Chronically ill adults’ educational needs on self-medication. The patient chosen for this essay is a sixty year old man. This patient was one of the palliative care patients that the team of district nurses I was allocated to work with in my community placement care for. The patient has terminal liver cancer. The patient lives with his wife whom is his main carer. The district nurses had to visit him every day of the week. The patient had a syringe driver on situ which needed to be filled with a new dose of medication every 24 hours.
Also the extension set needed to be changed to the other side of the patient’s body when the side it was on became sore. The main care needs for the patient were to palliate physical symptoms and maintain independence for as long and as comfortably as possible. The main focus of patient care was to control the patient’s pain. Also the patient experienced nausea, vomiting, and constipation . These symptoms were unwanted side effects of the opioids he was taking. During my placement the condition of the patient worsened. Pain increased, along with the side-effects of the medication taken by the patient.
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Some of the activities that the patient was able to perform independently became difficult, such as getting to the toilet and maintaining personal hygiene. The patient became restless at night time due to the increase of pain. At this point the amount of opioids taken by the patient was increased by the doctor, so that as well as the medication in the syringe driver the patient could take a set amount of strong opioids when required by mouth to relieve the pain. I will relate this care issue to the research article I have chosen to critique and discuss.
These oral opioids where always administrated by his wife. The patient was unable to do it himself due to his physical deteriorated condition. However was always the patient that asked to take the medication when he felt he needed it. I have chosen this patient because cancer is a chronic illness for many people and more people are living with cancer for longer. Also I have a personal interest in the subject. The article I have selected to critique is called “Chronically ill adults’ educational needs on self-medication” Kawkab Shishani, (2008).
The critique framework I will use to critique this article methodology and methods is Polit (2006). In this article the language and style used overall is clear and easy to understand. Some research and statistic language is been used which can make some smalls parts of the text difficult to read and understand for any reader that is not familiar with that language. According with Macnee (2004) not been able to understand some terms in a research report can be frustrating and creates barriers to use of the research in practice.
These show that recognizing and understanding some of the research language will make it easier to use it in practice. The aim of the study is clearly stated within the first parragras of the text. Shishani (2008) explains clearly why the research study was needed, why it was carried out in the manner it was and also decribes the gap in knowledge that is adressed by his research study. Shishani (2008) included several paragraphs of background information that help him to justifie the proposed study. These paragraphs present the significance of the problem along with supporting documentation from the literature (Boswell, 2007).
According with Macnee (2004) the literature review identifies where the gaps in knowledge maybe and also give the reader a picture of what has already been studied in relation to the problem. In Shishani (2008) article studies and surveys were presented to highlight the significance of the problem under investigation. They stated that despite the benefits of chronically ill adult’s education on self-medication the evidence presented suggests it is not being addressed. According with Macnee (2004) the method used in a research report need to describe the process of implementing the research study.
It needs to include who was included in the study and how information was collected. Shishani (2004) selected a quantitative method for his research study. Quantitative research is often identified with the traditional scientific method that gather data objectively in an organized manner so findings can be generalized to other situations/populations (Burns&Groves,2001). According with Denscombe (2003) because it uses numbers and can present findings in the form of graphs and table, it conveys a sense of objective research.
Therefore the researcher needed to devote time and considerable skill to statistical analysis and to produce appropriate tables and graphs to represent the results. The use of this method in Shishani (2004) seemed appropriate with the purpose of the study. Shishani (2008) stated at the beginning of the study that it results maybe relevant also to non- Arab countries as medication use is a global concern. Also quantitative research is more appropriate when the problem involves a limited set of variables (Colquhoun, 1994).
In his study Shishani (2008) included a dependent variable, information needed about the appropriate self-medication of prescribed medications and an independent variable, used to explain or predict the outcome of interest, knowledge of medications: name, dose, frequency, benefits, side effects, and management of side effects. Other variables that have an influenced in this study results are chronic illnesses, medications, and demographic characteristics such as gender, age, education level, heath insurance, type of heath insurance etc…
According with Colquhoun (1994) with a limited number of variables the data can be collected from a larger sample of population. This allows statistical control over bias and chance error, and increases the generalizability of the results. In Shishani (2008) research study the large number of variables means that the results can not be generalizable and can not be expressed as a cause and effect. Shishani (2008)) have not control about any of the variables therefore we can not conclude any of them as a cause of the dependent variable or what kind of influence on the dependence variable each one of them have.
