Critique of Colella & Gejerman’s Study “Survivorship Health Information Counseling for Patients with Prostate Cancer” Laura Laughbaum, SN Lake Superior State University

Abstract
This paper is an academic critique of an article written by Colella and Gejerman (2013) titled: “Survivorship Health Information Counseling for Patients with Prostate Cancer.” The authors undertook a research study to examine whether specialized discharge education counseling increased prostate cancer patients satisfaction with their care and education related to their chronic health problems after radiation therapy. My examination systematically focuses on specific aspects of the article in terms of process and validity of research methods and results. I have attempted to develop a cohesive and unified explanation which not only expounds the particulars of the research but which also formulates a clear interpretation of that research throughout. I suggest that the lack of communication of the researchers in this article about their methods of sample selecting and data analysis greatly reduces the validity and generalizability of their findings.

Critique of Colella & Gejerman’s Study “Survivorship Health Information Counseling for Patients with Prostate Cancer” In their article, “Survivorship Health Information Counseling for Patients with Prostate Cancer,” (Colella & Gejerman, 2013) outline a quasi-experimental research design involving two sample groups (one experimental and one control) of fifty-two males with prostate cancer that had undergone radiation therapy. In their introduction to the article, the authors state that “survivorship care if often overlooked, and health care providers fail to include potential latent chronic problems resulting from cancer treatment in their education interventions (Colella & Gejerman, 2013). This statement basically outlines the premise behind the research. The authors articulate their recognition of the fact that educating must be focused around cancer patients needs not just during cancer treatment but afterwards as well. Their research itself is based on exploring the possibility that patient satisfaction in their care is increased by survivorship counseling based specifically on the needs of prostate cancer survivors when compared with the satisfaction shown with general discharge education.
Problem
Colella & Gejerman’s (2013) study problem is clearly introduced in the beginning paragraph of this article which stated that cancer survivorship care and education are overlooked by health care providers in the cancer care continuum, leading to patient dissatisfaction in their care (Colella & Gejerman, 2013). The problem is thoroughly explained by a descriptive statement on the background of the problem which offered numerous statistics on the scope of the problem, namely, the prevalence of prostate cancer and rates of survival. Consequences of the problem that prostate cancer patients face after therapy such as urinary incontinence and erectile dysfunction as well as care dissatisfaction were summarized. Multiple citations supporting these statistics and implications were provided. Of particular importance to the authors is the fact that although eighty-percent of cancer patients seek survivorship health counseling, only twenty-percent actually receive information about chronic the health conditions caused by their cancer therapy which leads to wide spread patient dissatisfaction (Colella & Gejerman, 2006). This statement alone builds a persuasive argument for a new study. The researcher’s argument led logically to undertaking of this study, in that its goal is to determine if survivorship education improves patient satisfaction in their care and to provide strategies to health care providers in their efforts of educating cancer survivors. In their research, Colella & Gejerman (2006) focused on answering a specific research question which is stated clearly in the article as, “Will the addition of survivorship discharge health information counseling that includes patient health information preferences for men completing radiation therapy for prostate cancer improve satisfaction when compared to usual discharge health information?” (Colella & Gejerman, 2006). The components of the research question was outlined specifically in a PICOT (Population, Intervention, Comparison, Outcome, Time frame) (Colella & Gejerman, 2006) format which was quite clear in the introduction of the article. The PICOT format made it apparent that the independent variable was survivorship discharge health counseling and the dependent variable was patient satisfaction. The variables were further explained through a section on concept definitions. Although the researches did not explicitly state their hypothesis, the implication is that the researchers expected that patients who were provided with survivorship health discharge counseling related to their prostate cancer would report higher levels of satisfaction in their care. The problem of cancer patient’s satisfaction of their survivorship care is significant not only to oncology nursing, but to all areas of nursing as the prevalence of cancer is wide spread and many nurses will need to offer care and support to patients related to either the cancer itself, or the chronic health problems that can develop after cancer therapy. In order to provide a high standard of survivorship care, nurses need to be aware of its importance to patients and be equipped with tools to provide the education and care necessary to meet the needs of such cancer survivors. Colella & Gejerman (2006) do not mention a specific theory or model on which there research is based, but they do set down as conceptual framework in the article’s “Definition of Concepts” section. The conceptual definition section used cited sources to define the following terms: satisfaction, survivorship, and survivorship discharge health information counseling. The concepts were not only defined, but thoroughly explained by the provision of background information and implications each had on cancer patients. By providing an good explanation of their concepts, the authors specified what exactly they were studying, and gave incite into understanding the results and what they were hoping to achieve by their study. The framework was a sufficient guide to their study methods as the conceptual definitions were the same as the operational definitions. The authors interpreted the findings of this study within the context of the framework and tied them back to the framework at the end of the report.
