Empowerment In Geriatric Rehabilitation Health And Social Care Essay
The chosen articles for this assignment are articles written by Wallin, et al (2006) published by The Journal of Ageing and Society. 27, 147-164; Cott, (2004) published by The Journal of Disability and Rehabilitation. 26. 24 pp1411-1422; Trappes-Lomax (2006) published by the Journal of Health and Social Care 14(1), 49-62 and Cunliffe et al (2004) 33: pp246 -252. See appendix 1
Parahoo (2006) defines a literature review as an evaluative report of information found in literature relate to a chosen subject area. These literature reviews are concerned with the meaning 'older people attach to their rehabilitation'. The reviews describe, summarise, evaluate and clarify key findings of available literatures. Rehabilitation is concerned with lessening the impact of disabling conditions. These are particularly common in older people and considerable health gain can be achieved by their successful rehabilitation. Physical rehabilitation in the context of long-term care can improve physical and mental state, and be of benefit to those with dementia (Forster, 2009).
Rationale for choice of topic:
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This topic area was chosen as it is felt that this is a subject that warrants more investigation into its effectiveness and the implication it has on the lives of the elderly people. With the changing population demographics, there is an increasing age mortality which results in a greater number of old people and although this age group is not the only group affected by the question of meaning attached to rehabilitation but the increasing age tends to heighten how it is related to the older people.
In pursuance of updating the author's knowledge in the meaning of older peoples' empowerment in geriatric rehabilitation, a lot of literatures were reviewed. Extensive manual and electronic searches of literatures were conducted for the purpose of identifying reviews and articles related specifically to the chosen topic. The following databases were searched: Cinahl, PubMed, Ovid, Cochrane library, Blackwell synergy, The Swetwise, the Journal of Aging and Society, the Journal of Disability and Rehabilitation, Clinical Rehabilitation, The Journal of Nursing Philosophy, Health and Social Care in the Community and a lot of books. Literatures were also accessed from local libraries, nursing homes intranet and the internet.
Search terms used include: older people; frail elderly; long-term care; rehabilitation; meaning; interview; qualitative; quality of life; life satisfaction, validity, and searches were limited in English Language. Amongst the articles reviewed are: Client - centred rehabilitation: client perspectives (Cott, 2004); Buying Time 1: a prospective, controlled trial of a joint health / social care residential rehabilitation unit for older people on discharge from hospital (Trappes-Lomax, 2006); Rehabilitation and Older People (Wade, 2003); Sooner and Healthier: RCT and Interview study of early discharge rehabilitation service for older people (Cunliffe et al, 2004). These chosen articles are of great interest to the author due to its subjective evaluation of the participants. From the author's personal experience and my involvement in the care of the elderly, most elderly people perceived rehabilitation as control and as an act of containment. Clients' perspective fits in with clients - centred approaches and some of the research highlighted client centeredness, in terms of decision making.
It is imperative for research to be critique in order to evaluate its scientific integrity, that is identifying strengthens and weaknesses, the applicability and transferability of it recommendations (Cormack, 2000). This assignment aims to critically appraise range of studies / policy documents studies which examines "The Meaning Older People gives to their Rehabilitation Experience". An attempt will be made to analyse the validity of the reports using the module guide as a framework which provide step - step approach using systematic headings from the chosen articles aim to analyse the data. The title, abstract, author, introduction, methodology, sampling results, ethnical issues will be critique. In all, it transferability will be discussed and conclusion drawn. Though, the title is concise and informative, it does not reflect vividly to the entire elderly population understudy, since the target ages were between 65 - 93 years but not all the older people. The title includes the key word of the articles, since many retrieval systems depend on the title for searching or indexing (Denscombe, 2003). The title attracts my attention to the area understudy, its short words and has the research question being implicit in it (Hollaway and Wheeler, 2002).
