Critique
The following is the systematic critique of the article titled, “Implementing a Competence Framework for Administering Medication: Reporting the Experiences of Mental Health Nurses and Students in the UK” (Hemingway et al., 2012). The nursing critique has been done in accordance with the guidelines provided in the article title, “Step-by-step guide to critiquing research. Part 2: qualitative research” (Ryan, Coughlan and Cronin, 2007). The research article is published in the journal of Issues in Mental Health Nursing, which is a peer reviewed journal.
The research article by Hemingway et al., 2012, is a qualitative study that employs an assortment of approaches to draw conclusion. To begin with the critique, the title of the paper suggests the key idea of the paper. The title is long and explanative. The paper suggests that the article has something to do with implementing competence in administering medicine and the study is conducted among mental health nurses and students. Just like most qualitative studies, the study does not validate a research finding, but intends to capture a firsthand picture of the experience related to the subject. The subjective data revealed by the study could be interpreted from any perspective. In this paper, the author’s perspective on the subjective data is presented. The advantage of such studies over quantitative studies is that, it provides a holistic perspective. Nevertheless, quantitative studies present more unbiased data, when compared to qualitative studies. The paper is authored by researchers from universities and the mental health foundation in U.K and Australia.
The paper has an abstract, that provides a brief account of the study. Administration of medicine in psychiatric practice, is a high risk activity and raises serious concern in patient and nurse’s safety. The researchers have used a questionnaire to study the experience of administering medicine among nurses and final year students. 827 nurses and 44 students, participated in the survey. The article is mainly a content analysis of the reply. The abstract tells the readers what to expect from the paper. The paper is published in 2012, which is in the recent past, and thus the perspective of the study can be applied to present times.
The paper begins with a small introduction. Drug administration is a part of medical management. In addition to prescription, it is important that the patient is aware of the side effects of the drug and also its beneficial effects (White, 2004). The aim of administering the drug, is to bring about the desired effect and to prevent side effects (Snowden, 2010). The study was built on the above ethical principle of drug administration.
The organization that participated in the study, wanted to implement a four step skill acquisition approach among its staffs. This training will complement the nurse’s career and also prove advantageous to the management (Hemingway et al., 2011). This four staged approach is presented as a flow chart in Figure 1 of the paper. The introduction tells the readers, the purpose of the study and its significance. The justification for the study is convincing, but the reason for taking a questionnaire based approach is not explained in the introduction.
Background: Approximately 90% of the mental health patient are prescribed medicine (Healthcare Commission, 2007; National Institute of Mental Health, 2008). A need to develop a robust and effective management system to ensure patient safety has been felt by many organizations (Department of Health, 1999). Nurses work as front desk staff and play an important role in delivering medicines, safely to the patient (Guy, 2007). While doctors prescribe medicine, pharmacist deliver medicine and nurses administer it to the patient. As the health care system undergoes reforms, the role of nurses has expanded, and they are found in the role of prescribing medicines to the patient. Close to 40% of the nurse’s time is spent in administering medicine to the nurses (Armitage and Knapman, 2003). Studies suggest that 9% of all patients admitted in U.K hospitals experience harm associated with drug administration (Davies, 2006). It was found that many of these unfortunate incidents were preventable. The figures presented in the literature review are really astonishing. The harm caused by medications, costs the health care of U.K, £750 million (Healthcare Commission, 2007). In addition, the patient also reports dissatisfaction. The authors reasoned out the need and significance of the study. The study is backed by literature support.
Through literature review, the researchers identified several factors that could prevent effective administration of medicine. The factors include: poor pharmacology knowledge, overcrowding, shortage of staff, lack of support, resources, influence of environment and context, and inability to calculate dose. All these factors are supported by literature evidence. All these sources are primary sources and thus reliable. The literature review is well done, and the findings from earlier studies have been provided in an objective manner wherever applicable. It reflects the theme of the study and has taken into account multiple realities in the field.
