Introduction

This essay is about the evaluation of two research articles.  Throughout the essay the author will discuss and critically evaluate both articles following a self-adaptation of Cormack’s (2000) framework. This will include evaluation and comparison of research methods, sample selection processes, data collection methods and methods of data analysis, ethical considerations and future research and learning.  The author will not attempt to decide which particular article is best as they will both have strengths and weaknesses.

Chosen area of research

The area of practice for this assignment is the information requirements of people whose lives are affected by breast cancer.  The author has a strong interest in this area of nursing and its effects upon sufferers’ lives.  It is vital for all health care professionals to remain aware of the extending affects of this disease.  A diagnosis of breast cancer does not just have medical effects but also emotional and psychological effects.  The diagnosis will affect every aspect of a patient’s life and the lives of their families, (Odling, Norberg, Danielson, 2002).

Literature search

The author carried out a literature search in order to select suitable research articles for this assignment.

The search was carried out using the CINAHL database.  The keywords entered were: breast cancer, experiences and method.  These were each limited to the years 1998 – 2004 and limited to articles that had the full text available.  All three results were then combined giving a total of 265 hits.

The two research articles to be reviewed were selected from these 265 articles.

Articles selected

The first of the two articles that have been selected for review is from the Journal of Advanced Nursing and is entitled ‘The information concerns of spouses of women with breast cancer: patients’ and spouses’ perspectives’, (Rees, Bath and Lloyd-Williams, 1998), (Appendix 1).

The Journal of Advanced Nursing is a quality peer reviewed journal.  This means that before an article is published it is reviewed by experts in the relevant field; they look at factors such as clarity, originality, relevance and the evidence base in order to improve the quality of the publications.  All articles published are double-blind reviewed; medical statisticians also review articles that include statistical content, (Journal of Advanced Nursing, 2003).

The second of the two articles is entitled ‘Information needs of women with non invasive breast cancer’ it was written by Brown, Koch and Webb, (Brown, Koch and Webb, 2000), (Appendix 2).

This article was published in the Journal of Clinical Nursing which is an international scientific journal that aims to promote the development and exchange of knowledge that is specific to all aspects of nursing practice.  They publish only high-quality papers significant to clinical nursing.  All articles submitted for publication are double-blind refereed, (Watson, 2004).

Throughout this assignment the author will refer to the articles as article 1 or article 2 respectively in the order above.

Critical evaluation

The purpose of critical evaluation is mainly to ensure that if implementation of findings is proposed the patients will derive genuine benefits.  Therefore a critical review must identify the strengths and weaknesses in a piece of research and this should be carried out in a systematic manner, (Eachus, 2003).

Titles

Article titles should be concise but they should also give a good indication of the content of the report, (Eachus, 2003).

Article 1’s title is fairly concise and to the point.  It draws the readers’ attention to the area of study and also makes reference to the population of people being studied.  It is not to long and therefore does not confuse the reader, (Parahoo, 1997).

Article 2’s title is very short but does state the area of study (information needs and breast cancer) and the population being studied (women with non-invasive breast cancer).

There is no real right or wrong title, only a misleading or confusing one, (Parahoo, 1997).

Authors

The Cormack (2000) framework asks whether the authors have appropriate academic qualifications and whether they have appropriate professional qualifications and experience.

The authors of article 1 are: Charlotte Rees, BSc (Hons) and is a PhD student at the centre for Health Information Management Research, University of Sheffield.  Peter Bath, BSc (Hons) MSc PhD a lecturer at the School for Health and Related Research, University of Sheffield.  And Michael Lloyd-Williams, BSc (Hons) MBCS CEng a lecturer at the University of Sheffield in the Department of Information Studies, (Rees, Bath and Lloyd-Williams, 1998).

The authors of article 2 are Marina Brown, BN, RN, a research assistant for The Royal District Nursing Service, South Australia.  Tina Koch, PhD, RN, who is The Royal District Nursing Services chair in Domiciliary Nursing, Flinders University of South Australia.  And Christine Webb, PhD, RN, a professor of Health Studies at the University of Plymouth.

Eachus (2003) tells us that the authors of a research article may or may not be well known in the field and that only experience will tell you this.  The institute to which they are attached may give an indication of the likely quality of the article, (Eachus, 2003).

Abstracts

An article abstract or summary should be a concise statement that gives the reader a clear idea of what the researchers were trying to achieve, how they were trying to achieve it and whether it was achieved, (Eachus, 2003).

Article 1 has a short abstract in which the authors tell the reader what type of study was carried out and where and why it was carried out.

It briefly explains how the study was performed and how the data were gathered.  The reader is told how the findings produced several important issues, how the validity was established and what implications these findings may have.

Likewise article 2 has a summary in which the aim is clearly identified.  The reader is told who the study participants were, how the data were gathered and analysed and that several key issues were identified from the data.  The summary briefly mentions the impact these findings may have on the role of the nurse and the contributions that can be made by the study.

Both article 1 and 2’s abstract or summary appear to include all the necessary information, they are concise and give the reader a good idea of what the articles contain.

Introduction

An introduction needs to be just that, it should introduce to the reader the aims of the study, identify the problem or issue being researched and give a rationale for the study being carried out, (Cormack, 2000).

Article 1 has a short introduction that gives a basic background about breast cancer, citing findings from other research about this subject.  There is a section specifically for the aims further on in the article so this is not mentioned in the introduction.

Article 2 has a more detailed introduction; it gives a background on breast cancer.  The introduction of this article tells us the reason the researchers had for carrying out this study.  The authors state that ‘it was thought valuable to discover what information was needed by women both in terms of content and delivery’ and that ‘the present study builds on this earlier research by learning from women about their needs and experiences, particularly focusing on issues surrounding information’, (Brown, Koch and Webb, 2000).

Literature Review

A literature review examines and summarises articles about a chosen topic, this is an essential stage in any research process.  It should be done in order to find out what has already been written and researched about the chosen topic, that way research will not be repeated unnecessarily, (Hek, Judd and Moule, 2002).

Article 1 has an extensive literature review which appears very detailed and brings forward many previous findings of cancer and breast cancer research.  However what stands out most is that there is no reference to how the search for literature was carried out, i.e., what databases did they use?

Article 2 also has a large literature review; it does state which databases were used and what other information sources they used.  The authors have then presented their review findings under three headings.

Methodology

When selecting a research design the methods used may be the personal preferences of the researchers.  Quantitative is often selected over qualitative due to its scientific nature and surveys conducted using questionnaires may well be selected over interviews due to factors such as cost and time.  However short-cuts should not be made if the best knowledge is to be gained, (Parahoo, 1997).

Article 1 uses a qualitative approach with focus group methodology.  The researchers held four single sex focus group discussions, there were three groups of women, each age-stratified, which simply means they were put into groups according to their age, this was done in order to achieve relatively homogeneous groups, and one group of men.

Article 2 also uses a qualitative approach with a constructivist approach.  The researchers felt that with this approach it was best to use participant interviews.

The focus group approach to research may be defined as group discussions organised to explore a specific set of issues.  This discussion process serves to generate data for analysis, (Lane, McKenna, Ryan and Fleming, 2001).

The idea of focus group methodology is that the group process can aid people in the exploration of their views in ways that would be less easily accessible in a one-to-one interview, (Webb and Kevern, 2001).

Mansell, Bennett, Northway, Mead and Moseley (2004) believe that focus groups provide valuable opportunities to explore the thoughts and feelings of research participants in more depth than would be possible in a questionnaire, survey or through personal one-to-one interviews, (Mansell, Bennett, Northway, Mead and Moseley, 2004).

They are not alone in this belief as Lane et al (2001) also state that the interaction between participants may reveal information that would be difficult to obtain in an individual interview, (Lane et al, 2001).

However it is thought that the breadth and depth of information that it is possible to obtain in one focus group sitting is limited, also the discussion may be dominated by certain participants.  This may mean that if one-to-one interview techniques are used the moderator may have more control, (Lane et al, 2001).

