Student Nurse

Research and Evidence


INTRODUCTION

The author of this assignment will critically appraise a research report in the Nursing Times titled Young people's perceptions and access to health advice (Sherman-Jones 2003) (appendix 1). This article was chosen for a number of reasons. Firstly the topic of young people's health is frequently discussed in the media, often negatively. A search on BBC news online resulted in 46 articles within the month 27 October to 27 November 2003 (appendix 2) and similarly Scotsman Newspapers online facility produced over 100 articles for the same period (appendix 3). Sexual health was one of the 5 key areas that the Health of the Nation (Department of Health 1992) report highlighted, including teenage conceptions. Teenage health is an area that the Scottish Executive (2003) is also interested in promoting through its Improving Health in Scotland document.

On a personal level, adolescent health is of great interest to the author and it is intended that this assignment will increase her knowledge, not only of young people's health experiences but also the importance of research to her continuing professional development. The article is directly related to other modules undertaken by the author namely family planning and health promotion.

It is proposed that the author will examine both positive and negative aspects of the article and provide a personal evaluation using a systematic analysis of the research that follows a set criterion (McSherry 2001).

Research is important in healthcare today and is part of the evidence-based practice that underpins nursing. This stemmed from government policies and the introduction of clinical governance (Kopp 2001, McSherry et al 2002). Not all research is relevant and that is why it is important to do a thorough critique.

CRITIQUE

The title of the study is 'Young people's perceptions of and access to health advice' (Sherman-Jones 2003). The aim was to investigate the experiences young people have obtaining health advice and how this differs from professional's views. However the professional's views are excluded from the title even though Polgar and Thomas (2000) claim that it should contain information pertaining to any groups being researched. It is clear though, that the research is qualitative in nature by the use of the word 'perceptions', which infers depth of understanding.

An abstract lets the reader know whether a research article would be relevant to their practice or development. However in this article some essential components are missing. Although it is succinct, it fails to mention qualitative nature of the study and the full aim of the research. It omits details of the sample and data collection methods, which Polgar and Thomas (2000) advocate and state additionally it should contain details of any previous findings leading to the current research being commenced. However in its favour , the abstract does state the conclusions and recommendations and despite a fifty word limit on abstracts in this journal (Nursing Times 2002) the researcher has still managed to include the essence of what this study is about.

Anne Sherman-Jones is assistant director of commissioning and service development at Mid Sussex Primary Care Trust. This signifies that she is responsible for the updating and improvement of existing services and creating new initiatives. Therefore issuing recommendations to the trust to renew contracts for services or enabling the implementation of improvements (Banks-Smith 2001) allowing the implementation of the National Service Frameworks and other targets set out by the government. Holding an MA indicates a high level of academia. So although the article does not state her previous background or whether she is a nurse, Sherman-Jones it could be assumed, is suitably qualified to carry out this research project.

The review of literature is not extensive, but on first inspection is generally relevant to the research undertaken. The majority of the literature search being centred on confidentiality and sexual health indicates that the researcher felt these were going to be areas that the interviewees would perceive as an issue, from the literature she had already reviewed (Polgar and Thomas 2000).

The recommended number of references for this article is fifteen to twenty (Nursing Times 2002) however there are only 8 references cited throughout from seven sources. It was felt that other equally suitable articles and policies could have been included. Such as 'Confidentiality and young people's toolkit' compiled jointly by the Royal College of General Practitioners (RCGP) and Brook (2000). This appears to supersede the British Medical Association policy cited, and could have proved a vital source of information clarifying how issues of confidentiality are being addressed.

In relation to the review of sexual health literature, recent research articles include 'Young People's Perceptions of Contraception and Seeking Contraceptive Advice' carried out on behalf of the Department of Health (Counterpoint Research 2001). This is a qualitative study that looks at the views of young people accessing sexual health services, and may have aided the researcher with her own study. However most research done up until now is quantitative which tends to show trends and statistics (Hewitt-Taylor 2002), although still very useful it does not consider the thoughts or feelings of those involved (Neary 2000). Favourably the articles she has reviewed have covered both quantitative and qualitative studies.

The majority of research and information available relates to teen pregnancy and contraception with little on health promotion topics like smoking, alcohol, diet and exercise, although these do exist as do a number of projects focusing on the mental health of adolescents.

The reader feels there is a weakness in the referencing technique as secondary references should be used only on rare occasions, and attempts should be made to use primary sources where possible (Napier University 2002). Nonetheless this has not been done, perhaps because the guidelines from Nursing Times (2002) are not explicit about how they prefer references to be documented.

The article as a whole has used little research findings and evidence and although current literature in this field is limited it has been used to back up the arguments rather than be reviewed. The appraisal of literature is a crucial factor in evidence-based practice (Thompson and Cullum 1999), although not the only factor. However other articles may have been reviewed but discarded from the final document.

