JOURNAL CLUB

PRESENTATION
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Moderator : Presented by:
Dr. Sunita Srivastava Dil raj
Reader MSc Nursing 1 st year
CON, ILBS CON, ILBS
 ARTICLE 1:
2
QUANTITATIVE
RESEARCH
 TITLE
A quasi-experimental study to improve
health service quality: implementing
communication and self-efficacy skills
training to primary healthcare workers in
two counties in Iran.

3
 ARTICLE DETAILS
 Author : Hossein Shahnazi,Marzieh Araban, Mahmood
Karimy, Mansooreh Basiri, Ali Ghazvini and LAR Stein
Journal: BMC Medical Education
 Publishing year: 2021
 DOI: https://doi.org/10.1186/s12909-021-02796-4
 Impact factor: 3.6 (2024)

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 Question
What is self-
efficacy
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SELF-EFFICACY
Self-Efficacy is the main element of the
social-cognitive theory that refers to an
individual’s belief or judgment about their
ability to perform tasks and
responsibilities.

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 INTRODUCTION
 Service satisfaction is affected by service quality, quality of
service delivery, and levels of service recipients’ expectation of
service quality
 Measurement of service recipient satisfaction is a common
method for evaluating the treatment quality in healthcare
organizations
 Generally, the concept of satisfaction in providing health
services refers to the feeling or attitude of service clients. There
is a direct relationship between patient satisfaction and
remaining in treatment.
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 NEED OF THE STUDY
 In Iran, primary healthcare coverage is offered to over 95 %
of rural areas, but quality of care is the main concern of
health policymakers.
 Since satisfaction is an important index of quality and
performance of health care and given the lack of
information on how CS and SE of health workers affect
patient satisfaction

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 AIM OF STUDY
The present study aimed to evaluate
the impact of an educational
intervention, based on SE and CS, for
PHC workers.

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 METHODOLOGY
 Approach: Quantitative Research
 Design: quasi-experimental
 Sampling Technique: Randomization

 Population: PHC workers & services recipient

 Setting: Health centers of saveh and zarandieh and
rural areas of saveh and zarandieh.
 Sample size:- a. PHC worker:-105
b. Service recipients:- 364 10
SAMPLE SIZE FOR PHC WORKERS

 Setting power to 80 %, with a medium effect size and alpha

= 0.01, the sample size needed for PHC workers was N = 44
per group (N = 88, in total), based on similar previous study
done by EJ Kim, KR Lee.
 In anticipation of drop-out, N = 105 PHC workers were
approached to participate in the study.
 One left just before beginning the study, leaving N = 104
PHC workers (N = 60 and N = 44 in intervention and control
groups, respectively).

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SAMPLE SIZE FOR SERVICE RECIPIENTS

 Sample size needed for service recipients was calculated at N

= 303 based on previous research,
 Setting power to 80 %, with medium effect size and alpha =
0.01.
 Of the N = 364 service recipients screened for eligibility none
were excluded,
 leaving N = 182 in both intervention and control conditions.
 Subsequently, N = 2 and N = 4 were lost to follow-up from
intervention and control groups respectively, leaving N = 358
for analyses (N = 180 in intervention group and N = 178 in
control group.
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CONSORT DIAGRAM

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INCLUSION CRITERIA FOR
PHC WORKERS
Anticipated continued employment for the next
6 months.
At least one year of work experience (both
determined through interview)
willingness to participate in the study.

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EXCLUSION CRITERIA FOR
PHC WORKERS
 If they were absent from two consecutive
training sessions.

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INCLUSION CRITERIA FOR
SERVICE RECIPIENTS.
Residence in Zarandieh or Saveh.
Receipt of PHC services in the last 3 months
Being 15 years or older.
willingness to participate in the study.

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EXCLUSION CRITERIA FOR
SERVICE RECIPIENTS

Exclusion criteria for service recipients not

mention.

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RANDOM ALLOCATION FOR
PHC WORKERS
PHC workers in Zarandieh and Saveh had similar
scientific and cultural characteristics,
PHC workers in Zarandieh were placed in the
control group, and PHC workers in Saveh were
placed in the intervention group.
This was done by randomizing which site would be
placed in control (using flip of a coin).
Thereafter, personnel numbers were utilized to
randomly sample PHC workers in each site. 18
STUDY DESIGN PHC

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RANDOM ALLOCATION FOR
SERVICE RECIPIENT
using random numbers table from the list of
clients seen by PHC workers in the last 3
months, and then were contacted and
informed of the research purpose.
Appointments took place at their homes
where they completed the satisfaction
questionnaire.
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 TOOLS
A multi-part assessment included demographic
information, and valid/reliable measures of SE, CS
and satisfaction

PHC worker SE was assessed with 4 questions, with

answers on a five-point Likert scale ranging from 5 =
“always” to 1 = “never.“ Higher scores indicated higher SE.

Cronbach’s alpha for SE scale was 0.82 for this 21

 MEASURES FOR
COMMUNICATION SKILL
A checklist was used to assess PHC worker communication
performance with clients in seven areas (2 items for starting the
session, 6 items for creating a relationship, 3 items for data
collection, 2 items for attending to client’s perception of referral
source, 3 items for providing information, 2 items for mutual
agreement and 4 items for ending the session).

Performance of the skill received a score of 2 (yes) whereas not

performing the skill was scored 1 (no). Scores on this construct
ranged from 22 to 44.

