Research is a significant component of the educational process and is essential for current and future professional nursing practice (Tingen, 2009). To describe what nursing research is, Tingen (2009) uses a definition by Polit and Beck (2006, p4) who describe it as a:
‘Systematic inquiry designed to develop knowledge about issues of importance to nurses, including nursing practice, nursing education and nursing administration.’
Without research, nurses would not be able to practice evidence based care, the importance of which is stated within the Code of Conduct (Nursing and Midwifery Council 2008). According to Haynes and Haines (1998) evidence based practice aims to integrate current best evidence from research with clinical policy and practice.
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It is important to critically evaluate any research study to establish the significance and worth of each individual publication (Hek, 1996). For the purpose of this assignment I will use a universal critical appraisal tool that can be used to evaluate any type of research, which can be located in Appendix 1. It has been adapted and devised using appraisal tools from Hawker et al (2002) and the Critical Appraisal Skills Programme (CASP) (Public Health Resource Unit, 2007).
I have chosen to review the topic of therapeutic relationships within the field of mental health nursing. I feel this is a vital component in the nursing role, and something every mental health nurse should be skilled in. Literature states that the therapeutic relationship is a central element of care through which many aspects of mental health nursing is carried out (Priebe and McCabe, 2006).
My question is ‘what role does the therapeutic relationship have within mental health nursing?’ I carried out my literature search using the Cinahl database. Although there are a variety of database choices, Cinahl produced ample results so other database searches were not required. Table 1 summarises my literature search results.
Table 1: literature search strategy
key words/phrases used
database headings used
search limits (inclusions/exclusions)
(Search was conducted on 1st April 2011)
‘therapeutic relationship’ and ‘mental health’
‘Therapeutic relationship’ and ‘psychiatric’
I searched the terms ‘mental health’ and ‘psychiatric’ separately but in conjunction with the words ‘therapeutic relationship’ to ensure a more in-depth search as both terms are used interchangeably within literature. The three papers I have selected to review are Johansson and Eklund (2003), Scanlon (2006) and Forchuk et al. (2005). They were chosen so that both qualitative and quantitative research is included and that differing perspectives on the therapeutic relationship were researched. A summary of the relevant information from each article can be found in a critical appraisal grid in Appendix 2. Elements of the summary will be referred to in the following discussion.
Any research paper should make clear the purpose of the study being reported so that the reader can establish whether or not it is relevant to them (Couchman and Dawson, 1990). It is suggested that an abstract or summary is a good way to give a brief overview of the content of the paper (Couchman and Dawson, 1990). Greenhalgh (2010) recommends that the introductory sentence of a research paper should state the background to the research. All three highlighted papers clearly set out their aims and give background information as to the importance of their study and why it has been chosen. The Forchuk et al. (2005) study aims to replicate a successful pilot study conducted several years earlier, but seemingly on a larger scale.
When assessing the methodological quality and approach of a paper Greenhalgh (2010) proposes five key questions. They are; was the study original, whom was it about, was it well designed, was systematic bias avoided and was it large enough and continued for long enough to make the results credible (Greenhalgh, 2010). Johansson and Eklund (2003) give good rationale for the research design using literature as evidence. Both authors are experienced in the field of psychiatry, but the first author conducted all interviews, which helped to maintain consistency and credibility.
Scanlon (2006) appears to have spent time designing her study, using established literature as well as her own experience to develop an interview guide which was piloted to ensure its suitability. The Forchuk et al. (2005) study describes a clear and concise research design using cluster randomisation. The study had a control group to compare to a group receiving the model used in the aforementioned pilot study.
Any research involving human participants and animal materials or specimens is subject to ethical review, whether it is clinical, biomedical or social research, including the secondary use (Sheffield Hallam University, 2011). Literature regarding ethical considerations varies in the areas they discuss but in general, there are four main areas of ethical concern where the rights and dignity of the participant must be preserved, namely ensuring consent; prevention of harm; protecting confidentiality (Behi and Nolan, 1995; Marion, 2004); and that the research process provides more benefit than harm (Behi and Nolan, 1995).
