Title of the Article
The article by Fulmer et al (1999) is appropriately and succinctly titled. The title identifies the study population (elderly people living in their homes) and the key variable of the study, which is medication compliance. Also, the title clearly identifies the research problem; it is about an intervention that aims to increase medication compliance among elderly people living in their homes. Also, from the title, the study population is elderly people living in their homes. However, the independent and dependent variables have not been specified in the title.
Abstract
The article summarizes the study’s main aim, methods, results, and conclusions. The abstract aptly conveys the content and purpose of the research. It states the main aim to give a brief description of the scope of the study. It also has a concise description of the research results and conclusion based on the findings. However, the key words have not been identified and defined in the abstract.
Introduction
Statement of the Problem
The problem statement is a concise explanation of the issue (problem) that the study addresses. It helps place the research study into context and generates the research questions that the study seeks to answer. In the study, the problem statement for the study is clearly described. Background information, which has a review of relevant studies that report a high rate of medication non-compliance among elderly people, precedes the problem statement.
This brings the study into context and makes the problem statement easily identifiable. Also, the argument provided for this study is persuasive. The researchers give a convincing argument on why interventions that promote medication compliance among elderly people are important. Citing statistics from earlier studies, the authors contend that the rate of non-compliance among elderly patients with congestive heart failure (CHF) after discharge is high, posing a serious health risk to elderly people living at home. As such, methods that promote compliance are important. This forms the basis for stating the purpose statement of the study.
Also, the significance and application of the interventions in nursing practice is clear. The authors believe that daily video-telephone reminders of elderly people will enhance adherence to cardiac medication. This nursing intervention will decrease health risks and result to improvement in patient outcomes. Additionally, the article describes a co-variation between two variables (medication non-compliance and the factors that affect drug adherence).
It portrays the image that patient factors such as lack of knowledge of the medication’s role, high depression level, age, and poor cognitive functioning increase non-compliance. The connection created between these attributes allows the researcher to use quantitative techniques to survey the subjects (elderly people) to support it. Thus, the quantitative approach is proper; it helps show a link between degree of non-compliance and patient factors.
The study clearly identifies and states the hypothesis. The study’s aim was to test the effectiveness or benefits of video-telephone reminders in promoting medication adherence among elderly people with chronic conditions and living at home over the usual care. The authors hypothesized that medication compliance would result to improved Minnesota Living with Heart Failure (MLHF) and the Medical Outcome Survey 36-Item Short Form Health Survey (SF-36) scores. Nevertheless, the research question(s) have not been provided in this study.
Also, the introduction explains various aspects and concepts with clarity using correct scientific terms and phrases. It is concise and specific; however, the introduction does not describe the specific attributes of the study population. It, however, predicts the relationship between the study variables (MLHF and SF-36 scores and medication compliance). Also, the hypothesis is clearly linked to the literature review. The hypothesis is also consistent with the literature review. The literature reviewed identifies gaps in research; it analyses the various interventions used to improve compliance, as identified in other studies. This lays the ground for the intervention (video-telephone reminders) and the hypothesis being tested in the study.
Literature Review
The literature review involves current and primary sources of data on the topic. The study (published in 1999) used relatively current primary sources (journal articles published between 1987 and 1998) in the literature review. The literature review only uses primary sources i.e. articles published in various journals, relevant to the topic. Journal articles offer compelling evidence (level I evidence), which increase the reliability and validity of the study.
Moreover, research evidence from earlier studies is useful in developing a basis for the current study (Garrard, 2011).The literature review is systematic; it begins by describing the phenomenon of noncompliance and its effects, noncompliance measurement methods, factors that affect compliance and strategies to improve medication compliance. According to Sekaran (2003), systematic literature review is useful in the synthesis of evidence and providing a rationale for conducting the study.
The literature review provides a basis for the study reported in the article. The literature review analyses evidence on compliance interventions including reminder charts (computer-based), which, based on evidence from earlier studies, is a cheap and effective way of promoting medication compliance. The role of advanced technology in medication compliance interventions forms the basis for the study. It examines the effectiveness of video-telephone technology, compared to traditional telephone reminders in promoting medication compliance among the study population. The study defines and describes in detail the key concepts related to medication compliance among elderly people living at home.
It describes the key concepts including non-compliance, the role of advanced technology, compliance strategies based on earlier research findings and categories of compliance strategies. Though the study has no clear conceptual/theoretical framework, it nevertheless, gives a rationale for experimentation of interventions that enhance medication compliance among the elderly given the serious health risks associated with non-compliance. The researchers did not use a concept map or theoretical model to describe the relationships between the concepts (Garrard, 2011). The lack of a conceptual map or framework is not justified in the study.
