Appraising

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The Experience and Challenges of Rural Persons with Cancer and their Families: A Critical Appraisal of Qualitative Research

Models of Critique

A critical appraisal of qualitative research requires the assistance of appraisal tools. Using tools helps the assessor justify the quality of the evidence by analysing the research design, the methodology, and the study's validity (Hoffman et al., 2017). Two tools have been used to assess the quality of this article. The QARI (Qualitative Assessment and Review Instrument) tool focuses on assessing congruence between methodology and the study as a whole (Hoffman et al., 2017, Joanna Briggs Institute [JBI], 2020). It also encourages the assessor to look at influences the researchers have and whether the participant's views are effectively described (Hoffman et al., 2017). The CASP for Qualitative Research (Critical Appraisal Skills Programme) checklist is the second tool used, and it focuses on assessing validity, credibility, and applicability (Hoffman et al., 2017, Critical Appraisal Skills Programme [CASP], 2017). Both tools have ten questions to aid the assessor to appraise the evidence; however, they each focus on different aspects, making it necessary to use two tools to provide a valuable appraisal.

Authors

The authors of this article are reliable, as evidenced by their experiences and their departments. They are from the nursing and midwifery department, and the health and human sciences department of two well-known Australian Universities (Coyne et al., 2019). The research conducted is about “understanding the experiences and challenges for persons with cancer and their families from rural Queensland” (Coyne et al., 2019, p. 609). The topic researched is relevant to the authors' departments as it is concerned with nursing and health. The QARI tools questions six and seven address the researcher's influence (Lockwood et al., 2015). It was noted in the article that the lead researcher was an experienced family researcher, and to ensure rigour, three participants were asked to review the themes and transcripts (Coyne et al., 2015). It could be assumed that the authors have played a role in culturally influencing the study due to their positions and affiliations. However, according to Lockwood et al. (2015), a high-quality report should point out the values and beliefs of the authors, and this one does not.

Title/abstract

           The article's title: “The experiences and challenges of rural persons with cancer and their families” (Coyne et al., 2019, p. 609), clearly describes what the research is about. CASP tool question one addresses whether the research aims have been clearly stated (CASP, 2017). The abstract includes information on the objective, design, participants, results and conclusions. The information provided in the abstract clearly states the aim of the research. It provides a brief background as to why the research was undertaken. A summary of what was identified that may improve practice in future was provided. It is clear, concise and provides a good overview of the research article.

Journal

The article was published in 2019 by Elsevier in the journal, Collegian (Coyne et al., 2019). This journal is reliable as evidenced by the following information; Collegian is “The Australian Journal of Nursing Practice, Scholarship and Research [and] is the official journal of Australian College of Nursing” (SCImago Journal & Country Rank [SJR], 2020, scope section). It has an H factor of 32, meaning that the journal has published at least 32 articles, and of these articles, 32 or more have been cited at least once (SJR, 2020). 

In 2019 it had an impact factor of 1.830; the impact is measured by the average number of citations the journal received in 2019 during the previous two years (Elsevier, 2021). The journal had a Q factor of 1 in 2020, making it among the top 25 per cent of similar journals in terms of the impact (SJR, 2020). 

Introduction/Background

The introduction provides a detailed background, a list of keywords used, and supporting evidence gathered from relevant and recent literature. The research question was “What are the experiences, needs, and resources of persons with cancer and their families who travel for treatment?” (Coyne et al., 2019, p. 610). The literature provides evidence that there are health disparities in people who live rurally compared to the rest of the population (Coyne et al., 2019). It provides a background as to why this occurs, including poor health literacy, limited access to health care and later diagnosis (Coyne et al., 2019). Families have been included in the research as the evidence clearly articulates that people living rurally often rely on their family members for care due to limited resources (Coyne et al., 2019). Communication between patients, families and health professionals is often poorer in the rural community (Coyne et al., 2019). The researchers noted in the introduction the inclusion of a theoretical concept, “Family Systems Nursing”, to help understand the rural family as an element in the care process (Coyne et al., 2019). Explaining the role of theory in research is important as it helps influence the design and adds to the quality of the research (Trainor & Graue, 2014). A “summary of relevance” (Coyne et al., 2019, p. 609) has been provided as an overview of the introduction and background. It outlines the challenges people who have been diagnosed with cancer, and their families face when living rurally (Coyne et al., 2019). It provides a summary of “What is already known” (Coyne et al., 2019, p. 609) and “What this paper adds” (Coyne et al., 2019, p. 609). Including information on what the paper adds provides evidence of the significance or impact that the research has. In this case, the research has highlighted the need for increased communication with patients and their family living rurally and the importance of care being tailored for people living rurally (Coyne et al., 2019). This article provides a good introduction and background as it provides evidence on why the research is needed, the reason for including families, and how it can improve future practice. A weakness is that it does not highlight if there were any gaps in the literature.