Medicine with Respect (MwR) project is an opportunity to review the existing system and learn ways to improve. It is a four stage system. In stage 1, psychopharmacological knowledge is developed. Stage 2 is called the Observed Structured Clinical Examination (OSCE), in which the training is provided in a simulated clinical environment, before actual clinical placement. In the third stage, the nurse administers medicine in a clinical environment and in stage 4, the nurses are assessed using a questionnaire. This is suggested as an appropriate project to address the concern in drug administration. The background provides a brief description of the method and its benefits, in the light of the literature review. The aim of the study is well supported and the literature review is used to rationally explain the concepts in the study. Though it is a qualitative study, the theory and concepts are well explained. Both qualitative and quantitative approach was used in the methodology. The quantitative study of this theme is already conducted by the researchers in a separate paper (Hemingway et al., 2011). The aim and the objectives of the study discussed in this paper, are listed with clarity. The aim of the survey, is to evaluate the mental health nurses and students, on the usefulness of MwR assessment. The objective of the study is to ascertain: i. the reason for participation in MwR ii. identify positive and negative aspects of the project iii. establish the benefits of MwR. Since, it is a qualitative study, there are no clear hypothesis. Nevertheless, the objectives were specific and has scope for application in day to day nursing practice. (Hemingway et al., 2012)
Method: The study was a part of a large survey. Only the qualitative data are researched in this study. Registered mental health nurses from South-west Yorkshire Partnership Foundation Trust and third year nursing students from the University of Huddersfield, participated in this survey. The South-West Yorkshire Partnership Foundation Trust, caters to the mental health of ~ 900,000 people. Medicine is administered by nurses under different care setting. However, students may need supervision while administering medicine. Though the survey questionnaire was distributed to 827 nurses and 44 final year students, only 195 nurses and 41 students participated in the questionnaire. The response rate for nurses was very poor. Only 24% nurses responded to the questionnaire, i.e. more than 75% never responded. The questionnaire had 17 closed questions and 5 open questions. The authors have provided details of the question in the methodology section. Information on ethical consideration and permission is also provided in the paper. Only open ended questions are analyzed in this paper.
The questionnaire was sent to the participants, through email. In case of student participants, they were asked to fill the questionnaire on the final day of class. The contents of the questionnaire were analyzed according to the method provided by Newell and Burnard (2006). All four authors have participated in reading the contents of the reply and identifying text, ideas and themes. The data were scrutinized closely and grouped into clusters based on the themes. The rigor of the instrument used to collect data was also assessed based on published literature (Polit and Beck, 2008).
The study employs a naturalistic and interpretative approach. There is coherence between the objectives and the data collected. The samples of the study are those who experience the phenomenon from their day to day life, and thus can appreciate the importance of the study. The sampling is done on purpose, and thus one can expect to see the richness in the data. Samples were further selected based on the themes that emerged from the findings. The advantage of quantitative study is that it can provide more information and depth. The open ended question would provide an opportunity for the participants to open up. It was a semi-structured interview; the data were collected online. So it is difficult to determine the originality of the reply. However, meeting all the nurses individually would be a difficult task. Considering that the participation in the study was voluntary, one can assume that the information provided was correct. The questions are linked to the purpose of the study. There was no report of data saturation and the researchers expect to find new information. Many researchers have already tried out the MwR protocol and thus the approach is dependable. Each stage of the research can be traced back and is well documented.
The data analysis is done in a credible fashion by the experts. The raw data is coded into themes and categories. No computer software is employed in the analysis and all the analysis is done manually. The participation of four researchers in the process can help reduce bias. Nevertheless, it is not possible to eliminate bias completely in this kind of research.
Result: In the result, four overlapping themes were identified. The first theme was the ‘reason for participating in MwR’; the second was ‘the positive aspect of MwR’; the third was ‘negative aspect of MwR’ and fourth was ‘the service user benefit’. The authors have expressed the result in discursive manner. In case of students, it was a mandatory training. Nurses expressed various reasons like, ‘due to drug incidence at the ward”; “everybody in the ward did it”; “working in the treatment team”. The limitation of article size must have prevented the authors from presenting more response. In-spite of the huge sample size, the nurses had only 3-4 unique reasons for participation. Participants also opined that participating was part of the assessment.
Under the “positive aspect of the test theme”, the participants identified several advantages of participating in the test. The training helped the participants consider the immediate environment, while making decisions and administering medicine. This will help reduce interruptions and distractions. Few of the environmental factors that came up in the response were: “privacy and dignity in the patient’s home, “helped deliver medicine in meticulous manner”, “ensures knowledge based practice”, “I can automatically follow the routine now”, “universal protocol for drug administration”, “learned more about drug administration”, “working knowledge of medications and their side effects’, “influence for nurses”, “to update present knowledge”, “safety emerged as the major benefit” and “makes you think about what you are doing”, were some of the response.
Under the theme ‘negative response to MwR’, the following responses were obtained: “need for and frequency of MwR assessment”, “quite repetitive”, “no special advantage from participation” and “was only a waste of time”, “damaging confidence”, “stressful, too much time”, “not satisfied with the preceptorship” and “the training is not of special use for nurses who have been practicing for long”, were some of the feedback.
In the theme, ‘perceived user benefits’, the response was as follow: instills confidence, creates awareness on the process, decreases medical error, prompts staff and students to discuss, inclusive approach, creating awareness on the side effect of medicine, enables the person to make an informed choice, etc.
The findings are presented in a narrative form and it is convincing. Since it provides both the positive and negative aspect of the study in the form of patient dialogues, the judgement of the researcher does not create bias. The negative aspects of the study are as strong as the positive aspect of the study. The reader can interpret the meaning of these finding from his level of judgement.