The study by Johansson and Eklund (2003) was initiated by the ethics committee of the county council, so it is assumed they were recruited to complete the study, although no information is given other than the authors had no collaboration with either of the two settings used to recruit participants. Although written consent was sought it is not stated as to whether the participants understood the aims of the study. Both Scanlon (2006) and Forchuk et al. (2005) provide little information other than ethical principles being followed.
For any study to take place, the subjects must be selected, and this is called sampling. The process used to select a group of people, events, behaviours or situations must ensure that the subjects are representative of the population being studied (Burns and Grove, 2007), or the research will not be credible. The population being studied will guide what process will be used to complete the sampling process (Burns and Grove, 2007). Johansson and Eklund (2003) give in-depth and referenced reasoning for their chosen sampling process. However their attempts at ensuring ‘maximum variation’ can be argued to have failed with only 9 participants recruited.
In contrast, little information is given by Scanlon (2006) as to her sampling process, but there is a clear inclusion criterion for the sample of six participants. The sampling process used by Forchuk et al. (2005) appears to be in-depth with attempts to reduce any potential limitations or barriers. A large sample size of 390 participants partook in the study, which was a year long. A dropout rate of 36% resulted in 249 completing the study.
Burns and Grove (2007) define data collection as ‘the precise, systematic gathering of information relevant to the research purpose or the specific objectives, questions, or hypotheses of a study.’ The choice of data collecting technique used will be determined by the type and purpose of the study being conducted (Burns and Grove, 2007). The data collection method utilised in the Johansson and Eklund (2003) study was an open-ended in-depth interview with a clear focus. The interview was hand written during discussion with no other recording equipment used. They themselves admit that this can introduce bias and the potential for data to be missed using this process. To maintain consistency the interviewer was the same person for all interviews, but the person transcribing is not stated.
Other than developing a piloted interview guide, Scanlon (2006) does not give detail about the data collection technique, other than semi-structured interviews being conducted. The interview guide is attached as an appendix. Data collection methods in the Forchuk et al. (2005) study would appear to be very thorough involving 5 tools, 3 of which were designed solely for this research.
After the data is collated, the research will be of no use to anyone if it is not analysed as it will have no meaning or explanation (McMichael, 2007). Analysis transforms the data collected into new knowledge (Thorne, 2000) and with its primary purpose being to impose some order to data so that conclusions can be made and communicated (Massey, 1995). The analysis process in the Johansson and Eklund (2003) study would appear to be very thorough. However the interviewer was one of the researchers categorising, so the transcripts were known and analysis may have been affected. Scanlon’s (2006) research provides a good example of thorough data analysis, using a recognised coding procedure comprising of three sets of coding. In contrast Forchuk et al. (2005) give little information regarding their data analysis providing only one small paragraph explaining how t-tests were used to test hypothesis.
The findings or results of any study should be presented in a way that advises the reader of any significant outcomes (Burns and Grove, 2007). It is suggested that tables and discussion are separate to as to avoid confusion (Couchman and Dawson, 1990). Johansson and Eklund (2003) give a good example of separating the ways in which the data is presented, with an in-depth discussion about each category. Sub categories were created to provide further clarity and quotes from interview are used to emphasise points. However the table gives little information other than the headings for each category and brings little value to the report.
Scanlon (2006) uses an in-depth discussion to relay her findings, with quotes from participants supporting literature on the topic area. The study’s aims have clearly been achieved. Considering the extent of data collected, the findings are surprisingly sparse in the Forchuk et al. (2005) paper. Baseline data is presented in a table, but little information is available as the findings did not support the hypothesis.
Generalisability refers to the extent to which research findings are valid and relevant to other settings (Pibouleau, 2009) and how useful they are (Altman and Bland, 1998). Pibouleau (2009) explains how poor reporting of generalisability can be a barrier to research findings being introduced to clinical practice. If findings are not generalisable then they will not be suitable to be implemented into clinical practice. The small scale of the study by Johansson and Eklund (2003) indicates that it is weak and that its generalisability is limited. They attempt to argue that due to having no contrasting findings that it gives rise to a certain degree of representativeness, but their conclusion contradicts this by stating there was some variation, the culprit being a patient with psychosis. Scanlon (2006) reports her study to not be generalisable due to its small scale. However, it does discuss how therapeutic relationships fit in with the role of psychiatric nursing, so the study can be argued to be transferable to the wider population. The Forchuk et al. (2005) study failed to meet its aims, so is not generalisable in any way. This is despite it being based on a successful pilot study conducted some years previously.