About the Authors:
A brief enquiry into the authors' background in regard to their academic, professional qualification and their experiences are important to determine, it worth as this can influence the outcome or result of the study (Cormack, 2000 and Bell, 2005). In the first article, Talvitie and Wallin are both with the Department of Health Science, University of Jyvaskyla, Finland; Catta with the Centre for Health Promotion Research, Leeds University and some of her work will be referred to in this assignment Catta et al (2003). And Karppi is with Research Department, Social Insurance Institute of Finland (SII), which funded the study under critique. Burns and Grove (2006) stated that a funded study has to be reviewed and be recognised for it scientific and social merit by the body funding it. However, working within the funded organisation one can easily be influenced. The authors participated in the study (Polit et al, 2001). However, their respective qualifications were not provided in the article to determine their credibility in research (Cormack, 2000).Cott, C.A (2004) is of the Department of Physical Therapy and Graduate Department of rehabilitation Science, University of Toronto, Canada. Trappes-Lomax, et al (2006) are all based within the Department of Public Health & Epidemiology, University of Birmingham UK; and Cunliffe and colleagues are all of the Department of Health, Shaping the Future NHS, Long Term Planning for Hospital and Related Services, London.
Reviews / Themes:
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Many researchers (Cormack, 2000; Burns and Grove, 2003) have insisted that introduction should identify the research intention, the rationale underpinning the statement of purpose and importance of the study. The general aim of the articles was stated as to promote older people's autonomy and to enhance their ability to live near independent lives which is significant to nursing practice. However, the authors in all the four articles failed to state the purpose of their studies explicitly in the introduction. They have made references to various related works established in the field understudy (Cormack, 2000). The rationale for any constraints such as the existence and significance of a knowledge gap, have been clearly stated.
The themes for article written by Wallin et al (2007) is that the older adult perceived rehabilitation as a means of getting away normal life and enjoying themselves; as sense of vacation and as a disappointment because they had little chance to participate in the planning of the rehabilitation programme. The article by Cott (2004) findings was to demonstrate that client - centred rehabilitation embraces much more than goal setting and decision making between individual clients and the professionals. The article by Cunlifte et al, ((2004) was to evaluate an early discharge and rehabilitation service for the older people.
The review was presented as an integral part of the introduction (Denscombe, 2003). Reviewing literature is to gain broad background understanding of the subject matter to support the research intent and how the current study was informed and built from previous work (Cormack, 2000 and Moore, 2006). There is a brilliant indication within the articles and the reference list a lot of primary and secondary sources of background reading have been done (Berry, 2004 and Kumar, 2005). The authors have built on the existing knowledge by relating it to both recent and previous publications on the subject in their literature review (1994-2006) (Cutcliffe and Ward, 2003). They were able to contrast the previous works on effects of institutionalisation and rehabilitation to older people. They have been influenced by past works in the rehabilitation of the older people as physical recovery orientated rather than social participation, as it was the view and idea of some older people but not many studies had been explored into the older people's experiences and perception. They have been able to do more extensive research on the scope of the study.
This is defined as the theory and analysis of how the study should proceed. It rules the choice of method, the techniques or procedure used to gather and analyse data (Parahoo, 2006).This involves collecting data of different forms from the same subjects (Porter, 2000). Triangulation of different data sources can also aid validation (Parahoo, 2006). By using two different methods of research, the researchers may gain a different perspective of the topic under investigation and the results from any one method can be confirmed, (Couchman and Dawson, 1995). Researchers need to be aware that using both qualitative and quantitative approaches in the same study will not necessarily provide the whole picture, findings may be contradictory. This can enhance understanding of research methodology and the phenomenon being studies (Parahoo, 2006).
Within the study a qualitative method of research will allow a focus upon the perspective of the clients, (Couchman and Dawson, 1996). This will allow their views to be valued. Emphasis can then be placed upon meanings, descriptions and experiences of the clients, (Coolican, 1994) Qualitative research allows us to understand human behaviour, by finding out the interpretations of events through the eyes of the participants rather than relying on measuring concrete facts. To know the meaning of rehabilitation as per elderly people, one should study it from the perspective of the individuals; therefore qualitative approaches can be described as holistic rather than reductionist. Qualitative research mainly concentrates on written words, or speech, and aims to understand the motivations and interpretations of people rather than explaining why something happens. It may be exercised where the researcher seeks a deeper truth, aiming to make sense of or interpret phenomena in terms of people's belief, attitudes, experiences, behaviour and interactions which generate non- numerical data (Denzin, 2005). A common approach in the qualitative research is phenomenological approach which focuses on describing how the individual experiences this development, (Patton, 2002). This appears to be appropriate for this study as the aim and objective of the study was to obtain a deeper understanding of older peoples' meanings, which could not have been adequately be addressed as quantitative approach. In any case, a small level quantitative data (descriptive statistics) was incorporated, in all the articles to support the description the researchers were attempting to formulate. A criticism of using the qualitative approach is that it is anecdotal, unscientific and produces findings that are not general (Punch, 2000).
