Research Paper: Difficult Patients Mitigating Risks

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[. . .] Research Methodology

It is essential to precede any planned review with a search to establish the existence of extant reviews. Such a search will typically identify both quantitative and qualitative systematic reviews. In formulating a review question an existing qualitative systematic review is a helpful starting point because:

1. It may help in identifying key issues that have a bearing on the acceptability or effectiveness of a programme or intervention;

2. It may help in identifying barriers or facilitators to the implementation of a programme or intervention.

3. It may help in identifying important perceptions of the experience of the condition that may help in either the selection or targeting of a candidate intervention.

In identifying related nursing studies an existing qualitative systematic review is a useful source of possible studies for inclusion, capitalising on a previous review team's search processes.

An existing qualitative systematic review may also assist in interpretation of an effectiveness review in exploring possible explanations regarding any heterogeneity identified across quantitative studies: in informing tactical decisions on splitting the review, on which subgroups to analyse and in justifying a review team's position on 'lumping vs. splitting'. It can also identify possible explanations for unexpected findings such as where effects are greater or lesser than the review team had anticipated or, indeed, where there is no effect when some demonstration of effect is predicted.

Finally it is important to identify whether an existing review already satisfactorily addresses the question of interest as this removes the need for replication or, at the very least, provides a starting point for an update process.

Methods for identification of systematic reviews

Methods for identifying existing reviews will include the following:

1. Searches of databases of reviews

2. Searches of general databases using the publication type "review" or review-related terms (e.g. "overview" or "systematic review") (See Table 1)

3. Looking through the reference lists of policy documents, editorials, or statements from professional bodies.

You should note that qualitative systematic reviews employ a similarly diverse range of terminology as reviews in general. For this reason you will need to employ an imaginative variety of terms. A search strategy illustrating a majority of these more specialist terms is provided in Table 2.

Table 2 Search terms to identify existing qualitative systematic reviews

1. Qualitative systematic review* OR (systematic review AND qualitative)

2. evidence synthesis OR realist synthesis

3. Qualitative AND synthesis

4. meta-synthesis* OR meta synthesis* OR metasynthesis

5. meta-ethnograph* OR metaethnograph* OR meta ethnograph*

6. meta-study OR metastudy OR meta study

7. OR/1-6

Because your review team may be interested in perspectives on the disease in general or on experiences (of either providers or recipients of care) of the intervention you may choose to conduct sensitive search strategies (i.e. maximising your chances of retrieval) that combine the string of terms from Table 1 with the condition or the intervention separately rather than focus only on the intersection of both condition and intervention (See Table 3). Note too that the term "qualitative systematic review" is occasionally used more loosely (e.g. within analgesia or pain relief studies) to describe those reviews where it was not possible to perform a quantitative meta-analysis. Use of this term may therefore result in unexpected "false hits."

Table 3 Searching for qualitative systematic reviews of Condition OR Intervention

1. Qualitative systematic review* OR (systematic review AND qualitative)

2. evidence synthesis OR realist synthesis

3. Qualitative AND synthesis

4. meta-synthesis* OR meta synthesis* OR metasynthesis

5. meta-ethnograph* OR metaethnograph* OR meta ethnograph*

6. meta-study OR metastudy OR meta study

7. OR/1-6 {Combining qualitative systematic review synonyms}

8. 7 AND Postnatal Depression {Combining review terms [1-6] with Condition}

9. 7 AND Cognitive Behavior Therapy {Combining review terms [1-6] with Intervention

10. 8 OR 9 {Reviews of Postnatal Depression or Reviews of Cognitive Behavior Therapy}

Current Cochrane guidance states that:

"The formulation of a question to be addressed by a Cochrane review will often usefully be informed by qualitative research. This statement carries no implication that the qualitative research should be subject to systematic review."

The emphasis of this Section is thus on the identification of relevant individual studies that are closely associated with the question to be addressed by a Cochrane Review. As Chapter Two makes clear qualitative research may contribute to many of the elements of a focused PICO question. For ease of reference these are summarised in Table 4.

