Health & Medical Question

Hi I need help writing a discussion post, all citations are in APA and is based on the attached article, I will attach the course text for help as well

respond to the following:

Identify the clinical question and describe each portion of the question.

Population – (introduction section)

Comparison (Methods section)

How will you apply this information in your practice setting?

P atient Safety Issues
S
KIN PREPARATION AND
ELECTRODE REPLACEMENT
TO REDUCE ALARM FATIGUE
IN A COMMUNITY HOSPITAL
INTENSIVE CARE UNIT
By Debbie Leigher, BSN, RN, CNML, Paula Kemppainen, BSN, RN, and
David M. Neyens, PhD, MPH
This article is followed by an AJCC Patient Care Page on
page 396.
©2020 American Association of Critical-Care Nurses
doi:https://doi.org/10.4037/ajcc2020120
390
Background Nurses in intensive care units are exposed
to hundreds of alarms during a shift, and research shows
that most alarms are not clinically relevant. Alarm fatigue
can occur when a nurse becomes desensitized to alarms.
Alarm fatigue can jeopardize patient safety, and adverse
alarm events can lead to patients dying.
Objective To evaluate how a process intervention affects
the number of alarms during an 8-hour shift in an intensive care unit.
Methods A total of 62 patients from an intensive care unit
were included in the study; 32 of these patients received
the intervention, which included washing the patient’s
chest with soap and water and applying new electrocardiography electrodes at the start of a shift. The number
of alarms, clinical diagnoses, and demographic variables
were collected for each patient. A Poisson regression
model was used to evaluate the impact of the intervention on the overall number of clinical alarms during the
shift, with no adjustments to the alarm settings or other
interventions.
Results After relevant covariates are controlled for, the
results suggest that patients in the intervention group
presented significantly fewer alarms than did patients in
the control group.
Conclusions Managing clinical alarms is a main issue in
terms of both patient safety and staff workload management. The results of this study demonstrate that a relatively simple process-oriented strategy can decrease the
number of alarms. (American Journal of Critical Care.
2020;29:390-395)
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
www.ajcconline.org
W
ithin intensive care units (ICUs), most equipment has safety alarms embedded that alert staff of changes in various patient parameters and situations.1
This technology can increase the already large number of alarms—sometimes
hundreds—nurses encounter during shifts1,2; many of those alarms are not
clinically relevant.3 Frequent auditory alarms can result in unintended consequences that have implications for patient safety (eg, patient injuries, fatalities) and quality
of care.4 Managing these clinical alarms has been identified as a “top 10” safety concern.5
Although all alarms must be acknowledged or
dismissed, clinically relevant alarms require nursing
intervention, whereas false alarms do not. Various
factors can create false or nonactionable alarms: the
patient’s motion, incorrect alarm parameter settings,
the patient’s condition, care being provided to the
patient (eg, bathing or turning), improper skin preparation or electrocardiography (ECG) electrode placement, or faulty connections of leads or electrodes.
Here we use the term false alarms to describe both
false alarms and nonactionable alarms.
In its 2013 Sentinel Alert, the Joint Commission
reported that between January 2009 and June 2012,
alarm-related events led to the death of 80 patients
and to a permanent loss of function in 13 patients.6
Because of the critical importance of patient safety
and the rising number of alarm-related events, the
Joint Commission issued a national patient safety
goal related to alarm management, mandating that
hospitals make establishing an alarm safety system a
hospital priority and identify the most important
alarms to manage.6 In addition, the Joint Commission required accredited hospitals to implement
policies and procedures to manage alarms and
appropriately educate staff.7 When clinical alarms are
more likely to be false than clinically relevant, a
work culture can emerge wherein nurses may delay
responding to alarms, especially when the setting
has a large patient census or a high patient to nurse
ratio, and thus may miss critical alarms.8-10
The ever-increasing number of alarms can lead
to a phenomenon known as alarm fatigue.7,11 Alarm
fatigue can occur when a nurse is exposed to frequent
About the Authors
Debbie Leigher is a nurse manager and Paula Kemppainen
is an assistant nurse manager, Greer Memorial Hospital,
Prisma Health System, Greer, South Carolina. David M.
Neyens is an associate professor, Department of Industrial Engineering, Clemson University, Clemson, South
Carolina.