Cronbach’s alpha was 0.78 for this measure 22

 MEASURES FOR PATIENT’S
SATISFACTION
The client satisfaction questionnaire consisted of 42 items in 6
domains (8 items for access to services, 6 items for continuity of
care, 8 items for humaneness of staff, 5 items for
comprehensiveness of care, 5 items for provision of health
education, 10 items for effectiveness of service).

Responses were evaluated using a 5-point Likert scale from

“strongly agree” (= 2) to “strongly disagree” (= -2). Higher and
more positive scores indicate more satisfaction.

In Iran, face- and content-validity, and reliability were confirmed 23

RELIABILITY OR VALIDITY
Reliability was assessed for SE and CS
questionnaires, in 20 health workers; and for
service satisfaction questionnaire in 30 clients
were similar to the target population in terms of
demographic characteristics. Cronbach’s alphas
were 0.81, 0.79 and 0.73 for SE, CS, and
satisfaction questionnaires, respectively, when
considering each questionnaire as a whole.
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DATA COLLECTION PROCESS
 Data were collected prior to training.
 PHC workers reported on SE and demographics,
whereas trained observers completed the CS checklist
while observing interactions between PHC workers
and clients.
 Clients completed the satisfaction questionnaire via
self-report; persons with no or low literacy completed
the questionnaire via interview.
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What is blinding

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 Staff members assisting
with
BLINDING observations/interviews
were blind to condition,
and clients were blind
to condition.

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 INTERVENTION
Intervention group
 The training program was designed and held for the
intervention group
 Duration: four 90-minute training sessions.
 Training methods included: Lecture and question-and answer
sessions to increase awareness and consolidate learning; film
screening; role-playing to enhance SE and
improve CS; discussion group to improve SE and CS;
instruction booklets; and texting key points of effective
communication as reminders.
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 INTERVENTION
Control group
 The control group received routine training.
 Typical training is 2 years consisting of course work,
and in-service training.
 Topics cover general, oral and elderly health; problem
solving; collaboration; social factors impacting health;
human rights; and cultural beliefs.

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 DATA ANALYSIS
An independent
Data were analysed
sample t-test was
via SPSS 19 using chi-
used to compare the
square tests for
mean scores of CS
categorical variables,
questionnaires
independent sample t-
between
tests and paired t-
intervention and
tests.
control groups. 30
 DATA ANALYSIS
Also, a paired t-test Also, a Wilcoxon
was used to was used to
compare the mean compare the mean
scores of CS scores of SE, and
questionnaires satisfaction
questionnaires
before and after before and after
training sessions. training sessions.
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 DATA ANALYSIS

 Data normality was confirmed using the Kolmogorov-

Smirnov test, histograms, and normality of residuals.

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 ETHICS
The Research Ethics Committee of the Saveh
University of Medical Sciences approved the
study protocol (Number: IR.SAVEHUMS.
REC1396.16).
 Also, all participants in this research completed
a written informed consent.

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 RESULTS
1. From 364 service recipients, 358 (180 in the
intervention group and 178 in the control
group) who completed the post-test
underwent the final analysis.

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 TABLE 1

Comparison of categorical
variables in clients seen by two
groups of primary healthcare
workers assigned took
intervention and control group.

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DEMOGRAPHIC DATA
Group type
Personal Intervention Group Control group (n-178) P value
attributes (n=180)
Number Percentage Number Percentage
Sex
0.67
Male 79 43.9 82 46
female 101 56.1 96 54
Education

Illiterate 15 8.4 11 6.2

Elementary 99 55 92 51.7
High school and 46 25.6 57 32 0.54
diploma
Academic 20 11 18 10.1 36
DEMOGRAPHIC DATA
Group type
Personal Intervention Group Control group (n-178) P value
attributes (n=180)
Number Percentage Number Percentage
job

Student 8 4.4 10 5.6

Farmer/shepherd 43 23.9 54 30.3 0.39
Staff 7 3.9 5 2.9
Housewife 90 50 88 49.4
Other 32 17.8 21 11.8
Insurance

Yes 169 93.9 170 95.5 0.49

No 11 6.1 8 4.5
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 TABLE:- 02

Comparison of categorical
variables in primary, healthcare
workers assigned to intervention
and control

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Table:- 02 COMPARISON OF CATEGORICAL VARIABLES IN PRIMARY, HEALTHCARE WORKERS ASSIGNED TO INTERVENTION AND
CONTROL
Group type
Personal attributes Intervention Group Control group (n- P value
(n=180) 178)
Sex Number Percentage Number Percentage
Male 25 41.6 16 36.4 0.58
Female 35 58.4 28 63.6

Education
Elementary 8 13.3 6 13.6
Middle school 11 18.3 5 11.4
High school and 33 55 32 72.7 0.12
diploma 8 13.3 1 2.3
Academic
Work experience
<10 15 25 9 20.4
10-19 19 31.7 12 27.3 0.66 39
 TABLE :-3
Comparison of communication skills
and self-efficacy in primary health care
workers assigned to intervention and
control at baseline and 3 months follow
up.