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Sampling is the process of selecting people or units from a population of interest, so that by studying the sample, the researchers may fairly generalise their results back to the population from which they were chosen. The researchers in this case used a purposive method in recruiting clients which is a judgemental sample of individuals chosen by certain pre-determined criteria relevant to the research question (Robson, 2002). This method is mainly used when the researchers is seeking to contribute to the understanding of phenomena but not to generalising the findings to the target population and is difficult to evaluate the precision of the researcher's judgement, (Parahoo, 2006). This appears to be appropriate in this research since it has the potential to provide rich data (Morse, 1994). Patton (1990) suggested that no guidelines exist for sample size in qualitative studies, but the sample size was purposively recruited from the randomly selected sample from the main study, which is very good for the study, more data will be collected before saturation is reached and have three researchers to work on them (Holloway and Wheeler, 2002), the age range (between 65 and 93), the number of settings (7), the periods and the exclusion criteria scheme, however they failed to justify the criteria (Cormack, 2000).
The writers specified how the data for the study was collected. Two semi- structured interviews were conducted for 15 to 45 minutes and 45 to about 2 hours in the setting and in the participants respective homes and audio tape were used. The adoption of qualitative methodology and the use of semi-structured interviews allowed way for cross checking so that inconsistencies in recall could be identified and probed (Cutsliffe and Ward, 2003). The semi-structured interviews are credible in this study in the sense that the informants can be verbally be assisted to understand the questions and the interviewers can ask any question for clarifications, probe further for responses as well as being able to observe body language, which cannot be gained when using questionnaires (Munhall, 2001). However, by interview, it cannot be guaranteed that interviewees are being honest as they may not understand the question or they may distort the truth or withhold vital information and face to face interviews may compromise the anonymity of the interviewees (Parahoo, 2006). However, one to one interviews, use of tape recording can be useful to check the original wording of any statement one might want to quote, or keep to make sure that what one's write is accurate, it helps if one is attempting any form of content analysis and need to listen several times in order to identify categories and allows one to code, summarise and to note a particular comment (Bell, 2005). Audio taped information enhances reliability and author triangulation adopted for validity (Burns and Grove, 2005). The notes taken and short diary kept during the interviews ensure trustworthiness and provide accurate representations of the participants' experiences such as gestures and facial expression. The reflective diary maintained throughout the study shows clearly their thoughts, involvement in the data and interpretation of the data.
The six months interval between the interviews may help to retest any theories developed in the writing up stage (Cormack, 2000). The authors however failed to mention any breaks during the interview, since it is ethically appropriate for this client group (Holloway and Wheeler, 2002). They equally failed to record any limitations such as reflexivity that might have influenced the process of the data collection. Reflexivity is a continuous process of reflection by researchers of how their own values, behaviour, perceptions or presence and those of the respondents may affect the data they collect (Parahoo, 2006). In the absence of statistical tests for validity and reliability, this sort of reflexivity is crucial to qualitative study if it is to be persuasive (Cormack, 2000). The authors gave a brief description of the guiding topics and some of the specific questions that were asked, provided the data for the study, but they failed to mention any questions that appeared uncomfortable to answer by the interviewees and they failed to indicate their individual roles within the study.
Though, qualitative research is not physically invasive but it may result in an invasion of the mind of the participants (Bryman, 2005). The articles were approved by their respective ethical committees. The transcription of the interview data amongst themselves ensures the anonymity of the clients (Sullivan, 1998). An informed consent is an ongoing process in a qualitative study but the writers of the articles failed to recognise this and kept silent of the older people who were or may not be competent to sign their own forms (Denscombe, 2003). There was no record of obtaining permission before recording the interviews and what would be done to the data after the transcription.
