CULTURAL INFLUENCES IN REHABILITATION

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Chapter 3 METHODOLOGY

INTRODUCTION

The methodology of this quantitative study describes methodologic decisions and examines the rationale for those decisions. These decisions include sample selection, approach to the research, and the research instrument. In addition, the reliability and validity of the study is discussed. Reliability measures include the discussion of the instrument, observational measures, self-report and proxy. The validity of the variables, including threats to internal validity, describes the threat of mortality, attrition, and selection bias. Other threats to external validity, such as expectancy efforts, external events and treatment effects are included (Polit & Beck 2004, 2008). The methodologic decisions to minimize any threats to this study are based on the focus of this study, to document trends in inpatient rehabilitation post discharge outcomes (Polit & Beck 2004, 2008). The research question, to determine if rehabilitation patients maintain functional gains post discharge to the community setting, guides the rationale for these decisions. Further, examining the relationships of selected variables and maintained functional performance is analyzed. These variables will be described as demographic information, medical information, and discharge information of the population, post discharge from inpatient rehabilitation services into the community (Melnyk & Vineout-Overholt 2005).

RESEARCH SAMPLE

Type and size of the research sample group

This study examines the outcome trends of patients discharged from an inpatient rehabilitation setting in an urban rehabilitation hospital in the central southern region of the United States of America, to the community or home environment. Community or home environment will be identified by discharge to home, board and care, transitional living or assisted living (UDS for CMS 2005). Approximately 244 patients are expected to be studied that have been discharged to these community or home settings. Of these 244 subjects signing Informed Consents (Annexure D), it is expected that more than 50% of the subjects will complete the study. Only 74 subjects declined participation in the study at initiation and did not sign the Informed Consent, while 170 subjects agreed to Informed Consent (Annexure D). Diagnosis or impairment groups assigned to subjects will be recorded and includes those occurring in this inpatient rehabilitation setting, meeting inpatient rehabilitation criteria (UDS for CMS 2005). These diagnoses, referred to as impairment groups, include, but are not limited to: stroke, brain dysfunction-traumatic and non-traumatic, amputation, arthritis, pain, orthopaedic conditions, cardiac disorders, pulmonary disorders, burns, congenital deformities, major multiple trauma, developmental disabilities, and debility/ other (UDS for CMS 2005). The expected mean age of the studied sample is 65 years old or greater, due to the historical data of this facility, providing rehabilitation services for the Department of Health and Human Services, Centre for Medicare and Medicaid Services (2005). No control of other demographic characteristics of this sample (gender, race/ethnicity, marital status) was imposed.

Selection of research sample

The statistical theory of acceptance sampling allowed for the inclusion of study participants meeting inclusion criteria. Criteria for admission to inpatient rehabilitation were established and further, following inpatient rehabilitation services, subjects were discharged into the community setting. This eliminates any subjects experiencing death during the inpatient rehabilitation stay, which represents a small mortality rate (<0.2%) of this setting’s discharged rehabilitation patients, consistent with the literature (Ottenbacher et al 2004). In addition, subjects admitted to the inpatient rehabilitation facility that were transferred to an acute care facility were not assigned discharge FIM scores and were not included in this study for analysis. Both mortality rate and acute care transfer rates of this facility are within the United States of America’s National Benchmarks for the UDS for CMS data (2005). Those subjects discharging to intermediate care, skilled care facilities, acute care facilities, chronic hospitals, another rehabilitation hospital, an alternate level of care unit or sub-acute setting, as indicated on the IRF PAI (UDS for CMS 2005:Annexure A), were also not included in the studied sample

