How relevant and effective is the information given

in a phase III cardiac rehabilitation programme?

Item Type Thesis or dissertation

Authors Williams, Margaret R.

Publisher University of Chester

Download date 10/05/2023 05:16:39

Link to Item http://hdl.handle.net/10034/78633

Methodology

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3. Methodology

Having decided on the aims and objectives of this small evaluative research study,

consideration was then given to the preferred method of data collection. Whilst

evaluation research has a distinctive purpose, this does not place restrictions on the

type or style of research or type of data collection. Choices about the method of data

collection are largely dependent upon the questions to which answers are sought;

this outcome based evaluation seeks to find answers about the patient experience. A

further consideration for the researcher concerns the practicalities of the chosen

method such as, time, resources, and access to the participants.

Whatever method of data collection is adopted, there is a requirement for the

participants to answer questions, which places a burden on the participant in terms

of cognitive demands. A variety of cognitive requirements such as literacy, verbal

and language skills, ability to follow instructions, recall information from memory and

comprehension of the question may be necessary dependent upon the method of

data collection chosen. The researcher should consider these requirements when

selecting the method of data collection as potentially the choice may exclude the less

literate, and affect the quality and accuracy of the data obtained (Bowling, 2005).

The three main methods of data collection considered for this study were face to

face interviews, focus groups and questionnaires.

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3.1 Interview

Interviews can be used to collect quantitative and qualitative data, they have the

capacity to describe, explain and explore issues from the participant’s perspective. A

structured interview equates to an interviewer administered questionnaire, the

researcher uses a pre-determined set of questions which normally generates

quantitative data. They are often associated with social surveys where collection of

large volumes of data from a wide range of respondents is required. A semi-

structured interview allows for more flexibility, the interviewer has a clear list of

issues to be covered but allows the respondent to elaborate on points of interest.

Unstructured interviews involve the introduction of a theme or topic by the

interviewee and the respondent is free to develop their own thoughts and ideas.

These less structured approaches to interview are essentially qualitative in nature,

although they are described as distinct methods, in practice, they exist on a

continuum and it is possible for the interview to slide back and forth along the scale

(Tod, 2006).

In terms of the cognitive requirement of the participant, the face to face interview,

which may only require the participant to have basic verbal and listening skills and

speak the same language as the interviewer, could be regarded as the least

burdensome method of collecting detailed information (Bowling, 2005).

A friendly, motivating interviewer can help respondents, increase response rates,

probe for responses and aid clarity of response. However, Denscombe (2003)

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cautions against the ‘interviewer effect’, the personal attributes of the researcher

such as, gender, age, and ethnic origin. These attributes can impact on the honesty

and amount of information the interviewee is prepared to divulge, as such, this can

influence the quality of the data. The social interaction required for interviews can

lead to social desirability bias, resulting in over reporting of desirable behaviours and

under reporting of socially undesirable behaviours. Whilst interviewing can be a

flexible and efficient way of gathering data, for the researcher, interviews can be very

labour intensive, time consuming, and expensive (Denscombe, 2003).

3.2 Focus group

A focus group is a small group of people who are brought together to explore

attitudes and perceptions, feelings and ideas about a topic. They excite group

interaction and discussion and encourage contribution from participants who might

be reluctant to engage on a one-to-one interview basis. Whilst one advantage of a

focus group is that they do not discriminate against people who cannot read or write

(Goodman and Evans, 2006), they can discriminate against people with other

communication difficulties such as deafness, dementia and ethnic minorities who do

not share a common language.

Kitzinger (1995) supports the view that focus groups can be the most appropriate

method for researching particular types of questions; they are used extensively in

nursing research and have the potential to provide a rich source of data. This

method of data collection allows the researcher to highlight inconsistency within the

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group as well as providing examples of conformity and agreement. The emphasis for

the researcher is to discover the collective view through relatively informal

exchanges and discussion, for some participants this may require revision of their

original ideas and understanding. Value is placed on the interaction within the group

as a means of discovering information, rather than just collecting each individual’s

point of view (Kitzinger, 1995).

Formulation of a successful focus group requires considerable preparation and skill,

selection of the participants is fundamental to the success of the group and

facilitation of the group requires an experienced moderator and a second researcher

to act as observer. Problems can arise if an assertive group member dominates the

proceedings and intimidates more timid members of the group; part of the

moderator’s role is to manage the group to avoid this happening (Krueger and

Casey, 2000). Whilst focus groups have the potential to provide a rich source of data

and extend the scope of understanding with regard to a specific topic, McLafferty

(2004) advises that they require considerable commitment in terms of time and

energy to recruit participants, facilitate the group, transcribe and analyse the data.

The group participants must also be prepared to invest time and effort in order to

attend the group. The moderator has a responsibility to members of the group to

ensure they are not exploited or distressed through their participation in the process

and in this event must be prepared to offer additional support if necessary (Gibbs,

1997).

