FÖRSLAG TILL FÖRBÄTTRINGSARBETE OCH KVALITETSUTVECKLING
Bilaga 5. Mall för kvalitetsgranskning av studier med kvalitativ forskningsmetodik –
patientupplevelser
reviderad 2014 SBU:s granskningsmall bygger på tidigare publicerat material [1,2], men har bearbetats och kompletterats för att passa SBU:s arbete.
Författare: ____________________ År: _________ Artikelnummer: __________
Anvisningar:
• Alternativet ”oklart” används när uppgiften inte går att få fram från texten. • Alternativet ”ej tillämpligt” väljs när frågan inte är relevant.
Kommentarer (urval, patientkarakteristika, kontext etc):
Hög Medelhög Låg
a) Utgår studien från en väldefinierad problemformulering/frågeställning?
Kommentarer (syfte, problemformulering, frågeställning etc):
a) Är urvalet relevant?
b) Är urvalsförfarandet tydligt beskrivet? c) Är kontexten tydligt beskriven? d) Finns relevant etiskt resonemang?
32
mall för kvalitetsgranskning av studier med kvalitativ forskningsmetodik 5:1
e) Genereras hypotes/teori/modell? f) Är resultatet överförbart till ett
liknande sammanhang (kontext)?
g) Är resultatet överförbart till ett annat sammanhang (kontext)?
Kommentarer (resultatens tydlighet, tillräcklighet etc): a) Är datainsamlingen tydligt beskriven?
b) Är datainsamlingen relevant? c) Råder datamättnad?
d) Har forskaren hanterat sin egen förförståelse i relation till datainsamlingen?
Kommentarer (datainsamling, datamättnad etc):
a) Är analysen tydligt beskriven?
b) Är analysförfarandet relevant i relation till datainsamlingsmetoden?
c) Råder analysmättnad?
d) Har forskaren hanterat sin egen förförståelse i relation till analysen? Kommentarer (analys, analysmättnad etc):
a) Är resultatet logiskt? b) Är resultatet begripligt? c) Är resultatet tydligt beskrivet? d) Redovisas resultatet i förhållande
33 Bilaga 3 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Aira et al, 2003. Finland
The aim of this study was to determine factors that influence inquiring about patients’ alcohol consumption.
Interviews with a total of 35 physicians were undertaken.
Audio recordings were listened to and verified to ensure the precision of the transcripts. All interviewees were coded as a number in transcripts were entered into the QSR NVivo 1.0 software.
Seven main themes were presented in the results:
Sensitive nature of alcohol drinking.
Unless the patient raised the question himself, it was hard to address the subject.
Reason for consultation.
Easier to ask about the patient’s alcohol consumption in certain contexts.
Awareness of patient’s alcohol problem.
When the physician knew about the patients issues, a discussion was more easily initiated.
Patient factor.
Physicians tried to evaluate if the patient could be an excessive drinker before asking.
Availability of intervention tools.
The effectiveness and availability of screening tools was an influencing factor.
Expectations of effectiveness of interventions.
Several physicians had low expectations on the outcome of an intervention
Lack of time.
Most doctors considered lack of time to be a significant obstacle to raise the topic of alcohol.
Medelhög kvalitet
Svagheter:
Hade dock kunnat vara mer detaljerad angående data- och analysmättnad.
Saknar ett etiskt resonemang och hur forskarna hanterat sin förförståelse.
Styrkor:
Studien har ett väldefinierat syfte med en tydlig metod samt ett stort urval.
34 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Ampt et al, 2009. Australien Identify the influences affecting GPs' choosing to screen and choosing to manage SNAP (Smoking, Nutrition, Alcohol and Physical activity) lifestyle risk factors, as well as identify influences on screening and management when multiple SNAP factors exist
15 GPs and one nurse were interviewed and audio-taped. Interviews were transcribed using an external service. Analysis performed vith QSR NVivo7 software. Themes and framework was developed by both authors.
The analysis was made using the Theory of Planned Behaviour as a framework.
The results were presented in relation to three research questions.
Assessment
Different characteristics of the patient influenced GPs to ask some, but not all, about selected SNAP factors.
Motivating the patient
The assessed motivation of the patient was considered before making an intervention.
Giving Advice and educating the patient
Different patient-characteristics, such as educational level, influenced how or if the patient should be given lifestyle-advice.
Arranging follow-up appointments and Referring to other personnel and agencies
The patient’s perceived motivation and probability for showing up at a follow-up appointment was considered.
Managing multiple SNAP factors
Which factor was addressed first when facing several lifestyle hazards was often decided by the patient.
Medelhög kvalitet
Svagheter:
De flesta deltagarna har medverkat i en liknande studie och uttryckt intresse för denna under
rekryteringen vilket kan ha gjort att urvalet inte är representativt för den större populationen.
Styrkor:
Datainsamling pågick tills datamättnad uppnåddes. Forskarna använder ett teoretiskt ramverk i analysen vilket skapar en struktur på studien.