In article 2’s method of one-to-one interviews the researchers used open-ended questions during the interviews with a few leading questions as prompts rather than direct questioning.  They give some examples of the questions used.

Interviews are characterised by letting interviewees say in their own words what is important to them about the subject.  This technique of semi or unstructured interviewing of different people allows a build up of themes and categories of experiences that can be used to develop theories about peoples experiences of health care, (Cormack, 2000).

A drawback of this ‘loose’ type of interview is the lack of control the researcher has compared to a structured interview.  The interviews of article 2 lasted between 40 minutes to just over two hours.  It is unlikely that a topic could be explored in any depth in less than 30 minutes however interviews that last over two hours will tire the researchers and the interviewee therefore casting doubt on their ability to concentrate fully on what they are doing, (Parahoo, 1997).

Sample Selecting

Article 1 uses a purposive sampling technique to recruit participants.  They were selected on the basis of several predetermined characteristics; the potential participants were all selected from a Sheffield-based support group.  The researchers were granted permission to contact the potential participants by the support group chairperson.  The group members were then contacted via letter inviting them and/or their spouses to participate in the study.

Article 2 chose their participants on a convenience basis.  The participants were recruited via one consultant breast surgeon at a South Australian teaching hospital.  Potential participants were identified from medical records and telephoned by the surgeon’s practice manager who enquired whether they would be willing to be approached by the researchers.  If the woman agreed she was again contacted by telephone to have the research further explained to her, then she was sent an introductory letter and consent form by post.  Each woman was assured that they could withdraw at any time.  The sample size was intended to be between 5 and 10 women.

Researchers have many sampling choices available to them that stem from theory or method or from simple practicalities such as time and money.  A sample therefore should be chosen purposefully and many sampling strategies can be used.  Sample sizes can be affected by the researcher’s time, budget and geographical location.  The number of participants that are needed should be determined by the researchers as there is no single correct sample size, (Byrne, 2001).

The sampling section of article 1 is very short and simply states the sampling method used, the selection criteria for potential participants, where they were selected from and how they were contacted.  There is no mention of the sample size although this is given in the abstract.  There is no reason given for the sample method used or the sample size chosen.  Article 2 gives the reason for the small sample size as being that they were not trying to gain a large amount of information that could be generalised but rich data that would generate understanding.  Article 2 also gives selection criteria and the reasons for the criteria.

Although the sample size of article 2 was quite small and restricted the author feels that it was a good enough sample to achieve what the researchers had stated they wished to do.  If they had wished to generalised their findings then the researchers would have needed a representative sample from different ethnic, social and age groups however this undertaking would have been unrealistic, (Byrne, 2001).

It is also important that although they have stated that it was not their intention to generalise their findings they have still explained their sampling method and reasons so that readers can assess whether or not the findings can be useful in other settings, (Parahoo, 1997).

As the researchers in article 1 were aiming at exploring the information concerns of women or spouses of women with breast cancer it would make sense for them to choose their participants from a population that would include people from different social, ethnic and age groups, (Parahoo, 1997).

However as their participants were all selected from one area and from one single support-group the likeliness of having a true representative sample is slim, this was given as a limitation of the study.

The sampling method used in this article was purposive; this is the most common method of sampling used by qualitative researchers.  It involves the researcher deliberately choosing which participants to include in the study on the basis that those selected can most likely provide the necessary data, (Parahoo, 1997).

Data Collection

There are many ways to collect research information, 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 as this gives the research findings their credibility, (Hek, Judd and Moule, 2002).

Validity underpins the entire research process and refers to the degree to which an instrument measures what it is supposed to be measuring and reliability is the degree of consistency or accuracy with which an instrument measures the attribute under investigation, (Cormack, 2000).

Article 1 fully describes the focus group interview procedure and clearly states what role the researcher/moderator held within each group session.  We are told how the discussions were guided and which direction they took, that each interview was audio-taped, and also that each participant was given a demographic questionnaire to complete.  The validity was established by participant evaluation; all of the participants were sent a copy of the results along with an evaluation sheet, 56.8 % of the participants responded.  All of those who responded thought the results were a fair interpretation of the discussions.

Article 2 explains what their method of data collection was (interviews) and briefly explains how they were carried out; again we are told what role the researcher/interviewer held.  We are given two examples of the leading questions used. The article tells us that the interviews lasted between 40 minutes and 2 hours, that they were audio-taped and that they took place in each woman’s own home.  However no part of this article tells us how they validated their findings.

Ethical Considerations

There is great emphasis on documenting any risks, benefits, and safe-guards of humans used for research.  Researchers should show any precautions taken for protecting human subjects and meeting ethical research standards.  A researcher should also ensure that it is possible for a participant to with-draw at any time, (Valente, 2003).

It is essential that all research participants give their voluntary informed consent, consent is vital as it respects the autonomy of individuals, their right to privacy and their right to choose, (Tingle and Cribb, 2002).

As a result of the Nuremberg trials of Nazi war crimes the World Health Organisation (WHO) developed the Declaration of Helsinki.  All nursing research carried out in the U.K should comply with the fundamental principles within this declaration.  The 1975 revision of the declaration recommended codes of practice for researchers; this resulted in guidelines being developed by national bodies such as the Royal College of Nursing, (Tingle and Cribb, 2002).

Article 1 has a section on consent where we are told that all participants were asked to sign a consent form granting permission for the group discussions to be audio-taped.  The participants were also asked to sign an anonymity clause to prevent them disclosing the discussion content outside of the group; offering the participants guarantees of discretion and anonymity.  There is however no mention of ethical committee approval being requested.

Article 2 gained approval for the study from the Social and Behavioural Ethics Committee and the Royal District Nursing Service.  Prior to commencing all participants received information so they were able to give informed consent.  The researchers also considered aspects such as each person’s physical and psychological wellbeing whilst discussing potentially disturbing issues.  If problems had arisen the researchers were prepared to discuss referral to sources of help and information.

Results

Cormack (2000) asks whether the results are presented clearly and whether enough detail is given to enable the reader to judge how reliable the findings are.

Article 1’s findings section has a clear table of results of the participant’s demographic characteristics.  The rest of the results are broken down and described under three headings.  Each section has direct quotes given from the discussions, these quotes are coded to the focus group they came from.  Incidentally most of the quotes come from focus group three.  This section is clear and easy to read with findings and conclusions throughout.

Article 2’s section of data presentation is far lengthier, the information is given under eight headings.  These headings were those used to identify clusters of significant statements representing similar experiences.  Quotes are used with pseudonyms, there are slightly fewer quotes used in this article although it feels as though much more information is given.

The method used to present data depends on a number of factors such as the type of data, the target readers, and the study design.  It is essential that findings are presented in such a way that they are clearly understood, (Cormack, 2000).

Results that are given in written format, as is the case for both articles here, are particularly efficient when trying to describe a situation or event that is emotional.  Text format also has the potential to convey large amounts of data and considerable detail in a compact format.  Also data gained from the demographic questionnaire was best summarised in tabular form as these types of data are not well presented in text format, (Cormack, 2000).

Data Analysis

In article 1 the discussions were transcribed fully as four separate documents.  Data analysis was executed using a manual, cut-and-paste method of theme analysis and the constant comparative method.  Analysis followed several stages: the analytical stage which involved the identification of strong themes running through the data, the next stage was the identification of information units and the last stage involved categorising the information units.  All data was then coded across the groups.  Finally themes were established and corresponding verbatim quotations were used to support all themes.  The responses from the demographic questionnaire were analysed using the Statistical Package for the Social Science (SPSS).

Article 2 followed five steps of analysis for each interview.  Step one was to read fully each transcript to gain a feeling for it.  Step two was to extract significant statements relating directly to the experiences of information.  Step three was the development of clusters by comparing statements in each interview that represented similar experiences.  Step four was to provide a summary of each experience using the individual clusters and step five was to compare and contrast stories providing a summary of the similarities and differences of experiences.  This five step analysis was an adaptation of Colaizzi’s (1978) framework.

