Discussion: Literature Search, Part I
One of the more important questions you will need to ask and answer for yourself as you develop your research study is: “Which qualitative research approach best fits my research question?” You may be able to reframe your research question to fit more than one qualitative approach; generally, though, one of the available approaches is likely to fit better than the others once you have a well-defined question. The only way to make this determination is to develop a familiarity with different approaches.
In this Discussion, you will conduct a literature review of your topic area, focusing your choice on a research study that uses one of the qualitative approaches covered this week.
Make sure you get the complete citation of the article, as well as the , because your Instructor will want to review the article.
To prepare for this Discussion:
- Review the reading materials about the different approaches in this week’s Learning Resources.
- Conduct your own literature search to find a published study that represents one of the approaches.
- Review the following resources before proceeding with your own article review:
ASSIGNMENT
my research question is ( What are the factors related to African American males being targets of police brutality at disproportionate rates? )
Contribute a 3-paragraph Discussion post in which you respond to the following:
- Summarize the characteristics of the approach of the research article you chose during your literature search.
- Summarize the research article, including the citation and sufficient information for your classmates and Instructor to locate the article.
- Present a short critique of that article based on the “R8360 Guidelines for Reading and Evaluating Qualitative Research Articles” document.
Required Readings
Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice (4th ed.). Thousand Oaks, CA: SAGE.
Chapter 3, “Variety of Qualitative Inquiry Frameworks: Paradigmatic, Philosophical, and Theoretical Orientations” (pp. 85–168)
Chapter 4, “Practical and Actionable Qualitative Applications” (pp. 169–242)
Basic Qualitative Research
Bowers, B. J., Fibich, B., & Jacobson, N. (2001). Care-as-service, care-as-relating, care-as-comfort: Understanding nursing home residents’ definitions of quality. The Gerontologist, 41(4), 539–545. Retrieved from http://gerontologist.oxfordjournals.org/
Care-as-Service, Care-as-Relating, Care-as-Comfort Understanding Nursing Home Residents’ Definitions of Quality by Bowers, B.; Fibich, B.; Jacobson, N., in The Gerontologist, Vol. 41/Issue 4. Copyright 2001 by Oxford University Press – Journals, The Gerontological Society of America. Reprinted by permission of Oxford University Press – Journals, The Gerontological Society of America via the Copyright Clearance Center.
Qualitative Case Study
Donnelly, C., Brenchley, C., Crawford, C., & Letts, L. (2013). The integration of occupational therapy into primary care: a multiple case study design.BMC family practice, 14(1), 1.
Grounded Theory
Barello, S., Graffigna, G., Vegni, E., Savarese, M., Lombardi, F., & Bosio, A. C. (2015). ‘Engage me in taking care of my heart’: a grounded theory study on patient–cardiologist relationship in the hospital management of heart failure. BMJ open, 5(3), e005582.
Heuristic Inquiry
Howard, A., & Hirani, K. (2013). Transformational change and stages of development in the workplace: A heuristic inquiry. Journal of Integral Theory and Practice, 8(1/2), 71–86.
1
R8360 Guidelines for Reading and Evaluating Qualitative
Research Articles
1. Find the research question. It’s typically located at the end of the literature
review, right before the Methods section. NOTE – it may not be written as
a question, but the intended question is often found within the declared
purpose or objective, if the author has not explicitly stated it in question
form.
a. Describe the phenomenon of interest. Evaluate how consistent it is
with what is typically explored in a qualitative study.
b. Consider the target group(s)/individual(s)/organizations identified
in the question. How clearly does the author convey the group of
interest in a way that is consistent with qualitative research?
c. Review how the question is phrased. Is appropriate qualitative
terminology used? How well does this question indicate to the
reader as to what type of approach is being used?
2. Check the article title.
a. How consistent is the terminology and intent of the title with the
research question?
3. Identify the research problem that emerges from the literature review/
background.
a. How does the author(s) justify a social problem?
b. How thorough is the discussion of research that has been done,
and note if the phenomenon or choice of group is not clearly and
sufficiently justified (e.g., just one or two studies; articles from
obscure journals, non-academic sources; or literature that is more
than five years older than the study’s published date).
c. How appropriate is the research problem to a qualitative inquiry?
4. Identify the research purpose.
a. To what extent is the purpose aligned with the research problem
(terminology, group of interest, phenomenon of interest)?
5. Identify the approach.
a. Where in the article is the qualitative approach identified?
b. How well is the approach explained and justified?
6. Consider the description of the sample.
a. How well was the inclusion/exclusion criteria described? How was
the number of cases justified (Mason, 2010)?
b. Was a particular sampling strategy identified? Was it correctly
implemented? If not, how well were the discrepancies described?
c. How well does the sampling strategy fit the approach?
d. Did the authors include a description of their efforts to achieve
data saturation (see Guest, Bunce, & Johnson, 2006; Mason,
2010)? Theoretical saturation, if appropriate? What was their
strategy and how well was it achieved? To what extent does their
effort threaten or support the credibility
of the study?
7. Consider the recruitment, invitation, and informed consent process.
a. Were these elements explained well enough that you could judge
this a credible and rigorous process (Guest, 2004)?
b. To what extent was the informed consent process sufficiently
detailed? And, was this sufficient to protect participants from harm
and insure confidentiality?