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TABLE:-3 Comparison of communication skills and self-efficacy in primary health care workers assigned
to intervention and control at baseline and 3 months follow up.

variable Group time Intervention Control p value

Group group
Mean±SD mean±SD
(N=60) (N=44)
Starting the Baseline 2.52±0.62 2.38±0.51 0.06
session 3 months follow up 3.79±0.46 2.87±0.72 0.001

P-value 0.001 0.001

Creating a Baseline 8.95±1.57 9.0±1.54 0.68

relationship 3 months follow-up 11.91±1.78 9.75±2.03 0.001

P-value 0.001 0.06

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TABLE:-3
variable Group time Intervention Control p value
Group group
Mean±SD mean±SD
(N=60) (N=44)

Data collection Baseline 5.0±0.78 4.84±0.63 0.18

3 months follow up 5.51±0.56 4.55±0.49 0.001

P-value 0.001 0.04

Attending to Baseline 3.25±0.89 2.84±0.75 0.01

client perception 3 months follow-up 3.78±0.48 2.77±0.62 0.001
of referral
source P-value 0.001 0.39

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TABLE:-3
variable Group time Intervention Control p value
Group group
Mean±SD mean±SD
(N=60) (N=44)

Providing Baseline 4.67±0.75 4.59±0.87 0.56

information 3 months follow up 5.49±0.64 4.69±0.61 0.001

P-value 0.001 0.55

Mutual Baseline 2.87±0.56 2.84±0.73 0.95

agreement 3 months follow-up 3.21±0.58 2.66±0.64 0.001

P-value 0.001 0.27

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TABLE:-3
variable Group time Intervention Control p value
Group group
Mean±SD mean±SD
(N=60) (N=44)

Ending the Baseline 5.64±1.0 5.37±0.85 0.06

session 3 months follow up 6.81±0.92 5.66±1.10 0.001

P-value 0.001 0.17

Self-efficacy Baseline 31.52±2.91 31.32±2.64 0.67

3 months follow-up 34.25±4.0 31.26±4.52 0.001

P-value 0.001 0.79

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 TABLE 4
Comparison of client satisfaction in two
groups of primary health care workers
assigned to intervention and control at
baseline and 3-months follow-up.

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TABLE:-4 Comparison of client satisfaction in two groups of primary health care workers assigned to intervention and
control at baseline and 3-months follow-up.

variable Group time Intervention Control p value

Group group
Mean±SD mean±SD
(N=60) (N=44)

Access to Baseline 1.75±0.60 1.73±0.47 0.59

services 3 months follow up 2.89±1.0 1.80±0.56 0.001

P-value 0.001 0.32

Continuity of Baseline 1.19±0.97 1.33±0.87 0.28

care 3 months follow-up 2.72±1.14 1.40±1.06 0.001

P-value 0.001 0.34

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TABLE:-4
variable Group time Intervention Control p value
Group group
Mean±SD mean±SD
(N=60) (N=44)

Humaneness of Baseline 1.22±0.84 1.18±0.79 0.63

staff 3 months follow up 2.88±1.17 1.23±0.82 0.001

P-value 0.001 0.28

Comprehensiven Baseline -1.09±0.67 -1.04±0.60 0.14

ess of care 3 months follow-up -1.70±1.22 -0.61±1.14 0.001

P-value 0.001 0.11

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TABLE:-4
variable Group time Intervention Control p value
Group group
Mean±SD mean±SD
(N=60) (N=44)

Provision of Baseline 1.22±0.84 1.18±0.79 0.63

health education 3 months follow up 2.88±1.17 1.23±0.82 0.001

P-value 0.001 0.28

Effectiveness of Baseline -1.09±0.67 -1.04±0.60 0.14

services 3 months follow-up -1.70±1.22 -0.61±1.14 0.001

P-value 0.001 0.11

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 TABLE 5
Comparison of clients satisfaction and self-
efficacy median in two groups of primary
health care workers assigned to
intervention and control at baseline and 3-
months follow up.

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Table:-5 comparison of clients satisfaction and self-efficacy median in two groups of primary health care workers
assigned to intervention and control at baseline and 3-months follow up.

variable Group time Intervention Group Control

Median(IR) group
N=178 median (IR)
N=178)
Access to services Baseline 2(2) 2(1)
3 months follow up 3(3) 2(1)

Continuity of care Baseline 1(2) 1(2)

3 months follow-up 2.5(1.75) 1(2)

Humanness of staff Baseline 1(1) 1(2)

3-months follow-up 3(2) 1.2(1.5)
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TABLE:-5
variable Group time Intervention Group Control
Median(IR) group
N=178 median (IR)
N=178)
Comprehensiveness Baseline -1(1) -1(2)
of care 3 months follow up -2(2) -1(2)

Provision of health Baseline 1(0) 1(0)

education 3 months follow-up 2(3) 1(0.5)

Effectiveness of Baseline 1(2) 1(2)

services 3-months follow-up 3(4) 1(1.75)
51
TABLE:-5
variable Group time Intervention Group Control
Median(IR) group
N=178 median (IR)
N=178)
Self-efficacy Baseline 30(10) 30(10)
3 months follow up 32(10) 30(10)

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 DISCUSSION
Present study Similar study Dissimilar study

The present study stated Consistent with our overall Unlike our findings, a
that Satisfaction among
findings, previous study systematic review by
clients of trained PHC Barth and Lannen
workers generally increased conducted by Boissy et al.
also stated that showed that
from pre- to post-training
Similarly, SE and CS communication skill communication skills
increased among trained training increased patient of professionals can
PHC workers from pre- to satisfaction and improved be improved; yet,
post-training; and following
empathy and SE among patients do not
training, SE and CS necessarily give
improved among trained physicians.
higher satisfaction
PHC workers as compared
to non-trained PHC workers.
score.
53
 DISCUSSION
Present study Dissimilar study

Results indicate training has the In another study by Shilling et al.