The authors draw on pre-existing research to formulate the purpose of their own study. Additionally, they seem to have drawn on a comprehensive list of sources throughout the study. For example, with the implementation of the independent variable (health counseling) they provided their patients with health information gleaned from existing resources on health conditions related to prostate cancer. Also, when evaluating the dependent variable (patient satisfaction), they relied heavily on a previous utilized questionnaire from other prostate cancer studies, which indicates that they closely followed the findings outlined in the literature. Specifically, in their use of the Patient Satisfaction Questionnaire, which could possibly have introduced problems of internal validity, which is the degree to which it can be inferred that experimental intervention rather that other variables is responsible for the outcome (Polit & Beck, 2014). The authors referenced multiple articles to assure the reader that their questionnaire has been found to have high construct validity in its ability to assess patient satisfaction. While this is the case, the authors note that they put a commendable effort into selecting the best research to reference by meeting strict exclusion criteria. Their use of the John Hopkins Nursing evidenced-based practice appraisal tool to guide them in assessing the strength and quality of the evidence they found in their literature review and then used in their study instills confidence in the reader. Generally, the review of literature seems comprehensive and a majority of the studies were high level-one research studies. The authors referenced previous studies on cancer survivorship from various reputable oncology journals. However, the list of references did not reflect a multidisciplinary approach to their review. It is surprising that given the nature of the problem being study, that none of the references were from psychological journals. On a positive note, the authors did an excellent job in explaining in detail the studies they did use. They even provided a very convenient, comprehensive table outlining each study’s intervention and statistical findings. In terms of being up-to-date, the review of the literature seems valid. That is, the article includes a well organized bibliographical reference list of twenty-two sources and eleven of those sources were published during or after 2009. A vast majority of those studies took place after 2006. Although the researchers did not indicate any gaps in knowledge, the literature seems to be directly related to the development of this study and is involved in the development of the the research hypothesis and intervention as discussed above.
Research Design Colella & Gejerman (2006) used a design experimental in nature that involved assignment of participants to an experimental group that received an intervention, survivorship discharge health education through their pilot survivorship program, or a control group that received only “usual care health counseling.” The intervention of the experimental group was clear and adequately described. For example, the authors explained what educational resources and delivery methods were used to provide their educational intervention. The “usual care health counseling” provided to the control group was not elaborated on at all. Despite a solid intervention and control group, this study can only be categorized as quasi-experimental because it is not clear from the authors’ description of the design if it contained randomization, the signature of a true experiment, in its selection of participants (Polit & Beck, 2014). The confounding variable identified in the study was the ability of the participants to read and understand the survivorship educational material because their inability to do so would have effected the results of the study. Although it is unclear to what extent randomization was used to select the subjects for this study, the researchers presumably did control extraneous subject characteristics somewhat by using homogeneity by only selecting English-speaking participants. Controlling confounding variables is vital to insure outcomes (patient satisfaction) reflect the influence of the independent variable (survivorship education), but homogeneous sampling limits the generalizability of this study’s findings to other types of cancer patients (Polit & Beck, 2014) . The concepts and goals of this study are clear, but given the lack of specific explanation of their sampling technique and control methods, there is not enough information in this article to permit true replication.
Sampling
Unfortunately, the the authors did not describe their sampling methods at all, except to state that fifty-two male, English-speaking participants were recruited who had received radiation therapy for prostate cancer (Polit & Beck, 2014). No explanation is provided from where or how the participants were recruited or assigned to their specific groups. The authors did not indicate that a power analysis was conducted to determine they had an adequate sample. The inclusion criteria was evident and included spoken language, gender, diagnosis, and treatment type. The article did not provide response rates (i.e. The number of people participating in a study relative to the number of people sampled) (Polit & Beck, 2014). The lack of knowledge in regards to the response rate prevents the reader from assessing whether there was a possible non-response bias-- differences between subjects who participated and those who did not (Polit & Beck, 2014). The results of this study would be altered if a number of cancer patients did not feel well enough to participate due to the stage of their cancer, thus making it very unreasonable to generalize the results of this study to the targeted population of cancer patients. This article’s explanation of their sampling method is disappointing and makes it difficult to draw conclusions about whether the evidence has relevance to clinical practice for the general population.