Methodology

Qualitative research aims to help the reader understand the patients/people's experiences, behaviours, and concerns of the patients/people involved (Hoffman et al., 2017). Methodologies used in qualitative research are based on the underlying philosophical perspective (Hoffman et al., 2017). The philosophical perspective that this article is based on appears to be the interpretive perspective; however, the article does not clearly state the philosophical perspective. The evidence is drawn from people who have been through the experience, which is an example of the methodology; phenomenological interpretive approach (Hoffman et al., 2017). The method section of this article is brief and includes some details of the methodology but not all details.

Congruence Between the Methodology Used and Other Study Aspects

The QARI checklist tool focuses on congruence between the methodology and different stages of the research (Hoffman et al., 2017). The abstract in this article points out that a qualitative study was conducted. The aim was to understand the experiences of the sample population (Coyne et al., 2019), thus supporting that the philosophical perspective is interpretivism. This evidence supports the congruence between the design and the research question addressed in the QARI tool question two (QARI, 2020). It would suggest that there is congruence between the methodology and the philosophical perspective, as addressed in question two. However, there is no formal statement on the philosophical perspective. Congruence between methodology and the method used to collect the data is assessed in QARI question three (QARI, 2020). Data was collected in the form of words through interviews from a small sample size (Coyne et al., 2017). This is congruent to the interpretive approach, phenomenology, as it supports understanding in-depth experiences, where three to ten sample sizes are sufficient (Hoffman et al., 2017). The study sufficiently represents the data, as it includes single experiences and themes identified by all participants making it congruent to the phenomenological approach addressed in QARI question four (Lockwood et al., 2015). QARI question five addressed the congruence between the methodology and the interpretation of results (QARI, 2020). This is evidenced in the article as the phenomenological approach was to “understand the experience and challenges for persons with cancer and their families from rural Queensland” (Coyne et al., 2017, p. 609), and the results have been used to inform health professionals to better support their needs (Coyne et al., 2017).

Is the Methodology Trustworthy?

The CASP tool assesses the rigour, credibility, and significance of the research (Hoffman et al., 2017). Rigour can be assessed in terms of trustworthiness in qualitative research (Rose & Johnson (2020), and this is an area the CASP tool assesses well. The CASP tool question two addresses whether the methodology used is appropriate (CASP, 2017). A qualitative methodology is appropriate to address the aims of this study as the research question aims to understand experiences (Hoffman et al., 2017, Coyne et al., 2019). CASP tool question three addresses whether “the research design was appropriate to address the aims of the research” (CASP, 2017, p. 2.), which can be established by whether the author has justified the design (CASP, 2017). The authors did not include a statement to justify why they used the research design. CASP question four addresses whether the recruitment strategy was appropriate (CASP, 2017). This has been done well in this article as there is a clear statement about the participants. Information is provided on how and why they were recruited. There is a statement about why some participants were not able to participate. CASP question five addresses whether the data was collected appropriately for the research (CASP, 2017). This was explained well in this article. There is a section providing details on the setting that includes a definition of rural. The interview process and questions have been included, and the analysis of the data has been explained. The authors have included a brief discussion on the limitations of this study, that the researcher began with a mixed-method approach; however, this needed to be revised to a qualitative design due to a poor response rate (Coyne et al., 2019). The methodology used in this article is appropriate for the research question and has been justified well in most instances. The recruitment process and data collection methods are trustworthy. A weakness is that some information has not been clearly stated, such as the phenomenological perspective, and although the design is clearly stated, no justification is discussed.