potential to improve PHC efficacy teaching CS to physicians did not
and communication skills, and to have a significant effect on patient
satisfaction. Differences between
generally improve client findings of this study and other
satisfaction with services. studies may be due to differences
in client samples. For example, in
Schilling et al. service recipients
were cancer patients whereas in
the present study clients were
primary health care recipients.
54
 STRENGTH
According to author According to presenter

• Permission was mentioned

• Reliability of the tool was mentioned
• The randomized design of • Clear mention of the patient excluded in
this research is a strength. the study

55
 LIMITATION
According to author According to presenter

• Results should be replicated in • Intervention could be

physicians, nurses, midwives mentioned more briefly
and other health professionals. • Participant are not equally allocated in
• Statistically, no control was intervention and control group in PHC
workers.
used for factors that may
influence outcomes, including
PHC worker or client
demographics.
• Nesting within site or PHC
worker was also not 56
 LIMITATION
According to author According to presenter
• Alphas were not corrected for • Table 3 may be mention more briefly.
family-wise error, but given the
consistency and magnitude of the
expected effects, results are likely
replicable.

• In addition, formal mediational

analyses were not performed to
ascertain if the impact of training
on client satisfaction is mediated by
PHC worker communication or
57
efficacy or both.
 RECOMMENDATION
Future studies may wish to conduct follow-up
beyond 3 months to determine whether
results enhance or diminish over time, and
whether booster training may be appropriate.
Future work with extended follow-up might
determine client outcomes such as symptom
reduction, or program outcomes such as staff
turnover and client drop-out.
58
 CONCLUSION
 Communication skills training improved the self-efficacy
of PHC workers to effectively communicate with clients.
 Improved PHC worker communication skills with clients,
 Improved clients’ services satisfaction.
 Findings are encouraging, and such training may be
deployed in other practice settings,
 Since it was delivered in only 4 group sessions of 90 min
each.
59
Transparent Reporting of Evaluations with
Nonrandomized Designs (TREND
) Statement Checklist

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Paper Item No. Descriptor Reported?
Section /
Topic Page No.

Title and Abstract

Title and 1 • Information on how unit were

Abstract allocated to interventions
2

• Structured abstract
recommended 1
• Information on target
population or study sample 2

Introduction

Background 2 Scientific background and

explanation of rationale
1 61
Paper Item No. Descriptor Reported?
Section / Topic
Page No.

Theories used in designing

behavioral interventions
Methods
Participants 3 Eligibility criteria for 2
participants, including
criteria at different levels in
recruitment/sampling plan
(e.g., cities, clinics, subjects)

62
Paper Item Descriptor Reported?
Section / No.
Topic Page No.

• Method of recruitment (e.g., 2

referral, self-selection), including
the sampling method if a
systematic sampling plan was
implemented

• Recruitment setting 2
• Settings and locations where the 2
data were collected
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Paper Item Descriptor Reported?
Section / No.
Topic Page
No.

Interventions 4
• Details of the interventions 4
intended for each study
condition and how and when
they were actually
administered, specifically
including:
• Content: what was given?

• Delivery method: how was 4

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Paper Item No. Descriptor Reported?
Section / Topic

Page No.

• Unit of delivery: how were 2

the subjects grouped
during delivery?

• Deliverer: who delivered

the intervention?

• Setting: where was the

intervention delivered?
65
Paper Item Descriptor Reported?
Section / No.
Topics Page No.

• Exposure quantity and duration: 4

how many sessions or episodes or
events were intended to be
delivered? How long were they
intended to last?

• Time span: how long was it 4

intended to take to deliver the
intervention to each unit?

• Activities to increase compliance or

adherence (e.g., incentives) 66
Paper Item Descriptor Reported?
Section / No.
Topic
Page No.

Objectives 5
• Specific objectives and
hypotheses
Outcomes 6 • Clearly defined primary and 3
secondary outcome measures

• Methods used to collect data 3

and any methods used to
enhance the quality of
measurements 67
Paper Item No. Descriptor Reported?
Section /
Topic
Page No.

• Information on validated 3
instruments such as
psychometric and
biometric properties
Sample 7 • How sample size was 2
Size determined and, when
applicable, explanation of
any interim analyses and
stopping rules 68
Paper Item No. Descriptor Reported?
Section / Topic Page No.

Assignment 8 • Unit of assignment (the unit 2

Method being assigned to study
condition, e.g., individual,
group, community)

• Method used to assign units 2

to study conditions, including
details of any restriction (e.g.,
blocking, stratification,
minimization)
69
Paper Item No. Descriptor Reported?
Section /
Topic Page No.

• Inclusion of aspects employed to

help minimize potential bias
induced due non-randomization
(e.g., matching)
Blinding 9 • Whether or not participants, those 3
(masking) administering the interventions,
and those assessing the outcomes
were blinded to study condition
assignment; if so, statement
regarding how the blinding was
accomplished and how it was 70
Paper Item No. Descriptor Reported?
Section / Topic
Page No.

Unit of 10 • Description of the smallest

Analysis unit that is being analyzed to
assess intervention effects
(e.g., individual, group, or
community)
• If the unit of analysis differs
from the unit of assignment,
the analytical method used to
account for this (e.g.,
adjusting the standard error
estimates by the design effect
or using multilevel analysis) 71
Paper Item Descriptor Reported?
Section / Topic No.
Page No.

