When carrying out any type of interview it is important to understand the multiple factors that shape the relationship of interviewer and interviewee, which can in turn influence the quality and content of information that is a significant task in interpreting research data (Manderson et al. 2006). Factors other than age, class, and gender, arguably, also influence the conduct of the interviews. This must be identified by the interviewers and researchers. Nunkoosing (2005) also suggests that power is always present in an interview. It can be argued that power can be present in an interview but it depends on the interviewer and how they approach the interview. There can be situations where the interviewees can have the power as they are the ones that are important to the research and this must also be identified by the interviewer and appropriate changes should be made if this is the case.
Wilkens et al. (2005) did not state the interviewer’s background which may have influenced the outcome. A study by Perry and McLaren (2003) used semi-structured interviews to interview stroke patients. This study did identify the interviewer bias and therefore stated the background of the interviewer. This study also tried to overcome the bias of the interviewer by establishing a rapport with the participants by assuring confidentiality, showing genuine interest, eliciting and pursuing rather than guiding narration, remaining neutral and accepting of negative presentation of healthcare experiences, responding as an individual within the interview situation (Perry et al. 2003). In order to make the study by Wilkens et al. (2005) more reliable the above approaches should have been taken and shown that these problems existed in their study.
The study by Girou (2002) uses a RCT. A RCT is a study in which the participants are assigned by chance to separate groups that compare different treatments (Cormack 2000). The researchers and the participants can not choose which group they are assigned to. Using chance to assign people to groups means that the groups will be similar and that the treatments they receive can be compared objectively. At the time of the trial, it is not known which treatment is best. It is the patient's choice to be in a randomised trial. Randomisation is done to ensure that the results they get are correct and not bias and occurring by chance (Altman and Bland 1999). The study by Girou (2002) uses the term randomised clinical trial in its title. When looking at the abstract from this article the term randomised controlled trial is used. This is very misleading as the two terms can mean two different things. When writing an article the same terms should be used throughout the research to limit confusion.
Girou (2002) used randomly sealed envelope to assign participants to a random group. They however did not state how the envelopes where randomised and mixed. The envelopes were given to the participants when they arrived, which is not randomisation but convenient as there may be certain types of people who always arrive early or late. This can bias the results as there may be an association between arriving early and hand hygiene, (bias was not eliminated).
The microbiologist who examined the culture plates was unaware of the hand hygiene method used so a single blinded was added to this study. This was a good point in the study as the study by Lucet et al. (2002) did not blind the microbiologist and there results could have had examiner bias. In order to give more credit to research a double blinded study would be used. In this study however, it would be difficult to blind the participants, as the two washing methods were completely different. This may have biased the results and participants may have a preference and use it differently to the other method.
To make this study more randomised, one way of doing it was by putting the details of the participants (such as age gender) in the computer to make sure the tow different groups are as similar as possible and produce to groups. In a randomised clinical trial there is normally a control group and a treatment group. This study however, compared two different methods that are both used so there was not new method of hand washing.
Toulotte et al. (2006) uses a case comparison study. A case-comparison study is one in which a group of cases is identified. A second group of controls is then selected. The two groups can then be compared with respect to a particular variable (Cormack 2000). Such studies are conducted retrospectively, not prospectively. Case-control studies have the disadvantage, compared to the randomised study, that the groups may not be equivalent on other factors. Case-control studies are a less-expensive and often-used type of epidemiological study that can be carried out by small teams or individual researchers in single facilities. The disadvantage of case-control studies is that they do not give any indication of the absolute risk of the factor. For instance, a case-control study may tell you that a certain behavior may be associated with a tenfold increased risk of death as compared with the control group.
Toulotte et al. (2006) identified two groups one of fallers and one of non-fallers. The groups were identified according to a definition and two clinicians after interviewing the participants assigned the participants to a fallers or non-fallers group. This method of group allocation is not random. When interviewing patients regards to their fall history they may have not remembered that they had fallen this could have altered their group allocation.
When using quantitative studies the researchers themselves are less likely to cause a bias towards the research as they are not intervening in any way they are just there to take the results and explain the procedures. For example the study by Girou (2002) the researcher did not intervene when the hand washing was taking place. In the case-comparison study by Toulotte et al. (2006) interviewing did take place but this was a different type of interview compared to Wilkens et al. (2005). They interviewed participants to assign them to a specific group. This study could have had interviewer bias as they chose according to a criteria which groups the participants went in.
