Muscle Training Intervention in Heart Failure Article Review

Muscle Training Intervention in Heart Failure Article Review Principles of Research in Nursing Practice A Critical Appraisal of Padula, C. A., Yeaw, E. and Mistry, S. (2009) A home-based nurse-coached inspiratory muscle training intervention in heart failure. Applied Nursing Research, 22: 18-25. Guidelines by Burns and Grove (2011) form the basis of this appraisal. Statement of the problem purpose of the study Padula et al. (2009) begin by discussing the clinical problem that led to the research being conducted. Disabling dyspnoea in heart failure (HF) is affecting patients’ quality of life. Impaired inspiratory muscle function has been recognised as a potential source of dyspnoea in HF. The purpose of the research emerges logically from the clinical problem which is to determine the effectiveness of an inspiratory muscle training intervention (IMT) on dyspnoea and health-related quality of life (HRQOL). The purpose of the study is directly linked to the clinical problem because the experimental hypothesis; if upheld may facilitate improved therapies for HF patients. Literature Review This section is clearly defined and well organised. A review of the abstracts for the eight sources cited in the ‘IMT in HF’ section denotes that all are relevant primary data-based studies. There are only two sources cited within 5 years of the acceptance date for publication. Sources should be current (Burns Grove, 2011). The researchers fail to acknowledge whether a systematic search strategy was exercised (Moule Goodman, 2009). Furthermore, the investigators may have found additional sources if they had included theoretical literature. Padula et al. (2009) paraphrase the knowledge gleaned from each source and form a critique of the overall methodology used in these studies. Three of the studies did not employ a control group; this decision may have threatened their capacity to infer causal relationships. In the RCTs, sample sizes were small and effect sizes were not published. Consequently, the ability to detect differences in outcomes between groups was compromised (Seers Critelton, 2001). The literature review identifies gaps in the knowledge base which builds a case for the present study. Padula et al. (2009) report that further research is necessary to determine the precise intensity of IMT. Study Design Sample There is ambiguity regarding the study design as the researchers refer to the study as an RCT on two occasions. On closer inspection, the study does not meet the criteria for this classification as complete experimental control is not possible (CASP, 2014). The study is a two-group quasi-experiment with pre- and post-test design (Hek Moule, 2006). This design is appropriate to address the research question. Although participants are assigned to groups with equal probability, the method selected (i.e. coin toss) is not entirely appropriate for small sample sizes (i.e. n=31) because it may lead to imbalance between the size of the experimental group and control group. Schulz Grimes (2002) explain that when a succession of tails or heads is thrown, it is tempting for the researchers to modify the results. This may result in subtle differences between groups. A more sophisticated method would be to use computer generated random numbers (Crombie, 2005). RCTs are conducted in research units to ensure greater control over extraneous variability. The present study was conducted in patients’ homes. The research population was stable HF patients without coexisting pulmonary disease or cognitive impairment. The sampling method is nonprobability convenience because the researchers recruited participants by means of newspaper advertisements and physicians’ offices (Clark-Carter, 2001). This method may have excluded patients who did not visit their physician on a regular basis. The article fails to include a power analysis; a test to assess the study’s ability to detect significant differences. The researchers acknowledge that the sample was small (n=31). An effect size for IM strength was reported (d=0.48). Data Collection The data collection methods are appropriate for measuring the dependent variables (Padula et al. 2009). Test-retest reliability values are documented for the following measures: PI max, the Borg scale (1982), and self-efficacy. These values should be documented for all data collection methods (Burns Grove, 2011). This useful