8. Review the data collection tools and procedures.
a. Are the actual data collection tools included in the article? If so, to
what extent are the questions
i. Open-ended?
ii. Not leading?
iii. Using appropriate, non-technical language?
2
iv. Consistent with the purpose and approach?
v. Insightful or open-ended so that participants might reveal
surprising or unexpected experiences?
b. To what extent are the data collection tools consistent (content
and procedures) with
the identified approach?
c. To what extent are the data collection procedures consistent with
the identified approach?
d. How well are the details, consistencies, and inconsistencies of the
procedures explained? Was the detail sufficient that you could
judge the procedures as dependable and rigorous?
e. To what extent did the authors include discussions of reflexivity in
the data analysis process (Mauthner & Doucet, 2003)?
9. Consider the data analysis process.
a. Was the data analysis process explained in sufficient detail that
you as the reader could follow?
b. To what extent did the authors follow a published or well-source
method of analysis? What was it and was their choice consistent
with the approach?
c. To what extent did the authors include discussions of reflexivity in
the data analysis process?
10. Read the details of the analysis.
a. How did the authors summarize the participants in the study? Was
there sufficient detail provided to verify that the sampling strategy
had been successfully implemented?
b. How were the themes or key concepts identified? Was a published
strategy followed? Was that strategy consistent with the approach
of the study?
c. How were the results presented? How well did the themes
represent the underlying categories or concepts? Were the figures
or tables (if included) helpful in understanding the results?
d. Did the authors note any unexpected findings or discrepant cases?
If yes, what was surprising, if no, does this suggest a potential
bias?
11. Review the discussion and how results compared with prior research.
a. Was a summary of the results clearly presented in the beginning of
this section?
b. To what extent were each of the key results interpreted and
contrasted with prior literature? How did the authors handle results
that challenged or diverged from prior studies?
c. To what extent did the study results and conclusions answer the
research question?
d. How credible was the discussion of limitations?
e. Do the study limitations weaken the transferability of the study?
f. To what extent would the suggestions for future studies be helpful
for persons who want to do more research in this area? Are they
too broad? Unfocused?
12. Evaluate the conclusion.
a. Did the authors convey a clear “take-home” message?
b. To what extent were the conclusions appropriate given the study
approach, scope, purpose, and limitations?
3
References
Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough?
An experiment with data saturation and variability. Field Methods, 18(1), 59–82.
Mason, M. (2010). Sample size and saturation in PhD studies using qualitative
interviews. Forum Qualitative Sozialforschung / Forum: Qualitative Social
Research, 11(3). Retrieved from http://nbnresolving.
de/urn:nbn:de:0114fqs100387
Mauthner, N. S., & Doucet, A., 2003. Reflexive accounts and accounts of
reflexivity in qualitative data analysis. Sociology, 37, 413–431.
Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative
research projects. Education for Information, 22(2), 63–75.
http://nbnresolving/
BioMed CentralBMC Geriatrics
ss
Open AcceResearch article
Pneumonia care and the nursing home: a qualitative descriptive
study of resident and family member perspectives
Soo Chan Carusone1, Mark Loeb1,2 and Lynne Lohfeld*1,3
Address: 1Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada, 2Department of Pathology and
Molecular Medicine, McMaster University, Canada and 3Program for Educational Research and Development, McMaster University, Canada
Email: Soo Chan Carusone – chansy@mcmaster.ca; Mark Loeb – loebm@mcmaster.ca; Lynne Lohfeld* – lohfeld@mcmaster.ca
* Corresponding author
Abstract
Background: Nursing home residents are frequently sent to hospital for diagnostic tests or to
receive acute health care services. These transfers are both costly and for some, associated with
increased risks. Although improved technology allows long-term care facilities to deliver more
complex health care on site, if this is to become a trend then residents and family members must
see the value of such care. This qualitative study examined resident and family member perspectives
on in situ care for pneumonia.
Methods: A qualitative descriptive study design was used. Participants were residents and family
members of residents treated for pneumonia drawn from a larger randomized controlled trial of a
clinical pathway to manage nursing home-acquired pneumonia on-site. A total of 14 in-depth
interviews were conducted. Interview data were analyzed using the editing style, described by
Miller and Crabtree, to identify key themes.
Results: Both residents and family members preferred that pneumonia be treated in the nursing
home, where possible. They both felt that caring and attention are key aspects of care which are
more easily accessible in the nursing home setting. However, residents felt that staff or doctors
should make the decision whether to hospitalize them, whereas family members wanted to be
consulted or involved in the decision-making process.
Conclusion: These findings suggest that interventions to reduce hospitalization of nursing home
residents with pneumonia are consistent with resident and family member preferences.
Background
The demand for long-term care in facilities is increasing in
response to changing demographics and social values. As
of 2000, an estimated 46 percent of Americans 65 years
old will spend time in a nursing home before they die. By
2020, the total number of older adults using nursing
home care in the United States is expected to more than
double [1].
The functional dependence and clinical complexity of
health problems that long-term care facility (LTCF) resi-
dents have are also increasing. In 1997, the United States’
National Nursing Home Survey found that 75% of elderly
nursing home residents needed help with three or more
activities of daily living (bathing, dressing, eating, transfer
from bed to chair, toileting), and that 44% had difficulty
with both bowel and bladder continence [2]. Although
Published: 23 January 2006
BMC Geriatrics 2006, 6:2 doi:10.1186/1471-2318-6-2
Received: 19 September 2005
Accepted: 23 January 2006
This article is available from: http://www.biomedcentral.com/1471-2318/6/2
© 2006 Carusone et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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This statement makes a good case for the social problem and cost-effective alternatives using epidemiological reports. Literature gap is justified by 4 studies from good, somewhat dated journals. The research problem (descriptively examining preferences) is appropriate to a qualitative study.