35 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Beich et al 2002. Danmark To explore the suitability of a screening based intervention for excessive alcohol use by describing the experiences of general practitioners who tried such an intervention in their everyday practice. 24 GPs were interviewed. Interviews were undertaken both individually and in focus groups.
Audio data was used for the analysis rather than transcripts, so no shadings of meaning would be lost. Qualitative Media Analyzer software was used.
Results are presented in six main headings. These are as follows:
Should screening target young binge drinkers?
Different views on this matter are presented, but doctors mainly thought the subject should be addressed elsewhere and earlier.
Truthfulness of the patients’responses.
Doctors perceived the patients as untruthful when it came to reporting their alcohol use.
Effects on the doctor-patient relationship.
Some where worried the relationship with the patient could be damaged.
Difficulties of counselling patients on drinking.
Counselling on health issues were seen as an integral part of the job, but advice on alcohol cold easily gain an unwanted moral dimension.
Practical and skills constraints.
Important barriers where identified as lack of time and training.
Doctors’conclusions
SBI was seen as disruptive to the flow of counselling and the extra workload was too high.
Medelhög kvalitet
Svagheter:
Uppföljning av tidigare studie som borde beskrivas tydligare.
Styrkor:
Urval och bortfall är ingående beskrivet
36 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Gilje Lid T & Malterud K, 2012 Norge
To explore and describe what made the doctors initiate discussion of alcohol, how they brought up the subject, and what happened when they did so without prior invitation from the patient.
Two focus groups consisting of 13 GPs in total.
The interviews were recorded, transcribed and then analysed by identifying meaning units which was then thematised.
Results were presented in four main themes:
Acting on a hunch or on a cue.
The patients’ behaviour made GPs aware of alcohol issues.
Routinely taking or creating an opportunity to explore.
It was common to include alcohol with discussion with other health issues.
Confronting the patient.
Asking questions directly to the patient about alcohol was common as they lacked other strategies.
Does it really matter at all?
Some doctors wonder if the intervention really makes any difference to the patients drinking habits.
Medelhög kvalitet
Svagheter:
Datainsamling finns beskriven men är något ostrukturerad.
Styrkor:
Väldefinierat syfte och relevant urval.
Datamättnad uppnås enligt författarna.
Resultaten beskrivs välstrukturerat och understöds med citat från intervjuerna.
37 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Johansson et al, 2005. Sverige
The aim was to explore factors influencing GPs’ decisions regarding screening for high alcohol consumption in the consultation setting in order to suggest a new strategy for a more widespread implementation of routine alcohol screening and advice.
13 GPs working at three healthcare centers were interviewed in focus groups. The transcribed interviews were analysed using a deductive framework. Categorization was made by one of the authors using the NUD*IST v.4 software.
The results were presented in four main themes with following sub-categories.
Strategies for identifying people with high alcohol consumption in society:
Different professionals’ responsibilities. The role of healthcare.
Factors
determining which patients should be screened for high alcohol consumption at the healthcare centre:
Specific symptoms, Time, Age, Patient-physician relationship, Consultation setting
Current routines concerning alcohol prevention at the healthcare centre:
Perceived alcohol-related symptoms or diagnosis led to discussion. A need for interest and belief in interventions was necessary.
Why healthcare staff in general abstain from asking about alcohol consumption
Lack of time and absent indications was presented as reasons for not screening.
Hög kvalitet
Svagheter:
Saknar etiskt resonemang samt någon kommentar om data- respektive analysmättnad. Styrkor: Metoden är utförligt beskriven. Bortfall behandlas. Resultatet är detaljerat, författarna pressenterar resultatet utan tolkning och understödjer med citat vilket gör det enklare att följa.
38 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Jonsson et al, 2013. Sverige
Belysa
distriktssköterskornas erfarenheter av att samtala med patienter om alkoholrelaterade frågor Åtta distriktssköterskor intervjuades och spelades in. Tematisering och kodning genomfördes i samband med analysen.
Upplevelse av trygghet – Kontinuitet, erfarenhet och
kunskap stärkte tryggheten. Bristande resurser, tabubelagt ämne och bristande möjlighet att slussa patienten vidare upplevdes som en otrygghet
Personliga värderingar – Egen erfarenhet och
inställning till alkohol. Förutfattade meningar om hur en riskbrukare ser ut.
Patientansvar – Några överlämnade initiativet att ta
upp alkoholfrågor till patienten. Patientens öppenhet och vilja att diskutera påverkade samtalet.
Medelhög kvalitet
Svagheter:
Om intervjuerna även hade skett i andra landsting där strukturerna ser annorlunda ut hade överförbarheten i studien påverkats
Styrkor:
Tydligt och väldefinierat syfte
Välstrukturerat resultat .
39 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Lock et al, 2002, England
This study aimed to examine primary health care nurses’ attitudes to alcohol intervention, including perceived barriers and facilitating factors, which influence their involvement in this area of work.