APPROACH TO RESEARCH

Evidence based practice

Due to a lack of research reported in the literature, rehabilitation studies must be conducted to generate evidence to guide the practice of rehabilitation and rehabilitation nursing. Healthcare providers should base their treatment decisions or practice, on evidence from well-designed studies, as opposed to decisions based on opinion or tradition. Care delivery outcomes are defined as the observable or measurable efforts of some intervention or action (Melnyk & Fineout-Overholt 2005:307). These outcomes are focused on the recipient of the rehabilitation service and are measured at the individual, group, organization, and community level.
Outcomes research measures the effect of an intervention, directed toward populations (Melnyk & Fineout-Overhold 2005:307). In this study, rehabilitation measures are directed toward the people with disabilities. The goal of evidence based practice is to establish care delivery standards (in rehabilitation) or to develop policy statements about the best practices in rehabilitation (Melnyk & Fineout-Overholt 2005:457). Therefore, this outcomes research will produce evidence-based decision making and action as a result of its findings.
Melnyk & Fineout-Overholt (2005:301) identified evidence based contributors to outcomes. These contributors were grouped by illness severity, patient characteristics, location of services, and provider characteristics. The patient characteristic contributors, resembles the descriptive demographics or patient identification data on the IRF PAI (UDS for CMS 2005:Annexure A). In this study, the data will be grouped and labelled as Demographic Characteristics. Similarly, the medical information on the IRF PAI (UDS for CMS 2005:Annexure
A) includes the impairment group or diagnosis, and the number of comorbidities, as well as the outcomes of functional status (FIM) and the length of stay, with the onset of impairment to determine length of stay efficiency. These contributors will be grouped and labelled as Medical Information, providing information to illness severity. Finally, the data grouped and labelled as Discharge Information, is not unlike the location of services described in studies of evidence based practice, according to Melnyk & Fineout-Overholt (2005). For this study, similar contributors that are included as discharge information are: the community setting the patient is discharged to, whether the patient will be receiving home health services or not, and the person the patient is being discharged with. Therefore, this described data is grouped, labelled and reported, as identified in evidence based practice studies, as contributors to outcomes.

Controlling external factors

In non-experimental research, difficulty results in ensuring constancy of conditions (Polit & Beck 2004:202). In this quantitative non-experimental study, maintaining a constancy of conditions in the environment will be addressed by the investigator to enhance external validity.

Constancy of setting

Data gathered by telephone interview post discharge follow-up from inpatient rehabilitation will be performed in a consistent manner, but in a variety of community or home environments of the subjects. This may include a variety of settings, as described in the sample, although all are discharged to the home/ community. Other settings considered as community or home by UDS for CMS (2005), include board and care, transitional living, and assisted living, and may not allow constancy. As indicated by Polit & Beck (2004:201), data gathered by interviews should be conducted in basically the same type of environment. This discourages a variety of settings, such as the home, place of work, or the investigator’s office. The constancy of setting for this study is the community; although by definition has minimal variations.

Constancy of respondents

A variety of respondents, ranging from the subject to the subject’s proxy, including spouse, caregiver, significant other, and/or attendant, will be communicating the physical functional performance of the studied subject by telephone interview. This variety of respondents could be compounded by the subjects and/or their proxy, assuming different roles (e.g. wife, husband, parent, child), with responses being influenced by roles and social desirability responses (Polit & Beck 2004:359). Social desirability response bias is the misrepresentation of the response by giving answers congruent with prevailing social values (Polit & Beck 2008:432). To assist the investigator in constancy of conditions, the standard decision tree (UDS for CMS 2005:Annexure B) will be utilized for FIM scoring, post discharge follow-up, only by the trained, certified FIM Registered Nurse Investigator, to facilitate an effective telephone interview. Indirect and carefully worded questioning will assist in alleviating this response bias. In addition, sensitivity to the role of the respondent will be considered. Self-report is further discussed, Section 3.3.4.2. Telephone follow-up.

Constancy of time

In addition to constancy of setting and respondents, the time of day and/or the time post discharge (80 to 180 days) of when data collection is performed should optimally be consistent. Time constancy could be difficult for this quantitative study due to the unavailability of subjects by telephone at differing times of the day, in different home or community settings. However, all efforts will be made by the investigator to obtain data consistently, utilizing the structure of the FIM Decision Tree (UDS for CMS 2005:Annexure B); at no more than 80 to 180 days post discharge. Follow-up FIM data of functional performance of the subject will be obtained, with an effort of a minimum of three contact attempts per subject

Management of variables

Assignment of subjects to groups will be used to manage extraneous variables. These groups are identified by the data collection instrument, IRF PAI (UDS for CMS 2005:Annexure A) and will include demographic variables, medical information, and discharge information. Although these groups are used to analyze data, as identified in outcomes of evidence based practice studies (Melynk & Fineout-Overholt 2005), they will not be assigned or controlled prior to the study. In addition, homogeneity should enhance the interpretability of the relationships among the variables. Analysis of variance will increase the precision of the design by determining the relationships among these variables.

