provision of evidence-based care
The provision of evidence-based care is a feature of modern healthcare services. Consequently, all professionals need to be able to appraise the literature and determine the best evidence available. This critique focuses on one topic within mental health care - the use of seclusion in mental health. Exploring and evaluating two chosen articles on seclusion demonstrates the quality of information and evidence on the topic and also allows for comparison of methodological approaches in the evidence base.
Background
The practice of seclusion remains a controversial and provocative subject (Griffiths, 2001). Seclusion as a practice appears to range from the simple act of locking a patient in a room to placing them in a secure space where they cannot harm themselves (Hoekstra et al, 2004). It is also an intervention that is typically instigated and managed by nurses (Hoekstra et al, 2004).
The mental health literature appears to show that seclusion is seen as a legitimate intervention by some hospital staff, but is “dreaded” by mental health patients (Griffiths, 2001). Seclusion is also generally believed to be effective and it appears that no true alternatives to its use exist (Griffiths, 2001). However, it is viewed by some as an anachronistic and punitive form of ward management (Muir-Cochrane and Holmes, 2001). Some literature reviews suggest seclusion and restraint are basically efficacious in preventing injury and reducing agitation (Fisher, 1994). Another point in terms of reference to clinical practice is that it is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint (Fisher, 1994). However, it is also apparent that restraint and seclusion have deleterious physical and psychological effects on patients and staff (Fisher, 1994), which would suggest that this is an area which needs further investigation and review.
The chosen articles were picked because they deal with two aspects of seclusion - staff and patient opinion and experience of the intervention. As it would appear that the practice of seclusion is likely to continue, it may be important to understand the effects it has on those involved - staff and patients, and how it is understood and viewed by these two groups. The literature on seclusion provided a range of articles but these were narrowed down to two. Hoekstra et al (2004) carried out a Grounded Theory study into the experiences and coping mechanisms of patients who had undergone seclusion, and how the practice had influenced patient-staff relationships. Meehan et al (2004) utilised a cross-sectional survey to explore patient and staff perceptions of seclusion, the effects of seclusion, patients' feelings during seclusion and any possible changes to the practice which might ameliorate the more negative aspects of the intervention.
Method and Methodology
The search engine/gateway PsycInfo was accessed and searches were carried out utilising the following keywords with their associated hits:
- Seclusion
- Seclusion + mental health nursing
- Seclusion + clinical practice
- Seclusion + perceptions
- Seclusion + experiences
Inclusion/Exclusion Criteria.
The list of returned citations was further limited by defining parameters as follows:
- Full text
- English Language
- Nursing.
- Peer-reviewed
- Research/systematic review.
- Original Articles.
The express aim was to review identify two research articles, one qualitative, one quantitative, leaving the author with a targeted sample of articles relating to the subject. Two articles of similar scope were chosen to compare qualitative and quantitative articles which were addressing similar questions; i.e. perceptions and experiences of seclusion in the mental health setting.
Research Question
The primary tool in developing effective research studies is identifying and asking the right research question (Thompson, 2000; Burns and Grove, 1999). The research question in quantitative research has been argued to strongly affect the quality of the whole research study (Thompson, 2000). It is also important to be able to distinguish between problem and purpose in nursing research (Burns and Grove, 1999). The research questions were evaluated against a set of criteria which pose questions about the nature of the question or 'hypothesis'. It is notable that in the two papers selected, the research question had a similar meaning, but that two entirely different approaches were utilised.
To begin with it is important to consider whether the research question is clearly stated. In the paper by Hoekstra et al (2004), the research question is not definitive, covering as it does three separate areas of enquiry. However, the authors clearly state that the 'study is of an exploratory nature, aiming to increase our understanding of, first, patients' seclusion room experiences; second, how patients cope with such an event; and, third, how the seclusion experience affects relations with care providers' (Hoekstra et al, 2004). Silverman (2001) explores the notion of the research 'problem' as a broad area of enquiry within qualitative research. It may be that by encompassing three areas of enquiry they are being true to the generative nature of qualitative research (Gilbert, 2001). However, such a broad scope does not suggest anything like a targeted research design, and the ability to address the 'problem' of seclusion from the point of view of these three 'questions' may not be achievable within the qualitative paradigm.
For Meehan et al, (2004), the research question is contained within the aim of the study, namely exploring the perceptions of staff and patients of seclusion. However, the use of the term 'exploring' does not quite fit with the notion of a quantitatve design. However, it is clearly stated, with four distinct areas of study defined.
Another consideration is whether the question relates to the topic under consideration. The set of questions stated by Hoekstra et al (2004) examine the nature, scope and effects of seclusion as a concept and as an experience. As such, the question does relate to the topic by exploring the topic and its sequelae. Similarly, Meehan et al (2004) explore perceptions of seclusion by staff and service users, and relate these clearly to the topic through their literature review.