The researcher states that based on the findings her main aim is to improve the services available to the young people in this community and make them user friendly. The object of the study was to let the adolescents say what they thought mattered. There is no specific research question outlined, although the reader is given the impression that determining the right services for young people is what is being asked. The goal to fill a knowledge deficit, is what a good research question or aim should do (Cormack and Benton 2000).

No hypothesis exists for this study and according to Polgar and Thomas (2000) this is advantageous, reducing the likelihood of bias. Although hypothesis can be ever changing to adapt to the findings others may view this approach as too flexible and inconsistent. Gray and Smith (2002) recommend that novice researchers have a more structured approach and use specific objectives to guide their research, as done in this report by targeting areas of perceptions, preferences, improvements and barriers to existing services and comparing teenagers and professionals' views.

The researcher used a qualitative method for this project because she wanted to understand what the young people actually thought of the existing facilities. Although she does not mention in the report that it is qualitative she gives the impression of wanting more depth by the terminology used, advocating that it aided open debate. Qualitative research is an ideal way to gain awareness and understanding of the issues being investigated (Thompson et al 2002).

An approach called phenomenology, a type of qualitative research strategy particularly useful in healthcare is the research framework used. It advocates that the researcher be free from influence or prejudice so that the study is a true reflection of the individual's experience, taking place in their own environment. Polgar and Thomas (2000) propose that collecting data on the health needs of a community would be classed as descriptive research in which involves gaining in-depth knowledge of the person and their feelings, meanwhile acknowledging that all individual views may be different.

Descriptive research gives valuable insight, although it can be a time consuming process and difficult to interpret, limiting its use considers Polit et al (2001). Mays and Pope (2000) argue that the use of qualitative research is becoming wide spread and Sackett and Wennberg (1997) concur saying its essential, as the trend of qualitative work being published in medical and nursing journals increases.

The purpose is stated throughout the article, affirming that discovering what young people think of current services is intended. The aims are to ensure that the services commissioned are going to be what the target community wants. Using a qualitative study method enables the objectives to be achieved by ascertaining descriptions and perceptions of those involved (Sackett and Wennberg 1997). Consequently generalisations are not made through gaining depth and insight from a small sample of participants chosen for their collective experiences.

The method used to collect data in this research approach is interviews, which take place in the participants favoured surroundings, and are known as field research. The interviews, mainly in the form of focus groups facilitate this although it is apparent that not everybody felt it was a comfortable setting in which to divulge their thoughts and feelings. Accordingly one to one interviews and written answers were utilised also. Greenhalgh and Taylor (1997) insist that by using different methods of data collection this helps to create and all round depth of information called triangulation. By collecting the information in these ways it is hoped that validity of the findings will be increased (Mays and Pope 2000).

In order to gain the specific sample of teenagers and professionals for the study contact was made with those providing the current services to the young people. This method of sampling is called purposive sampling. Greenhalgh and Taylor (1997) encourage this method of deliberately targeting people who fit the criteria as it means all those participating will actually have known the experience. It is an effective way to obtain a sample, although it may produce biased results, as the sample is not typical of the population. However in this particular case the researcher wants it to be representative of those involved rather than the population as a whole. The sample was made up of secondary school children, youth centre members, previous teenage mothers and a selection of professionals involved in teenage health services. Some useful information is provided about those that took part in the research project, commenting on job title and indicating mixed backgrounds and age range of the young people. It is inferred that at least nine professionals took part in the research, but the actual numbers involved in the study of either young people or adults are not conclusive. Polgar and Thomas (2000) reason that there is no ideal sample size, the most appropriate being enough to enable the researcher to carry out the study effectively and be representative, although the number involved should also be noted within the report. Some participants were older than anticipated, but their involvement was justified demonstrating once again the changeable nature of the research objectives (Greenhalgh and Taylor 1997).

The data collection method used is dependent upon the purpose, the design and costs involved (Polgar and Thomas 2000), and in this case interviews are the preferred method. The use of open questions and trigger questions allows the respondents personal views to be discovered and initiates discussion, this should give the researcher as much information as possible to analyse (Greenhalgh and Taylor 2000). The report does not say how much participation the researcher had in the discussions and whether she used prompts. The mechanism for recording the interviews is not substantiated however excerpts from the responses are included in the text. As the reader has no means of knowing whether these quotations were documented from field notes, which are open to the researcher's interpretation, this could constitute a validity issue. Polgar and Thomas (2000) and Marrow (1996) recommend the use of audio-visual equipment for recording field research as this aids accuracy and avoids distortion of the facts.

A semi-structured approach was applied in the focus groups and interviews using open questions to initiate discussion. This means that the respondents have some freedom over the way the discussion progresses and the researcher has some control to keep it on track (Polgar and Thomas 2000). The questions asked were aimed at achieving the research objectives set out in the paper. Their usage was rationalised for the one to one interviews also.

Whether ethical approval was sought is not made clear but the researcher may have felt this unnecessary because there were no health risks involved although there are moral issues (Polgar and Thomas 2000). Obviously consent would have to be obtained from those involved in return for assurances of privacy and confidentiality. However as some of the interviewees are under 16 there may well be issues with consent. Those of a young age may also feel obliged or even coerced particularly as the researcher has made it known that finding willing participants was a difficult task.