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3.3 Questionnaire

The use of the questionnaire as a data collection tool allows for facts and opinions to

be obtained, they are a flexible and versatile method of collecting data and are

frequently used to evaluate a course, assess satisfaction with hospital care, or for

market research (Denscombe, 2003). Questionnaires need to be designed to answer

the questions being asked, established questionnaires have the advantage of

accepted validity and reliability, however they may not be suitable for a specific

project, researchers intent on designing a questionnaire need to consider this can be

time consuming, and may also involve considerable costs (Murphy-Black, 2006). A

major decision for the researcher intending to use a questionnaire is the method of

distribution and administration, as previously discussed questionnaires may be used

to guide face to face interview, alternatively they can be for self administration,

involving distribution either by post, telephone, or personal contact. Bowling (2005)

holds the view that the chosen method of administration can influence the quality of

data collected. Self administration of questionnaires as a method of data collection

requires a functional level of reading, writing and interpretation skills by the

participant. Whilst low response rate is a problem often associated with

questionnaires, a questionnaire handed out personally has the advantage that the

respondents connect it with an individual or organisation and this can improve the

response rate (Murphy-Black, 2006).

The final decision to choose a questionnaire as the methodology for this study was

influenced by, time constraints, economics and logistics. To use an interview or

focus group approach would not have been practical for the researcher or the
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participants due to time and resource constraints. The problem of low response rate

often associated with questionnaires was avoided in this study, as the cardiac

rehabilitation team were present when the majority of the questionnaires were

completed by the participants.

The data for this study was collected via a series of short questionnaires, comprising

both quantitative and qualitative questions, from people recruited to a cardiac

rehabilitation programme. The questionnaires were distributed personally by

members of the cardiac rehabilitation team.

3.4 The Cardiac Rehabilitation Programme

The Cardiac Rehabilitation programme is based upon a structure designed to cater

for the needs of patients at the different stages of their disease and recovery

process. For the purposes of providing a logical approach to cardiac rehabilitation

programmes these stages are considered in the United Kingdom as four phases

(appendix 1). This study was confined to phase III when people referred to the

cardiac rehabilitation programme in the Wrexham area attend their exercise and

education programme.

A multidisciplinary team consisting of nurses, exercise physiologists and

physiotherapists, dietitians, pharmacists, and occupational therapists delivers the

phase III programme in the Wrexham area. People recruited to the programme have

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all experienced a cardiac event or diagnosis; they attend the phase III programme

either in the hospital physiotherapy department as an out-patient, or in a community

leisure centre, according to their risk stratification.

In the Wrexham area, each person being considered for the phase III programme

attends a pre-programme assessment; this includes a physical, social and

psychological aspect and is necessary to ensure patient safety in the programme.

During this assessment each attendee is risk stratified by the cardiac rehabilitation

team and allocated a suitable environment in which to participate in the exercise and

education programme. The programme is structured as a seven week ‘rolling’

programme, with one or two new people joining each week (in each location), and

usually, two people (from each location) finishing each week. Potentially, a maximum

of ten attendees per location is allowed in each location, in accordance with staff to

attendee ratio (1:5) as recommended by the British Association of Cardiac

Rehabilitation (2007).

The patient attends the cardiac rehabilitation programme for seven weeks; each

week the programme consists of one hour of exercise in a gymnasium followed by a

one hour group educational talk facilitated by one of the members of the

multidisciplinary cardiac rehabilitation team.

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3.5 Sampling

3.5.1 Target population

This was derived from all those who were known to the cardiac rehabilitation team

and were attending their phase III exercise and education programme within the

Wrexham area. The vast majority of those attending the phase III programme, were

previously known to the cardiac rehabilitation team via phases I and II. A small

minority were referred directly into phase III via their consultant, GP or from the

tertiary hospital.

3.5.2 Sample selection

The need to specifically select a sample for this study was not considered

appropriate, the study focussed on collecting data from subjects who were available

to the researcher because they happened to be attending the phase III programme

whilst the data collection was in progress. A convenience sample (n=54) was

enrolled from patients who were attending the programme whilst the data collection

was in progress.

3.5.3 Inclusion/exclusion criteria

All patients who were attending a phase III programme were invited to participate in

this study, completion of all, part, or none of the questionnaires was voluntary and

return of the questionnaire was taken as consent to participate in the research. No

other inclusion/exclusion criterion was required except attendance on the day of the

talk and data collection.

 
3.6 Recruitment to the study

Patients were invited, but not coerced into taking part in the study, the patients were

given a verbal explanation of the details of the study and they were invited to ask

questions to clarify any matters. This included information about the purpose of the

study, right to confidentiality, and right to withdraw. An information sheet with written

details of the study was also available (appendix 2) with a Welsh version of the

information sheet available for patients who requested it, this was never required. To

ensure continuity with regard to the verbal explanation of the study and the

distribution of the questionnaires between the groups, the health professional

responsible for distributing the questionnaires at each location was given a guidance

sheet to follow (appendix 3).