Implications for practice
The research by Johansson and Eklund (2003) offers very little implication for practice other than to offer issues that should be addressed in future similar studies. The study is flawed, and has limitations and contradictions within the discussion. Both authors have previous experience in research in the topic area which is evident in the referencing of their own work, so it raises concerns that these issues have not been addressed in previous work. In contrast Scanlon (2006) recognises all flaws in her study, and gives several recommendations for future research. The fact that the interview guide is included and the findings discussed in such depth allows the study to be replicated. Very little can be gained from the Forchuk et al. (2005) research with regards to enhancing practice, but recommendations are made for future study, almost as a token gesture. However, the paper does highlight factors to consider when planning the discharge process to ensure success, so cannot be completely dismissed.
Considering the significance of therapeutic relationships within the field of mental health and the importance it plays within the role of the nurse, the analysis of the highlighted papers is disappointing. The Johansson and Eklund (2003) paper is flawed offering nothing significant for clinical practice. The Forchuk et al. (2005) study failed to meet its aims and as a result provided very little information other than the importance of providing support in the transition from hospital to community. Although very valid, this is does not compensate for the complete failure of the research which was based on a successful pilot. It can be argued that the only paper critiqued that can offer anything to clinical practice is that published by Scanlon (2006), but then her conclusions infer the opposite. Despite the fact that her study can easily be replicated and recommendations for future research are offered, she casts doubt by having a negative focus on her findings.
This critical review has little to offer to address my question, but the background research and literature reviews within the reviewed papers does offer a rich source of secondary information. Despite that none of the studies have generalisability; they do highlight issues that future researchers should be aware of. From this review it seems that a qualitative approach is best suited to a study in this topic area. It is recommended that the flaws and limitations highlighted in the above research designs are used to establish an effective method for evaluating the role of the therapeutic relationship in mental health nursing.
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A Universal Critical Appraisal Tool
Adapted from HAWKER, Sheila et al (2002) Appraising the Evidence: Reviewing Disparate Data Systematically. Qualitative Health Research, 12 (9), 1284-1299 and the Critical Appraisal Skills Programme (CASP) appraisal tools: http://www.phru.nhs.uk/Pages/PHD/CASP.htm
1: Research aims and research question: Is there a clear statement of aims and a research question?
Is the goal of the research clearly stated?
Are reasons given for why the research is relevant or important?
2: Research approach/design: Is the approach appropriate and clearly explained?
Is the research approach/design justified?
Is an explanation offered as to why it was chosen?
3: Ethics: have ethical issues been addressed and was necessary ethical approval obtained?
Are issues of confidentiality, sensitivity and consent addressed?
Are research governance processes clearly described?
4: Sampling: Is the sampling strategy appropriate to address the research aims?
Is how the participants were recruited, selected or allocated explained?
Are details provided (e.g. race, gender, age, context) of who was studied?
Is the sample size for the study justified?
5: Data collection: Are the methods of data collection appropriate and clearly explained?
Is it clear how the data were collected and are the methods chosen justified?
6: Data analysis: Is the description of the data analysis sufficiently rigorous?
Is there a clear description of how analysis was done –
Qualitative – Is there a description of how themes or concepts were derived?
Quantitative – Are reasons for the statistical tests selected described and statistical significance discussed?
7: Findings: Is there a clear description of the findings?
Are findings explicit, easy to understand and in logical progression?
Are tables, if present, explained in the text?
Do results relate directly to the aims?
Are sufficient data presented to support the findings?
8: Transferability or generalisability: Are the findings of this study transferable, or generalisable to a wider population?
Are the context and setting of the study described sufficiently to allow comparison with other contexts and settings?
Is there sufficient detail provided about the sample (as in section 4)?
9: Implications and usefulness: How important are these findings to policy and/or practice?
Do the findings contribute something new and/or different in terms of understanding, insight or perspective?
Are ideas for further research suggested?
Are implications for policy and/or practice suggested?
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