Corresponding author: David M. Neyens, PhD, MPH, Department of Industrial Engineering, Clemson University,100
Freeman Hall, Clemson, SC 29634 (email: dneyens@
clemson.edu).
www.ajcconline.org
alarms and becomes desensitized to them.8 Alarm
fatigue has been described as the most common
factor contributing to alarm-related events,3,7,12,13
and it is well known that alarm fatigue can jeopardize patient safety and that adverse alarm-related
events can lead to patient fatalities3,7,12 and staff
workload management issues.13 A recent study
showed that alarm management and nuisance
alarms remain problems.14
Much of the previous research on alarm fatigue
has examined the issue from the perspective of
technology and alarm parameters.8,15,16 A technologyonly intervention will not, however, completely
alleviate alarm fatigue because factors related to
organizational best practices and nursing best practices influence alarm management and subsequent
alarm fatigue. The literature focuses on specialized ICUs and ICUs in
large academic hospitals,2,3,7,15,17 but the
patient population in a
community hospital’s ICU is typically more diverse
than that in specialty ICUs at larger facilities. Common diagnoses and conditions among patients in a
community ICU—like the one included in this
study—include congestive heart failure, pneumonia,
gastrointestinal bleeding, sepsis, cardiac arrhythmia,
alcohol withdrawal, suicide attempt, postoperative
complications, diabetic ketoacidosis, and chronic
obstructive pulmonary disease. This diversity makes
managing alarm fatigue through technology-centric
strategies (eg, by adjusting alarm parameters) a challenge for nurses.8,16,18,19 Therefore, alternative strategies are needed to reduce the number of false
alarms and to address and reduce the effects of
alarm fatigue and increase patient safety.
One possible way to reduce the number of false
alarms is to improve skin preparation before placing
ECG electrodes. Cvach et al20 reported that daily
electrode changes reduced by 46% the number of
alarms per bed day in 2 acute care units. Hermens
et al21 recommended changes in sensor placement
procedures in an effort to reduce the number of false
Alarm events can lead to
potential harm for patients.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
391
alarms related to surface electromyography, and they
proposed that preparing patients’ skin could improve
electrode–skin contact, thereby resulting in fewer nonrelevant alarms. In addition, an American Association
of Critical-Care Nurses Practice Alert outlined 7 nursing actions related to false alarms that may reduce the
number of such alarms22: properly preparing the skin
for ECG electrodes, changing ECG electrodes daily,
customizing alarm parameters and levels on ECG monitors, customizing delay and threshold settings for
oxygen saturation via pulse oximetry, providing initial
and ongoing nursing education about devices with
alarms, establishing interprofessional teams to address
issues related to alarms (eg, developing policies and
procedures), and monitoring only those patients who
present clinical indications for
monitoring.1,22 Several of these
clinical decision–related or
technology-mediated interventions can affect the number of
alarms that occur in an ICU,
and they are well documented
in the literature.5,8,15,16,18 We
must, however, further evaluate how preparing the skin
for ECG electrodes and changing the electrodes
affect the number of alarms while accounting for specific patient types and characteristics. Therefore, the
objective of this study was to evaluate how a process
intervention of preparing the skin (ie, washing a
patient’s chest with soap and water) and changing
electrodes at the start of each shift affected the number
of alarms throughout an 8-hour day shift in an ICU.
Methods
Data Collection
The study included 100 patients, with 50 patients
in each group. Each patient was included in the
study for a single 8-hour shift, and no individual
patient was included in both groups. If a patient
experienced no alarms during the 8-hour period,
they were excluded from the analysis. After exclusions, the study included 62 patients. We counted
alarms hourly during the 8-hour period to calculate
the total number of alarms during the work shift.
Several demographics were collected for each patient:
age, primary and secondary diagnoses, body mass
index, activity level, and alertness. Prisma Health’s
clinical engineering department automatically
extracted the hourly counts for red, yellow, and blue
alarms for each patient during the study, but we
included only red and yellow cardiac alarms in the
analyses. A yellow alarm is a low-priority patient
alarm and a red alarm is a high-priority patient
alarm. According to the Philips IntelliVue MP70
Patient Monitors documentation, a blue alarm is a
technical alarm that indicates that the monitor cannot reliably measure or detect alarm conditions.