Statistical 11 • Statistical methods used to 4 and 5

Methods compare study groups for primary
methods outcome(s), including
complex methods of correlated
data

• Statistical methods used for

additional analyses, such as a
subgroup analyses and adjusted
analysis
• Methods for inputing missing data,
if used 72
Paper Item Descriptor Reported?
Section / Topic No.
Page No.

Statistical software or programs used 4

Results
Participant 12 Flow of participants through each 3
flow stage of the study: enrollment,
assignment, allocation, and
intervention exposure, follow-up,
analysis (a diagram is strongly
recommended)
Enrollment: the numbers of participants 3
screened for eligibility, found to be eligible
or not eligible, declined to be enrolled, and
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enrolled in the study
Paper Item No. Descriptor Reported?
Section / Topic

Page No.

 Assignment: the numbers of 3

participants assigned to a study
condition

 Allocation and intervention 3

exposure: the number of
participants assigned to each study
condition and the number of
participants who received each
intervention
74
Paper Item No. Descriptor Reported?
Section /
Topic Page No.

 Follow-up: the number of 3

participants who completed the
follow-up or did not complete
the follow-up (i.e., lost to follow-
up), by study condition
 Analysis: the number of 3
participants included in or
excluded from the main
analysis, by study condition
• Description of protocol
deviations from study as 75
Paper Item No. Descriptor Reported?
Section / Topic
Page No.

Recruitment 13 • Dates defining the periods of

recruitment and follow-up
Baseline Data 14 • Baseline demographic and 5 and 6
clinical characteristics of
participants in each study
condition
• Baseline characteristics for each
study condition relevant to
specific disease prevention
research
76
Paper Item Descriptor Reported?
Section / Topic No.
Page No.

• Baseline comparisons of those lost

to follow-up and those retained,
overall and by study condition

• Comparison between study

population at baseline and target
population of interest

Baseline 15 • Data on study group equivalence 5 and 6

equivalence at baseline and statistical methods
used to control for baseline
differences 77
Paper Item Descriptor Reported?
Section / Topic No.

Page No.

Numbers 16 • Number of participants (denominator) 4 and 5

analysed included in each analysis for each
study condition, particularly when the
denominators change for different
outcomes; statement of the results in
absolute numbers when feasible

• Indication of whether the analysis

strategy was “intention to treat” or, if
not, description of how non-compliers
were treated in the analyses
78
Paper Item Descriptor Reported?
Section / Topic No.

Page No.

Outcomes and 17 • For each primary and secondary 4 and 5

estimation outcome, a summary of results for each
estimation study condition, and the
estimated effect size and a confidence
interval to indicate the precision

• Inclusion of null and negative findings

• Inclusion of results from testing pre-

specified causal pathways through
which the intervention was intended to
operate, if any 79
Paper Item No. Descriptor Reported?
Section / Topic

Page No.

Not
Ancillary 18 • Summary of other analyses reported
analyses performed, including subgroup
or restricted analyses,
indicating which are pre-
specified or exploratory
Not
Adverse 19 • Summary of all important reported
events adverse events or unintended
effects in each study condition
(including summary measures,
effect size estimates, and
confidence intervals)
80
Paper Item Descriptor Reported?
Section / Topic No.
Page No.

DISCUSSION

Interpretation 20 Interpretation of the results, taking 4 and 5

into account study hypotheses,
sources of potential bias, imprecision
of measures, multiplicative analyses,
and other limitations or weaknesses
of the study
Not
Discussion of results taking into account reported
the mechanism by which the intervention
was intended to work (causal pathways) or
alternative mechanisms or explanations 81
Paper Item No. Descriptor Reported?
Section / Topic
Page No.

• Discussion of the success of and barriers to 7 and

implementing the intervention, fidelity of 8
implementation

Not
• Discussion of research, programmatic, or reported
policy implications
Generalizabil 21 • Generalizability (external validity) of the trial 8
ity findings, taking into account the study
population, the characteristics of the
intervention, length of follow-up, incentives,
compliance rates, specific sites/settings
involved in the study, and other contextual
issues 82
Paper Item No. Descriptor Reported?
Section / Topic

Page No.

Overall 22 • General interpretation 7 and 8

Evidence of the results in the
context of current
evidence and current
theory

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 ARTICLE 2

INPATIENT FALL PREVENTION FROM THE PATIENT’S PERSPECTIVE

: A QUALITATIVE STUDY

84
 ARTICLE DETAILS
Author : Bethany Radecki, MSN, RN, ACNS-BCa,
Staci Reynolds, PhD, RN, ACNS-BC, CCRN, CNRN,
SCRNb , Areeba Kara, MD, MS, FACP
Journal: Applied Nursing Research
Publisher: ELSEVIER.
Publishing year: 2018
DOI: https://doi.org/10.1016/j.apnr.2018.08.001
Impact factor: 3.2(2018) 85
 INTRODUCTION
 Falls and falls with injury are one of the most commonly
reported adverse events in hospitals.
 In the United States, approximately 700,000 to 1,000,000
patients fall annually during their hospitalization and up to
half of these falls result in an injury (Agency for Healthcare
Research and Quality [AHRQ], 2013)
 Falls may prolong length of stay and contribute to morbidity,
making fall prevention a priority for hospitals (Miake-Lye,
Hempel, Ganz, & Shekelle, 2013).