Discussion: The summary of the study and the findings are once again provided in the discussion. There is repetition of the background and method sections in this part of the paper. The results were then compared with an earlier study conducted by the author and were found to be concordant (Hemingway et al., 2011; Hemingway et al., 2010). According to the researchers, majority responded positively. The number of participants who responded positively is not provided. MwR was an evidence based framework that will improve medicine administration (Healthcare Commission, 2007).
According to the authors, the MwB framework was successful in the many ways. It facilitated the acquisition of knowledge, encouraged problem solving skills, technical skills and overall nursing competence (Eisenhauer, Hurley and Dolan, 2007). MwR innovation can benefit the nurses who administer medicine (Banning, 2004; Happell, Manias and Pinikahana, 2002; Latter et al., 2001; Morrison-Griffiths, Snowden and Pirmohamed, 2002; Ndosi and Newell, 2009). One of the major critique of the project was the presence of repetitiveness. However, the authors suggest that the essential part of the training was to ensure repetitiveness, as it enhances competence (Armitage and Knapman, 2003; Brady, Malone and Fleming, 2009; Mary Fry and Dacey, 2007). Some participants have questioned why they were asked to participate, while experienced nurses were not asked to participate? Studies suggest that errors are not always linked to experience (Brady, Malone and Fleming, 2009). The study focused on the skills of pre and post registered nurses. Nurses who are well informed and confident are more likely to engage users to manage their own medication (Duxbury et al., 2010; Hemingway et al., 2011).
The researchers have related the finding with other published literature during the discussion. There has been exaggerated claims, because, the original purpose of the research was to understand the usefulness of MwR and there were negative feedbacks. The long term follow-up and absence of control, makes their claim exaggerated. This is only a preliminary study in which a percentage of the participants have benefited. No quantitative or comparison is done between negative and positive feedback. The aim of the study is not adequately addressed.
The researchers have been faithful in describing the positive and negative aspect of the study. This makes the study credible. They could have discussed about the consistency seen in the participant’s views. Consistent remarks will help in the interpretation process. The time duration of the MwR training, and the duration for which the participants were engaged during the training is not provided anywhere in the paper. The experience of the researchers has an important influence in interpreting such type of result. No generic tools were used in the data analysis. It was solely based on the researcher’s judgement and creativity. The research question and the approach of the authors could have influenced their interpretation.
The data analysis is important in determining the outcome of such kind of studies. The findings are explained with sufficient clarity and thus, it is easy to know if the conclusions are rooted in these findings. The method used for coding and retrieving data could have been explained in detail, instead of repeating the aim and methodology in the discussion. The sample size for nurses is sufficiently large. However, the data cannot be generalized, as the nurses had responded varyingly to the questions. There is the richness in the data, and this could be a result of large sample size. The data provides sufficient depth and this will enable the readers to understand the phenomenon. The purpose of the study was to discover the experience of the participants in the training. The study has served the purpose very well.
Conclusion: In the conclusion, the authors have claimed their findings to be consistent with findings of other researchers. The conclusion states that the study was useful in drawing conclusions. Safety has been suggested as the main perceived benefit. Abuse of psychotic medicine is common among patients and nurses. Minimizing their use is a challenge, that can be addressed through the effective administration of psychotic medicine. The training enhances safety, increases nurse’s confidence and competence.
The researchers have tried to conclude the paper based on the context. No new information is provided by this study. The findings are not reflected in the conclusion. The competence level of the nurse, patient safety and nurse’s confidence were not objectively measured and thus it is not possible to draw conclusions. The findings from the study has implication in nursing practice. No clear recommendations were made and the implied recommendation of the MwR is not very convincing. Most of the references are books and journal articles. The information is presented in the context of the study. No claim has been made from a secondary source and thus the frame work of the study appears to be credible.
Limitation: Every research has its limitation and a good research article will mention the limitations of the study. The given article was also good in enlisting its limitations and it is reasonable and well understood. The first limitation being the small sample size. Only 25% of the nurses responded to the assessment question, while majority of them did not respond. The poor participation rate works against the conclusion drawn from the study. The authors could have tried to identify the reason for this, which they did not do. The nurses who participated in the study were from a single institute, so it is difficult to generalize the findings. The findings from the study are applicable only to the nurses who participated in the training. It is not clear if the training, and the study is applicable to nurses and students who work in different contexts of care. The perceived benefits are to interpret with caution, as all the nurses who participated are not necessarily involved in the administration of medicine. The risk associated with the study was not looked into. The study only focused on the benefits. There is a tendency for the respondent to reply in a biased fashion, either in the positive or negative direction.
In my opinion, the paper has made an in-depth review on a very important topic. MwR training will be beneficial for nurses and it will improve competence. The authors could have done better at evaluating the usefulness. The findings from the research, is sufficient to improve future training. Each step in the research has been explained in sufficient depth. Considering the qualitative nature of the research, one cannot make strong claims.
References:
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