statistical test is a measure of the stability of the scores elicited over time (Sim Wright, 2000). A Chronbach’s alpha score was only documented for one of the measures. This statistical test measures internal consistency; i.e. how confident are we that the individual items in a scale are accurately measuring the same construct (Clark-Carter, 2001). The article reports that the research assistants followed a specified protocol, however this is not provided in the report. The article should document all the steps taken to reduce errors during the data collection process (Burns Grove, 2011). For example, it is unknown whether steps were taken to reduce user error in taking physiological measurements such as respiratory pattern. Measurements were taken at spaced intervals (i.e. weeks 1, 3, 6, 9 12); this design feature strengthens our confidence in the findings. Mention should be made here of the possibility of demand effects; the notion that participants may have modified their responses on the Borg scale to match the expectations of the study (McCambridge et al. 2012). Analysis The inferential analyses (ANOVA) conducted are appropriate for the type of data collected (Ratio/interval and ordinal; Dancey Reidy, 2011). Post hoc analyses were used to detect the location of the differences in two of the dependent variables; a best practice approach. A table showing all mean scores including significance levels for each dependent variable would be beneficial to the reader. A significant difference was detected for IMT strength in the experimental group (p Discussion The key findings are clearly stated and are consistent with previous literature. The researchers offer an alternative explanation to account for why a significant improvement in IM strength and dyspnoea in the IMT group was found. Participants may have become accustomed to the technique of generating high maximal inspiratory pressures; this is referred to as the training effect. This is a confounding variable that could compromise the internal validity of the study. The researchers account for why the secondary aim of the study was not met. The measurement for self-efficacy (the CSES) was inadequate for the purpose it was intended for. The researchers acknowledge the study’s limitations – the relatively small sample size (n=31). The strict inclusion criteria effects external validity as the findings cannot be generalised to patients with HF and coexisting COPD which is prominent in the population. This is acknowledged as a potential source of error. The study contributes to an evidence base for the use of IMT as an additional treatment for stable HF and provides recommendations for future research. Word count: 1100 References Borg, G. (1982). Psychophysical bases of perceived exertion. Science in Sports and Exercise, 14 (5): 377-381. Burns, N. and Grove, S. K. (2011) Understanding nursing research: building an evidence-based practice. 5th ed. Maryland Heights, MO: Elsevier Saunders. Critical Appraisal Skills Programme (CASP) (2014) CASP checklists [online]. Available from: http://www.casp-uk.net/#!casp-tools-chcklists/c18f8. [Accessed 1 June 2014]. Clark-Carter, D. (2001) Doing quantitative psychological research. East Sussex, UK: Psychology Press Ltd. Crombie, I. K. (2005) The pocket guide to critical appraisal. London: BMJ Publishing Group. Dancey, C. and Reidy, J. (2011) Statistics without maths for psychology. 5th ed. London: Prentice Hall. Hek, G. and Moule, P. (2006) Making sense of research: an introduction for health and social care practitioners. 3rd ed. London: Sage Publications Ltd. McCambridge, J., de Bruin, M. and Witton, J. (2012) The effects of demand characteristics on research participant behaviours in non-laboratory settings: a systematic review. PLoS One, 7 (6): e39116. Moule, P. and Goodman, M. (2009) Nursing research: an introduction. London: Sage Publications Ltd. Padula, C. A., Yeaw, E. and Mistry, S. (2009) A home-based nurse-coached inspiratory muscle training intervention in heart failure. Applied Nursing Research, 22: 18-25. Schulz, K. F. and Grimes, A. (2002) Blinding in randomised trials: hiding who got what. The Lancet, 359 (9307): 696-700. Seers, K. and Critelton, N. (2001) Quantitative research: designs relevant to nursing and healthcare. Nursing Times Research, 6 (1): 487-500. Sim, J. and Wright, C. (2000) Research in health care: concepts, designs and methods. Cheltenham, UK: Stanley Thornes. 1