The challenges of retrieving qualitative research are well-documented (Evans, 2002, Barroso et al., 2003). These include non-meaningful titles, poor quality and unstructured abstracts, a superficial depth of indexing, and poor description of qualitative method used. Several authors, such as Campbell et al. (2003), describe the difficulties they encounter when trying to retrieve all of the literature relevant to their work

Scoping searches are now an accepted stage of most types of systematic review (Jones, 2004). As Chapter Two demonstrates scoping searches can identify contextual information important to the protocol. Provided that reviewers do not allow themselves to be prematurely exposed to the results of studies for inclusion it is frequently helpful, and rarely harmful, to investigate the quantity and likely quality of the evidence available for the topic as well as the different study designs available for a particular question. This stage helps to conceptualise the review in terms of the language and concepts used in the literature and also to manage the logistics in terms of the yield and likely workload for the review team. The review team may also find it useful to engage in some form of "area scanning," that is to identify major organisations in the field, significant international or national policy reports and traditional reviews to orientate themselves to the main issues relating to the disease condition or the intervention. The aim is to develop a rounded out (holistic) picture of issues associated with the intervention.

It may well prove useful to identify, or alternatively, to construct a "logic model" to guide the development of the background section of a Cochrane Review and to assist in defining, and indeed refining, the review question. A sufficiently robust logic model may already be present in the identified literature, it may be constructed de novo as part of the scoping process or, indeed it may be a synthetic product of refining an existing model in the light of other relevant literature.

How might searching help to inform this scoping process? Scoping is envisaged primarily as a three-stage process:

1. Identification of existing systematic reviews (identified above as prerequisite in any review context)

2. Identification of key items of existing primary research

3. Elicitation of the views of stakeholders for the potential review

A review team will not always view it as desirable or feasible to undertake all three stages of the process. At a minimum they should undertake the first stage. They should then review the extent to which there is added value in proceeding to each subsequent step.


Caring for a patient with dementia poses many challenges for caregivers. People with dementia often suffer from progressive disorders that make it difficult for them to remember things, think clearly, communicate with others or take care of themselves. In addition, dementia can cause mood changes and even affect a person's personality and behavior. The rapid growth of the aging population is associated with an increase in the prevalence of progressive dementias. Nurses have a central role in assessment and management of individuals with progressive dementia. This essay provides some evidence-based practical strategies for managing the difficulties often encountered when caring for a person with dementia.

Reference List

Aud, M.A., Oliver, D., Bostick, J. And Schwarz, B. 2011. Effectiveness of Social Model Care Units for Dementia. International Nursing Research Congress 2005.

Care, N.D. 2010. Teaching and Learning. Pulse. Winter Edition.

Fletcher, S. And Zimmerman, S. 2010. Trainee and trainer reactions to a scripted dementia care training program in residential care/assisted living settings and nursing homes. Alzheimer's Care. 11(1): 61-70.

Goodman, C. 2011. The organizational culture of nursing staff providing long-term dementia care is related to quality of care. Evidence-Based Nursing. 47:1274-1282.

Gould, E., Cox, T. And Johnson, M.A. 2010. Best Practices-Dementia Care Training in Nursing Homes and Assisted Living Settings. Alzheimer's Care Today. 11(2).

Kleinpell, R.M. (2009). Outcome assessment in advanced practice nursing (2nd ed.). New

York, NY: Springer.

Kuske, B., Luck, T. And Hanns, S. 2009. Training in dementia care: a cluster-randomized controlled trial of a training program for nursing home staff in Germany. International Psychogeriatrics. 1(21): 295-308.

Mateo, M., & Kirchhoff, K. (2009). Research for advanced practice nurses: From evidence to practice. New York, NY: Springer.

Purnell, L.D., & Paulanka, B.J. (2008). Transcultural health care: A culturally competent approach (3rd ed.). Philadelphia: F.A. Davis.

Williams, K.N., Herman, R., Gajewski,… [END OF PREVIEW]

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