Study Design
This study included 2 groups. For patients in
the intervention group, a nurse prepared their skin
for electrode placement (by washing the patient’s
chest with soap and water) and changed the electrodes daily (before 8:00 AM). The same clinical staff
member prepared the skin and changed electrodes
throughout the entire study. We collected data only
on weekdays to ensure that the intervention was
consistent and done by the same provider. Patients
in the control group received standard care that
included changing electrodes only as needed, per
standard hospital procedure. We used 3M Red Dot
monitoring electrodes with foam tape and sticky gel
and Philips IntelliVue MP70 Patient Monitors for all
patients. Throughout the study, we did not modify
or adjust any parameters (eg, alarm thresholds) for
the equipment and monitors for any patient.
Statistical Analysis
We conducted all analyses in R statistical software version 3.3.2 (The R Foundation for Statistical Computing). Poisson regression is used when
the dependent variable is a count variable, and in
this study the dependent variable was the number
of alarms during an 8-hour work shift. Thus we
used a Poisson regression model to examine the
impact of skin preparation on the patient alarms.
We included in the model 2 covariates: the age of
the patient and a binary variable that indicated
whether the patient was active and alert during the
8-hour study period. We also created binary covariates as indicator variables for the presence of several diagnoses including alcohol withdrawal,
pulmonary disease, gastrointestinal disease, sepsis,
and cardiac disease.
Red and yellow alarms
were counted for an
8-hour shift in an
intensive care unit at
a community hospital.
392
Study Setting and Sample
This study was conducted after we obtained
approval through the Prisma Health institutional
review board (no. Pro00049513). The study took
place in the ICU at a community hospital. The ICU
is not specialized and is similar to a medical-surgical
ICU in that the patient population varies daily and
can include patients with diagnoses of cardiac, respiratory, or gastrointestinal diseases, sepsis, alcohol
withdrawal, postsurgical complications, suicide
attempt, and others.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
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Table 1
Characteristics of patients in the
intervention and control groupsa
Results
www.ajcconline.org
Intervention group
(n = 32)
Control group
(n = 30)
66.47 (15.41)
65.43 (17.21)
Female
53
57
Body mass indexb
Normal or underweight (≤ 24.9)
Overweight (25-29.9)
Obese (≥ 30)
34
19
47
40
13
47
Conditions
Alcohol withdrawal
Pulmonary disease
Cardiac disease
Gastrointestinal disease
Sepsis
16
63
69
31
31
3
37
33
33
17
Alert and oriented
66
77
Variable
Age, mean (SD), y
a Data are percentages unless otherwise indicated.
b Calculated as weight in kilograms divided by height in meters squared.
15
No. of patients
After exclusion, this study included 32 patients
in the intervention group (receiving skin preparation
and new electrodes) and 30 in the control group
(receiving standard care). The patients’ characteristics are described in Table 1. As mentioned, the
patients’ primary and secondary diagnoses were
separated into binary variables for several conditions, including some disease categories. A patient
was defined as experiencing alcohol withdrawal when
a physician had documented alcohol dependence in
the patient’s electronic health record. Pulmonary
diseases were identified broadly and included
respiratory failure, chronic obstructive pulmonary
disease, and pneumonia. The intervention group
had more patients with pulmonary disease than
did the control group. Cardiac diseases included
hypertension, hypotension, and cardiac dysrhythmia; these were distributed among the study population in a way similar to the pulmonary diseases.
Gastrointestinal diseases also had a similar prevalence between the groups and included all diagnoses related to the gastrointestinal system. Patients
with sepsis were identified in both of the groups.
Patients were defined as being alert if they were
alert and oriented (eg, not confused about person,
place, or time).
The number of alarms across all patients is
shown in the Figure. For most patients, between 1
and 10 alarms occurred during the 8-hour shift,
but more than 20 alarms occurred for 16 patients
during that period. One patient experienced 70
alarms during the 8-hour shift—the maximal
number of alarms during a shift within this study.
Because we automatically extracted from the system
all alarms for each patient, we do not know how
many of the alarms were clinically relevant and
how many were not.
We constructed a Poisson regression model to
predict the number of clinical alarms that would
occur for each patient during the 8-hour study
period (Table 2). We included all demographic and