Hewitt-Taylor (2001) believes that qualitative data requires systematic analysis and that a variety of data analysis procedures are commonly used, (Hewitt-Taylor, 2001).

Both of the articles under review use a systematic approach to analysis although they both use different methods.

The constant comparative method used on article 1 is a method of analysing qualitative data where the information gathered is coded into emergent themes or codes, the data is then constantly revisited until it is clear no new themes are emerging, (Hewitt-Taylor, 2001).

The constant comparative method is also known as grounded theory where as the framework in article 2 is a phenomenological method of data analysis.  Whether the grounded theory method or the phenomenological method is used the task of analysing qualitative data is arduous and demanding, (Parahoo, 1997).

Qualitative findings are reported textually and supported by relevant quotes from participants.  Qualitative research is about the importance of describing the experience of people from their own points of view, (Parahoo, 1997).

Limitations, Conclusions and Recommendations

Article 1 acknowledges several limitations in their study.  As already mentioned all the participants came from a support-group, this introduced a self-selection bias.  Only one person carried out the analysis, and the use of focus groups limited the sample size of the study.  The authors suggest that the findings be viewed with caution and point out that they are not representative of the wider population.  The conclusions are a good summary of the findings and give ideas for future research areas.  The authors also tell us how they are addressing their findings in a large-scale quantitative follow-up study.  There is a list of nursing implications given for readers to remember in their practice.

Article 2 has a summary and conclusion which gives an outline of the key findings and relates how these could affect nursing practice.  We are told that the study both reinforces previous research on this topic and adds new information that highlights areas for practice development.  Article 2 gives no limitations or recommendations for future research.

Valente (2003) tells us that when evaluating research the conclusions and implications should summarise the major findings and conclusions and there application to practice, research, theory and knowledge development.  Implications for further research should be given and cautions about generalising findings should be considered.  The implications need to describe how the research findings can be applied to nursing practice, can suggest future research studies and can improve theory and knowledge, (Valente, 2003).

Conclusion

It should be remembered that good practice is based on evidence and the best evidence comes from high-quality research.  It should also be remembered that not all research is high-quality.  Therefore evaluation is a must; this should start from evaluating the quality of the publishing journal right through to the conclusions.  The author feels that it is vital to remember that it takes time and practice to become skilled in the critical evaluation of research and one of the ways to achieve this skill is by continually reading research and reflecting (with the use of a framework) upon the strengths and weaknesses of each article read.  This essay has tried to highlight strengths and weaknesses of two articles and highlight the areas that are important in good critical evaluation.

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Evidence-based practice (EBP) is widely recognised within the role of nursing. Its implementation and purpose in the delivery of care is seen as an important driver for nursing practice and clinical outcomes (Cullen & Adams 2010). It has been defined as the:

“…conscientious integration of best research evidence with clinical expertise and patients values and needs in the delivery of high-quality, cost effective health care” (Burns & Grove. 2007, p.4).

EBP provides opportunity for nurses to ensure that clinical interventions and decisions making processes are safe and suitable for every patient group and enabling effectiveness in patient advocacy (Parahoo, 2006). An important part of practice and nursing culture, EBP should not be seen as an extra aspect to daily workload. Knowledge-base gained from pre-registration educational programmes and clinical experience should be the basis for the development of EBP (Cleary-Holdforth & Leufer 2008). Nurses critically reflect daily in clinical practice with the implementation and evaluation of care and it is important to understand that this forms the foundation in research for evidence. Quick reference for guidance does not necessarily need to be a lengthy process with accessibility to intranet and local policies, protocols and best practice statements. However, the self-recognition of base knowledge and skill should be continually developed (Parahoo, 2006). Nurses require time to strive for answers to clinical questions, expanding clinical expertise in locating research evidence. Using critique frameworks as suggested in Burns & Grove (2007), articles should be critically appraised with time spent deciding how they might apply to clinical practice. By taking a rigorous approach to appraisal, making an informed decision about the reliability and validity of sources of evidence, nurses can really look the effects in clinical practice and how the evidence can be delivered (Cleary-Holdforth & Leufer 2008). Nurses working in clinical settings should really think about dilemmas or problems that come up frequently in their clinical practice that they would like to know further research and evidence for.

It is expected that registered nurses should be comfortable and competent with the components of EBP such as forming clinical questions, literature searching skills, including accessing appropriate literature and showing enthusiasm in its development. Nurses need to have good resources and support from employers through providing access to library facilities containing major on-line databases such as EBSCO; Cochrane library database; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the British Nursing Index (BNI). Through the use of databases, a comprehensive literature review should be conducted to generate understanding of what is known and not known about the particular clinical problem (Cleary-Holdforth & Leufer 2008). The review can allow the nurse to decide whether adequate knowledge exists allowing for change in clinical practice or whether further research is required.

From this initial thought may follow development of clinical question creating ethical consideration and understanding of beliefs and values of patients and colleagues. Nurses should being with searching ‘highest level’ of evidence such as systematic reviews involving the compilation and ranking of evidence according to its methodological origin (Whiting. 2009). Systematic reviews summarise the results of high quality studies, often reviews of randomised controlled trials (RCTs). Described and the ‘gold standard’ to research, they identify which interventions work, those which are not as effective and where further research should be carried out. In this way, bias is reduced and the effects of treatments studied are not overestimated. By using such evidence, time will be reduced in the need for critical appraisal (Whiting. 2009). It is important to note that as nurses move forward having more autonomy in decision making and its emphasis of patient centred care there still remains lack of appreciation in ‘best evidence’ for patient response in emotional, psychological and holistic understanding and focus lies within scientific interventionism. Cleary-Holdforth & Leufer (2008) criticise that the described ‘highest level’ of evidence fails to acknowledge research based on patient experience and perception and aspect fundamental to nursing practice. This can be viewed in clinical guidelines developed by Scottish Intercollegiate Guidelines Network (SIGN), derived from systematic reviews of scientific literature all guidelines have levels of evidence statements with the ‘highest level’ of evidence being meta-analyses, systematic reviews or RCTs (SIGN 2010).

640 words

To apply evidence into practice it is vital for nurses to have role models that respect EBP, rather than relying on clinical expertise alone (Cleary-Holdforth & Leufer 2008). They must value ideas and effectively support the process if clinical questions arise. Role models need to be enthusiastic about EBP and having positive vision about the opportunities EBP can provide when integrated into day-to-day practice. Nurses need be able to view the benefits of applying best current evidence to their practice and therefore creating a positive motivation for EBP. At all levels, nurses need to be interested in using the EBP and adopt certain practices and attitudes. These include devotion, professional pride, positiveness, courage and willingness to carry out change and commitment to continuous learning (Cleary-Holdforth & Leufer 2008). The nurse will not only see maturity in professional self but also development of personal achievement and identity.

Decision makers and new found knowledge needs to not only be distributed but fully utilised and the nurse must ensure that colleagues receive, read, understand and appreciate the value of and actually utilise it in their own decision-making processes and, where appropriate, alter their behaviour.

As with any clinical intervention, evaluation of its effectiveness is essential and nurses must discuss with colleagues and participants

Further to this assignment will be appraisal and evaluation of two papers providing critique and discussion. Each will be assessed for the appropriateness for evidence-based practice.

Gethin, G. & Cowman, S. (2008) Manuka honey vs. hydrogel – a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. Journal of Clinical Nursing. 18 (3) p.466-474.

Gethin and Cowman (2008) clearly seek to measure the effective comparison of two healing agents on venous ulcers and use a quantitative paradigm with two views to methods of debridement, and indicate that an RCT was undertaken. In a quantitative research study there is focus measurement of the relationship between variables (Burns & Grove, 2007). Being the area of interest in the study, the variables that change over time are subject to statistical analysis. A prospective design has been decided on and to the reader indicates a collection of variable data with one or more points in the future. Macnee (2008) adds that time is a defining factor in the design of a quantitative study. In this case the time points were at week 4 and week 12 from initial baseline. A reasonable amount of information has been provided in the design title and allows the reader to be aware of the approach used. It seems that the research hypothesis is best addressed by quantifiable approach being the appropriate design methodology for investigation.