86
 BACKGROUND

Falls are one of the most common adverse events in

hospitals and can lead to preventable patient harm,
increased length of stay, and increased healthcare
costs. There is a need to understand fall risk and
prevention from the patients' perspectives; however,
research in this area is limited

87
 NEED OF THE STUDY
Effective fall prevention therefore requires
a partnership between the patient and
staff that respects and includes the
patient's view. Therefore, the need to
study and describe the patient's
perspective exists in tandem with the need
to investigate processes and interventions
aimed to decrease falls 88
 The aim of this study was
to describe the patient's
AIM OF perspective of fall
THE STUDY prevention in an acute
care setting to aid in the
design of patient
centered strategies.
89
 METHODOLOGY
Approach: Qualitative
Sampling technique: Purposive sampling
technique
Population: Patients in non intensive care
units
Setting: academic health center Midwest
Sample size: 12 participants
90
 SETTING
 The facility has been designated as a Magnet
Hospital for excellence in nursing services and high-
quality clinical outcomes for patients.
 Participants were selected from non-intensive care
inpatient units.
 The facility screens all inpatients for fall risk on
admission and every shift.
 In addition to universal fall risk prevention measures,
additional interventions are matched to patient
specific etiology to mitigate fall risk
91
DATA COLLECTION PERIOD

Interviews took place over a period of

seven weeks starting October 2014.
Data collection was interrupted for a
period of five months due to personal
leave and was completed in March 2016.
92
 ETHICS CLEARANCE

The study was reviewed and approved by

the local Institutional Review Board
(protocol #1407636143).

93
 PARTICIPANTS
Inclusion criteria
• A Glasgow Coma Scale of 15,
• Free of cognitive deficits,
• English speakers,
• A Johns Hopkins Fall Risk Assessment Tool (JHFRAT)
score of ≥6,
• Admitted to a non-intensive care unit (ICU), a unit
length of stay > 24 h,
• In a private room for confidentiality, and be ≥18
years of age.
94
 PARTICIPANTS

Exclusion criteria
Patient that fell during the current
hospitalization were excluded.

95
 The lead
investigator (BR),
RESEARCHER a Clinical Nurse
Specialist (CNS),
was responsible
for data collection.

96
 On selected days, the investigator asked the unit charge
nurse for a list of patients with JHFRAT scores ≥6
(patients considered at least at moderate risk of falling).

 Guided by this list, the investigator reviewed each

patient's chart to screen for exclusion criteria, as well as
to independently verify the fall risk score.

 For the units that had more than one patient eligible on
a given day, all names were written on a piece of paper
and then drawn out of a cup to decrease bias
97
 DATA COLLECTION
 Each participant was provided a study information sheet
describing the study & measures to ensure
confidentiality.
 Verbal consent was received to take part in the interview
and participants were assigned a unique participant
code.
 All interviews were conducted by the lead investigator. A
sign was placed on the patient's door requesting that no
healthcare workers enter the room during the interview.
98
DATA COLLECTION
Interviews were audiotaped and conducted
in the patient's private room using a
standardized open-ended interview
approach (Turner, 2010).
The interview guide was developed by the
investigators with input from local and
national experts in fall prevention.
99
DATA COLLECTION
The guide was designed to elicit patient
awareness/perceptions of fall risk and prevention
interventions.
Interviews were transcribed verbatim and checked
for accuracy

100
TABLE 1: PATIENTS INTERVIEW GUIDE

101
 DATA ANALYSIS
After five interviews were completed, the lead
investigator reviewed transcripts to identify themes.

Thereafter, data was reviewed after every two

interviews until data saturation was reached.

After ten interviews, no new themes emerged.

To verify saturation, two more interviews were

conducted. As no new themes emerged, data
collection was stopped. 102
 DATA ANALYSIS

This study applied the transcript analysis

was guided by constant comparative
methods(Kolb, 2001).

103
 DATA ANALYSIS
During open coding, the team, which consisted of a
CNS and a physician, read all transcripts repeatedly
to gain a general understanding of the data.

The team individually analysed the transcripts for

emerging themes.

Together, the team iteratively refined the themes

to reflect meanings in the data
104
 DATA ANALYSIS
During focused coding, the
team individually organized
initial themes into major
themes.

The team then met to

compare and discuss
until consensus was
reached 105
 DATA ANALYSIS
Throughout the analysis process,
investigators practiced reflexivity and
examined negative cases that might
lend to alternative explanations of the
data.

106
RESULTS
TABLE 2 CHARACTERISTICS OF PARTICIPANTS.
parti ages Gend Unit type JHFRAT fall Fall risk factors
cipan er score
t

1 86 F surgical 14 Age, fall history, one high risk

medication, one tether, mobility

2 89 F surgical automati History of more than one fall within

c last 6 months

3 59 F Medical 10 Two high risk medications, three tether,

progress mobility
ive
108
TABLE 2 CHARACTERISTICS OF PARTICIPANTS.
parti ages Gend Unit type JHFRAT fall Fall risk factors
cipan er score
t

4 54 M Surgical 8 Two high risk medications, one tether,

mobility.

5 71 M Medical 10 Age, one high risk medication, three

progress tether, mobility.
ive

6 60 M Surgical 6 Age, two high risk medication.

109
TABLE 2 CHARACTERISTICS OF PARTICIPANTS.
parti ages Gend Unit type JHFRAT fall Fall risk factors
cipan er score
t

10 58 M Surgical Automatic Two high risk medications, two tether,

mobility.

11 66 F Medical 6 Age, elimination, one high risk

medication, one tether, mobility.

12 68 M Medical Automatic Age, two high risk medication, three

progress tether, mobility.
ive
110
 INTERVIEW

Interviews took an average of six and a half

minutes with a range of 2.8 min to 16.8 min.
Family members were present during one
interview.