This leads into exploring whether the research question fits the aim and scope of the study. In Hoekstra et al (2004) the paper would appear to clearly define both the aim and scope of the study, as stated in the 'questions'. However, the authors go on to further define the scope of the study by stating that that a better understanding of this traumatic intervention would enable care providers to improve the care they provide and its consequences, leading to potentially improved therapuetic relationships (Hoekstra et al, 2004). Meehan et al, (2004) utilise a larger sample population which appears to fit the scope of the research question in size and potential.
Another issue is whether the research question is consistent throughout the paper. Hoekstra et al (2004) not only reiterate the three arms of the research question but also clearly link them to the stages of the research and the methodological process. Meehan et al (2004)
Building on this, it is important to understand if the research problem is based on an explicit rationale or background. For Hoekstra et al (2004), the study appears to be based on personal experience of the provision of care surrounding the intervention in question. As such, there appears to be an underlying clinical rationale for the study which is somewhat reinforced by the literature review. Meehan et al (2004) utilise their literature review to justify and underpin the study.
Finally, how appropriate the question is to the research methodology and the study should be considered. In the first paper, the stated research methodology is Grounded Theory (Hoekstra et al, 2001), which is a generative process of enquiry where new theory is allowed to emerge from complex qualitative data (Glaser and Strauss, 1967). The exploratory nature and broad scope of the three 'questions' is suitable to this kind of methodology which attempts to frame emerging concepts in the light of existing and future research.
Population and sample
The term population applies to the group of people the researcher wishes to research, and this is further defined by the notion of an accessible population, those to whom the researcher can readily or realistically have access (Stoner and Rutledge, 2005). The term sample refers to the smaller, limited group of people actually targeted and enlisted into the research (Stoner and Rutledge, 2005). While sampling is crucial to quantitative research, relating to important statistical validity (Burns and Grove, 1999; Thompson, 2000), it has different meaning in relation to qualitative research. The nature and selection of the sample is a fundamental aspect of reliability, validity, transferability, applicability and trustworthiness (Thompson, 2000).
The first question is whether the sample is representative of the target population (Stoner and Rutledge, 2005; Russell and Gregory, 2003). In the first study by Hoekstra et al (2004), there is no notion of the sample being representative of a whole target population, but given the nature of the study, there is no professed aim to achieve this. The sample appears to be a convenience sample of service users who had undergone the intervention, were able to communicate about it and for whom enough time had passed to allow a reasonable reflection on the experience. Providing a rationale for purposive sampling is an important part of reliability in qualitative research (Corben, 1999). As this is an exploratory study, sampling rigour is not necessarily an issue as long as the inclusion/exclusion criteria are appropriate and adhered to (Thompson, 2000).
This leads to the question of what the inclusion and exclusion criteria are, and if they are appropriate to the study, the design and the research question (Thompson, 2000). In Hoekstra et al's (2004) study, participants were included if they were able to provide information on the topic and were willing to be included. The next inclusion criterion was that the seclusion had occurred sufficiently long ago (although this is not defined) or over a period of time (Hoekstra et al, 2004). Subjects needed fluency in Dutch and needed to be not mentally deranged (Hoekstra et al, 2004). These seem to be practical criteria given the nature of the research in generating qualitative data on the topic. Conversely, Meehan et al (2004) do not specify at any length what the inclusion and exclusion criteria are, and appear to be using a convenience sample of staff and patients.
Research design and methodology
The research design needs to be evaluated in relation to the research question, to discover whether the design is appropriate to the study (Silverman, 2004). Suitability of research design is important in critical appraisal (Concato et al, 2000).
One important point is the presence or absence of an overall theoretical framework. Hoekstra et al (2004) do not provide an overall theoretical framework other than that of Grounded Theory as defining research design. The philosophy behind this method matches the purpose of an exploratory study (Russell and Gregory, 2003). It is important that readers of research understand the philosophical underpinnings of any method of research (Corben, 1999). However, details of the methodology are not given, other than to mention interviewing and the existence of certain steps. Corben (1999) suggests that is a common feature of many papers that they fail to make the research or methodological principles clear (Corben, 1999).
Another point is whether the context of the study is adequately described (Russell and Gregory, 2003). Context is particularly important in qualitative research. In the first paper, the context of the study is provided in the background, literature review and methodology. Hoekstra et al (2004) set the parameters of the study firmly within the context of clinical mental health nursing and hinge the design on a set of outcomes directly linked to practice. Meehan et al (2004) also clear describe the context of and nature of the mental health care settings in which their study was carried out, and further define these as having a degree of commonality or clinical and procedural cross-over which supports their inclusion.