BMC Geriatrics 2006, 6:2 http://www.biomedcentral.com/1471-2318/6/2
many LTCF residents are currently transferred to hospital
for diagnostic tests or to receive acute medical services, fis-
cal pressures, improved technology, and complications
associated with hospitalization suggest that more medical
care should be provided in nursing homes.
Pneumonia and other lower respiratory tract infections
(LRIs) are a major cause of morbidity and mortality
among nursing home residents. They are also the leading
reason for their hospitalization. One Canadian study
found that nearly one-third of all LTCF residents with
pneumonia were hospitalized [3]. Recent research sug-
gests that residents with pneumonia at a low- to medium-
level mortality risk may be managed safely in a LTCF for
less cost [4,5].
Some researchers have argued that the provision of health
care cannot be decontextualized from the environment in
which it is provided. As such, the locus of care is an impor-
tant issue. There are also a variety of perspectives to under-
stand in relation to this issue – specifically that of older
adults, their families, friends, and health care providers
[6]. Although the decision about where and when LTCF
residents should receive care is no longer solely in their
control, it is important to understand their preferences for
care.
Few studies have examined the care preferences of LTCF
residents and their families and most of this work has
been done with the use of surveys to assess the views of
well people in response to hypothetical situations. Two
such studies have found that nursing home residents gen-
erally prefer hospital-based care [7,8]. Kleinman [9], how-
ever, suggests that generic models of health-related
behaviors are very different from responses to specific ill-
ness episodes experienced by a person, and that the latter
are essential to understanding help-seeking behaviors for
sickness. The objective of this study was to learn if LTCF
care for pneumonia is consistent with resident and family
preferences using a qualitative descriptive study design.
Methods
This study was part of a multi-centred randomized con-
trolled clinical trial that tested the effectiveness and utility
of using a protocol for treating nursing home-acquired
pneumonia. The protocol listed signs and symptoms of
pneumonia and directed staff to follow a treatment path-
way that included criteria for deciding the appropriate
locus of care (LTCF vs. hospital). Twenty nursing homes
in southern Ontario were matched by size and one mem-
ber in each pair was randomly allocated to use the clinical
pathway. The other facility continued to follow normal
care practices to diagnose and treat pneumonia. From
November 2003 to June 2004, research nurses
approached primary decision makers (residents or family
members of residents who were deemed incapable of
making informed decisions regarding their care) to partic-
ipate in the qualitative study.
Sampling and recruitment
Inclusion and exclusion criteria for the clinical trial are
summarized in Table 1. After 30 days of follow up in the
clinical trial study, residents with pneumonia and family
members were invited by a clinical trial study nurse to par-
ticipate in the qualitative study. Our aim was to enrol
information-rich participants, or people who can best
describe the experience under study (purposeful sam-
pling) [10]. As a result, study nurses were asked to only
invite residents they deemed capable of remembering and
discussing care provided for a recent case of pneumonia
(residents), or family members who were most directly
involved in decision-making for residents unable to speak
about their own care. Residents and family members who
indicated they were willing to participate in this study
gave consent to have their names released to the
researcher (SCC) who then explained the study to them
prior to obtaining informed consent. Although our goal
was to recruit individuals until saturation of the main
themes was achieved, we were limited by the number of
eligible participants enrolled in the clinical trial during
the data collection period. However, a strong consensus
among participants’ views on the major topics raised dur-
ing data collection was achieved.
Data collection
Data were collected by the researcher (SCC) in one-time,
individual, semi-structured interviews with residents (n =
6) and family members (n = 8). All of the resident inter-
Table 1: Inclusion and exclusion criteria of the clinical trial*
Inclusion Criteria Exclusion Criteria
Have 2 or more of the following signs or symptoms:
• New or increased cough
• New or increased sputum production
• Fever (>38°C)
• Pleuritic chest pain
• New or increased findings on chest examination
1. Residents not expected to live longer than 30 d (from enrolment)
2. Residents who have had a previous anaphylactic or allergic reaction to
quinolones
3. Residents who have not provided consent
4. Residents with advanced directives stating that they are not to be
transferred to hospital for treatment
*This qualitative descriptive study was nested within a much larger multi-centred clinical trial.
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This is the purpose statement. The “embedded” research question is “How consistent is LTCF care for pneumonia consistent with resident and family preferences?”
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No rationale for the choice of a basic study was provided, but the choice does make sense, as the authors want to “describe” and “examine” preferences.”
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The intention to sample purposefully was clear, as was the intent to create a homogeneous sample of information rich cases. This is consistent with a purposeful sampling strategy.
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Saturation was mentioned, but efforts to achieve were thwarted by lack of participants, so this is a bit iffy.
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The researcher used an established, clearly described method for collecting data and enhancing dependability and rigor, including journaling, triangulation of sources and coding.
BMC Geriatrics 2006, 6:2 http://www.biomedcentral.com/1471-2318/6/2
views were performed in one of four nursing homes. Fam-
ily member interviews were performed in nursing homes,
at coffee shops, or by telephone. Interviews lasted
between 20 and 90 minutes, depending on the partici-
pants’ ability to express themselves. All but one interview
was tape recorded and transcribed verbatim for accuracy.