Gray and Smith (2002) claim that in qualitative research data collection and analysis are integrated and that by continually analysing the information the researcher can determine what data to collect next. The responses from the transcripts were arranged into five categories dependent upon the replies, in a process called coding (Polgar and Thomas 2000). The simultaneous analysing and collection promotes ongoing concepts being developed providing the means to discover, in this instance, if there is a knowledge gap between service users and providers.

Mays and Pope (2000) maintain there is no definitive way to ensure mistakes do not occur in qualitative research but that measures can be taken to improve the validity. The researcher in this study has a vested interest and as such it could be viewed that this could influence the outcome. However Gray and Smith (2002) feel that a researchers involvement would place her in a better position to report on the findings because she can understand the views of the sample better, yet be truthful.

According to Hewitt-Taylor (2002) qualitative evidence cannot be judged for relevance the same as quantitative by reliability, validity and generalisation but on how close it fits the phenomenon. The researcher clearly cannot report the transcript in full but provides a summary of her interpretation meaning inaccurate conclusions could result. To ensure the validity then it would be wise for the researcher to use triangulation by using more than one method of data collection or more than one group of participants (Mays and Pope 2000) as she has done. She further strengthens the report by using excerpts to back up her theories giving it credibility (Greenhalgh and Taylor 1997).

The process that has been used to collect and analyse the data is not described in immense detail, which causes difficulties for others wishing to carry out similar research (Mays and Pope 2000). This also brings into question the auditibility of the project, as the reader is unable to determine the exact number in the sample and how the interviews were transcribed and encoded.

The article is comprehensible, purposeful and gives suitable overview of the study thus it is fitting. The research finding are presented logically, set out in categories. Namely these are professional's views, young peoples views, determining what young people want, solutions and confidentiality. The researcher maintains her findings are the views of those interviewed and does not make generalisations.

Each category contains an interview question and a description of the theory developed, followed by a quotation from a participant to prove the point the researcher is making. The reader however questions the category entitled 'finding out what young people want' because the researcher doesn't appear to ask the young people but instead consults the professionals. The young people's views though are taken into account within other sections and both the professionals and youths contributed to what they felt would make things better. Literature is used to strengthen some of the themes developed. Polgar and Thomas (2000) propose that all the results should be made available within the results or findings section of the paper, however new information highlighted in the conclusion concerning midwives had not previously come to light. According to the report the teenagers did not have serious concerns over drugs advice yet the professionals claimed this was a problem and recommendations were made. This did not fit with the phenomenon as the young people did not 'establish this key point'. After it became evident from the findings that men receive less health advice no recommendations were produced to address this. The conclusions or recommendations section should tie together the phenomenon stated earlier (Polgar and Thomas 2000), which has not been achieved in these instances.

There has been no acknowledgement made of the limitations of the study. However the report may not be representative of the professional or teenage populations or of the existing services. The number and diversity of the sample could affect the outcome of the research.

CONCLUSION

The main implications for practice for this research are in terms of health promotion. It would be expected that these young people by being empowered to get the right services would be enabled to make informed choices in relation to their health as recommended by the World Health Organisation (1986). It is however difficult to measure the success of this study without further research. Although a quantitative study in the future could show an increase in service use, a qualitative study could show if teenagers have improved awareness of how to access advice or have better understanding of the health issues raised. Ewles and Simnett (1999) addressed this by stating that compliance can be measured though statistics but informed choice can be measured by an increased knowledge.

By critically appraising this study and carrying out the literature search the reader feels that those working in this area of nursing are becoming more aware of the issues raised. She acknowledges similar types of studies in the field of teenage health promotion are being undertaken throughout the country and notes that the majority of this research involves enabling the young people to make their own choices. Naidoo and Wills (2000) express this as a client-centred approach.

This paper also raised issues of confidentiality which, has been addressed nationally through government and inter-agency recommendations (Department of Health 2003, RCGP and Brook 2000).

There are however areas where further research needs to be carried out. The author suggests qualitative research specific to other services. Additionally the reader would like to see more information on providing equality of services to both males and females which was an issue raised within the report and is also an issue the government feels should be addressed (Department of Health 2003).

The author has increased her in knowledge of the issues surrounding teenage health problems and will continue to improve her professional development in this area. The ability to critically appraise effectively will become vitally important throughout a career within the nursing profession, as evidence-based practice is an integral part of clinical governance to which every nurse must adhere (Cranston 2002).

Importantly it should be noted that evidence includes research, experience, costs, and patient choice (Thompson et al 2002). Although not all evidence will be of equal significance and not all published evidence will be reliable (Richardson et al 2002). Some practices continue because they always have historically not because they are evidence-based, this is an ongoing issue debated by many (Sackett et al 1996, McKenna et al 1999, Hewitt-Taylor 2002).


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last updated 11/06/05

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