It is also important to consider the researcher-respondent relationship and researcher bias (Corben, 1999). In Hoekstra et al's (2004), the notion of researcher bias or protected relationships does not appear to be addressed. The same appears to be true for Meehan et al, (2004), but as a cross-sectional survey instrument which has been previously tested is used, it is not such an issue.
Data collection and analysis
The first consideration is whether the methods of data collection are suitable to the research design (Russell and Gregory, 2003). Hoekstra et al, (2004) spend very little time explicating data collection other than to state that questionnaires were audio taped and transcribed and analysed with the support of a computer package. Meehan et al (2004) state that they are using a cross-sectional design employing an already tested questionnaire. The data generated from the questionnaire were analysed using a computer-based statistical analysis tool. Simple percentage statistics are presented as results.
The use of graphical representation of data is crucial in the production of quantitative research reports. "Presenting data graphically does more than simply replace a summary table of means and standard deviations' (Thompson, 2000, p103). Thompson (2000) further explains that the strength of presenting data graphically is that the medium itself is intrinsically accessible and easily understood by the reader, which of course allows for easier appraisal and critique. Meehan et al (2004) utilise graphs and charts to present the data. However, the nature of any statistical tests, including calculations to achieve representative sample size or to increase statistical validity are not covered.
Hoekstra et al (2004) fail to clearly define their analytical framework or signpost the organisation and retrieval of data. Thus it is impossible to evaluate whether or not they have followed the chosen methodology (Corben, 1999). There is no triangulation or member checking (Russell and Gregory, 2003) which might have improved the quality of the paper. However, use of quotes does improve the quality and link the discussion back to the data itself. Themes are used as headings to signpost the findings.
Critiquing the quality of qualitative papers is notoriously difficult (Emden and Sandelowski, 1998), and in this instance, it is difficult to asses the quality of the data and discussion. It would appear from Hoekstra et al's (2004) study that they have presented some information about the subject, but in the absence of the ability to assess methodological rigour, the usefulness of these findings is limited. Conversely, Meehan et al's (2004) study presents comprehensive data in both the tables and the discussion.
- Ethical Issues
Ethical research is a fundamental concept for the truly accountable practitioner (Burns and Grove, 1999). Therefore, ethical questions consider issues of informed consent, confidentiality and anonymity. In Hoekstra et al's (2004) study, ethical approval was gained from two governing agencies, and ethical considerations further limited inclusion to those subjects for whom adequate monitoring and follow up was available through existing care provision. This is an important issue given the vulnerable nature of the target population. Informed consent was gained, but confidentiality and anonymity are not adequately addressed in this study.
Meehan et al (2004) gained informed consent from staff and patients, but only verbal consent from staff. They also gained ethical approval from an appropriate source. However, they do not address the issue of ongoing support or any psychological or emotional consequences for the participants.
Findings and relevance to practice.
The findings were appraised in relation to context and relevance to professional practice. The findings in the Hoekstra et al (2004) study show a range to of themes which are related both to the current literature and psychiatric nursing practice. The authors make a range of recommendations based on these (Hoekstra et al, 2004) However, given the difficulty in assessing methodological rigour in this study, it is consequently difficult to asses whether these findings have any transferability. It may be that this study is of some importance in developing theory and debate around these issues, and it could pave the way for future research studies to address the concepts and themes raised in the data analysis. This would give the study some worth. Hoekstra et al (2004) do state some limitations of their work, which include a small, localised sample, potential bias and the retrospective nature of the enquiry. These are quite significant in affecting the usefulness of this paper in application to nursing practice.
The findings of Meehan et al's (2004) study are explored in relation to their limitations and potential validity. The comparison between perceptions of staff and patients is particularly marked, and even with the limitations of this relatively small sample, the degree of statistical validity and the nature of the findings are very useful for clinical practice. Applicability to other settings and other people may still be questioned, and it might be that a larger sample with more exploration of a range of potential affecting variables might be needed to support these findings.
Conclusion
The findings from both these studies would appear to support the existing literature by demonstrating the equivocal nature of the intervention. It is an effective tool for managing certain situations, but has a range of effects on staff and patients, many of which could be termed as negative. However, the quality of both papers leaves the reader with questions about the usefulness of the findings. While both provide some insight into the pertinent issues, neither is methodologically rigorous or transparent enough for a full evaluation of their use as 'evidence' on which to base clinical practice. Such findings can illuminate areas of importance, and inform the nurse of how some clients may be feeling, which would foster more sensitive and client-centred practice. Similarly the discussions might help the professionals involved to prepare for the consequences of seclusion for themselves and their clients.
This critical review of two articles with contrasting methodologies has demonstrated that while research can provide insight into practice, the prerequisite for the utilisation of their findings is that they display transparent, methodologically correct processes. Therefore, neither of these two papers display true validity or transferability, but they do provide some evidence which will inform or illuminate professional practice.