Data were collected in the one non-taped interview by
extensive note taking during and immediately after the
interview. Interviews focused on four themes: partici-
pants’ experience with a recent case of pneumonia, pre-
ferred locus of care for pneumonia (hospital or nursing
home), perceived differences between LTCF- and hospital-
based care, and what constitutes ‘good care’. Preliminary
analysis of the first four transcripts revealed an important
but unanticipated theme: participants’ desired involve-
ment in treatment decision-making. This topic was there-
fore included in subsequent interviews. The interview
guides for the resident and family member interviews
were similar. The only differences were that resident inter-
views probed for more information about the actual care
that residents received, and family member interviews
addressed both family members’ actual preferences as
well as their views on the preferences and experiences of
the residents they spoke about (See Table 2 for the final
version of the resident interview guide).
Rigour and credibility
Numerous steps were taken to ensure that the findings
were faithful to the participants’ descriptions and interpre-
tations (credible), and that the research process could be
followed by another researcher (rigorous). All interviews
were conducted by the same person (SCC) to ensure con-
tinuity across interviews (reduce bias). Following the rec-
ommendations of Miller and Crabtree [11], the researcher
made reflective journal entries throughout the study. Two
types of triangulation were used in this study. Data were
collected from both LTCF residents and from residents’
family members (multiple sources of data), and two
researchers independently coded transcripts and com-
pared their findings (multiple researchers). A third
researcher, with extensive clinical and research experience,
was consulted at all stages of the study (peer review).
Ethical considerations
Informed consent was received from all participants prior
to conducting an interview. Individuals were assured that
their care would not be affected in any way by their deci-
sion about participating in the study. None of the study
nurses or researchers worked for a nursing home enrolled
in the study, and did not provide care outside of the study.
This study was approved by the research ethics board at St
Joseph’s Hospital in Hamilton, Ontario, Canada.
Data analysis
Following standard practice, audiotapes produced during
each interview were transformed into verbatim written
accounts (transcripts) by a professional typist. The
researcher (SCC) then compared the written and audio-
taped versions of each interview in order to correct tran-
scription errors. Data from earlier transcripts were
analyzed concurrently with ongoing data collection
[10,12] in order to ensure that emerging themes could be
further pursued in later interviews. Analysis followed a
five-phase process [12]. In phase one (description), tran-
scripts were read in their entirety without coding the data
and reflexive journaling was used to gain an overview or
overall sense of the views of study participants. Phases two
and three (organizing and connecting data) involved
more detailed transcript review to identify key phrases
and words, and then pattern coding [13] or clustering
them into themes, followed by data reduction and linking
across clusters. In phase four (corroborating/legitimat-
ing), two researchers (SCC & LL) individually coded the
transcripts and compared their findings to reach consen-
sus about disconfirming evidence and alternative explana-
tions. Phase five (representing the account) involved
highlighting results with supporting quotes (linking find-
ings to the data), and interpreting the findings in light of
relevant literature.
Presenting results
Following standard procedures for reporting interview
data [14], exemplars, or typical statements made by partic-
ipants, are presented initalics to support conclusions
Table 2: Interview guide for residents
Diagnosis
Thinking back to when you were sick, what sort of symptoms did you
have?
Who first told you that you had pneumonia?
How did you feel when they told you that you had pneumonia?
Have you had pneumonia before?
Treatment
What sort of treatment did you receive?
How often did you see the doctor?
What could have made the care that you received better?
Quality of Care
To you, what is the most important aspect of care?
What makes you feel like you are being well taken care of?
Preferences for care
If you had a choice, where would you have preferred to receive care
(in the nursing home or in the hospital)?
Would you like to be asked where you would like to receive
treatment? Or, would you prefer the doctor or nurses to make the
decision on their own?
Differences between hospital and nursing home
What sort of differences do you see between the care that you would
receive here versus the care that you would receive in the hospital?
What would make you think that you have to go to hospital?
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The entire interview guide is presented. Some of the questions are yes/no or short answer. No questions about what underlies the preference, other than the facility. Seems restricted in questions.
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The authors included a thorough description of procedures used to protect participants.
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As a basic qualitative study, no effort was made to go beyond simple questions about preferences, events and experiences.
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The process from moving from original data to transcripts was clearly described. The analysis process was sourced from well-known authors and sources. The process of achieving consensus across coders was well-described.
BMC Geriatrics 2006, 6:2 http://www.biomedcentral.com/1471-2318/6/2
drawn by the researchers. The views of LTCF residents and
family members are presented separately to aid compari-
sons across these two groups in the discussion section of
this paper. Participants are identified by a letter (“R” = res-
ident, “FM” = family member”) and a number based on
the sequence in which interviews were conducted. For
example, “R4” is the fourth resident we interviewed. Min-
imal editing was done to preserve authenticity while
ensuring readability [15]. Ellipses (…) were used where
irrelevant information was deleted from a quote. Where
necessary, clarifying information was added to a partici-
pant’s words in square brackets ([ ]).