The aim of a good quantitative design is to rule out these competing explanations (Polit, 1994). This represents a treat to the internal validity of Shishani (2008) study. In this study we can not inference that the independent variable is truly causing the dependent variable. According with Polit (2006) when the investigator does not have control over critical variables the reader need to be cautious when interpreting results and drawing conclusions about using the evidence in practice is appropriate. External validity is the generalizability of research findings to others settings or samples Macnee (2006).
Shishani (2008) has used in his study a type of no probability sample, which does not include random selection of subjects and therefore have a higher possibility of biased , called a convenience sample. A convenience sampling consists of subjects who meet the participation criteria and who can be readily identified and recruited into the study. According with Boswell (1994) it is the least representative of all the sample strategies. In Shishani (2008) study the sample was large and he provided a justification for the size of the sample. But the problem with convenience sampling is that available subjects might be atypical of the opulation and therefore the price of convenience sample is the risks of bias (Polit,1994). We can see that in Shishani (2008) study the subjects and it representativenes in the sample is very heterogeneous and irregular, most participants were between 45 and 65 years old compare with the other group of ages, most of the participants suffered from hypertension compared to other chronic illness in the study such as diabetes and also most of the participants were illiterate compared with small group of people that attended college. In Shishani (2008) study the data collection was achieved by using two different approaches.
First Shishani (2008) used medical record abstraction for medication information and health history. According with Polit (2006) records are a simple and convenience source of information. However, like in Shishinani (2008) study, researchers maybe unaware of records limitations, biases, or incompleteness. Also Shishini (2008) gathered new data directly from the participants through structured interviews o a self report method. When quantitative information is collected from the interview process the questions are completed through the use of structured format (Boswell, 2007).
In Shishiani (228) study questions are asked within the same pattern. The environment selected for the session is really important. Because the questions are presented by the interviewer, the ordering of the questions and the environment where the questions are presented allows for openness from the participants and the increase depth of the resulting responses (Boswell, 2007). RAs in Shishiani (2008) study met with almost all the participants in the primary health centres and in the participant’s home in some cases. That may have an influenced participants attitudes and made them less open to dialogue.
Also an important aspect of data collection process is the idea of interrrater reliability (Boswell, 2007). According with Boswell (2007) in studies that more than one data collector has been employ it is important to ensure accuracy by making each of the data collectors accumulate the information in the exact same way. It is important to train observers on the instrument that will be used in a study so that there is an inter-rate at least 90% of the time (Melynk, 2005). In Shishiani (2008) study that was not accomplished. RAs that collected the data from the participants where nursing students who have completed a year of pharmacology class.
Each one of them in some cases was unsure wherever a participant self-reported benefit of a medication was correct or incorrect. In his study Shishiani (2008) has used a descriptive statistical procedure to synthesize and describe data. Shishiani (2008) has used a Logistic regression test to analyze the relationships between his multiple independent variables and the dependent variable. The statistical test conducted by Shihniani (2008) showed that the research hypotheses were accepted as probably true as demonstrated by significant results obtained after the logistic regression test.
Although, as we have seen, the internal validity of this study could be enhanced thought the statistical control of extraneous variables. According with Polit (2006) correlation does not prove causation. The finding that two variables are related offers no evidence about which of the two variables cause the other. (Polit, 2006) The results obtained from the study were that most of the subjects knew the right dose and frequency of their medication and that a significant number of subjects needed information about prescribed medications in particular side effects and management of side effects (Shisniani, 2008).
In this study several factors were identified in chronically ill patients’ needs for education on medication; patients knowledge deficit on medication benefits, side effects and management of side effects. According to Shisniani (2008) the findings imply that providing patients with medication education plays a significant role in effective disease management. The patient involvement promotes patients’ independence and improves the outcomes of the self-management of chronic illness. Also nurses, physicians and pharmacists need to collaborate to ensure the patients receive adequate education on medication.
According with Shisniani (2008) effective education medication demands the use of different teaching strategies and individual and continues assessment of the patient at each visit. Nurses’ researches are examining the human condition in relation to heath and illness and therefore they are governed by ethical principles. In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected (ICN Code, 2006). According with Jeffers (2005) nursing researches ethical values reflect the values of the profession at all times.
Ethics concerns the morality of human conduct. In relation to social research, it refers to the moral deliberation, choice and accountability on the part of researches through the research process (Edwards, 2002). Five human rights in research has been identifies by the American Nurses Association (1995); the right to self-determination; right to privacy and dignity; right to anonymity and confidentiality; right to fair treatment and the right to protection from discomfort and harm. A core ethical issue is the need for voluntary consent of the potential research subject so that a fully informed individual participated (Boswell, 2007).