Home Alarm Case Essay

1) What is the LTV (looking 8 years out) of a customer who used auto-pay? The Life time value of a customer who used auto-pay is $1670.69 (LTV net of acquisition costs= $1373.69) 2) 2)What is the LTV (looking 8 years out) of a customer who did not use auto-pay? The Life time value of a customer who did not use auto-pay is $1361.87 (LTV net of acquisition costs= $1064. 87) 3) What is the maximum amount that Home Alarm could spend on customer and salesperson incentives to convert a residential customer to auto-pay? The maximum amount that could be spent should be the difference between the Lifetime Value of customers that sign up for non-autopay service ($1064.87) and the LTV for the ones who opted for an autopay service ($1373.69); which is $308,82. So far, Home Alarm doesn’t assign any budget for marketing at the time of sign up, so it could be a good idea to invest this amount ($308,82), or less, for a marketing campaign during the acquisition period, emphasizing the convenience of the automatic payment contract. 4) What new pricing strategies and services should Home Alarm consider to sign up new customers with auto-pay? One strategy to push new customers to sign up with autopay could be offering them the installation for free. In this case the cost of acquisition for each new customer who signs up for the autopay service would be $492 instead of $297. With this option, the lifetime value of each customer who opts for the autopay service will be $1178.69, lower than the amount that could have  been earned had they chosen this solution anyway, but higher than the $1373,69 that the company would earn had they not chosen the autopay. The main problem for this option is that we don’t have any information about the percentage of people that would choose the automatic payment without any incentive; indeed if we assume that 50% of the customer would choose the automatic payment in any case, we would earn 113,82 dollars (1178.69-1064.87) on average for each customer who decides to choose the automatic payment over the non automatic one, but we would lose $195 for each customer that would have chosen this method even without incentives. (Table 1) It could be worthwhile to offer just a reduction of the installation costs. For instance, offering a discount of 50% on the installation cost would increase the LTV of customers that choose autopay over non-autopay by more than $200 and would create a loss of only $97,5 per customer that would have opted for autopay without further incentive. Another strategy could be offering the new customers who opt for an automatic payment service a fixed price for the first three years (not increased by the annual 3% rate). In this case the LTV net of the acquisition costs would be $1305,5, still higher than the one the company would earn whether the customer opts for a not automatic payment. Moreover, offering 8 years of fixed price ($480) is still more profitable than the case in which the chose a not autopay method, but it is, in my opinion, not recommendable, because of the negative effect that it could have on the customer that chose this option before. Indeed they could decide to resign the contract and try to get a new one with the more convenient conditions. (Table 2) 5) What new pricing strategies and services should Home Alarm consider to convert existing customers to auto-pay? Taking in consideration the attrition rate during the past nine years, it seems to be more convenient try to convert the customers as early as possible; indeed the peak of the churn rate is between the third and the fourth year. One solution could be offering discounts for the customers that are willing to switch method, maybe offering them a reduction in the general rate. For example, the customers that opt for convert their payment method  could see their price increase just by 2% per year instead of the 3%. For instance, if the conversion happens during the first year, the LVT net of acquisition costs would be $1243.17 (the retention rate for the first year would be the same of the non autopay situation), significantly higher than the basic case. This numbers are obtained in the optimistic scenario where the attrition rate in case of switch would be exactly the same of the ones who initially chose for the automatic payment. (Table 3) Another option could be offering couple of years with a fixed price, as explained for the new customers.

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Create Structures And Styles And Use Them Essay - 1860 Words

Create structures and styles and use them to produce websites KU 1.1 Please see initial design folder 1.2 The main law I was concerned with while creating the site was the copyright, Designs and Patents Act. To ensure the site was in line with this act with regards to images I created the Background of the logo myself using GIMP2 I then converted the background of a Lion rampant to Alpha so I could place this image on top of the background image. I am also covered by the creative commons to take and change an image found on the web. Since there was work completed on the image the final logo can be claimed as my own intellectual property. ST 1.1 Planning involved consideration of navigation method, colour scheme, logo design, favicon design, font choice and site name. Once these had been decided upon I started to gather resources for the project. The first thing that was obtained was the site font, this was found by going to google fonts and searching for stencil. A stencil font was chosen as the website is for booking and finding out about airsoft (a sport like paintball but using plastic pellets instead of paintballs) and therefore this font gave the site a military-esque feel relating back to the military theme. The next consideration to deal with was colour scheme originally a black and brick red colour scheme was chosen but later seeing the site using this scheme it was deemed too dark, I, therefore, opted for an off-white and red colour scheme as this lifted the pageShow MoreRelatedThe Tolo House Designed By Portuguese Architect Alvaro Leite Siza1234 Words   |  5 Pages$150,000 budget and took the concept of sta irs to a whole new level. Inspired by influences of the works such as Piranesi, Escher, and Wright he was inspired to use lighting and space to create a house much in the style of Fishburn, working not to stand out but rather to fit closely within its site, making the site almost a part of the structure which Siza designs. 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