Results
Participants
Participants included six residents and eight family mem-
bers. All of the residents were females between the ages of
76 and 93 years (mean age = 84 years). Residents varied
greatly in their functional status, as measured by a modi-
fied-Barthel Index used to rate status on 10 daily functions
for a summary score that ranges from 0 (full dependence)
to 20 (full independence) points. Four of the residents
were extremely dependent (Barthel Index < 10, range: 0 to
9) and two were moderately independent (Barthel Index
10–20). Two residents had been hospitalized for pneu-
monia while enrolled in the clinical trial. Half of the fam-
ily members were female (2 wives and 2 daughters or
daughters-in-law) and the other four were sons of LTCF
residents. The seven residents they spoke about (5 of them
female) ranged in age from 84 to 96 years (mean age = 91
years) and scored very low on the Barthel Index (0–12).
One of the residents they spoke about had been hospital-
ized for pneumonia and died upon return to the LTCF. All
the participants were recruited from five nursing homes (2
for-profit, 3 not-for-profit) with 100–250 beds (see Table
3 for a summary of participant characteristics).
Participants readily spoke about the four topics raised in
the interviews. Both residents and family members pre-
ferred that care be provided in the nursing home (when
possible), although for slightly different reasons. They
also had different views on how decisions about locus of
care should be made.
Preferred locus of care
Both residents and family members largely preferred that
pneumonia be treated in the nursing home. This appears
to be a function of both their beliefs about pneumonia
and how they define good care. Both groups of partici-
pants believed that hospital care is clearly necessary for
some conditions (e.g. fainting, broken bones, operations,
and heart problems) but not for pneumonia (‘I don’t want
to go to hospital [for pneumonia]. If you need an operation,
that’s different’ [R3, page 5]).
Residents: Although all residents in the study had been
diagnosed with pneumonia or a LRI, and two of them had
even been hospitalized for this condition, they were gen-
erally not very concerned by such a diagnosis. Some resi-
dents referred to their illness simply as a ‘cold’ or the ‘flu’
and seemed to have had trouble believing it was pneumo-
nia (‘I thought, “Oh, no, I haven’t got pneumonia!” I was just
surprised that I had it, or that I was supposed to have it.’ [R5:
page 1]). They generally felt that pneumonia could be
cared for in the nursing home (‘I don’t want to be in the hos-
pital again… I know they have taken people from here to the
hospital. I guess when they get pretty bad… [but] I don’t think
they could get any better treatment then we get here.’ [R2, page
7]).
Family members: Family members were more concerned
than residents about the diagnosis of pneumonia, recog-
nizing that it could be a serious illness in the elderly.
Table 3: Participant characteristics
ID (relationship) Sex* Age* Hospitalized* Barthel*a
R1 Female 76 Yes 6
R2 Female 84 No 9
R3 Female 93 No 14
R4 Female 86 No 17
R5 Female 84 Yes 0
R6 Female 83 No 7
FM1 (son) Female 96 Yes 3
FM2 (daughter) Female 88 No 8
FM3 (son) Female 98 No 3
FM4 (daughter-in-law) Female 93 No 12
FM5 (son) Male 88 No 0
FM6 (wife) Male 88 No 0
FM7 (son) Female 84 No 0
FM8 (wife) Male 92 No 10
* Characteristics of resident
a Modified Barthel Index: 0 indicates complete dependence and 20, complete independence.
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Good description of participant characteristics. Lots of variance residents’ functional status, hmmm. And it’s interesting that the residents and family members do not appear to be related.
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The results of the analyses are organized well. Each theme is described from each point of view, quotes are clearly indicated, participants are distinguishable. Some interesting differences between residents and families were found, but nothing that was surprising.
BMC Geriatrics 2006, 6:2 http://www.biomedcentral.com/1471-2318/6/2
However, many of them still felt that it can usually be
managed on-site:
‘In the elderly, [pneumonia] is quite a serious thing. If it’s
caught early, which it is usually in the nursing home, I think
it’s better to be treated here. With the antibiotics that they have
now, and the [fact that the] nurse came in every day and
checked her every day [for] the oxygen level, the care was ter-
rific.’ [FM4, page 2]
Despite preferring on-site care for pneumonia, some fam-
ily members acknowledged that they were not sure what
level of acute care a LTCF could provide:
‘I think [my mother] would get better care [in the nursing
home] than she probably would in the hospital, except she
would not be very ill. Because when she is very ill, I don’t think
they would be able to look after her [here]. They haven’t got the
facilities. I don’t think they’re geared to do that.’ [FM2, page
5]
In some cases, family members acknowledged that even if
their loved one was very sick, it was not necessarily desir-
able to provide care in hospital:
‘Let’s be honest about it. He’s 88. He’s been on the verge of
death several times. The man has no quality of life at all; zero…
Why are we going to use hospital resources when all we really
want to do is make him comfortable in his last hours or months
or years, or whatever he’s got left? I don’t think hospital inter-
vention is going to improve his quality of life at all.’ [FM5, page
2]
Defining good quality care
Both residents and family members expressed the view
that residents with pneumonia can receive more comfort
and personal attention in a LTCF than in hospital, and
therefore preferred in situ care.
Residents: For these participants, signs of good care
included paying attention to a resident’s comfort, as well
as personal attention, interest, and time given by nurses
(‘We’ve got some real nice nurses here. They really care.’ [R2,
page 6]; ‘They always take time to listen to you if you tell them
there is something wrong’ [R3, page 6]). The only treatment-
related aspects of care that residents specifically men-
tioned involved easing discomfort (‘ [In this facility] they
usually give me Tylenol and good care. [They] see that I’m
looked after alright and comfortable’ [R2, page 5]).