Gethin and Cowman (2008), aimed to select adults presenting with venous leg ulcers having over 50 percent of the wound area covered in slough. Further to this, they followed substantial inclusion and exclusion criteria which was clearly stated and indicated in the research including tables that could be easily understood by the reader. There could however be potential problem with this as a more tightly controlled or restricted sample could lead to limitations to clinical meaningfulness (Parahoo, 2006). The researchers goal is to avoid bias which could potentially distort findings and making it difficult or impossible to interpret results (). There is inconsistency in the description of the members in the study that could indicate bias. The researchers use both the term ‘subject’, ‘participant’ and ‘patient’ and to the reader, this could be questioned as to how removed the researchers were from those in the sample (Macnee, 2008). Had ‘sample’ been used consistently then the reader could interpret this as being a distance and impersonal approach. Reassuringly the researchers state that they removed themselves from selection process and used blinded randomisation by two persons independent of the study to eliminate personal bias. Blinding refers to the group allocation and the concealment from one or more individuals involved in the research process (Karanicolas, Farrokhyar & Bhandari 2010).

The larger the sample size in a quantitative study, the more likely the study will apply to clinical situations and aiming to make generalisations about the larger population based on findings (Parahoo, 2006). The study uses a sample size of 108 which seems small and perhaps is unlikely to produce results of statistical significance failing to disclose the actual effectiveness of the agent used. It may have been that Gethin and Cowman (2008) failed to get enough funding to support their study or an increase in sample size would have been too time consuming. Non-probability sampling was used with recruitment of subjects attending a clinic. This type of sampling limits the extent of generalisation of the results to the population outside the research (Burns & Grove, 2007).

Failure to enrol the predetermined number of subjects creates limitation and restricting what a reader may learn about the study. Further to this, Gethin and Cowman (2008) did not discuss

During the data collection stage of the process, there are two important considerations: the potential impact on the reliability and validity of the study. Reliability refers to how reliable the data collection methods are, this is the extent to which the selected methods will collect the same data on repeated occasions. The more consistent this is, the more reliable the methods are (Macnee, 2008). Gethin and Cowman (2008) used local clinical investigators who took part in a pretrial inter-rater reliability (IRR) study determining the level of agreement between the three raters when assessing slough as a percentage within wound bed. As the assessment was split between three data collectors, the reader could query potential differences in subjective opinion in deciding the percentage of slough within the wound bed. Thus influencing the accuracy and consistency in measurement making the measure less reliable.

Validity refers to the extent to which the methods used to collect and analyse the data accurately measures what the researchers intended it would measure (Macnee, 2008). They selected to use Visitrak Digital Planimetry a tool for wound measurement. Sugama et al. (2007) explores and concludes that this type for wound measurement device was a efficient reliable system applicable for use in clinical practice improving validity of the research. It must be noted however, that this is only valid if the users are fully competent in its use.

An important methodology feature of RCTs is to minimise bias and maximise the validity of the results (Whiting 2009). Gethin and Cowman (2008) failed to blind participants and data collectors due to the obvious orange staining from the Manuka honey. For a reader this is a immense flaw in the research introducing bias.

The data collected in quantitative research must either be numerical or converted to numerical data and entered into a database (Macnee, 2008). Gethin and Cowman (2008) selected to use a Statistical Package for the Social Sciences (SPSS) and further a statistician who was completely disconnected from the research in terms of collection and interaction with the subjects. This is a very positive aspect of the research and

Gethin and Cowman (2008) failed to elaborate why participants pulled out from the study and a reader should be highly concerned as to what exactly happened to these subjects and question averse reactions to the chosen product. A nurse having found this during a literature review would suggest there are too many weaknesses in the research to apply this to clinical practice and decision making. A main concern is the safety of patients and I would decline to use this product until further research was carried out considering all the available evidence potentially utilising a systematic review approach. Until then, it would not influence decision making in relation to methods of debridement. This intervention applied in everyday clinical practice could potentially have adverse consequences that outweigh the potential benefits. The cost was not reported and it may be that the Manuka honey treatment is very expensive providing only small health benefits and failing to make good use of resources. It may have been beneficial for the researchers to provide a rough idea of the cost of producing one unit of benefit.

An aspect fundamental to nursing practice is to incorporate understanding of the participants perspective about their experiences (Leufer & Cleary-Holdforth 2009). This is not something that was not explored, had funding been available qualitative research, which will be explored in the next paper could have been incorporating using two design methods.

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Hancock, H. C. & Easen, P. R. (2006) The decision-making processes of nurses when extubating patients following cardiac surgery: An ethnographic study. International Journal of Nursing Studies. [Online] 43 (6) p.693-705.

The following assignment will critically analyse the mentor’s role in facilitating learning within the practice setting. It is of importance to define the following terms: mentor’s role, facilitating learning, accountability, and supporting students who are failing in practice setting. The importance of establishing effective working relationships, an analysis of the learners’ needs, promote effective assessment and the evaluation of learning will be analysed. Finally, the conclusion will be drawn from the analysis of this assignment.

A mentor is a clinical practitioner who supports, guides, supervises and facilitates student learning during a clinical practice Stuart (2007). Mentors are seen as a fundamental influence to students in a learning environment where students utilise their theoretical knowledge in to practical, learn key skills and achieve the required competence for registration. Ali

et al

(2008) also states that mentoring is an important that every nurse has to assume, formally or informally, sooner or later. Historically the concept of mentor dates back from the Greek mythology. Mentor was a friend of Odysseus who left his wife Penelope and son Telemachus, whilst he went to war. Odysseus asked his friend to guide and support his son therefore being his mentor (Pellat, 2006). The author agrees with the above authors as she is an experienced nurse who guides junior nurses, through reflection and feedback in their duty of care.

Nursing and midwifery council [NMC] (2008) recommends that prior to the commencement of placement, mentors are to ensure that all students are allocated a mentor one week before to let the student and mentor prepare for the experience. A mentor does not only advise and guide students, but he or she is a role model to junior nurses. According to Morton and Palmer (2002) cited in Ali

et al

(2008) by being a role model , the mentor provides an observable image of imitation, demonstrating skills and qualities for the student to emulate. NMC (2006) notes that the role of a mentor in a clinical setting is fundamentally focused on the NMC competencies. Chandan and Watts (2012) noted “that mentor’s role goes beyond teaching knowledge and skills as they alleviate anxieties and supports students with acceptance and socialisation into both the higher education and clinical contexts”.

Mentors establish effective working relationship by demonstrating their competence in building adequate skills to support learning for students who will becoming part of the team within the clinical settings. The key role of a mentor is to a help the student integrate into their designated practice setting. Royal College of Nursing [RCN] (2007) suggests that the relationship between a student and a mentor can be achieved by welcoming, orientating inducting and integrating the student into the multi-disciplinary team within the first 24 hours of entering learning environment. Learning can be facilitated by a positive relationship between mentors and students. This can create a mutual relationship built on understanding and empathy facilitating students to maximise their potentials within the clinical setting (Zellers

et al

, 2008). This relationship between student and mentor can be enhanced by working 40% of direct and indirectly of their time and also alongside the mentors shift pattern.

A mentor supervises the students assigned to her within a practice setting. Taylor cited in Stuart and Sundeen (1997) define supervision as an intensive interpersonally focused, one to one relationship in which one person is designated to facilitate the development of therapeutic competence in the other person. However, Ironbar and Hooper (1989) suggested that the supervisor should be someone with extensive clinical experience and training, who can provide expert support and guidance with well-planned learning opportunities, the provision of support and coaching for students in order to facilitate learning According to Johansson

et al

, (2010) the relationship between the student and mentor is the most factor contributing to clinical learning experience. Students attain direct knowledge and skills resulting in becoming aware of their roles. Willis report (2012) mentions that “Effective understanding of collaboration and inter-professional working is a key component of pre- registration nursing education”.

