensus about the definition for
exacerbations as well as how they are identified and understood by COPD-patients.
Few studies suggest that the patients have poor understanding of the meaning of
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Critique
exacerbations while other studies confirm that COPD-patients are well-aware of these
terms. The meta-synthesis by Harrison (2013) suggests that previous qualitative studies
have only examined about the patient’s experience in COPD-exacerbations rather than
how they identify exacerbation-symptoms. Few patients report that they feel safe while
self-managing exacerbation at home. Though many researchers have published about
exacerbation assessment (Sundh, 2013), there is no clear evidence of how COPD-
patients recognizes and manages exacerbations (Risør, 2013). This has motivated
them to propose this qualitative study to understand how COPD-patients identify and
manage COPD-exacerbations.
Research design
Objectives/aims are defined as the specific accomplishments that are formulated
by the researchers to attain what they have planned to inquire (LoBiondo-Wood 2014).
Williams (2014) has stated a clear, concise, acceptable and achievable objective/aim as
‘to explore the current understanding as well as experience of COPD-patients in
identifying and managing COPD-exacerbations- at-home’ as given by Moule, (2013).
They utilized qualitative design which involves a systematic, highly-interactive
and subjective approach used to explore the etiologies, facts, ideas, motivations and
personal-life experiences by giving meaning to them (Polit, 2016). Qualitative
researches are undertaken to describe and improve the understanding of person’s
experiences as discomfort, breathing difficulties, pain, and/or caring (Grossoehme,
2013). According to Yin (2015), qualitative researches are superior to quantitative
researches in investigating the emotions of the persons and also in discovering and
understanding the person as a whole. This design will help them to perform in-depth
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Critique
analysis ‘to explore the experience in finding-out and managing the COPD-exacerbation
by patients at-home’ to find solutions.
Sampling
In a study, the criteria that specify the patient/population characteristics are
known as eligibility or inclusion criteria while the characteristics that the study-
population should not possess is termed as exclusion criteria (Gerrish, 2015). According
to Polit (2016), the eligibility criteria is defined as the criteria that designates any specific
characteristics of the target population through which participants are recruited for the
inclusion in a research-study. They have recruited known case of COPD patients
(target-population) within their inclusion and exclusion criteria as suggested by Iverson
(2014).
Their inclusion/exclusion criteria includes: the patients diagnosed with COPD,
>40 years of age, forced expiratory- lung-volume (FEV1) in 1-s; post-bronchodilator
<80% and predicted ratio of FEV1 with forced-vital lung-capacity (FVC) of <0.70, history
of smoking more than 10 pack years, able to sign in informed consent, MRC- dyspnea
scale score ≥2, registered in a general health-practice & as an COPD-exacerbation
patients requiring home management and/or hospitalized treatment in the previous
year, and/or got referral to any lung-rehabilitation centers, absence of any other
pulmonary diseases and cardiac failure (chronic) as given by the New- York cardiac
association’s grading system with grade- IV (severe), life- expectancy: above 3 months,
ability to clearly understand and write English.
They have recruited those patients who met their eligibility criteria by identifying
them in hospital- admission records, lung rehabilitation centers as well as in general
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Critique
health-practice with the help of a respiratory (research) nurse. The patient
characteristics in this study that includes: gender (male/ female), age, severity of COPD
(GOLD: stage- II, III & IV), duration of COPD symptoms, use of home oxygen, history of
previous attendance in any lung-rehabilitation programmes and patient’s living set-up
(living with spouse/family and/or living alone), is appropriate.
These criteria should be identified before sample recruitment as proper selection
of inclusion and exclusion criteria can enhance the external & internal validity of the
study-findings, improve study- feasibility, minimize the study’s cost and reduce ethical
constraints (Polit, 2016). Specifically, proper recruitment criteria will fairly enhance the
homogeneity of the population selected that enables control of extraneous variables as
well as increases the likelihood to obtain an unbiased interpretation of study-results
(McDonagh, 2013).