Homogeneity

Although all subjects were initially included in this study by meeting admission criteria into inpatient rehabilitation facilities and discharged into the community, some subjects were eliminated after informed consent was signed due to the medical order of an alternate discharge destination that was not predetermined according to the expected, planned trajectory. Therefore, the research findings will not be generalized to subjects that were not discharged into the home or community setting as indicated on the IRF PAI (UDS for CMS 2005:Annexure A). Those discharge destinations not included in this study, indicated on the IRF PAI (UDS for CMS 2005), include: transitional living (03), intermediate care (04), skilled nursing facility (05), acute unit of own or another facility (06-07), chronic hospital (08), another rehabilitation facility (09), other (10), died (11), alternate level of care unit (12), and sub-acute setting (13). Those discharge settings that were included in this study are: home (01), board and care (02), transitional living (03), and assisted living (14). This selection by the investigator allows for a homogenous group with confounding variables, as
determined by the focus for this study on the subjects discharged to the community, post inpatient rehabilitation.

Descriptive analysis

Descriptive Statistics will be used to examine differences in FIM outcomes at discharge and post discharge, 80 to 180 days. The mean, standard deviation, and standard error of the mean for both groups will be analyzed to determine if any difference is attributable to the intervention of inpatient rehabilitation services. Paired t-tests for equality of means will be utilized. Paired t-tests will allow two measures from the same subjects (Polit & Beck 2004:488). The null hypothesis will be rejected, or accepted, in making inferences about the relationship of functional performance at discharge, 80 to 180 days follow-up, to determine if inpatient rehabilitation patients maintain functional gains post discharge to the community setting.

Analysis of Variance

The analysis of variance (ANOVA) will assist the investigator in testing the differences between the means of extraneous variables. Extraneous variables that were identified by UDS for CMS (2005) and the literature review (Ottenbacher et al 2004; Bottemiller et al 2006; Lutz 2004; Aitken & Bohannon 2001; Andstrom & Makler 1998; Schmidt et al 1999) include: age, gender, race/ ethnicity, marital status; diagnosis or impairment group, comorbid conditions, LOS/LOS efficiency; and living setting/ community, home health services including therapy, person living with. Analysis of variance is utilized to detect and interpret relationships of these variables with outcomes as in evidence based studies, such as maintaining functional performance, indicated by the post discharge FIM.
To test the differences of the variables statistically, analysis of variance (ANOVA) will be used. The variability of the dependent variables of functional performance (FIM) at follow-up will be analyzed to determine the variability attributed to the independent variable(s) by mean group differences (Polit & Beck 2004:490; Polit & Beck 2008:596). F-ratios will be computed for each variable. The groups will be determined by the variables identified at data collection, as demographics (age, gender, race/ethnicity, marital status), medical information (impairment group, co morbidities, and LOS efficiency), and discharge information (living setting, home health services, person living with). The analysis of variance will decompose the dependent variable of follow-up functional performance into the variability attributed to the independent variables and all other variability, such as the individual differences (Polit & Beck 2008). This will assist in determining the relationships of the selected variables and maintained functional performance.

Using Records
Advantages of records

The charts and records of the subjects in this inpatient rehabilitation hospital were a valuable resource of available data. As required by the United States of America, Department of Health and Human Services, Centre for Medicare and Medicaid Services (UDS for CMS 2005), the inpatient rehabilitation facility patient assessment instrument, IRF PAI (UDS for CMS 2005:Annexure A), is included in the record of each individual rehabilitation patient or subject, including identification information, demographics, admission information, payer information, medical information, medical needs, FIM scores assigned at admission and discharge, discharge information, and quality indicators (Annexure A). The problem of reactivity and response bias was minimized when data was obtained from existing records. Permission was obtained to utilize these records from the patient and/or family by Informed Consent (Annexure D) and by the institution responsible for the records providing rehabilitation services to the subjects (Annexure C). Institutional Review Board Approval was also obtained from a University setting, as requested by the approving provider of the rehabilitation services (Annexure C).

Telephone follow-up

Self report methods required by telephone follow-up to obtain FIM scores at 80 to 180 days is dependent on respondents, or their proxy, such as family members/ relatives, friends, caregivers, or attendants, willingness to verbally share the accurate information of physical performance (Polit & Beck 2008:369,468). Every effort was made by the Investigator to put the respondents at ease, to encourage openness and honesty, without any approval or disapproval. Informed consent allowed withdrawal from the study at any time if the subject or their proxy did not choose to verbally provide the information. In addition, a decision tree (Annexure B) recommended for telephone follow-up (UDS for CMS 2005), and utilized by UDS for CMS (2005), required structure and training to lessen ambiguity, to facilitate obtaining accurate FIM data post discharge. Further, the telephone interview included sensitivity to different roles and response bias, with a permissive interview to allow honesty, utilizing open and closed questioning appropriately by the investigator.