A well collaborated learning contract can enable the mentor to facilitate learning with a clinical setting. According to (Worrall, 2007) an effective orientation to a clinical placement can help the student to feel relaxed and encourages motivation for learning through early identification of learning objectives. To have the opportunity of being a member of the multi-professional team, the mentor must ensure that the student is fully integrated into the team and working alongside professionals so that he or she can gradually become competent in most clinical of skills. Learning within a clinical setting can be facilitated through the use of a variety of approaches by mentors and staff who have the right skills. Mentors facilitate learning to students by applying reflective learning as a learning technique that reinforces the mixing of theoretical and realistic learning into practice. According to (Pritchard and Gidman, 2012; Carr, Heggarty and Carr, 2010) “Reflective learning is an effective tool in supporting mentorship, allowing students the opportunity to reflect on past experiences and to learn from them before moving forward”. (Pritchard and Gidman, 2012) elaborated further that by adopting new teaching approaches, mentors can address students past experiences enabling the students to have some confidence to reflect on what they have learning outcomes.

NMC standards support learning and assessment (2008) outlined certain principles to be achieved in order to become a mentor. Mentors’ should be able to create an environment that can facilitate learning by supporting students, encouraging learning activities, off ward learning experiences, assessments, supervision, professional vision and applying evidence based practice within the clinical settings. It is a requirement that all registered nurses are to convey professional knowledge and competence to student nurses by regularly taking part in the learning and development of students through teaching, activities, supervision and assessments NMC (2010). NMC (2008) requirements recommends day to day support for the students’ by their allocated mentors in order to enable student learning experiences and assess practice learning outcomes. This can create a conducive learning environment within a clinical setting by teaching or providing learning opportunities for students and colleagues through planning, reflective practice and evaluating learning activities.

Mentorsare influential in helping the student reach theiraims and objectives. They carry out assessments to ascertain the student’s level of theoretical knowledge, practical clinical skills and also taking into account the learners previous experiences can aide mentors to facilitate learning. Sharing knowledge and experience with students assist the mentor to identify the student’s individual learning style Ali

et al

(2008). Therefore a mentor can facilitate a student’s learning by keeping his or her knowledge and skills up to date by researching into current trends and annual mentorship update. The role of a mentor is to ensure that there is readily available of learning resources, precise learning opportunities and a plan on how the student can achieve the planned learning objectives. Mentors must possess qualities such as a being an educator, good effective communication skills, acting as an advocate and good leadership qualities to institute an effective working environment for student nurses. However this can develop students’ in understand what is expected of them in the near future.

Accountability is part of the mentors’ role in facilitating learning in a clinical setting through professional judgments on students’ performance. Mentors are accountable for confirming students who have met their NMC competencies in practice. Learning can be facilitated through appropriate support and supervision in carrying out summative assessment of the student‘s competence when carrying out clinical skills during teaching sessions. Mentors are accountable for every decision and action they make on the care provided by students (NMC 2010). They have the duty to facilitate learning and support failing students by giving constructive feedback and effective teaching sessions. However Duffy (2004) recommends mentors to fail students who are not able to meet the required level of practice because it is the mentor’s responsibility to make the final assessment and to be aware that they are accountable for passing or failing the student NMC, (2006). Keeping sufficient and evidence based records can help mentors to support their decisions.

Rodgers (1969) defines facilitation as a style of teaching that assist mentors in understanding students’ effective style of learning that includes student focused learning, none commanded, self-directed reflective whilst involving them in the learning process. Mentors are regarded as effective facilitators in both skills and art because they engage everyone in the learning experience. By acting as an advocate, mentors can facilitate student growth and development resulting in students being able to solve problems simultaneously. Within the clinical setting mentors’ critical reflection as a method for teaching and learning can create an even pathway for the students to pursue their learning journey. According to the NMC code of practice (2008b, p: 5) have the duty to share their knowledge and skills to facilitate students’ and their colleagues development by teaching new skills for example depot injection techniques and completing risk assessment documents. Mentors can facilitate learning by using physical resources such as teaching aids to enhance learning for students and colleagues within their clinical settings.

It is essential for the mentor to facilitate learning to students by encouraging them to attend on and off ward learning activities for example, meetings, practice sessions, student forums and other health departments in order to acquire expertise clinical skills and knowledge and for further development. Mentors must ensure that there is a vast range of potential learning opportunities available to learners in order to facilitate learning and meeting specific students’ learning needs. At the same time the mentor needs to be mindful of the quality of the learning experience and consider how they can further develop the learning environment to enhance the students’s experience. The role of a mentor within a clinical setting is to develop the student clinical skills through teaching and explaining the clinical procedures and to provide the appropriate knowledge base for nursing interventions.

Learning can be facilitated by equipping the clinical setting with all useful and adequate resources for carrying out the teaching sessions. Mentors can also obtain new knowledge and skills through their guidance and support of students (Klasen, 2002). Their contribution to a supportive learning environment and quality learning outcomes for students can be brought about by being approachable, supportive and being aware of the student’s style of learning. Mentors plays a significant role in the assessment of student’s level of capability assesses your level of capability student gains the optimum experience from the clinical learning environment. It is also important when embarking on the mentorship course and in house training for other qualified staff to assist students translate theory into practice. Mentors needs additional skills through structured learning activities and teaching sessions to utilise in an environment settings designed for this purpose, Gopee (2011). Quinn (2000) commented that mentors can enhance students’ skills performance and development in a methodical and acute way by providing the students with feedback and reinforcement.

Communication is the most important tool that a mentor can utilise to facilitate learning for students within a clinical setting. As a skilled communicator a mentor needs to establish additional communication skills for the management of students’ complex issues arising within the clinical setting. Components of communication are essential in a clinical setting because mentors are able to exchange information and establish an effective working relationship. Ali and Panther (2008) commented that mentors should use effective communication and facilitation of skills to develop a personal and professional relationship with the students allocated to them. Learning can be facilitated by carrying out the initial, intermediate and final interviews thus allowing the mentor to find out about the student’s previous learning experiences, identifying the individual’s strengths and weaknesses and their level of participation, Doel and Shardlow (2005)

.

Interaction between students and Mentors enables more flexible and individualised learning process using a one to one effective approach within a structured learning environment (Warren, 2010). Enhancing learning through assessment can assist the mentor’s ability to research and prepare an appropriate environment, which is conducive with learning, teaching and assessment.

The provision of teaching and learning activities facilitate learning within a clinical setting as it enables the students to achieve the intended outcomes during their placement by relating theory to practice while developing critically reflective skills in order to facilitate learning NMC (2008). Mentors can facilitate learning by providing inter-professional learning opportunities for example integrated skills teaching model. By utilising the Kolb’s (1984) learning cycle mentors can integrate of theory into practice and the art of and science of nursing by using the four stages of learning namely Activist, Reflector, Theorist and Pragmatist. Mentors can facilitate student leaning by having a well-structured teaching session that includes style and space, providing feedback and identifying future learning needs. Learning styles promotes better student integration into clinical settings. Frankel, (2009) states that nurses learning styles promote better integration of theory into practice. The ability to critically analyse and evaluate the strengths and limitations of learning, teaching and assessment within their practice area is one of the mentors’ roles. However, through the knowledge the mentor possesses they can develop and present innovative approaches to enhance students’ learning. By carrying out student assessment a mentor can facilitate learning to a student by observing the student during a teaching session where by the mentor is bale to know the student’s learning style for example visual, auditory and kinaesthetic learning.

Introduction

Older adults in society face a wide array of experiences, obstacles, and transitions in their daily lives. In the research article “Maintaining the Balance: Older Adults with Chronic Health Manage Life in the Community” by Cynthia S. Jacelon, common themes were discovered when analyzing the lifestyle of older adults living with chronic illnesses, which were identified as activity, attitude, health, autonomy, and relationship (Jacelon, 2010). These five themes span a multitude of areas of life, and the research article stressed the importance of keeping a balance between them (Jacelon, 2010). This strategy of balance supports living a fulfilling and successful life as an older adult, especially with the added struggle of facing a chronic illness, and physical deterioration that accompanies aging to varying degrees (Jacelon, 2010).