A number of hierarchies of evidence have been developed to allow different research methods to be ranked according to the validity of their findings (Evans 2003). The 3 chosen articles can be placed according to the hierarchy of evidence pyramid. The RCT would be classed higher on the hierarchy of evidence followed by the case comparison study and the qualitative research being placed lower down. Having a hierarchy of evidence is a good way of classifying the merits of research, however when using qualitative studies it is not classified highly. Qualitative research does have a place in research and the outcome of the research can be very useful in a clinical setting.
When carrying out any type of research a recruitment of people must be carried out (Hicks 1999) to take part in the study. When selecting participants it must be decided the type of participants required and a clear definition of these participants must be given. A sample should be chosen purposefully and many sampling strategies can be used. Samples vary considerably in the extent to which they represent the population, but the researcher who pays particular attention to the representativeness of the sample increases the possibility of generalizing the findings to a larger group. The researchers should determine the number of participants that are needed, as there is no single, correct sample size (Byrne 2001). It is also important that the authors explain their sampling method and reasons for sample chosen so that readers can assess whether or not the findings can be useful in other settings (Parahoo 1997).
Winkens et al. (2006) uses a convenient sample of 13 participants from a stroke population. This sample size is a very small sample size considering the number of people who have or have had a stroke and 13 people cannot be sufficient enough to represent the whole stroke population. In this study however the authors felt that saturation had been reached with 13 participants. The sample was also a selective group of mainly recovered, Dutch patients who had a good prognosis and most of the participants the stroke had occurred a long time ago. Therefore, the results of this study cannot be generalised to all patients with stroke, especially the patients who do not have good prognosis.
The study by Girou et al. (2002) used 23 nurses. The sampling was carried out in a university hospital in 3 intensive care units. All workers were asked to volunteer for the study. Volunteering for a study already causes some bias in the research even before it is carried out. This study however failed to mention how they were asked and how many workers were asked. It then stated that when a worker refused to participate an alternative person enrolled. They did not state who the alternative person was nor did they state how many participants they used to begin with and only mentioned the number of participants in the results section.
It also stated that the participants were previously instructed in the use of alcohol based solutions when the policy was launched but this was a year ago. Participants may have forgotten or developed a different way of hand washing and so there may not have been a standardised procedure of hand washing between participants. A written protocol was available to participants, but it did not state how many read the protocol before the study. It would have been better to ask all the participants to read the protocol to make the study standardised. The participants were given no information prior to the study except the protocol. A study by Lucet et al. (2002) used a standardised hand hygiene technique and stated what they were. Girou et al. (2002) however did mention the reason for having non standardised hand hygiene procedure.
The study by Toulotte et al. (2006) used a group of 40 healthy elderly women. A convenient sample was used as they were selected from senior citizen clubs. This study did not state how they gathered their participants from each of the clubs although they did state 45 women volunteered. All 45 volunteers could have come from the same club and so the collection of participants were not randomised as well as they could have been. In order to improve the method of sample collection they could have selected a number of volunteers from each club. Doing it this way may have left the researchers with a smaller sample size.
The sample size used by Toulotte et al. (2006) was larger than the sample size used by Girou et al. (2002) and Winkens et al. (2002). It can be argued that even if Winkens et al. (2002) used more participants they would not have got any more themes. Marshall (1996) states that an appropriate sample size for a qualitative study is one that adequately answers the research question. It can be argued however, that researchers may get the answer to their question but there may be more answers that are not collected due to them stopping for example at 13 participants.
The number of required subjects usually becomes obvious as the study progresses, as new categories, themes or explanations stop emerging from the data. This therefore requires a flexible research design. Quantitative studies differ from qualitative studies by having a set number of participants at the beginning of the study, whereas the qualitative study is set over a longer period of time and they interview participants one after the other and when they have got all the information they can get they will stop interviewing.
In a quantitative study power calculations should be used to give the sample size needed to give a significant result (Nelson et al. 2001). The study by Girou et al. (2002) used a power calculation to get the number of patient care activities that they would need to have a 5% significant level. In terms of sample size they only used 23 people who completed several care activities. This suggests that the data gained were not independent of each other. The study by Toulotte et al. (2006) used 40 volunteers but it did not use a power calculation to determine that sample number. Using power calculations are important as an insufficient sample size has a low probability of detecting a statistically significant difference between groups, even if a difference really exists.
When selecting a sample population, researchers may set inclusion and exclusion criteria. These criteria are based on such factors as age, gender, the type and stage of a disease, previous treatment history, and other medical conditions. It is important to note that inclusion and exclusion criteria are not used to reject people personally, but rather to identify appropriate participants and keep them safe. The study by Winkens et al. (2006) stated an inclusion and exclusion criteria for the selection of there participants which could be justified. For example they had an exclusion criterion of very severe cognitive or communicative problems. As the research required a form of cognitive thinking during the interview it was appropriate of the researcher to use these exclusion criteria. The study by Girou et al. (2002) also used an inclusion and exclusion criteria. They did not use any samples that were visibly soiled as this was identified as a contraindication to alcohol based solutions.