The process of analysing data in qualitative research is ongoing, starting during data collection, with the researcher processing data and making judgements about aspects of it, as it is received (Parahoo, 2006). Once all data from the taped interviews has been collected, it will be transcribed, which will take approximately three times as long as each interview (Couchman and Dawson, 1995). The results were represented in a clear, detailed description and in simple language which makes the text easy to read and understood (Ogier, 1999). A consideration relating to rigour is credibility; the authors returned the interview interpretation back to the participants so that they can check for any discrepancy (May and Hope, 2000). It appears that the authors adapted adequate rigorous techniques in the analysis. The use of author triangulations enhances validity, and direct quotations, when presenting depth and recognition of individual experiences. The identified themes and applicable quotations generally provide a clear picture of how the themes emerged from the data. They explained the coding (Polit et al, 2001), which makes it easier for the readers to assess the validity of the emergent themes based on the quality and quantity of quotations provided. Bringing quotations from clients, thus allow the reader to conduct his own meaning of the expression to the participants. It will also help the readers of the research, who may not understand clearly the aim, objective and process of the research, and to judge its accuracy and applicability accordingly. In any case, they fail to mention the framework used in the coding and the analysis.
The key findings that came out from the saturated themes shows that the clients have different and varying needs and expectations of rehabilitation programme, which were categorized into three. They were - the sense of confidence with everyday life; which they perceived as facilitating everyday living at home; as sense of vacation; and it was also seen as a means of getting away from normal life and enjoying themselves and finally as a sense of disappointment and frustration with the limited opportunities to participate in the planning of their rehabilitation programme. There was no proper integration of the participants since they were grouped on accordance to their geographical origins during most of the periods. And they failed to mention any effect of the attrition on the result.
The writers have addressed the research as set out at the beginning of the research about their discussions, findings and the significant of the study have been a sense of confidence with everyday life; ' a sense of vacation' and a sense of disappointment. The outcome of the study was also compared with that of the previous works of the literature such as Hinck, 2004; Cattan et al, 2005 in the literature review. They acknowledged a fault in their sampling and have suggested a comparative study of sub-geriatric clients in order to illuminate the contract (Cormack, 2000). A recommendation was made about promoting a patient - centred and partnership in care, which entails a holistic approach. However, the suggestion made by the authors about professional communication skills cannot be justified within the context of their research, since there were no professionals incorporated in their study.
However, precaution has to be taken, if these findings are to be replicated across the union, since meanings to a phenomenon changes with pervading cultural and sub-cultures (Hammersley, 1992) and it is unlikely that older people in Finland have the same culture to older people in United Kingdom (UK). Transferring the findings to UK will have different impact due to different health care system such as the role of pervasive and perceived institutionalised involvement, different professional regulatory bodies and variance in the education and training, and the role of mental health professionals. The overwhelming impression from the views reported in UK is that rehabilitation settings are driven by an attribute of control and containment rather than empowerment (Parry-Crooke, 1999).
In the article by Cunliffe et al (2004) it was shown that rehabilitation improves the levels of activity and the psychological well-being of the elderly. That person - centred style of care helps to improve the outcome of older people's lack of confidence, and may lead to better health outcomes. All the articles have demonstrated that there is need for rehabilitation for these client group.
It can be seen that the aim of this literature review has been achieved in exploring the meaning of rehabilitation to the elderly people. The study reveals that different people attach different meaning to rehabilitation. It has brought an interesting knowledge into practice; an awareness of the participants having varying meanings to it concept. Promotion of older peoples' autonomy in the community entails a holistic approach which should have included sociological issues and the settings should have been in the clients' homes.
An empowerment approach appears to be preferable to medical approach adopted. Though, the overall findings has been biased toward fairly fit older people, who were coping at home with a level of support, the age differences also might bring about different health issues, such as mental health. Furthermore, clients were not given choice to form groups during sessions, and the groupings were biased towards geographical origins. However, the recommendations made - patient - centred and partnership in care are of great importance.
In the NMC's code of professional conduct (2004), great emphasis is placed on the responsibility nurses have in ensuring that clients possess the best up - to - date evidence based knowledge and skills to deliver care possible. Therefore, improved knowledge through education and research will be the basis of evidence based practiced for change and improvement.
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