Method
Protection of Human Rights
For studies involving human subjects, ethics and human rights form the basis for IRB’s approval. The IRB/ethics review board must approve such projects. Recruitment of the subjects involved two sites; an urban ambulatory clinic (Columbia Presbyterian Medical Center or CPMC) and an urban-based home health care facility (Visiting Nurse Service of New York or VNS). The researchers sought IRB’s approval before selecting the participants from each site. IRB approval was also sought for the methods used to select eligible subjects (an automated flagging in the VNS management information system and medical logic module in CPMC’s informatics network.
For a study to gain IRB’s approval, it must benefit the participants (human subjects) and have minimal risks to their health. The study’s design reduces risks to participants by seeking prior informed consent to decrease emotional/psychological risks. Moreover, during the 6-week period, the calls (telephone or video-telephone) made only lasted for a short duration (only 3-5 minutes) to avoid stressing the participants. At the same time, the study’s design increases benefits to the subjects; the outcome of the intervention was to increase medication compliance and thus health outcomes of the participants. This was the main benefit of participating in this study. Overall, the benefits of the intervention exceeded the risks to the patient, hence its approval.
Research Design
Different research designs are suitable for different studies. The study used a randomized controlled clinical trial (RCT) where the participants were randomly selected into either the control group or experimental group. This research design was right for this study as “experiments are the most powerful designs for testing hypotheses of cause-and-effect relationships” (Polit & Beck, 2006).The purpose of the study was to test the effectiveness of a clinical intervention or therapy involving the experimental group (daily video-telephone reminders) and control group (daily telephone reminders).
A comparative analysis of the different concepts strengthens the research findings (Polit & Beck, 2006). The study made comparisons and inferences that made the findings more interpretable. The researchers compared the first group (elderly people receiving daily video-telephone reminders), the second group (elderly people receiving daily telephone reminders) and the control group. Also, the researchers made within-group comparisons using post-intervention interviews to enhance consistency. They collected data at specific points within the study (baseline, intervention, and post-intervention).
The data collected was longitudinal data and it involved three collection points within the 6-week period for both the control and experimental groups (baseline data, intervention data, and post-intervention data). By reducing researcher bias through randomization, the researchers were able to meet internal validity. Randomization involved random assignment of subjects into control and experimental groups based on a table of random numbers. Blinding was not used as the research assistants were aware of the subjects assigned to any of the three interventions. To control attrition and other extraneous variables eligible subjects had to meet the inclusion criteria.
It involved two sites, which enhanced, which achieved some level of external validity. However, a threat to external validity for this research relates to sampling; it included elderly people from only two sites within Manhattan. This means that the results cannot be generalized to other settings or locations.
Population and Sample
The study specifies and describes the characteristics of the study population in detail. It provides the participant’s age, condition and settings. The researchers “recruited community dwelling people age 65 and older who had the primary or secondary diagnosis of CFH” (Fulmer et al., 1999). However, the researchers would have given more details including the participant’s gender, ethnicity, and race. The researchers employed purposive sampling technique to select the sample subjects. It was the most suited sampling design for this study. It involved “600 eligible subjects; of these, 60 agreed to take part” (Fulmer et al., 1999).
The researchers used a table of random numbers to randomly select subjects into either control or experimental group. A power analysis showed that a sample of 60 was enough to meet an acceptable level of significance and detect a difference between the control and experimental groups. Therefore, the sample size was representative and consisted of 20 participants.
Data Collection and Measurement
The researchers give congruent descriptions of the ‘operational’ and conceptual terms used in the study. The two interventions (daily telephone reminders and daily video-telephone reminders) are well-defined and described in detail, which could allow repeatability and replication. Also, it describes the MLFH and SF-36 instruments completed to test cognitive functioning of the participants. The researchers used proper methods to compute the key variables of the study. For both baseline and post-intervention data, the MMSE 30-item questionnaire measured cognition; the SF-36 measured the physical functioning and the MLFH assessed symptom difficulty management among the participants. The article describes in detail the measures/instruments used to collect data in the data collection procedures part.
Also, in the article, the researchers give evidence from past studies to support the validity and reliability of the instruments used. For instance, in the study, the researchers use the MMSE because of “its clinical brevity and popularity in clinical practice” (Fulmer et al., 1999). Additionally, the researchers describe the data collection methods like the MEMS caps; they use the data collection methods to collect information about medication compliance among the elderly participants. This enhances the validity and reliability of the data collection methods.
Procedures
In the article, the interventions (daily video-telephone reminder and telephone calls) were sufficiently detailed and fully implemented. “Randomization occurred using a table of random numbers after the elderly people agreed to take part” (Fulmer et al., 1999); eligible subjects were randomly selected into control and experimental groups. To minimize bias during data collection, the research assistants obtained the first pre-intervention (baseline) data by objectively using the right instruments. Moreover, all participants in either the experimental or control group received the respective intervention. This enhanced intervention fidelity.