Although residents were more hesitant than family mem-
bers about expressing any negative opinions about care,
several of them were able to clearly identify problems,
such as extremely busy staff or their lack of availability (‘
[The nursing home] is better, I think. I think they have more
time here – not that they have a lot of time, but they seem to
have more time than in the hospital.’ [R5, page 4]), including
the lack of availability of some doctors (‘We call Dr. [So-
and-So] “the Phantom”: He goes to the office and then shoots
down the hall!’ [R1, page 1]). Unlike family members, res-
idents generally brought up such issues with an under-
standing or accepting attitude (‘You just put up with what
you have to’ [R5, page 4]).
Family members: These participants, like the residents we
spoke with, thought that a caring attitude and personal
attention from nurses are signs of good care:
‘Well, [in] the hospital, if I remember correctly, they don’t have
the time. The poor nurses, they just don’t have the time. Every-
thing is sort of rush, rush, rush, and they don’t really listen.
[My mother] went in when she hurt her knee… and we were
there from 11 at night until the next morning. At eight o’clock
at night she came home… [In the hospital], they’re so rushed
that [the nursing home] is better. [It] is more personal care.’
[FM4, page 1]
Nurses’ attitudes and personality were also important
aspects of care (‘My mother liked a friendly person, somebody
she could kid around with and joke [with]’ [FM1, page 7]).
Family members also wanted to be reassured about their
loved ones’ care (‘Where she is now, I have no qualms leaving
my mom there because I think it’s one of the best homes there
are… Before she was in [another nursing home and] I
wouldn’t have left my mom there’ [FM2, page 2]; ‘She gets very
good care. It’s a very good nursing home. It’s one we chose’
[FM7, page 2]).
Although family members generally preferred that care be
given in the nursing home, they were much more critical
than the residents of the care provided in LTCFs. They also
more readily identified benefits of hospital-based care
(‘Definitely there is no doctor here [at the nursing home] on
a permanent basis, so the hospital would provide better care,
once admitted’ [FM3, page 2]; ‘ [In the hospital] it’s not a
question of taking blood, sending it to the laboratory and hav-
ing somebody come back three days later… they immediately
check it and they know exactly [what is going on]’ [FM1,
page 3]).
The number one complaint made by family members
about nursing home care was that the staff are too busy
and, in some cases, personal care is inadequate (‘Some-
times he [urinates] in bed. It’s not a pleasure for him… It takes
so long before [the nurses] come… They’re always in a hurry.
I can see it’s because they are too short of staff’ [FM6, page 3]).
Although not a major theme, some concern was also
expressed over the level of training that staff receive:
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‘In a nursing home, 90-something percent of [the residents’]
contacts are with the lowest paid, medically unqualified peo-
ple… Some of the health care aides are lovely, you know, they’re
really nice. But … the training is very short, as far as I can
determine.’ [FM1, page 7]
Reasons for preferring nursing home care for pneumonia
Both residents and family members identified other fac-
tors associated with their preference for LTCF-based care.
The most central of these was the view that the LTCF is a
resident’s ‘home’.
Residents: Many of these participants stated that they did
not want to go to hospital even though one can receive
good care there. The reasons they gave for this view were
that hospitals were busier, more isolating, and more con-
fining than nursing homes (‘You are hooked up to every-
thing… oxygen, the heart machine… You don’t know the nurse
that’s hard.’ [R1, page 2]; ‘I think it’s more comfortable here
[in the nursing home] than in the hospital. There’s not as
much going on in the halls as in the hospital.’ [R5, page 4]).
The LTCF had become their home (‘Everybody knows me. I
am friends with everybody.’ [R6, page 3]; ‘I think most people
like it back in the nursing home. Hospital is hospital. I’m not so
good in the hospital. You want to be in your own room.’ [R4,
page 7]). Some residents also mentioned the inconven-
ience that going to hospital caused family members.
Family members: Family members also preferred that their
loved ones receive pneumonia care in the nursing home,
although they were more willing to accept that hospitali-
zation might be necessary. Many of them indicated that
the LTCF is the senior’s home and the benefits of being in
familiar surroundings (‘I think the same surroundings really
helps the elderly patient; [my mother] would be still in her
own room and her own bed. Even in my mother’s case, where
she now has this dementia, she talks about her room like her
home’ [FM3, page 3]). Some family members also
expressed the view that in situ care was preferable because
of the difficulties that residents have adjusting to life in
the hospital (‘To transfer [my mother] to hospital and get use
to the hospital environment, I think is more detrimental…
[even though] I think they would get more superior treatment
in the hospital… and the medical staff assessment there would
be far superior than in the nursing home’ [FM7, page 1&3]).
This was particularly the case if the LTCF resident had
dementia:
‘I think the confusion is more in the hospital. [The last time
my mother was in the hospital] the nurse said, “Can you stay
to just keep your eye on her?”… [My mother] was going to go
home and therewas just no two ways about it. They couldn’t
keep her there. She had the whole floor in an uproar.’ [FM2,
page 2]
From a personal perspective, several family members also
explained that it is more convenient for them if their loved
ones receive care in the LTCF:
‘The family’s more comfortable [in the nursing home], I
think… One, there’s parking; two, I don’t have to deal with,
“Can I go in [or] can I not?”… It’s more familiar. It’s the cen-
tral place. My mother is already there. We don’t have to lug her
back and forth [to see my father].’ [FM5, page 3]
Making the decision about locus of care
Although both residents and family members preferred
that pneumonia care be provided in situ, they differed in
their opinion of how they would like the decision to hos-
pitalize to be made.