That means the individual always have the choice to participate or not participate and may withdraw at any time. Full disclosure and self-determination are the two mayor elements on which informed consent is based (Polit, 2006). The participants in Shisniani (2008) study were informed of the study purpose, benefits and risks and also of the voluntary nature of participation. Anonymity was maintained at all times. Confidentiality was explained to the participants but it is not mention in the text wherever the data collected were locked securely in a safe place at all times.
The human subject approval for the ethical conduct of research was obtained from the Ministry of Heath (Shisniani, 2008). The patient I look after in the community had his pain increase during my placement. Also the side effects from the medication he was taking worsened. The patient needed an increased dose of oral medication that was always administered by his wife. Due to the patient’s increasingly demanding needs, his wife, as his main care, was showing feelings of despair and powerlessness. She always gave the right amount of medication to the patient but at times she was confused about the time it was given.
The patient and his wife were worried about the changes in his condition and they always had questions for the district nurse about what was happening and what could be the best way to manage the changes. The patient and his wife had limited knowledge of the medication and side effects of the medication taken by the patient. The team of nurses looking after the patient were not experienced in palliative care. Also they had never met with the cancer specialist nurse whom was also involved in the patient’s care. Implementations of the research carried out by Shisniani (2008) could have a direct effect on the care of the study patient.
An adecuate education given to the patient and his wife about patient’s medication, side effects and the managed of side effects could reduce their anxiety level and could potentially prevent futher complications. A mutidisciplinary approach of all the professionals involved in the patient care could unable to achieved it. Also the multidisciplinary approach in palliative care is central to providing whole-person care (Lugton, 2000). The introduction of an information pack could benefit the patient education on anything related to the medication he was taking.
Also beneficial could be the introduction of some kind of documentation allowing patient and patient carers to write down the time and dose of medication given. Shisiniani (2008) states effective medication education required and assesment of patients on individual basis. The reassessment of both pre-registration and district nurse training, specifically in palliative care would have important implications for the care received by this patient and his wife . That could increase the professionals involved in patient’s care skills and knowledge when assesing the study patient.
According to O’Neill (1997) the assessor should possess knowledge and some understanding of the particular client of group and the treatment that they are undergoing. Dissatisfaction with regard to information received is an all too common theme pervading research into the needs of patients with cancer (Suominen,1994). There are important barriers to research utilisation in practice. According with Huchinson (2003) the include time constraints, lack of awareness of available research literature, insufficient authority to change practice, inadequate skills and lack of support for implementation of research findings.
Winter (1990) states that nurses should evaluate their position as research consumers, to be able to identify problems in this area and to develop means to better use research findings. According with Huchinson these barriers may be overcome by organisational commitment that would facilitate mobilation of resources to promote change and by increasing the time available for nurses to review and implement research findings. The article was clearly presented. Accurate referencing was included through the report which enabled the reader to study it.
Whilst this article was published in a credible journal, limitations were identified which may reduce its transferability, although the findings may help with nurse education and enhance patient care. Recommendations in the text suggest further studies in this field: mainly the recommendations are for longitudinal studies to be conducted to examine the effects of medication education on progression of chronic illnesses, satisfaction, and finally cost effectiveness. Also Shisiniani (2008) study could have beneffit from he use of qualitative approach to the study that could showed the patients perspective and experience of the impact of medication education on their lives. Qualitative studies in this field will produce results which would be richer in information, especially to identify the types of medications that chronically ill adults have difficulty taking appropriately. Research is an instrument used to test a theory or phenomena where by data is accumulated to generate a test or theory. The purpose of research is to expand on existing knowledge and interpret new knowledge.
Research in nursing aspires to answer questions relating to practice and to assist in decision-making. Before changing practice in view of a new research it is important to be able to critically analyse research studies. This requires reflecting on the information provided in a study and involves a cautious evaluation of advantages and restrictions. Questions should be asked regarding the quality of research studies and a full assessment of the findings should be carried out to determine if it is applicable and beneficial to patients. Ethical considerations should also be addressed to protect patients from potential harm.
Health care professionals have an obligation to undertake research and provide the necessary evidence to improve the quality of patient care. In applying research to your practice area, patient care is enhanced and the care provided is cost-effective. During the process of critiquing the Kawkab (2008) research article I have an enhanced understanding of the research process and recognised its importance in the nursing profession. This improved understanding will enable me to develop skills in accessing and implementing evidenced-based research.
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