111
 THEMES

Qualitative analysis revealed three major themes

that were consolidated as follows from the
patient's viewpoint:
(1) How I see myself,
(2) How I see the interventions, and
(3) How I see us.
112
 THEME 1: HOW I SEE MYSELF

The theme “How I see myself” describes patients'

perspectives of how they see their personal fall
risk.
The theme is supported by five sub-themes
including: awareness, acceptance/rejection,
implications, emotions, and personal plan

113
SUB THEME 1.1 AWARENESS

Most patients were aware of being identified as a

fall risk. A few patients mentioned supporting
evidence of the fact.
“Yea, I got the little band saying so”
(participant.10)

“They have told me”

(Participant 8) 114
 SUB THEME 1.2 ACCEPTANCE/REJECTION

More than half the

“Suspect is a better word.
patients believed they
What makes me suspect?
were a fall risk. All
We characterize what we
that believed they
visually see. You [nurse]
were at risk had
may see a slight limp and
physical limitations
think he may be vulnerable
that put them at risk.
to fall.”
(participant 5)

115
 SUB THEME 1.3 IMPLICATION

“It means I am in trouble. That you, you know I fall

Many patients described how the fall risk identification
real easy.”
affected them. While some patients viewed it as a
(participant 1)
consequence, othersa considered
“I've had to spend it an
lot of time in bedadvantage.
here. Can't
move; can't do nothing.”
(participant 4)
“Protect me, make me feel safe.”
(participant 7)
116
 SUB THEME 1.4 EMOTIONS

Here patients described how being a fall risk

made them feel.

“Insecure maybe, unsure of yourself.”

(participant 5)

“Vulnerable”
(participant 9)

117
 SUB THEME 1.5 PERSONAL PLAN
When asked what
part the patient
played in preventing “Well, I just try to be careful.”
a fall, they described (participant 1)
the actions they
would take such as “Stay close and get a hold of
being careful or something. That's the main
holding on to
thing.”
something.
(participant 12)
118
THEME 2: “HOW I SEE THE INTERVENTIONS”

The second major theme “How I see the interventions”

describes how patients see the fall interventions put
into place by the nurses and is supported by two sub-
themes: what I see and hear and usefulness of
equipment.

119
 SUB THEME 2.1: WHAT I SEE AND HEAR
In describing what nurses did to prevent falls,
patients often reported what they saw nurses do
and tell them.
“Well, they [nurses] got my bed alarm, chair alarm.
Whenever I move or stand up, they're in here.”
(participant 6)
“Oh my gosh, they [nurses] don't let go of you for five
seconds. They put a strap around you and … I've been using
my walker.”
(participant 2)
(
120
SUB THEME 2.2: USEFULNESS OF EQUIPMENT

A participant's ideas
often come from
“(The bed alarm) is a
external clues provided
by non-professionals, good precaution. It
including the news makes them [nurses]
media, the Internet or aware.”
books.
(participant 5)

121
SUB THEME 2.2: USEFULNESS OF EQUIPMENT

However, some patients

did not find the
“(Gait belt is) A waste, a
interventions useful.
One patient described waste of time… She
how the gait belt would [nurse] couldn't lift me up
not keep him from if I did fall.”
falling in relation to his
size. (participant 12)

122
 THEME 3: “HOW I SEE US”

The last major theme “How I see us” describes

how the patients perceived the teamwork
between themselves and the nurses to prevent
falls.

123
 THEME 3: “HOW I SEE US”
 Ninety percent of the patients believed they shared
the same fall prevention plan as the nurse.
 When the patients felt like the interventions in place
were useful, they did not describe any barriers to
participating in the fall prevention plan
 Patients described how they know they were to call
the nurse for help when getting out of bed, but their
need to use the bathroom overrode the instructions
from the nurse.
124
 THEME 3: “HOW I SEE US”

“I think they're [interventions] kinda bad because I

would have to sit there and wait for them to come
in, wait for them to sit at the door, it would be like
10-15 minutes and I have to go to the bathroom.
But you'll see, if I have to go to the bathroom, I
have to go to the bathroom.“
Participant 4

125
 THEME 3: “HOW I SEE US”

“Yesterday, I had to wait a long time. I had to wait to

go pee and when you take that Lasix, it don't work.”

(participant 12)

126
 DISCUSSION
Present study Dissimilar study
In our sample, most patients Previous investigations
were aware that they were focusing on patients'
identified as a fall risk. This perceptions of their own fall
heightened awareness may be
risk have found that patients
attributed to the initiatives
implemented by the facility do not perceive their risk
during the study period which accurately (Shuman et al.,
included discussing fall risk 2016; Sonnad, Mascioli,
factors with patients. Cunningham, & Goldsack,
2014). 127
 DISCUSSION
Present study Similar study
Our patients identified the Despite a lack of evidence
alarms as part of the fall supporting the effectiveness
prevention plan, but most of bed and chair alarms to
viewed the alarm as a useful
prevent falls, they are often
alert for nurses when a patient
was out of bed rather than a used in fall prevention
reminder to wait for help. Of programs (Hempel et al.,
note, only one patient 2013; Sahota et al., 2014).
described the alarm as a useful
tool to remind themselves to 128
 DISCUSSION
Present study Similar study
We found that the biggest We found that the biggest
barrier to following the fall barrier to following the fall
prevention plan for patients prevention plan for patients
was waiting on assistance was waiting on assistance for
for toileting. Even when toileting. Even when patients
patients perceive they are perceive they are at risk for
at risk for falling, they may falling, they may not follow
not follow through on the through on the plan to reduce
plan to reduce this risk this risk 129
 STRENGTH
According to author According to presenter

• Not mentioned • Themes were clearly described

• Patient interview guide was
mention
• Inclusion criteria for patient clearly
described
• Data saturation was mentioned
• Ethical consideration was
mentioned

130
 LIMITATIONS
According to author According to presenter

• They interviewed patients in non- • Quality, rigor no mentioned

ICU setting in a single center which • The were no transcripts returned to
may limit generalizability. participants for comment and/or
• All participants spoke English. Correction
• They cannot comment on any • The participants feedback about the
ethnic or cultural differences in findings were not present
perception.