Williams (2014) has used purposeful (judgmental) sampling which is a non-
probability sampling in which they have selected the samples based on personal
judgment by which ones will be most informative (Polit, 2016). Though, this sampling
technique can induce subjectivity in sample selection by reducing chance of being
selected for the study, it is one of the best sampling techniques in qualitative study that
involves volunteer informants which can supplement the study.
Their purposeful selection of COPD-patients will help them to attain their
objectives as this method has enabled the researchers to select the samples based on
their personal judgment voluntarily to meet their study preferences to explore their
experiences in identifying and handling the COPD-exacerbation at-home.
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Critique
Data collection
Data collection is defined as the process of gathering data to address the study
problem (LoBiondo-Wood 2014). They have used semi-structured interview schedule
that focused on the topics as experience, identification and management of COPD-
exacerbation by COPD-patients at-home which lasted from 20 to 55 minutes by
encouraging the participants to respond within their topic, as advised by Polit (2016).
They have audio-taped their field notes immediately after their interview in-order to
provide the interview’s context that also aids in their data analysis. The questions in
their interview schedule proves that they have collected data regarding the experience,
identification as well as management of COPD-exacerbations which suggests that their
data collection tool is based on their objective to be explored.
The advantages of semi-structured interviews include: enables interviewer to
prepare and appear competent at the interview because of prior preparation; allows
freedom to the informants to tell-out their own views; provides valuable, reliable with
comparable qualitative-data; promotes 2-way communication by allowing interviewee to
question the interviewer (functioning like an extension-tool); provides not just the
answers but also the reasons for it and it also allows the informants to discuss sensitive-
issues (Polit, 2016). The disadvantages include: the interviewer should be skilled;
necessitate sufficient participants to draw comparisons; requires effective preparation
(no prescriptive or leading questions); skill in analyzing collected data; time consuming;
resource intensive and able to ensure confidentiality (Yin, 2016).
They could have used focused-group interview as an alternate in which a group
of 4 or more members can be gathered for a discussion conducted by the researcher
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Critique
with a written question set (Polit, 2016). They are carefully planned sessions that helps
to gather rich informations from the participants. This also helps the participants
(homogeneous group) to express their views easily in a similar background.
Data analysis
Qualitative analysis involves organizing and interpreting the narrative data to
discover underlying facts, themes, and patterns of relationships (Yin, 2016, THS. 2015).
The researchers have audio-taped the collected data, transcribed verbatim and then
anonymised their transcripts by importing into a qualitative software-data programme
(NVIVO-10) to enable storing, organizing and analyzing the data. They have analyzed
using grounded-theory approach and by constant-comparative measure with open-type,
axial-type and selective-coding as well as memo-writing in-order to trace-out the
existing theoretical linkages and conceptual details from the collected data.
Appropriate methods should be selected in qualitative analysis as it involves
organizing data, providing structure and eliciting meaning from data to frame themes,
concepts and theories (Yin, 2016). Unlike quantitative, qualitative analysis is labor-
intensity process that necessitates creativity, hard-work and conceptual sensitivity.
Absence of standard analytical rules, enormous work requirement and reducing data for
reporting purpose challenges qualitative analysis (Polit, 2016).
The researchers mentioned that they ensured rigour in their coding process by
allowing 2 interviews to be encoded by a well-experienced qualitative-researcher in their
department (but external to their study). Additionally, all the research team-members
met at regular intervals to discuss about the process of data-analysis and data-
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interpretation. These processes have helped them to achieve transparency as well as
credibility of study-findings (Yin, 2016).
The study-findings suggest that COPD-patients have identified their
exacerbations based on their visible (objective/measurable) symptoms that include
cough producing sputum as well as invisible (subjective) features as sensations in chest
along with bodily knowledge. Majority of COPD-patients appeared to use both visible
and invisible approaches in recognizing COPD-exacerbations based on their previous
experience. Patients were also found to use self-management strategies at the
exacerbation time that includes intake of self-medications as antibiotics & steroids and
monitoring their improvement and they contact health-professionals only when they
were unable to manage by their own.
