The article Effective Interaction with Patients with Schizophrenia: Qualitative Evaluation of the Interaction Skills Training Programme is a mixed method study that focuses on the qualitative research results and the effects the ISTP had on relationships between caregivers and patients, in terms of the caregivers lived experience. This paper will be examining the study using the qualitative critiquing approach and will use this information to determine whether the results of the study have the rigour and credibility to be applied to nursing practice.
Statement of Phenomenon of Interest
The purpose of this article was to evaluate the effects that the Interaction Skills Training Programme (ISTP) had on caregivers in terms of how they perceived the experience of taking the course and what effects if any it had on how they delivered care to their patients. This phenomenon of interest is clearly identified in the title of the article as well as in the purpose and findings abstract on the first page. The justification for using a qualitative method was to meet the researcher’s goal of understanding the caregiver’s lived experience. The philosophical underpinnings behind this research was to add validity to ideas that were formulated back in the 1950’s when researchers had started writing about interaction and communication between schizophrenic patients and their social environment (van Meijel et al. 2009).
The purpose of the study was to get an emic view from the caregivers who took the ISTP. The caregivers who took the training course were asked to share their learning experiences and then comment on the effects the training had on the way they delivered care to the patients in terms of the quality of their therapeutic alliances (van Meijel et al. 2009). The significance of this work to nursing is to use the results of this study to promote the effectiveness the ISTP has on improving therapeutic relationships between caregivers and patients.
The purpose of the research was to get lived experience from caregivers who took the ISTP. Using a semi-structured interview process is a very accurate way to gather the data the researchers were looking for to answer their research questions. According to Lobiondo-Wood, Haber, Cameron, & Singh (2009) interviews allow for richer and more multifaceted data to be collected, especially when they are looking for open-ended answers. The method of using the data gathered from the recorded interviews of the 17 caregivers to help explain the phenomenon of interest is adequate. It is difficult to know whether the researcher completed the study with any consistency because there weren’t enough details described in the process. For example it is not known whether the researchers or properly trained interviewers conducted the interviews.
Research design and research tradition
This study used two different methods to collect data, which is mixed design of research. Lobiondo-Wood et al. (2009) describe mixed methods research as drawing conclusions using qualitative and quantitative methods in a single study. This is also considered a form of triangulation. Essentially this study started as a quantitative study where a larger sample of participants (n= 102) were tested using a questionnaire instrument called the Working Alliance Inventory (WAI) (van Meijel et al. 2009). The WAI measured the quality of the therapeutic relationship. A smaller sample of participants (n= 17) that showed either significant or no changes on the WAI scores were selected for the qualitative portion of the study which consisted of audio-taped interviews. This research study comes from a constructivist paradigm which is typical of a qualitative research study as it focuses on the naturalistic approach. The study seems to encompass an epistemological approach which is described under the constructivist paradigm as valuing subjectivism. Values are also a factor because the values of the participants in the qualitative study do add to the understanding of the phenomenon. For hierarchy of evidence this study would be a level VI which is described as evidence deriving from a single descriptive or qualitative study (Lobiondo-Wood, & Haber 2009).
This study uses a non-probability purposive sampling method. Even though it is a mixed method study it is the qualitative data that is considered to be the data that is used to support the phenomenon stated in the study therefore it would be appropriate method of sampling for this study. Lobiondo-Wood et al. (2009) note that non-probability sampling uses non random methods and is less generalizable than probability sampling which makes it more suitable for qualitative research. They go on to say that purposive research is described as harder to generalize because the sample is taken from a quantitative view; however this method is necessary for the qualitative researcher to pick participants based on the phenomenon of the study. Because the participants worked in the field directly related to the phenomenon of the study they are clearly appropriate to inform the research.
Very little is known regarding the setting as it is not clearly identified in the study. However it does state that the patients involved in the study were from a variety of places including inpatient, outpatient, and group home settings.
The qualitative part of the study focused entirely on human experience. The researcher captured this human experience by conducting 1 hour audio taped interviews on the 17 participants. The audio tapes were transcribed verbatim and then analyzed with software called winMAX which is a program that aids in qualitative text analysis (van Meijel et al. 2009). The analysis first coded the interview texts, after which the related codes were divided into five categories. The five categories included awareness and insightfulness, impact on attitude, impact on professional relationships, impact on job perception, and training related. Lobiondo-Wood et al. (2009) describes data saturation as the point where the researcher begins to notice recurring themes with the information being shared by the participants. Although not clearly stated in the study it appears that saturation may have occurred simply because of the number of participants used in the phenomenological study was 17 which more on the high end and it does appear that some commonalities were found among the responses of the participants.