131
 LIMITATIONS
According to author According to presenter
• While cognitive impairment
contribution to fall risk, this study
does not shed any light on patients
and family-centered strategies that
may decrease fall risk in this
scenario.

132
 CONCLUSION
 Decreasing patient falls continues to be high priority for
healthcare organizations. Most fall prevention programs
utilize clinician-led plan development and implementation
without true patient involvement.
 Nurses must develop a relationship with the patient to
facilitate understanding of their needs and how we can focus
on maintaining their sense of freedom.
 Developing these truly patient centered programs may
reduce the over-reliance on bed alarms and allow for
implementation of strategies aimed at mitigating modifiable
risk factors leading to falls.
133
Consolidated criteria for
Reporting Qualitative
Research(COREQ)
guidelines

134
Item Guide
Topic Reported
no. Questions/Description

Domain 1: Research team and reflexivity

PERSONALITY CHARACTERSTICS

Which author/s conducted

1 Interviewer/facilitator the interview or focus lead investigator
group?

What were the researcher’s mentioned on page

2 Credentials
credentials? E.g. PhD, MD 1

What was their occupation

3 Occupation
at the time of the study? 135
Item
Topic Guide Questions/Description Reported
No.

Was the researcher male or Not

4 Gender
female? reported
Experienc
What experience or training did Not
5. e and
the researcher have? reported
training

Relationship with participant

Not
Relationship Was a relationship established
6 reported
established prior to study commencement? 136
Item
Topic Guide Questions/Description Reported
No.

Participant What did the participants

knowledge of the know about the researcher? Reported
7
interviewer e.g. personal goals, reasons on page 2
for doing the research

What characteristics were

reported about the inter not
Interviewer
8 viewer/facilitator? e.g. Bias, reported
characteristics
assumptions, reasons and
interests in the research topic
137
Item
Topic Guide Questions/Description Reported
No.

Domain-2 Study Design

Theoretical framework

What methodological orientation was

Methodological stated to underpin the study? e.g.
9 orientation and grounded theory, discourse analysis,
Theory ethnography, phenomenology, content
analysis

Participant selection
How were participants selected? e.g.
10 Sampling purposive, convenience, consecutive, Purposive
138
snowball sampling
Item Guide
No.
Topic Reported
Questions/Description

How were participants

Method of
11 approached? e.g. face-to-face, face to
approach
telephone, mail, email face

How many participants were 12

12 Sample size
in the study?

How many people refused to

0
13 Non-participation participate or dropped out?
Reasons? 139
 Guide
Reported
Questions/Description
Setting
Academic
Where was the data
Setting of data health center
14 collected? e.g. home, clinic,
collection in Midwest
workplace

Was anyone else present Mentioned

Presence of non
15 besides the participants and on page
participants
researchers? 115
What are the important
Description of characteristics of the
16 Reported140
on
sample sample? e.g. demographic
Topi Guide
Item No. Reported
c Questions/Description
Data collection

Were questions, prompts,

reported
17 Interview guide guides provided by the
on table 1
authors? Was it pilot tested?
Were repeat inter views
Not
18 Repeat interviews carried out? If yes, how
reported
many?
Did the research use audio or
Audio/visual
19 visual recording to collect the
recording Audio taped
141
 Guide
Reported
Questions/Description
Were field notes made
Not
20 Field notes during and/or after the
Reported
inter view or focus group?
What was the duration of Average of
21.
Duration the inter views or focus six and half
group? minutes

22. Was data saturation

Data saturation Reported on
discussed?
page 115
Were transcripts returned
23 Not
Transcripts returned to participants for comment
Reported
142
and/or Correction?
Topi Guide
Item No. Reported
c Questions/Description
Domain 3: Analysis and Findings
Data analysis
24. Number of data How many data coders CNS and
coders coded the data? physician
Did authors provide a
25. Description of the not
description of the coding
coding tree Reported
tree?
Were themes identified in
26. Derivation of
advance or derived from Derived from
themes
the data? the data143
 Guide Questions/Description Reported

27. What software, if applicable, Not

Software
was used to manage the data? reported

28. Participant Did participants provide Not

checking feedback on the findings? reported
\Participant checking
Reporting

Were participant quotations

presented to illustrate the
29. Quotations themes/findings?
presented Was each quotation identified? Reported
e.g. participant number
144
Topi Guide
Item No. Reported
c Questions/Description
Was there consistency
30. Data and findings between the data
yes
consistent presented and the findings?

\Participant checking
Were themes identified in
31. Clarity of major
advance or derived from
themes s Reported
the data?
Clarity of minor Is there a description of
32. themes diverse cases or discussion
Reported
of minor themes? 145
THANK YOU
146