Results

The data in this article is presented in the form of descriptions of peoples’ experiences and perspectives. Presenting results in this format requires some interpretation to make sense of the information (Rose & Johnson, 2020). The results have been presented as themes to help the reader understand the experiences of the patient and their family members (Coyne et al., 2019).  The themes identified were “confronting diagnosis, challenges, and negotiating support” (Coyne et al., 2019, p. 611). Confronting diagnosis resulted in feelings of shock and disbelief for many patients and families (Coyne et al., 2019). The theme of challenges related to the way patients and their families managed treatment in the home, travelling for treatment and managing side effects (Coyne et al., 2019). Negotiating support provided information on how the patients and their families managed with limited recourses available when living rurally (Coyne et al., 2019).

Data Analysis

The process of data collection has been clearly described as using a thematic analysis of the interview transcripts (Coyne et al., 2019). Thematic analysis is appropriate for this study as it is widely used in health and wellbeing research and is a valuable tool to analyse qualitative research (Braun & Clarke, 2014). Several participants' identification of similar experiences (portrayed as key themes) illustrates that there is strength and validity in the study (McAleese & Kilty, 2019). An excel spreadsheet was used to display initial themes identified, which were further established through discussions within the research team, and reviewed by three participants (Coyne et al., 2019). Clearly documenting how data has been collected is important to show transparency and adds to the article’s validity (Trainor & Graue, 2014).  Including the participants in the review of the themes further increases the study’s credibility (Rose & Johnson, 2020). Having the participants included in the data assessment is known as ‘respondent validation’ as it further adds to the credibility of the study (Hoffman et al., 2017). The description of the way the data was analysed was done well and supports CASP question eight, “was the data analysis sufficiently rigorous?” (CASP, 2017, p. 5).  

Data Presentation

           The results were presented in the form of statements from patients and their families, with some interpretation provided by the authors (Coyne et al., 2019). QARI question eight addresses the question “are participants, and their voices adequately represented” (QARI, 2020, p. 3). This has been done well by the author through the presentation of participants statements. The participant's names have been changed, and there is a statement declaring that informed consent was obtained and that the study was ethically approved through appropriate committees (Coyne et al., 2019). QARI question nine and CASP question seven address ethics (QARI, 2020, CASP, 2017) and this has been done appropriately in this study, adding to its trustworthiness.  A weakness it that there is no statement about the relationship between the researchers and the participants, which is addressed in CASP question six (CASP, 2017). There is a simple statement that there is no conflict of interest; however, in qualitative research, it is important for the authors to examine their role and viewpoint in the questioning process (Kalu, 2019).  The description of participants has been done well, including a table of their demographics. The pseudonyms have been recorded at the end of statements providing context for the reader. The sample size is small but sufficient for qualitative research where detailed experiences are being evaluated (Hoffman et al., 2017).  There is a discussion in the limitations of this study that the researcher began with a mixed-method approach. However, this needed to be revised to a qualitative design due to a poor response rate (Coyne et al., 2019). The process of revising increases the interpretability and credibility of qualitative research results (Kalu, 2019). This is addressed as part of CASP question six and has been described well.  Overall, the results have been collected appropriately and ethically. They have been reliably and presented in a way that sufficiently presents key themes.  One weakness is there is little information on any bias that the researcher’s roles may have played in the questioning and data collection phase. 

Discussion/Conclusion

The discussion provides a good overview of the results. It provides evidence for and against the findings of this study and the literature reviewed. This is assessed as part of CASP question nine on whether there is “a clear statement of findings” (CASP, 2017, p. 5). The findings were discussed in relation to the initial question. The findings of the study answered the question by using the participant's stories.  Stories provide value and impact and provide the evidence needed to improve practice or make policy changes (McAleese & Kilty, 2019). CASP question nine also addresses whether triangulation has occurred (CASP, 2017).  There is no clear statement on this; however, triangulation can improve the study's comprehensiveness, and it occurs when data is collected from several different sources (Hoffman et al., 2017). Triangulation has occurred as evidence has been collected from patients and family members (Coyne et al., 2019). A weakness is that no evidence was collected from health professionals.  