When carrying out any form of research it must be ethically acceptable and proposal must be passed by the ethical research committee. Cormack (2000) suggests areas of importance to research include ethical committee approval, informed consent, confidentiality and anonymity. Ethical ‘issues’, according to Cormack (2000) are an integral part of all phases of the research process as well as to the use and application of research. Winkens et al. (2006) used a protocol which was passed by the Medical Ethics Board of each participating rehabilitation centre and informed consent was obtained by all participants. Girou et al. (2002) failed to mention in their study regarding ethical approval and gaining informed consent from participants. Toulotte et al. (2006) mentioned the approval of their research by the local University Ethics Committee. The participants in this study also signed a written consent form before the experimentation and after being informed of the protocol. Participants may agree to take part in a study before an explanation of the protocol is given. Even though Winkens et al. (2006) obtained consent they did not state how they obtained consent and when it was obtained.
It is suggested that data collection procedures should be adequately described (Cormack 2000). There are many ways to collect data in research. The choice of data collection method is influenced by the research approach used and the research question being addressed. The validity and reliability of the data collection method are very important and give the research findings their credibility (Hek, Judd and Moule 2002). In qualitative research data analysis often takes place alongside data collection to allow questions to be refined and new avenues of inquiry to develop. This method of data collection and analysis allows the researcher to go back and refine questions, develop hypotheses and pursue emerging avenues of inquiry (Pope, Ziebland and Mays 2000). The term grounded theory is used to describe the inductive process of identifying analytical categories as they emerge from the data which is what the study by Wilkens et al. (2006) used.
Winkens et al. (2006) used semi-structured interviews to collect their data. Their main outcome measure was descriptions of everyday consequences of mental slowness. Participants were asked to describe in their own words the problems that they encountered. They were asked to focus mainly on problems associated with mental slowness. Asking participants to focus on certain aspects can be biased. Data was collected over a period of 5 months. Using qualitative research designs can often be time consuming and expensive compared to quantitative research. The conversations were tape-recorded and transcribed. Transcribing can be time-consuming, costly and difficult. A constant comparison method was used which considered the relationship between new and analysed data.
Girou et al. (2002) used imprints taken of fingertips and palm of the dominant hand before and after hygiene procedure and the bacterial counts were quantified blindly. This study did mention the type of care the participants carried out whether or not they wore gloves and duration of care performed which could all have affected the outcome. The microbiologists were also blinded so they did not know where the samples had come from. This is good to do as the analyser has no bias towards the result. As the procedure of hand washing was dependent on the patients ability to thoroughly wash their hands this could have made a difference between participants as they did not go through a procedure with everyone. This article however did justify why they did not control the hand washing practice itself, as they did not want to interfere with the actual practice. This study did identify the limitation of their method collection. They stated they should have used the glove juice technique, which would have been better in recovering the whole bacterial burdens on hands. A study by Grabsch et al. (2004) did use the glove juice technique and therefore were able to collect better samples. A study by Lucet et al. (2002) looked at hand contamination before and after different handwashing techniques and also used the same microbiologist technique as Girou et al. (2002). Both the study by Lucet et al. (2002) and Girou et al. (2002) did not justify why they did not use the glove juice technique.
Toulotte et al. (2006) used various test to collect their data. A single leg balance test was used where the subject selected the foot they wanted to stand on. This is not randomised and it would have been better if the leg they stood on was consistent with all the participants. Gait analysis was also carried out under single and dual task conditions and various measurements were taken by video recording the participants walking. Recording the patients could have altered the results as participants may not like being recorded. This is a similar situation as being interviewed as these can influence the results and this must be identified in the research article.
The study by Winkens et al (2006) did choose the appropriate type of research. The study by Girou et al. (2002) used a RCT, however in its study there was little randomisation and therefore this study cannot be classified as a randomised trial. Toulotte et al. (2006) used a case comparison study which was appropriate for what they wanted to achieve with their research. Using both qualitative and quantitative research had its advantages and disadvantages. A major strength of the qualitative approach is the depth to which explorations are conducted and descriptions are written, usually resulting in sufficient details for the reader to grasp the “idiosyncrasies of the situation” (Myers 2002. p3). In health research quantitative research has been given more merit with RCT having the highest merits in health research. It is believed that qualitative research also has its place and should not be discredited. When selecting what type of research to carryout the researcher must make sure that it is the appropriate type of research for what they are looking for.
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