Residents: These participants often admitted that when
they were ill, they were ‘too sick to care’ and ‘didn’t care what
they did’ [R3, page 5]. Even when not so overwhelmed, res-
idents generally wanted their doctors to make the treat-
ment decisions for them. Several residents equated
voicing any preferences about care to their doctors with
complaining or with being difficult or bossy (‘Just tell [me
what to do], not [that] I would say, “No, I don’t like to go [to
hospital] ” and be bossy. That is not my person [ality], not at
all.’ [R4, page 4]). In one instance, a resident admitted that
she had voiced her preference to the nurse, but explained
she would never talk that way to her doctor.
Family members: In contrast, when possible, family mem-
bers wanted nursing home staff to suggest treatment
options and discuss their loved one’s care with them
before transferring the LTCF resident to hospital (‘I expect
them to be the professional on the job and make suggestions. If
I have a problem with their suggestion, they can always go to
option two with me.’ [FM5, page 2]).
Unlike the residents, family members were quite willing
to voice their care preferences. Several of them stated that
they were the ones who ultimately made treatment deci-
sions (‘I would rely on their expertise [to make the decision]
because I’m not in the medical field… [but] my wife and I
make the decision whether to allow them to go ahead’ [FM7,
page 2]). Despite clearly stating this central role, many
family members also admitted that they would usually
take the advice of staff:
‘When the [nurse] said, “Would you have any objections if we
send [your mother] to the hospital?”, I said, “No. If you think
that that’s what should be done, I think that’s what you should
do…. I’m not a doctor. If you think that’s the case, by all means
just phone me and I’ll be right there”.’ [FM2, page 5]
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Discussion
Understanding resident and family member preferences
about care is an essential ingredient to increasing satisfac-
tion with care [16]. In this study on nursing home-
acquired pneumonia, we captured the voices of both resi-
dents who were capable of making their own decisions in
regards to their care and of family members speaking on
behalf of residents who were incapable of expressing
themselves. Both of these groups preferred that care be
provided in the nursing home, although family members
were more open to the idea of providing residents with
hospital-based care. This preference is based on both their
beliefs about pneumonia (not a health problem that must
be cared for in hospital) and their assessment of ‘good
care’. For both groups of study participants, comfort and
personalized care were the two most important compo-
nents of care and were perceived as being more available
in LTCFs.
Regarding treatment decision-making, family members
believed that their preferences are regularly taken into
account by LTCF staff, although many reported they
would most likely take staff recommendations. Residents,
on the other hand, felt that doctors should make treat-
ment decisions, including locus of care. They were also
much more hesitant than family members to express treat-
ment preferences or criticize their care.
Other studies that have investigated resident preferences
for care (such as [7] and [8]) have found a greater prefer-
ence for hospital care. One plausible explanation for the
discrepancy between the study findings may be that peo-
ple tend to respond differently to questions about pre-
ferred locus of care if they are asked about hypothetical
versus actual situations.
The role of the nursing home or LTCF is another factor
that should be taken into account when developing pro-
grams to ensure patient- or resident-centred care. In
response to the recent economic restructuring of health
services in Canada, as well as changes in social values and
demographic patterns, increasing numbers of older adults
will receive care in a LTCF rather than in their own or a
family member’s home. In essence, these facilities will
serve as both a person’s home and a place where serious
health care needs are met. The results of this study suggest
that nursing home residents’ values and beliefs about
pneumonia do not elicit a strong desire for care in what
Kleinman [9] refers to as the professional sector (hospi-
tal), but rather that they focus on the more personalized
aspects of care that are traditionally associated with the
popular sector (i.e. family and home). In LTCFs, where
residents are personally known by staff and volunteers,
the more personalized aspects of care, as well as biomed-
ically appropriate treatments, are often available. This
means that both disease- and illness-related changes in
residents can be addressed when in situ care is provided.
This was important for even those family members who
indicated that an older person with pneumonia may
receive better medical care in hospital.
There has been increased interest in measuring nursing
home residents’ satisfaction with care through surveys.
However, little research has focused on understanding the
reasons why residents prefer certain aspects of care or
where such care is provided. Bowers et al. [18], in a qual-
itative study on nursing home residents’ definition of
quality care, identified three key components of care: care-
as-service (instrumental aspects of care, such as how well,
how quickly, and how consistently staff work is done),
care-as-relating (affective aspects of care, such as staff-res-
ident relationships and indications of affection), and care-
as-comfort (whatever maintains or improves residents’
physical comfort). In our study, residents’ examples of
good care included the two latter components, and family
members discussed all three of them.
One possible reason why residents did not include instru-
mental aspects of care when discussing ‘good care’ could
be their reluctance to criticize physicians. Family mem-
bers, on the other hand, often assume the role of ‘watch-
dog’ for their loved ones, identifying and addressing
problems with staff and facility administrators. Another
reason may be that Bowers et al. focused on nursing home
care in general, rather than on care for a specific health
problem. It may be that people may evaluate normal, day-
to-day care, such as the provision of meals and medica-
tions, differently than care received when they are ill. Our
findings suggest that for acute care in the nursing home,
residents may value comfort and caring related to their ill-
ness experience more strongly than the technical aspects
of care that are more often associated with disease and
hospital-based care.