The research article elaborated on strategies that the older adults employed to maintain a balance between the major themes of life in older adulthood. Strategies the participants utilized to maintain balance in activity were completing Activities of daily life, ADLs, and finding ways for their instrumental activities of daily life, or IADLs, to be tended to by themselves, or with the help of others (Jacelon, 2010). Also, the older adults came up with creative solutions to complete tasks that were otherwise too difficult (Jacelon, 2010). To keep their health in balance, participants noted managing their medications, seeking help when they felt unhealthy, and learning to cope with the realities of living with chronic illnesses (Jacelon, 2010). In regards to autonomy, the participants aimed to remain independent and stay in control of their aging process as they maneuvered new transitions and challenges (Jacelon, 2010). Older adults fostered a positive attitude by looking forward to the future, refraining from dwelling on losses, having a purpose to their lives, and having a positive perspective on life (Jacelon, 2010). Lastly, the older adults made an effort to stay socially involved with family and friends as their life progressed (Jacelon, 2010).

Methods

A one on one interview was conducted on Wednesday, September 20th, 2019 with a 94-year-old female at the Brightview Senior Living Facility. The participant was recruited for the interview to provide a personal account of their daily life as an older adult and their experiences through the course of aging. Permission was granted for the interviewer to take notes regarding the interviewee’s answers. For the purpose of upholding confidentiality, the interviewee agreed to be referred to by their initials, A.H., for this paper.

Findings

During the interview, A.H. provided information that illustrated her health, autonomy, activity, relationships and attitudes as a 94-year-old female. When asked how she would rate her overall health, A.H. stated that she believed that on a scale of one to ten (one representing the poorest health, ten representing optimal health), her health was an eight out of ten. A.H. attributed this rating to her ability to take care of herself, remain active, and she feels healthy and in tune with the world around her on most days. Even though A.H. rates her health positively, she explained that she has macular degeneration in one eye, and ocular venous occlusion in the other, which has resulted in obstructed vision in both eyes. Two major issues A.H. faces as a result of her chronic conditions are not seeing faces clearly, and not be able to read books. She has adjusted to these obstacles by getting in the habit of politely asking people their name when she cannot recognize them right away, and she has discovered that audiobooks allow her to listen to novels. A.H. does not see these adaptations as setbacks in her daily life. She stated that she recognizes how her health could be worse and that she is grateful to still be able to most things independently.

A.H. lives at the Brightview Senior Living Facility on the “independent” floor, where she is provided a breakfast buffet and dinner every day. A.H. explained that she is able to do all activities of daily living including bathing, getting dressed, doing her hair and makeup, and feeding herself. She is able to walk, but requires the use of a cane, or occasionally a walker, for stability.  A.H. does some instrumental activities of daily living, such as managing her own mail, making telephone calls, and obtaining and administering her own medication. Some IADL’s A.H. does partially, such as supplemental cleaning that her cleaning staff does not provide, making her own lunch which is not provided by her facility, and managing her transportation. However, A.H. does not handle her own finances, which are tended to by her daughter.

A.H. described her daily activities in detail. On Mondays, Wednesdays, and Fridays, A.H. participates in an hour-long exercise class in the gym, and on every other day, she takes a walk with her best friend in the facility around the local lake, or to the grocery store. In the afternoon, A.H. enjoys watching television with fellow residents, going to afternoon activities such as ballroom dancing, and enjoys listening to singers and musicians that perform at her facility. A.H. explained how prior to moving into the senior living facility, she lived in an apartment. This led to her feeling isolated in her daily life, since she did not leave the apartment often and only got a few visits a week from family. Since moving into the facility, she explained feeling more excited to try new things when opportunities arise, and she feels a greater inclination to participate in physical activity such as her long walks and exercise classes, which she believes have made her feel stronger. A.H. also elaborated on her religious activities, stating that she goes to church every Sunday as well as two additional weekdays. She also noted devoting several minutes throughout the day to private prayer. A.H. was adamant in stating her opinion that she does not know how anyone lives life without religion, as it is one of her main support systems.

A.H. mentioned some important friendships in her life that are central to her happiness. A.H. has daily phone calls with her best friend of 88 years, who she said is her closest friend. Also, A.H. met a group of women in her senior living facility with whom she has become friends, and she looks forward to eating dinner with them every night. A.H. expressed that living in close proximity to people and meeting her new friends has made her feel happier, and has given her a greater sense of purpose. She stated that in her apartment she would sit at home alone and occasionally talk on the phone, but now in the facility, she has friends that want to spend time with her and share meals, which gives her a sense of belonging.

A.H. also mentioned a close connection to her family, including sons, a daughter, grandchildren, and great-grandchildren, and she stated that seeing her family is one of her biggest joys in life. However, A.H. went on to mention her familial losses, mentioning losing her husband sixteen years ago, a daughter less than a year ago, and each one of her eight siblings. She stated that while she will have some times of sadness, she understands that remembering her loved ones in a positive light is better than dwelling on the sadness of her losses. One of A.H.’s biggest coping mechanisms for her losses is her devotion to her religion. A.H. said lighting candles in church for her loved ones gives her peace of mind and honors their memory.

Overall, A.H. was very optimistic regarding her lifestyle and said she looks forward to future events at her facility, dinners with her friends, and holidays spent with family. A.H. stated that she enjoys her daily life, especially after moving into the senior living facility, and she feels grateful to still have her mental and physical abilities to live a very independent daily life.

Discussion

The findings provide evidence that A.H. suffers from chronic illnesses that obstruct vision in her eyes, and has some instability in her walking, as she requires the use of a cane, or occasionally a walker. Also, A.H. provided information about  some of her losses, such as her daughter and her husband. However, amid these challenges in her daily life, A.H. rated her personal health an eight out of ten and maintained a positive outlook when describing her daily life and aging experience. One reason as to why her coping and experience with personal challenges is effective could be her spirituality and devotion to religion. A.H. provided evidence of a strong connection with her religion, describing how she attends church approximately three times a week and often prays throughout the day. Also, she specifically cited lighting candles in church to bring peace of mind regarding her lost love ones. In a research study analyzing the role of religion in positive aging of older adults, focus groups yielded results that illustrate how religion cultivates a sense of comfort, relief, and fortitude, most prominently in times of poor health or challenges resulting from the process of aging (Malone & Dadswell, 2018). With religion as a major aspect in A.H.’s life, and the conclusions of the study linking religion and greater mental strength when dealing with challenges, it is likely that A.H.’s spirituality is a contributing factor to her positive attitude when faced with her aforementioned challenges of aging (Malone & Dadswell, 2018).

From the interview, it can be determined that A.H. lived an isolated life prior to moving into the senior living facility. Her spouse has passed away, and she lived alone for over a decade, only receiving visits from family. However, her description of her life today is filled with interactions with other people, such as her best friend at her facility, her group of women she eats dinner with, and her group exercise classes. With her new lifestyle, A.H. reported feeling more purpose in her daily life and greater levels of happiness. A study suggests that this positive shift in A.H.’s purpose in life, involvement, and feeling of happiness can be attributed to her formation of new relationships at her senior living facility (Cornwell & Laumann, 2015). Forming new friendships in older adulthood has been proven to restore feelings of belonging and holding social importance to others, and also increase self-esteem (Cornwell & Laumann, 2015). These feelings coincide with how A.H. felt when she described her current living situation and could be contributing factors to helping her cope with her chronic illness and loss, all while remaining positive and active in her daily life.