Quantitative methods

This non-experimental, quantitative study will use statistics in a quantitative method to gather empirical evidence. This will be performed by obtaining two measures from the same subjects, to determine whether the variable that occurs at discharge (FIM) differs from the variable that occurs later in time, FIM at 80 to 180 days. This will be done with paired t-tests (Polit & Beck 2004, 2008). Thus, the research question: is the functional performance at discharge from the inpatient rehabilitation facility maintained later in time in the community? Additionally, analysis of variance (ANOVA) will be used to describe the relationship(s) between the dependent variable or functional performance, and the independent variables of demographics, medical information, and discharge information as indicated on the IRF PAI (UDS for CMS 2005:Annexure A). Thus, this study will also determine outcome trends following inpatient rehabilitation, by determining relationships among these variables and functional performance at discharge and then follow-up. These research questions include: the relationship between age, gender, race, marital status, and maintained functional performance; the relationship between impairment groups, comorbidities, length of stay efficiency, and maintained functional performance; and the relationship between discharge living setting, discharge with home health services, discharge to person living with, and maintained functional performance

Chapter 1 Background Information
1.1 INTRODUCTION
1.2 ACCESSIBILITY OF REHABILIATION
1.3 PREVELANCE OF THE POPULATION
1.4 CULTURAL INFLUENCES IN REHABILITATION
1.5 INSTITUTIONALIZATION OF PERSONS WITH DISABILITY
1.6 REHABILITATION PRACTICE TRENDS
1.7 BACKGROUND OF REHABILITATION POLICY
1.8 BACKGROUND INFORMAT ION ABOUT RESEARCH
1.9 STATEMENT OF RESEARCH PROBLEM
1.10 PURPOSE OF THE STUDY
1.11 RESEARCH QUESTIONS
1.12 ASSUMPTIONS UNDERLYING THE STUDY
1.13 SIGNIFICANCE OF THE STUDY
1.14 DEFINITION OF KEY CONCEPTS
1.15 LIMITATIONS OF THE STUDY
1.16 ORGANIZATION OF THE REPORT
1:17 SUMMARY
Chapter 2 Literature Review
2:1 INTRODUCTION
2.2 PURPOSE OF THE LITERATURE REVIEW
2.3 SCOPE OF THE LITERATURE REVIEW
2.4 LITERATURE REVIEW ON DISCHARGE TRENDS
2.5 LITERATURE REVIEW OF OUTCOMES MEASUREMENT
2.6 LITERATURE REVIEW ON FUNCTION RELATED TO FINANCE
2.7 LITERATURE REVIEW ON PROPOSED ALTERNATIVE MODELS
2.8 RESEARCH IN PROGRESS
2.9 STRENGTHS AND WEAKNESSES
2.10 FURTHER RESEARCH NEEDED
2.11 SUMMARY
Chapter 3 Methodology
3.1 INTRODUCTION
3.2 RESEARCH SAMPLE
3.3 APPROACH TO RESEARCH
3.4 RESEARCH INSTRUMENT
3.5 RELIABILITY AND VALIDITY
3.6 VALIDITY
3.7 SUMMARY
Chapter 4 Presentation and Discussion of the Data
4.1 INTRODUCTION
4.2 ANALYSIS OF THE SAMPLE
4.3 DO INPATIENT REHABILITATION PATIENTS MAINTAIN FUNCTIONAL GAINS POST DISCHARGE TO THE COMMUNITY?
4.4 THE RELATIONSHIPS BETWEEN POST DISCHARGE FUNCTION AND THE INDEPENDENT VARIABLES
4.4 SUMMARY
Chapter 5 Conclusion, Limitations, and Recommendations
5.1 INTRODUCTION
5.2 CONCLUSIONS AND LIMITATIONS
5.3 CONCLUSIONS OF THE RESEARCH QUESTIONS
5.4 DISCUSSION OF LIMITATIONS
5.5 IMPLICATIONS FOR PRACTICE
5.6 RECOMMENDATIONS FOR FUTURE STUDIES
5.7 SUMMARY
LIST OF REFERENCES
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