Legal and Ethical Issues
There is no mention of whether the participants were protected at all in any part of the study. There is no indication whether the participants in either stage of the study were explained informed consent. However because the participants in the first part of the study, which was a larger quantitative study, filled out a Working Alliance Inventory (WAI) (van Meijel et al. 2009), which is a type of questionnaire one could argue that by filling out the WAI the participants did give informed consent as they were aware of what they were doing. There was no indication as to whether or not the participants’ confidentiality was addressed. When looking at the qualitative part of the study that involved audio taping it would be important to clarify how or whether the participants’ confidentiality was addressed. Essentially more information could have been provided; we do not know how or where the audio tapes were stored or whether they were destroyed after being analyzed. If they were kept we don’t know whether the participants’ names were attached to the individual tapes.
The strategies used to analyze the data involved using audiotapes that were transcribed verbatim with the aid of the winMAX software program (van Meijel et al. 2009). The interview text was coded and then combined into 5 categories. It does appear that the researcher remained true to the data as they did analyze and categorize the data into the 5 sub categories to meet the criteria to answer their research questions. The steps described for data analysis were easy to follow and were clear and direct.
It is difficult to say how well creditability was met in this study. Although the participants of the qualitative study seemed to express their true experience with the ISTP, it is not clear whether any follow up was done by the researchers so it is not known whether enough time has been allowed to fully understand the phenomenon of interest. Furthermore it does not appear that the researchers verified the data that they collected from the recordings with the actual participants of the interviews. Therefore it is unclear whether or not some of the experiences expressed by the participants could have got lost in translation.
Due to the fact this was a mixed method study involving both quantitative and qualitative research methods it is difficult to see a clear audit trail as there seems to be a discrepancy in the accuracy between data collected in the quantitative study and the data collected in the qualitative study. The steps of the research process were not clearly described and outlined in this study particularly in the quantitative portion. Therefore it would be difficult to follow an audit trail which brings the topic of rigour into question. Rigour is described as the believability or quality of the study (Lobiondo-Wood et al. 2009).
Based on the qualitative portion of the study alone which was the expressed lived experience of the 17 participants in the ISTP from the data derived from the interviews, it would appear that the fittingness is met. The results of the five sub categories were very descriptive and clearly identified the human experience in terms of the impact the ISTP had on the participants. The results could lead one to see the value of taking a program like the ISTP to enhance the quality of their interactions with patients.
The findings or results of the study were presented within the context of the human experience. The ISTP is the independent variable and the effects of the training are the dependent variable. The findings were separated into the five categories that were derived from the interview process. By doing this not only was the context represented but it was further articulated into specific areas of the participants’ experience making the results even more understandable and meaningful to the reader. To help the reader conceptualize the results of the study better direct quotes related to the five categories by the participants were included in the findings. For example the results section titled “ Impact on Professional Relationships”, 15 of the 17 participants gave specific examples of the effect ISTP had on their relationships with their patients (van Meijel et al. 2009), one participant stated:
Before, I would have been more reserved, but now I’m a bit more outgoing, which has improved our interaction. He [the patient] has also noticed this and I can do more for him now. That boosts confidence. Our relation is better, he has become more inviting and we have fewer conflicts. (p. 257)
Earlier studies have indicated that there is a direct connection between positive therapeutic relationships and more patient compliance (van Meijel et al. 2009). Although the earlier research did not involve the use of ISTP the findings of this study does seem to support the theories from earlier studies.
Conclusions, Implications, and Recommendations
The conclusions show that there were positive results from the qualitative portion of the study. The participants were able to identify and articulate specific examples of how the ISTP had helped them in a positive way towards their relationships with patients, their job perceptions, and their collaboration with other caregivers (van Meijel et al. 2009). However these same positive results were not found in the quantitative portion of the research. During the interview process of the study the participants (caregivers) stated that the biggest improvement in terms of their therapeutic relationships was with the patients whom they had previously perceived as difficult to establish relationships. These were the type of patients that for unknown reasons did not participate in the quantitative portion of the study. This causes a discrepancy between the two parts of the study one yields positive results while the other (quantitative) seems to be flawed. van Meijel et al. (2009) recommended that more research be done on understanding how difficult therapeutic relationships have negative impacts on the treatment results. They also recommended that in depth studies in small numbers of problem cases, using possibly a multiple case study format that combines quantitative data collection and analysis methods with qualitative analysis techniques. Based on the positive results from the qualitative portion alone they further support the use of training programs such as ISTP to improve and strengthen relationships and quality of care for chronic psychiatric patients.
Based on the results of this study one can conclude that positive results from the more appropriate contextual qualitative approach should be considered and that the major flaw of this study was the quantitative portion as it is not appropriate for phenomenological studies and did not yield positive results. It seems that there were some obvious problems with the quantitative part of the study as the target patients which were the “ difficult” ones didn’t even participate in the study. In addition the instrument used in the quantitative part of the study is not appropriate to understand the lived experience. It would have been better if the study was simply a qualitative study rather than a mixed method study. It was also unclear in the methods section where the interviews took place. It should have stated the location and whether they all took place in the same location; this would help to strengthen the rigour of the study. In addition future studies should include interviews with both caregivers and patients to get the lived experience perspective from both ends of the therapeutic alliance.
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