Recommendations

In this study, the participant's stories provide evidence that improvements could be made to practice. CASP question ten looks at how valuable the research is (CASP, 2017). This can be done by assessing whether the researcher has identified their study's contribution to practice, if further research areas have been identified, and whether the findings could be helpful for other populations (CASP, 2017). The authors have identified recommendations for practice. The recommendations have been made based on patient and family values and evidence from supporting literature. This is evidenced in the identification of a critical value being strong family relationships, and one of the key recommendations was to develop partnership plans with patients and their families (Coyne et al., 2019). The need for tailoring assessments and patient education was identified to improve patients understanding of their illness and treatment (Coyne et al., 2019). Poorer health literacy was identified throughout the participant's stories and further evidence by supporting literature (Coyne et al., 2019).  They identified the need for further research focusing on using another recruitment process, another study design such a mixed-method approach and developing nursing interventions to be researched (Coyne et al., 2019). A limitation to this study was that they did not identify whether the findings could be helpful for others. This would have added to the value of this study.

Conclusion

QARI question ten looks at whether the study findings relate to the data collected (Lockwood et al., 2015). This conclusion in this article summarises how valuable the research has been and how the evidence can improve current practice. It points out the need to implement guidelines to identify people who live rurally, assess individual needs, and develop partnership plans with patients and their families (Coyne et al., 2019). This paper provides quality evidence to promote better practice guidelines for people living rurally with cancer. This would likely promote better health outcomes among the rural community.  It would have been helpful to include how this study could contribute to other populations living rurally. Evidence-based practice involves the inclusion of quality research, clinical expertise and patients’ values and circumstances (Hoffman et al., 2017). This study adds to evidence-based practice as it provides quality evidence through participants stories, and patients values and circumstances are considered thoroughly.  The researchers’ backgrounds and credentials evidence clinical expertise. A weakness is that there is no discussion on how the researcher’s clinical expertise may have influenced the study, and there is no evidence directly sourced from health professionals.

References

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Critical Appraisal Skills Programme. (2017). CASP Checklists. http://www.casp-uk.net/casp-tools-checklists.

Elsevier. (2021). Collegian. Retrieved May 26, 2021 from https://www.journals.elsevier.com/collegian

Hoffmann, T., Bennett, S., & Del Mar, C. (2017). Evidence-based practice across the health professions (3rd ed.). Elsevier.

Joanna Briggs Institute. (2020). Checklist for Qualitative Research. https://jbi.global/critical-appraisal-tools

Kalu, M. E. (2019). Using emphasis-purposeful sampling-phenomenon of Interest–Context (EPPiC) framework to reflect on two qualitative research designs and questions: A reflective process.  The Qualitative Report, 24(10), 2524-2535. https://doi.org/2309244141/se-2?accountid=16926

Lockwood, C., Munn, Z., & Porritt, K. (2015). Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. International Journal of Evidence Based Healthcare 13(3), 179-187. https://jbi.global/critical-appraisal-tools

McAleese, S., & Kilty, J. M. (2019). Stories Matter: Reaffirming the Value of Qualitative Research.  The Qualitative Report, 24(4), 822-845. https://doi.org/2231315732/se-2?accountid=16926

Rose, J., & Johnson, C. W. (2020). Contextualizing reliability and validity in qualitative research: Toward more rigorous and trustworthy qualitative social science in leisure research.  Journal of Leisure Research, 51(4), 432-451. http://doi.org/10.1080/00222216.2020.1722042

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Trainor, A. A., & Graue, E. (2014). Evaluating rigor in qualitative methodology and research dissemination: RASE.  Remedial and Special Education, 35(5), 267, http://doi.org/10.1177/0741932514528100