Conclusion

From the article “Maintaining the Balance: Older Adults with Chronic Health Manage Life in the Community”, five central themes were provided to analyze the lifestyles of older adults living with chronic illnesses. On that basis, a 94-year-old female was interviewed, and it was found that despite her chronic illness affecting her vision, she was able to maintain balance in her life according to the themes through friends, family, activities, religion, and independent living. All of these factors contributed to her overall positive view of her health, illustrating that balance between the five themes was a positive contributing factor to managing a purposeful life amid chronic illness associated with aging.

References

• Cornwell, B., & Laumann, E. O. (2015). The health benefits of network growth: New evidence from a national survey of older adults.
  
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• Jacelon, C. S. (2010). Maintaining the Balance: Older Adults with Chronic Health Problems Manage Life in the Community.
  
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• Malone, J., & Dadswell, A. (2018, June 8). The Role of Religion, Spirituality and/or Belief in Positive Ageing for Older Adults. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6319229/.

Introduction

Knee injuries are very common in sports; understanding mechanism of injury is an important aspect for diagnosing and managing them effectively (Webb and Corry, 2000; Bahr and Krosshaug, 2005). While making a precise diagnosis, it is necessary to re-evaluate the knee at different stages since acute examination of injury is often difficult and might be inaccurate (Olsson et al., 2016). As MRI is used as a diagnostic tool for evaluation of knee injuries, its early use influences the clinical decision making in some cases where clinical evaluation defers (Cashman and Attariwala, 2014). Due to early use of radiological diagnosis, there are chances of neglect during subjective history and physical examination (Navali et al., 2013).

A case of 24-year-old kick-boxer with the history of a non-contact knee injury with minor complaints is an example of a difference in clinical findings and imaging. MRI on the same day of his injury revealed the diagnosis of ACL and medial meniscal injury. Unconvinced with advice for surgery, he visited physiotherapy clinic after 8 days. This essay is about the difference of opinion due to distinct findings in imaging compared to those in clinical assessment and subjective history. Reflective discussion about physiotherapy assessment influenced by early imaging of the mentioned case is the objective of this essay.

Patient History

A 24-year-old male patient had clicking sound, pain and swelling in his left knee on lateral and posterior parts while playing kickboxing. On 15

^th

February 2017, he was doing his regular practice in the morning following his warm-up. During mid-practice session, he rolled awkwardly on the heel and outside of his left foot with leg straight, and balanced himself on outside of his foot. He felt clicking with some pain on the lateral and posterior side of his left knee. He had a little discomfort while walking after the incidence, so stopped his session. Later in afternoon, he started experiencing more pain in muscles around the joint and deep at the back of his knee. He also had swelling around his kneecap, so he visited the orthopaedic surgeon in a nearby hospital. Surgeon referred him for MRI in the same hospital so he got it done on same day.

The surgeon also gave him pain medications and suggested a long knee brace to use. He collected his MRI reports next day and revisited the surgeon. His reports mentioned – grade 3 tear of anterior cruciate ligament (ACL), longitudinal tear at posterior horn of medial meniscus, grade 2 tear of posterior cruciate ligament (PCL). Therefore, the surgeon advised surgery to repair torn ACL and meniscus. Since he was not convinced thinking he had less severe symptoms, he did not go back to the surgeon and decided to go for a second opinion. When the patient asked for his case file, only written MRI reports were given back to the patient and MRI films were kept at the hospital. He continued medication and used long knee brace while doing the activity. 8 days after the incidence, he visited a private physiotherapy clinic on his friend’s suggestion and got re-assessed.

The patient had no previous history of injury in his knee joint. He is active and played kickboxing for past 7 years at an amateur level without any severe complaints in the same joint. He owns a security agency and is a portrait painter. His main complaints after the incidence were pain and weakness of the left knee joint.

Subjective examination

According to his description, mechanism of injury was varus force on his left knee due to body weight managed on lateral arch and heel of foot with knee extended. While starting a kick he lost his balance lifting his medial foot and managed himself on lateral arch and heel of his foot. He felt a click in the postero-lateral aspect of his knee and said there was no twisting of his knee since he was just starting to kick. When he felt the click, he had slight pain so he stopped the activity immediately and decided to go home. Since he was comfortable while walking, he went back home riding his scooter (5kms). He had done a proper warm-up before his training but skipped cooldown on the day of injury.

When he went back home, his pain gradually increased by the afternoon. He was walking inside his house without any problem. After the lunch, he was sitting relaxed on his bed with legs long and he started feeling more pain. He had difficulty moving his leg, so he decided to visit the nearest hospital. His sister helped him to get to the lift and then took him to the hospital by car. He was sitting with his legs long on the back seat.

He presented with complaints of weakness in the knee joint and superficial pain around the left knee joint particularly in lateral head of gastrocnemius, hamstring muscle tendons, patellar tendon and quadriceps (3/10). Although he was walking with pain deep within the joint (5/10), he had no complaints of instability or locking in the joint while doing any movement. The range of motion was full in the extension of the knee with slight pain around the patella, end range of flexion was painful roughly in popliteal fossa (also lateral knee) causing difficulty to squat. Mild localised swelling was present around patella (supra- and infra-patellar).

His pain increased with activity (never 10/10) and reduced significantly with rest. Within 8 days his pain reduced and he was more comfortable doing his household and self-care activities. Initially, he used to feel morning pain and stiffness when he was using a long knee brace at night. His pain and stiffness were less after 4 days when he started using it just for activities outside the home and stopped using it completely at night.

The patient stays in an apartment and his flat is on the fifth floor with the lift facility. He stays with his parents and sister. His family is very helpful to him. Except for his sister, everyone in the family is earning. He was very co-operative during his assessment. Because of his injury, he was not able to do social activities such as meeting his friends and could not attend his painting exhibition. He was able to manage his work from home. Although he was not irritable with his pain and condition, he was worried about the surgeon’s advice since he wanted to continue kickboxing.

Clinical Reasoning

Initial pain, swelling and stiffness suggested an inflammatory response to injury, which was subsided until the patient came to the clinic. Since MRI report did not mention joint effusion and considering the swelling was localised, the cause of swelling might be bursitis. The condition of the patient did not aggravate even though he reduced the use of the brace and during physiotherapy assessment, he presented with mild localised swelling. Thus, findings were suggesting the cause of swelling being peri-articular rather than intra-articular issue (Johnson, 2000; Frobell et al., 2007).

Mechanism of injury was suggestive of hyperextension on imbalanced foot with ‘pop’ felt suggested injury to ACL, but the patient never complained of instability even after reduced pain. Therefore, the severity of ACL injury considered amongst the diagnosis was not correlating with MRI findings, making it necessary to re-evaluate during the further objective examination (Frobell et al., 2007; Navali et al., 2013). In addition, the patient had no locking during flexion and extension of the affected knee but had pain at the end range of flexion. Longitudinal tear of medial meniscus present in the MRI report was considered the cause of deep pain during a deep squat. This suggested the need to assess medial meniscus (Osborne et al., 1995; Johnson, 2000; Navali et al., 2013; Cashman and Attariwala, 2014).

Previously obtained MRI reports and notes by the orthopaedic surgeon played a role while doing the initial diagnosis. A focus of the assessment completely relied on ensuring the extent of ligament injury since the clinical presentation was not matching MRI reports. Thus, the reasoning was highly influenced and non-analytical leading to pattern recognition (Norman and Eva, 2010). This caused neglect towards other components of subjective history; such as symptoms felt postero-lateral to joint, varus stress felt during the incidence, etc. PCL injury in MRI report considered less likely thinking non-contact hyperextension is a rare mechanism for PCL injury to occur (Logerstedt et al., 2011b).

Hyperextension of the knee joint with varus stress being one of the common mechanisms for PLC injuries requires a high level of suspicion to diagnose the condition (Chahla et al., 2016). Given the fact that in this case patient’s symptoms were allowed to subside before doing provocative tests, there was time for more analytical thinking for appropriate diagnosis (Norman and Eva, 2010). A broader cognitive approach of hypothetico-deductive reasoning should help for identification of information cues such as the mechanism of injury (Edwards et al., 2004). The more problem-solving approach towards patient’s complaints could help, assessing for his PCL and posterolateral corner (PLC) to address his present complaints (mentioned in conclusion part). Thus, diagnostic approach with the forward reasoning of patient’s complaints might have helped to reach a possible diagnosis of tibial rotational dysfunction (Elstein, 2000).