Protection of Human Rights Colella & Gejerman (2013) state that their project was submitted to an academic institutional review board as well as their health care facility review board and was approved as both boards felt that the project did not meet the criteria for a human subjects research. There was no indication in the article that participants gave voluntary or conformed consent to be part of the study, although it is stated that each experimental group participant did agree to schedule a follow up appointment at which time the intervention education was given. It is safe to assume that the return of the completed questionnaire reflected the subject’s voluntary consent to participate. Risks to the subjects in this study were minimal, or expected to be no greater than those ordinarily encountered during routine hospital discharge (Polit & Beck, 2014). The only risk that the authors considered significant to mention was for the possible inconvenience of the patient taking time to receive the survivorship counseling. The authors did note that they tried to reduce this inconvenience by coordinating the intervention with scheduled treatment times. There is no evidence in the study that individual participants can be identified. The researchers noted that they provided anonymity, the most secure way of protecting confidentiality, by eliminating any patient identifiers on their satisfaction surveys (Polit & Beck, 2014).
Data Collection To collect the data from their study, Colella & Gejerman (2013) used a self-reporting questionnaire in the form of a Likert scale which consists of several statements that expressed a viewpoint on a topic, and participants are asked to indicate how much they agree or disagree with each statement (Polit & Beck, 2014). In this case, the researchers used the Patient Satisfaction Questionnaire, which they cited as being developed by prostate cancer experts and previously utilized in other studies. The questionnaire was five-points and measured the patient satisfaction of both experimental and control groups in the discharge education they received following the discharge intervention (“usual” and post survivorship counseling). The reliability, the degree of consistency with which an instrument measures an attribute, and the validity, the degree to which an instrument measures what it is intended to measure (Polit & Beck, 2014), of the Patient Satisfaction Questionnaire was addressed by the authors of this article. Unfortunately, they determined the validity and reliability solely on the word of two sited sources. Colella & Gejerman (2013) argued that the Patient Satisfaction Questionnaire has a high reliability alpha value of 0.89 (as cited in Harden et al., 2009; Northouse, Mood, Schafenackr et al., 2007). The authors felt that because the theoretical basis of their study was similar to previously random controlled trials on prostate cancer patient satisfaction, it was sufficient to conclude that the content and construct validity of the questionnaire adequately supported interpretation of scores from their study as well. Overall, the self-reporting instrument and procedure was appropriate for this type of study. However, it would have been prudent for the researchers to communicate some basic information about the actual procedure used in implementing the questionnaire to collect their data. Their lack of communication in regards to their approach leaves the reader questioning who distributed the questionnaires and if there were any efforts made to reduce response bias, the tendency of some individuals to respond to items in characteristic ways (e.g., always agreeing), independently of item content measure (Polit & Beck, 2014). It would be concerning if the nurse who provided the discharge counseling administered the questionnaire; the participants may have felt obligated to report satisfaction in favor of the nurse. An explanation of the collection plan would have afforded the reader an opportunity to better assess the quality of evidence produced by this study and to feel more confident in the validity of this study’s findings. The researchers’ explanation of their data analysis strategy was brief. Colella & Gejerman (2013) explicitly state that they used descriptive statistics using frequency distribution to analyze and compare their data of the “usual” discharge instruction satisfaction with the survivorship intervention satisfaction. The statistical results were presented clearly and simply in a cross-tab table. The results indicated that patient satisfaction percentages were significantly higher for those receiving the survivorship intervention than those receiving the “usual” discharge instruction. These authors did not provide any indication that they did any statistical hypothesis testing which uses objective data to decide whether a research hypothesis should be accepted as true or rejected as false (Polit & Beck, 2014). The validity of this study would have been strengthened by statistically controlling the risk of Type 1 error, an error made by rejecting a null hypothesis that is, in fact true(Polit & Beck, 2014). To explain, the researches concluded that that their intervention yielded higher patient satisfaction when compared to the “usual” discharge counseling when, in fact, the group differences could have been due to sampling error, not the fact that the survivorship counseling was actually more effective. To their credit, the researchers did provided some information about their program’s participants using data gleaned from the