These findings can be transferred into newly diagnosed patient settings where
educating them with visible and invisible symptoms will make them free from acute
exacerbations. Further researches have to be conducted to quantify the patient-
experiences by clarifying the current COPD-exacerbation’s definition and informing
clinical measures to enable earlier identification & management of COPD-exacerbation,
specifically in the tele-monitoring interventions.
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Reference
Gerrish, K., & Lathlean, J. (2015). The research process in nursing (7th ed.). Malden,
MA: John Wiley & Sons.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2013). Global Strategy
for the Diagnosis, Management and Prevention of COPD. Retrieved from
http://www.goldcopd.org/
Grossoehme, D.H et al. (2013). "I honestly believe God keeps me healthy so I can take
care of my child: Parental use of faith related to treatment adherence: Journal of
Health Care Chaplaincy, 19(2), 66–78. doi: 10.1080/08854726.2013.779540.
Grove, S. K., Grey, J. R., & Burns, N. (2015). Understanding nursing research: Building
an evidence-based practice (6th ed.). London, United Kingdom: Elsevier
Harrison, S.L. (2013). Consumed by breathing—A critical interpretive meta-synthesis of
the qualitative literature. Chronic Illn. 10, 31–49.
Hinkle, J.L. (2014). Brunner’s and Suddarth’s Textbook of Medical Surgical Nursing.
(13th ed.). Philadelphia: Lippincott Williams and Wilkins.
Iverson, K.M. (2014). Women veterans’ preferences for intimate partner violence
screening and response procedures within the Veterans Health Administration.
Research in Nursing and Health, 37, 302-311
Lewis, S.M., Heitkemper, M. M., & Dirksen, S.R. (2013). Medical Surgical Nursing:
Assessment and Management of Clinical Problems. (9th ed.). Missouri: Mosby.
LoBiondo-Wood, G & Haber, J. (2014). Nursing Research: Methods and Critical
Appraisal for Evidence-Based. Retrieved from https://books.google.co.in/books?
isbn=0323100864
8

Critique
Marraim-Webster. (2015). Critique. Retrieved from http: www//learners
dictionary.com/search/ Critique
McDonagh, M. (2013). Avoiding Bias in Selecting Studies - Methods Guide for
Effectiveness. Retrieved from https://www.ncbi.nlm.nih.gov › NCBI › Literature ›
Bookshelf
Moule, P & Goodman, M. (2013). Nursing Research: An Introduction. Retrieved from
https://books.google.co.in/books?isbn=1446293521
Polit, D.F & Beck, C.T. (2016). Nursing Research: Generating and assessing evidence
for nursing practice. Lippincott Williams & Wilkins: New Delhi.
Raluy-Callado, M. (2015). Epidemiology, severity, and treatment of chronic obstructive
pulmonary disease in the United Kingdom by GOLD 2013. Int J Chron Obstruct
Pulmon Dis, 10(1), 925–937
Risor, M.B. (2013). The complexity of managing COPD exacerbations: a grounded
theory study of European general practice. BMJ Open, 3, e003861\
Sundh, J. (2013). Management of COPD exacerbations in primary care: a clinical cohort
study. Prim Care Respir J, 22, 393–399.
THS. (2015). Epidemiology- Glossary of Epidemiological and Statistical Terminology.
Tropical Health Solutions. Retrieved from
http://www.tropicalhealthsolutions.com/statsglossary
Williams, V., Hardinge, M., Ryan, S., & Farmer, A. (2014). Patients’ experience of
identifying and managing exacerbations in COPD: a qualitative study. npj
Primary Care Respiratory Medicine, 24, 14062; doi:10.1038/npjpcrm.2014.62
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Yin, R.K. (2016). Qualitative Research from Start to Finish. Retrieved from
https://books.google.co.in/books?isbn=1462521347
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