Objective examination

The patient is strong and athletic, 176cm tall and 79kgs. He did not complain of any neurological symptoms such as burning or tingling around the knee joint. On sensory examination, he had normal sensations on and around knee joint when compared to non-affected side. There was redness observable around the patella and when compared to the opposite side, the area was warm suggesting of inflammation. On palpation, he had pain in overall gastrocnemius muscle, hamstring muscle and tendon, quadriceps muscle and patellar tendon (near patella), near head of the fibula. These painful muscles were in spasm (3/10 on VAS). There was no significant pain on the medial joint line.

The patient was keeping his left knee slightly flexed while standing since he was taking less weight on the affected side. He has bilateral foot over-pronation. Left PSIS level was slightly lower than right. He was walking with antalgic gait, causing less stance phase on left leg and swing phase reduced with small cadence. Single leg standing with support was painful and the pain was mainly in surrounding muscles and around the patella. Supported squat gave him deep pain posterior and lateral to the joint along with superficial pain in muscles. Supported step-up and step-down was painful in similar areas mentioned above. During all these activities, he had no complaints other than pain, such as giving away feeling or locking in the joint. The patient was confident while doing all these activities and mentioned that the pain was tolerable. Functional tests apart from gait were performed after initial pain relief for 4 days.

Active and passive ranges of knee joint were full but end range flexion was slightly more painful during both (more in active); the pain was deep in the posterior and lateral joint. Throughout the ranges, he had complaints of mild superficial pain in surrounding muscles and around the patella. Resisted activity was weaker and painful compared to the unaffected side. On manual muscle testing, strength for flexion and extension of the left knee was 4/5 compared to 5/5 on right knee.

Repeated assessment along with the pain management for 4 days was done to ensure pain and spasm relief. Hinged-brace instead of long knee brace was suggested to him. After the considerable reduction in pain and spasm (1/10), his further assessments for provocative tests to differentiate ligament injury were done.

Anterior Cruciate Ligament

ACL injury was assessed using only anterior drawer test. Test position was in supine with knee flexed at 90ᵒ, foot placed on the couch and stabilised by the therapist. The anterior translation given with both the hands by the therapist was slightly more in the left knee than that in right when tested (Grade 1). Although the test was positive, the tibial translation was not conclusive of grade 3 tear of ACL. Positive anterior drawer test, MRI findings and trauma in hyperextension of knee suggested ACL sprain.

Medial Meniscus

Joint line tenderness was checked from the first assessment until pain and spasm were relieved. Joint line palpation always performed in the flexed knee. The patient had no pain on palpation on the medial joint line gave a negative test for medial meniscus injury. Apley’s test was performed at the later stage. Test position was in prone by stabilising distal thigh with one hand and other hand giving vertical pressure on patient’s heel. Therapist maintained patient’s knee in 90ᵒ of flexion throughout the test. Apley’s test was also negative for the medial meniscus.  Therefore, subjective history and clinical findings ruled out medial meniscal injury.

Discussion

Diagnosis of ACL injury confirmed after objective examination, but subjective history was still not clearly suggestive of it being an only diagnosis. Since the patient had come for the second opinion, his previous diagnosis by the orthopaedic surgeon and MRI reports affected the decision making process during the assessment. However, the literature suggests that accurate patient history and examination are necessary components for diagnosing ligamentous and meniscal injuries. It is also advised to use MRI to confirm the severity of the injury (Frobell et al., 2007; Navali et al., 2013). Patient history, in this case, is not suggestive of medial meniscal injury. Besides, it is also not suggestive of complete rupture of ACL without other severe findings in MRI, such as joint effusion/haemarthrosis (Frobell et al., 2007; Navali et al., 2013). Only the MRI report was given to the patient and not the film before leaving hospital created suspicion about the quality of MRI and disputable practice. Two news articles published in British Medical Journal, “India turns spotlight on kickbacks for referrals” and “We need to end “cut” practice in India” dated 27 August 2014 and 7 July 2017 respectively, highlight issues with referral practice and rationality of decision making.

Valgus load in a hyperextended knee, rotational force, instability and hemarthrosis are features of ACL complete rupture mentioned in literature were absent in this case (Bahr and Krosshaug, 2005; Frobell et al., 2007; Logerstedt et al., 2011b). Anterior drawer test performed for assessment is the less sensitive test in acute cases as a spasm of surrounding muscle might influence leading to false negative results. It is suggested to be used along with Lachman test since it has got a high diagnostic value for ACL injury assessment (Benjaminse et al., 2006). Pivot shift is another widely used test which is less specific and sensitive compared to Lachman test (Benjaminse et al., 2006; Leblanc et al., 2015).

Medial meniscal injuries are common with valgus and twisting force on knee joint, often presenting with a catch or lock with movement (Logerstedt et al., 2011a). But in this case mechanism of injury was varus, ruling out the medial meniscus as a possible diagnosis. Joint line tenderness has higher values of positive and negative likelihood ratios, which was negative. Although Thessaly’s and McMurray’s tests are better diagnostic tests compared to Appley’s test; a combination of history, pain location and joint line tenderness can also play important role in diagnosis (Logerstedt et al., 2011a; Smith et al., 2015; Décary et al., 2018).

Mechanism of injury, in this case, might have caused PLC injury which occurs less commonly (Crespo et al., 2015; Chahla et al., 2016). PLC injuries are associated with concomitant injuries of cruciate ligaments. Since MRI report was also showing PCL and ACL involvement, along with the subjective history and pain location, to suspect PLC injury (Logerstedt et al., 2011b; Crespo et al., 2015); evaluation of PCL and PLC during first assessment would have helped towards a possible diagnosis. Although there are fewer studies on diagnostic tests, available studies mention that frog-leg test and posterolateral tenderness are useful to diagnose PLC injury (Ellera Gomes, 2016; Ranawat et al., 2008). Also, there are limited studies evaluating the specificity of PCL tests; but the posterior drawer test, quadriceps activation test, posterior sag test have a better sensitivity (Kopkow et al., 2013).

No patient reported outcome taken in this case to address psychosocial aspects. Factors such as difficulties in performing social activities, the surgical advice might be important in acute conditions affecting lower limb. Lysholm score used in ACL and meniscal injuries is responsive in acute trauma and might be useful patient reported outcome for knee injuries (Briggs et al., 2006, 2009; Logerstedt et al., 2011b)

Conclusion

Imaging has to be used as supportive to clinical finding and its early use might affect the decision making process. Knowing the right cues of available information is important for accurate diagnosis. Therefore, patient history and clinical evaluation play a major role in diagnosis. The findings in the MRI report were not clinically matching. Hence, a more analytical approach would have helped in this case, as the quality of MRI was unknown and only written reports were available.

A cluster of diagnostic tests is useful while assessing particular injuries instead of using only one or two tests. Some of the tests alone might not be of diagnostic value but in combination with other tests might improve quality of assessment. Better tests such as Lachman test and pivot shift test could be of more diagnostic value in conjunction with anterior drawer test for confirming the extent of ACL injury.

The patient recently assessed by different physiotherapist had the complaints of postero-lateral instability. Although patient manifested with postero-lateral instability after 14 months of injury incidence, early symptoms were quite localised postero-lateral to joint. Further diagnosis of his recent complaints is unclear. Thorough knowledge of pathoanatomy and high suspicion is necessary to speculate PLC injuries. These injuries might present with injuries to other ligaments in acute phases. Since PLC and PCL injuries might not present with early instability, it might be misgiving. Patient’s symptoms subsided in a short period, had a huge impact in ruling out the possibility of a broader diagnosis. However, patient history was enough suggestive to carry out clinical examination for PLC and PCL.

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