A greater understanding of residents’ and family mem-
bers’ preferences and satisfaction with treatment is crucial
to developing viable models of resident-centred care. It
may also play a vital role in enhancing resident coopera-
tion with care plans, thereby improving health outcomes
[19]. It is important, however, to make a clear distinction
between individuals’ preferences for locus of care and the
level of involvement they want to have in treatment deci-
sion-making. Our findings, and those of O’Brien and col-
leagues [9], suggest that despite having specific treatment
preferences, the majority of nursing home residents
believe that doctors should make important treatment
decisions. However, residents who do not want to play an
active decision-making role may still want doctors to con-
sider their preferences when faced with choices about
their care [20].
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The authors relate findings to scholarly publications as well as potential for social change by looking at bigger demographic patterns.
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The authors offer suggestions as to why they found discrepancies and supported with literature.
BMC Geriatrics 2006, 6:2 http://www.biomedcentral.com/1471-2318/6/2
Our findings are consistent with the literature in which
older patients have been consistently shown to want less
information and take a less active role in the treatment
decision-making process [21-23]. In this study, we also
found that residents were more hesitant to express their
care preferences to physicians than family members. This
may be related to their reluctance to criticize care (also
noted in other studies; cf. [24] and [25]), or possibly the
inability to evaluate their own care [25]. It may also be
due to the role that family (informal) caregivers fill, which
is to advocate on behalf of their loved ones in acute and
long-term care facilities.
It is important to note that in the LTCF setting, research
and patient-centred models acknowledge the pivotal role
that family members play in decision-making and quality
assessments. This research suggests that residents and
family members may differ in their evaluations of care
and their preferences for involvement in the decision-
making process. Consequently, providing resident-
focused care will require the understanding of both per-
spectives, particularly among people responding to actual
illness episodes.
There are several limitations of this study. Although it is
important to capture the voices of nursing home resi-
dents, interviewing residents can be challenging. Resi-
dents often have trouble expressing themselves and
providing in-depth explanations, two key components of
qualitative research. In some cases, residents conflate ill-
ness episodes over their lifetimes, making it hard to iden-
tify the specific context of their descriptions. Because of
the limited number of participants and the cross-sectional
nature of the study, we were not able to identify important
variables that may influence resident or family member
perspectives on care and determine if or how they change
over the course of an illness. Our findings may be limited
by the fact that no male nursing home residents were
interviewed. However, it should be remembered that
nursing home residents are mostly women. In the clinical
trial from which residents were selected, 70% of the par-
ticipants were female. This is similar to American profiles
of nursing home residents where the ratio of women to
men is approximately 3 to 1 [26]. Lastly, our study
focused specifically on the views of residents and family
members that were the primary decision makers in a resi-
dent’s care decisions. The preferences of other family
members and residents who cannot clearly express them-
selves may be different.
This study may be a good example of how qualitative
studies can identify the underlying reasons for preferences
around locus and type of care for older adults but not the
prevalence of such views. To answer that question, quan-
titative surveys of larger numbers of individuals randomly
selected from among LTCF residents and their families
would be needed.
Building on this research, we would hope that future stud-
ies on this important topic explore the views of a broad
range of residents and family members using a variety of
methods, such as interviews, observation, and surveys, in
order to more fully investigate factors that might influence
the preferred locus of pneumonia care of residents and
their family members. This includes individual factors
(such as cognitive status, length of stay in the nursing
home, past illness and hospital experiences) and contex-
tual variables (such as quality of care and consistency of
staff). It is also important to develop and use innovative
research methodologies tailored for the nursing home set-
ting to assess preferences for care and desired involvement
in the decision-making process.
Conclusion
The findings of this study have important implications for
both future practice and research on pneumonia care for
nursing home residents. Our work suggests that efforts to
provide more on-site care are consistent with resident and
family member preferences. The provision of acute care in
nursing homes may become a more widely accepted
option once additional work has been done to increase
public awareness of the clinical skills and resources avail-
able in that setting, and of resident and family views sup-
porting in situ care. Nursing homes may benefit from
highlighting their ability to meet both disease- and ill-
ness-related facets of care, providing both state-of-the-art
medical care as well as the personal attention and comfort
measures that residents and family members consistently
identified with good quality care. Although we are not rec-
ommending that nursing homes base their choice for
locus of pneumonia care only on stated preferences by res-
idents, we do suggest that even those seniors who do not
want to be actively involved in making treatment deci-
sions may have strong preferences for in situ care.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors’ contributions
All authors contributed to the design of the study and the
writing of the manuscript. SCC collected the data, per-
formed the data analysis, and drafted the manuscript. ML
provided general supervision and assistance in the inter-
pretation of the findings. LL supervised the data collection
and analysis, and contributed to the interpretation of the
findings. All authors read and approved the final manu-
script.
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This limitation is well-described, suggesting that saturation was not achieved, because of the challenges of finding participants, and because these participants were not able to generate rich thick descriptions.
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The take home message is very clear. The authors do attempt to justify and moderate their conclusions because of study limitations, and recommendations are carefully made with caveats.
BMC Geriatrics 2006, 6:2 http://www.biomedcentral.com/1471-2318/6/2
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Acknowledgements
This study was funded by the Canadian Institutes of Health Research
through an Interdisciplinary Health Research Team grant.
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