questionnaires. It is reassuring that both the experimental and control group’s participants were represented fairly equally by both college and non-college graduates (about fifty-percent of subjects held bachelor degrees)(Colella & Gejerman, 2013). This is reassuring because the level of education could have affected the patient’s perception of the discharge counseling and educational materials provided. To summarize, the data analysis of this report is weak. There is no mention of hypothesis testing, thus no statement of an achieved level of significance, the probability of making a Type 1 error (Polit & Beck, 2014), so the reader cannot be confident in the researchers’ statistical decision making or their acceptance of the hypothesis. Conclusion The conclusion of this article stated that results of this research article are shown to support the hypothesis of the authors to be correct as expected. An increase in patient satisfaction relative to the change in instructional strategy occurred within the experimental group and is attributed by the authors to the independent variable. The authors indicate that the project was a success: “The pilot results provide initial support for the implementation of cancer survivorship information for patients with prostate cancer undergoing external radiation”(Colella & Gejerman, 2013). The authors did not discuss their results in terms of previous research, but it is clear from the information they gave from their literature review that their findings were similar. Although the researcher did not discuss the strengths or limitation of their study, the authors did indicate that further research is needed in multiple sites with larger samples to gather additional date to support this approach to patients discharge and counseling instructions” (Colella & Gejerman, 2013). This indicates that the researchers, while holding on to the notion of success, acknowledge the fact that their results are related to one survivorship model for one type of cancer and more research and development need to take place to generalize the intervention to other cancer patients. The authors did acknowledge their the clinical significance of their findings to oncology nurses. They state that their study showed evidence that there is opportunity for oncology nurses to develop teaching models to help all health care providers in proving comprehensive survivorship care. Summary This report was well organized and identified a significant problem related to cancer care and a generous amount of detail from previous research. The researchers undertook a very thorough literature review and are to be commended. However, the efforts they made to discuss their own research pales in comparison. This article seriously lacked fundamental components of a rigorous research study which leaves the reader questioning the validity of the results. The most concerning aspects of this report, as previously mentioned, are the authors’ lack of communication in regards to their sampling strategy, their efforts to reduce bias, and their responsibility to do a rigorous data analysis. To provide readers with confidence in the construct validity of the their study, the researchers could have showed evidence that their participants were randomly selected and created two groups that were comparable at the onset of the study, reducing the threat of selection bias. The threat of response bias could also been lessened if the researched explained more about how and by whom their questionnaires were distributed. In terms of statistical validity, the researchers did not show evidence that they did any type of analysis other than using descriptive statics to compare and summarize the percentages of patient satisfaction for each group being studied. The use of inferential statistics such as hypothesis testing would have instilled more confidence in the conclusions that they drew based on their data. Overall, the goals of this study was admirable, but the results are not convincing based on what is seen in this report. Given the care that was taken in the research review and the effort put forth to conduct this pilot study, the researchers likely had a fully developed protocol and date analysis, but opted to abbreviate their presentation. Unfortunately, assuming that the proper methods and analysis were used is not sufficient to support changes in patient care nor enhance evidenced practice. In either case, this study did point out that patient education and satisfaction are not currently at optimal quality levels. Nurses still have a lot of work to do in filling in the gap of educating and supporting not only the patients with cancer, but the ones who have survived.

References
Colella, J., & Gejerman, G. (2013). Survivorship health information counseling for patients with prostate cancer. Urological Nursing, 33 (6), 273-280, 311.doi:10.7257/1053-816X.2013.33.6.373
Gysels, M., & Higginson, I. (2007). Interactive technologies and videotapes for patient education in cancer care. Systematic review and meta-analysis of randomized trials. Supportive Care in Cancer, 15, 7-20.
Harden, J., Falabee, M., Bickes, J., Schafenacker, A., Walker, J., Mood, D., & Northouse, L. (2009). Factors associated with prostate cancer patients’ and their spouses’ satisfaction with family-based intervention, Cancer Nursing, 32(6), 482-492.
Polit, D. F. & Beck, C.T. (2014). Essentials of Nursing Research: Appraising Evidence for Nursing Practice (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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