24 nurses were interviewed.
Interviews were carried out by one author who was known to the interviewees. Transcribed data was analyzed in accordance with grounded theory using the
FRAMEWORK method.
Grounded theory was used as a structural framework.
Seven themes were presented in the results, they were:
Problem relevance.
Most of the nurses recognised alcohol intervention as part of the job
Opportunities for intervention.
New registrations and health checks proved to be good opportunities for screening.
Role legitimacy.
All agreed that SBI was part of the nurses’ work.
Negative reactions.
Both nurses and patients experienced alcohol to be a sensitive and difficult issue.
Confusion about alcohol issues.
Confusion about what standard drink units entailed and what constituted the recommended levels of intake.
Attitudes to drinking.
Most nurses expressed a concern about excessive drinking despite it being socially accepted in the region.
Lack of training.
Lack of training and experience was a barrier.
Hög kvalitet
Svagheter:
Många i urvalet har varit delaktiga i en tidigare studie, hur detta påverkar resultatet beskrivs ej.
Styrkor:
Har ett väldefinierat syfte. Relevant urval och etiskt resonemang.
Beskriver och hanterat bortfall utförligt. Data- och analysmättnad uppnås enligt författarna. Följer grounded theory i analysen
40 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Mules et al, 2012
Nya Zeeland
The aim was to assess GPs' current practice and attitudes towards discussing alcohol use with their patients
19 GPs were interviewed. The coding and analysis was cross- checked by other members of the research team.
Results were presented in two themes and associated sub- categories:
Current practice.
Screening was not commonly undertaken unless there was clinical signs or social issues. There was also a hesitancy to arrange follow-up appointments as patients seldom turned up.
GP attitudes.
Most GPs agreed that alcohol prevention was included in their job, however many doubted the effect of their advice. Guidelines and screening tools were not commonly used as they were found too rigid and disturbing of the consultation. The taboo nature was mentioned as a reason for not discussing this subject as it could damage the patient-doctor relationship. Lack of time led the GPs to asking only patients who fitted the preconception of a heavy drinker. All agreed that more support was needed.
Medelhög kvalitet
Svagheter:
Syftet är något otydligt. Kortfattat etiskt resonemang. Datainsamlingen och analysen är kortfattad.
Styrkor:
Urval och bortfall är detaljerat.
Tematisering och kodning är utförd och kontrollerad av flera i forskarteamet vilket gör att risken för bias minskar.
Resultatet är detaljerat och välstrukturerat.
41 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
O´Donnell A & Kaner E, 2017 England Explore GPs’ perceptions of factors influencing the delivery and recording of alcohol interventions in routine consultations in their practices. Interviews with 14 GPs were conducted. The authors used the NPT (Normalisation Process Theory) as a theoretical framework to analyse and structure the transcribed data.
Results were presented in accordance with the NPT- framework and divided into four main categories:
Coherence
Ambiguous views on screeing tools was presented.
Cognitive Participation
Most GPs agreed SBI was useful but not necessarily willing to play an active part in it.
Collective Action
Alcohol intervention was directed towards patients who the GPs assessed to be changeable.
Reflexive Monitoring
Policy measures such as financial incentives were seen to have limited impact on the practice around SBI.
Hög kvalitet
Svagheter:
Inga kommentarer angående data- eller analysmättnad.
Styrkor:
Tydligt beskrivet urval och kontext.
Innehållsanalys i två steg för att hantera författarnas förförståelse.
Analys och resultat struktureras efter NPT.
42 Författare/ År/ Land Syfte Urval / Metod
Resultat Vetenskaplig kvalitet
Tam et al, 2013 Australien
The aim of this article were to understand the reasons for the low uptake of alcohol screening
questionnaires, and the overall low detection of at-risk drinking in the Australian general practice context
Four focus groups with a total of 19 GPs participated. The transcribed interviews were initially coded then using the themes identified in the first focus group to be further explored in the subsequent ones. The Straussian grounded theory research method was used.
The results were presented in four main themes:
Detecting at-risk drinking is important but difficult to do.
A general view that patients typically underestimated their alcohol use. Also, a concern about being perceived as judgemental by the patients.
Impact of social and cultural attitudes.
At risk drinking labels were seen as shameful by the community which led patients to be defensive or hide their use of alcohol.
Dynamics of patient-doctor interactions.
Asking about alcohol use was seen as a potential threat to the patient-doctor relationship.
Alcohol screening questionnaires lack practical utility.
Screening tools were rarely used and found difficult to implement in the general practice.
Hög kvalitet
Svagheter:
Syftet är något ostrukturerat. Författarna beskriver var de har fått etiskt godkännande ifrån, men inte hur det påverkar studien.
Styrkor:
Urvalet är relevant, dock är bortfallet stort men tydligt redovisat.
Resultatet är detaljerat och understryks med citat. Studien följer teoretiskt ramverk.