3.7 Ethical considerations

Prior to commencement of the study ethical approval was sought from the research

and development Internal Review Panel at the Maelor Hospital in Wrexham. NHS

research ethics committee permission was not required for this study because it was

considered to be part of service evaluation (appendix 4). The main ethical issues

considered for this study were to ensure voluntary consent and maintain

confidentiality and anonymity. This was maintained by ensuring that all the

questionnaires were entirely anonymous and untraceable back to the patient.

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3.8 Questionnaire development

Although there are several standard validated instruments for measuring patient

views, the specific aims and objectives of this study meant they were unsuitable.

However, other studies designed to explore the patient experience have shown that

a combination of specific closed questions and open-ended questions can elicit

quality data. The questionnaires developed specifically for this study were subject

specific and consisted of a mix of open ended and closed questions (appendix 5).

The criterion used for production of the questionnaires was based upon the need to

gain accurate, useful information in a straightforward but ethically acceptable way.

The questionnaires comprised of two sections. Section 1 examined patient views

with regard to the delivery and relevance of the information given in the talk with a

series of closed questions. Question 1 asked the patient to ‘rate the information

given in the talk’ using a tick box scale with four options, poor, average, good and

excellent. The instruction for question 2 was ‘Please read through the following

statements and decide how much you either agree or disagree with each. For each

statement, the patient recorded their answer on four point Likert scales ranging from

strongly disagree to strongly agree. The structure of this section was kept as simple

as possible, the questions were short and straightforward, choices were kept to a

minimum and the instructions were clear and unambiguous. Section 2 of the

questionnaire included three qualitative open comment questions designed to

examine the effectiveness of the information given in the talk. Each patient who

completed any or all of the questionnaires was asked to complete a demographic

sheet to include gender, age and diagnosis (appendix 6).

 
3.9 Data collection procedure

The phase III programme in the Wrexham area was in progress once a week in the

hospital and in three separate community locations during the period of the data

collection. This study was carried out in all of the cardiac rehabilitation programmes

in the Wrexham area for three months from April 2008 to July 2008.

Each week following the education talk the anonymous questionnaire was distributed

to the patients. The questionnaires took approximately 5 minutes to complete. The

questionnaire was completed by the patients themselves but staff members were

available to assist with any queries. The completed questionnaires were placed in a

folder by the patient as they left the session.

Although there are seven rehabilitation sessions in total for each patient, the group

educational talks are only delivered at five of the sessions; the remaining two

sessions are reserved for individual assessment and referral to phase IV. The

educational topics covered during the programme and included in this study were

coronary heart disease, diet, medications, exercise and the patient quiz, a

fun/informative way to prompt discussion in the group.

3.10 Validity and reliability

Validity and reliability of the research instrument is vital to persuade the reader that

the findings of the study are accurate and offer something constructive. Validity

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means that the data and the methods are correct, in terms of research this is

concerned with the truth and reality of the data. The validity of a questionnaire is

associated with the ability of the questionnaire to measure what it is intended to

measure. Reliability relates to the extent to which the research instrument produces

the same data time after time on each occasion it is used. As such, a questionnaire

is said to be reliable if it gives consistent answers. Whilst there are technical and

statistical methods of demonstrating validity and reliability, their use is beyond the

scope of this small scale research project.

The main method of assuring validity and reliability of the questionnaires used in this

study was to pilot the questionnaires on four people, two male, two female who had

previously completed the rehabilitation programme; this helped to ensure that the

potential sample understood the questions, were able to complete them and the

required information was obtained. Other professional colleagues involved in cardiac

rehabilitation were also involved in a peer review of the questionnaires to further

enhance the validation process.

3.11 Data analysis

The answers to the questions in section 1 of the questionnaire were pre-coded to

allow for speedier collation and analysis. Numerical data were keyed into the

computer and analysed using SPSS for windows, descriptive statistics including

frequencies and percentages were formulated to summarize and present the data.

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The responses to the three qualitative, open comment questions were thematically

collated and analysed manually. Analysis of this data involved multiple readings to

identify the key issues and themes, recurring themes were categorised according to

frequency and association with the original research question. Common recurring

themes were identified as evidence of increased knowledge, and intention to initiate

change based on the information received.

3.12 Bias

The researcher recognises a possible source of bias within the study due to the

method of questionnaire distribution. The members of the cardiac rehabilitation team

responsible for explaining the study and distributing the questionnaires were also

directly involved in the care of the patients involved in the study. As such it was

acknowledged this could have influenced their answers and led to acquiescence

bias. In order to avoid this, the participants were informed that the study was aimed

at improving future services and that their honest views were most important.

Furthermore, reassurance regarding their anonymity was reiterated each week prior

to the data collection, encouraging the patient to feel more confident about

responding honestly. Another measure adopted to help counteract the possibility of

this bias was to ensure that the person distributing the questionnaires was not the

person who had delivered the education talk.

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