The research assistants possessed relevant skills and training on video-calls to make daily reminders to the elderly people. The research assistant “also determined a convenient time for the patient to receive daily medication reminder calls” (Fulmer et al., 1999). This shows that the research assistants were properly trained to collect the data.
Results
Data Analysis
Data analysis involved methods to find the differences between the control and experimental groups. The statistical methods the researchers used in data analysis included “Statistical Package for Social Science-Personal Computer (SPSS-PC) and MANOVA” (Fulmer et al., 1999). The researchers compared these methods find out any differences between the groups based on data from the MEMS caps. The analysis of qualitative data involved a descriptive approach. They used MANOVA, a powerful analytic method, to test the differences between the three groups. The approach was important in calculating the statistical significance (P<.05), and in controlling for confounding variables in the study.
To avoid type I (α) and type II (1-β) errors, the researchers set the level of significance at 0.05 which is acceptable for one to reject an incorrect null hypothesis or fail to reject a correct null hypothesis. However, the researchers give no information on whether they performed an intention-to-treat (ITT) analysis or not. Also, the researchers did not include information on evaluation of missing outcome data (10 subjects) in the analysis.
Findings
The authors state two main findings of the study in the discussion section. This section summarizes statistical results and presents it using tables and bar graphs. For each measure, the researchers calculate test statistic such as the mean, probability (p-value) and variance. For example, “A significant time effect of P<.05 from baseline to post intervention” (Fulmer et al., 1999) and an increase in MLHF scores (P<.001) among the participants are reported. The tables present measured data i.e. demographic variables and intervention effects on the three groups while the bar graph compares the three groups at points of data collection (baseline, intervention, and post-intervention).
The study’s two findings are: “significant falloff in the control group’s medication compliance rate over time” (Fulmer et al., 1999) and “absence of a significant difference between the two intervention groups” (Fulmer et al., 1999). They are explained in detail, which can allow meta-analysis and comparisons. Also, in practice, the findings provide strong evidence for the use of daily telephone calls or daily video-telephone reminders to enhance compliance among elderly individuals living at home.
Discussion
In the discussion section, the study’s main findings are interpreted and compared to findings from other related studies. The results are interpreted and appropriate explanation given to the findings. Moreover, the authors correlate the study’s limitations with the results to ensure consistency. Among the limitations identified is “the extremely low participation rate (approximately 10%)” (Fulmeret al., 1999) and “the exclusion of individuals who routinely relied on pre-poured medications” (Fulmer et al., 1999). The study does not generalize the findings because of the small sample size and the limitations.
The researchers provide implications for future research on the topic. Moreover, by explaining the limitations of the study, they suggest that further studies should involve a larger sample ensure generalizability of the findings. Based on the results, the authors concluded that “telephone calls or electronic home visits could improve compliance significantly in a sample of elderly individuals with CHF who took, on average, 3 to 15 doses of medication every day” (Fulmer et al., 1999). But, this finding is not generalized to elderly population.
Global Issues
The article was written and structured well with each concept described in detail. Also, the methodology and procedure are presented with clarity, which can allow for replication of the study. The reader is able to understand the study as the various aspects are presented in a flowing manner. Moreover, the article presents the findings in a way that they can be accessed by practicing nurses, who can apply it in practice.
By publishing the article in a popular nursing journal, i.e. the Journal of Gerontological Nursing, the authors ensured that it will be accessible to majority of the nurses. The CONSORT flow chart was not used in this study. The researchers are qualified RNs and medical doctors with years of experience as practicing nurses.
Although the study identifies two main limitations, I have confidence in the findings of this study and believe that they are valid and truthful. The statistical measures and the instruments used in data collection support and confirm the findings, and thus can be applied in nursing practice. As explained in the study, increased medical compliance will increase health outcomes of patients and thus, nursing interventions like the use of daily video-telephone reminders or telephone reminders are important. Education of nurses on the role of daily video-telephone or telephone reminders will integrate the interventions into practice. This will contribute to improved medication compliance and hence, the health outcomes of elderly individuals suffering from congestive heart failure (CHF).
References
Fulmer, T., Fieldman, P., Kim, T., Carty, B., Beers, M., Molina, M., & Putman, M. (1999). An Intervention Study to Enhance Medication Compliance in Community-Dwelling Elderly Individuals. Journal of Gerontological Nursing, 25(3), 6-14.
Garrard, J. (2011). Health sciences literature review made easy: The matrix method (3rd ed.). Sudbury, MA: Jones & Bartlett.
Polit, D.F., & Beck, C. T. (2012). Nursing research: Generating and Assessing Evidence For Nursing Practice (9th Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Sekaran, U. (2003). Research methods for business. A skill building approach (4th Ed.). New York, NY: John Wiley & Sons.