diagnosis indicator variables in the initial model.
We used stepwise deletion to identify the best-fit
model. In that model, older patients were more
likely to have more alarms than were younger
patients. Patients who were alert and oriented were
more likely to have more alarms than if they were
not alert and oriented. Finally, patients in the intervention group were less likely to have more alarms
than if they were in the control group. No other
demographic or diagnostic indicator variables were
included in the final best-fit model.
10
5
0
0
10
20
Condition:
30
40
No. of alarms
Control
50
60
70
Intervention
Figure Histogram of the alarms during an 8-hour shift for all
patients in both the control and the intervention groups. The purple shading indicates where the alarms between groups overlap.
Discussion
In this study, we evaluated how preparing the
skin and changing ECG electrodes affected the number of alarms that occurred during a work shift in an
ICU at a community hospital. Some of the literature
suggests that this approach is one of several strategies
that might affect the number of alarms that occur in
this setting and thereby affect the likelihood of
alarm fatigue.9,22 When patient age and alertness are
controlled for, preparing the skin and changing electrodes did significantly reduce the total number of
alarms that occurred during the 8-hour work shift,
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5
393
Table 2
Poisson regression model predicting the likelihood of more alarmsa
Parameter
Regression coefficient
SE
Z statistic
Odds ratio (95% CI)
Intercept
Intervention: wash condition
Patient’s age
Alert and oriented
1.826
−0.484
0.014
0.296
0.185
0.065
0.002
0.077
9.887
−7.457
6.527
3.837
6.210 (4.302-8.874)
0.616 (0.542-0.700)
1.015 (1.010-1.019)
1.344 (1.158-1.566)
Null deviance
Residual deviance
1187.3
1074.0
df = 61
df = 58
a All model parameters were significant at P < .001. consistent with the types of reductions Cvach et al20 identified in their previous study. Reducing alarm fatigue is critical in terms of patient safety and nurse workload management.1 Many studies have been focused on technological interventions related to alarm management and alarm fatigue,15 but more straightforward and simple interventions may be beneficial, as organizational and process factors also affect alarm management. Given the Joint Commission’s suggestion to prioritize managing alarms6 and the need for effective strategies to address alarm fatigue, our relatively simple intervention can help meet the goal of reducing the number of alarms that occur. Given that our team used no other interventions during this study, that they did not adjust parameters, and that this intervention did not influence the clinical relevance of alarms, we expect that nurses missed no clinically important alarm. Rather, this intervention most likely reduced the number of alarms related to connection issues and movement of patients. Several limitations are associated with this study and can be addressed in future research. Our study sample was relatively small and included only 1 shift per day. Skin preparation and electrode changes for a full 24 hours may have implications that differ from skin preparation and electrode changes within an 8-hour shift, so future work should investigate the effects of this practice when 24 hours go by between intervention events. We included only uninterrupted monitoring, and we excluded from the study any patient who was moved for a procedure or imaging. Although we did not select any particular patients within the patient census for inclusion in or exclusion from the study, patients with specific diagnoses were unequally represented in each group. It may be possible to address this limitation in future research by focusing on specific diagnoses and populations of patients. We were not able to identify any statistical outliers or any impact Some practice-based interventions may reduce the number of alarms in an intensive care unit. 394 of diagnoses, but unobserved variables might exist that could affect these results. Future researchers should examine more homogeneous populations of patients, including pediatric patients and patients in other telemetry units. We conducted the intervention first and did not randomize assignment to the intervention and control groups because of operational restrictions in implementing the interventions. With targeted populations or adequate samples from groups with specific diagnoses, future research might indicate an interaction between a diagnosis and the intervention. Finally, we did not document a distinction between the alarms that were and were not clinically relevant, but we do not believe that skin preparation and new electrodes would have limited or reduced the number of clinically relevant alarms. False alarms and nonactionable alarms, however, can result from various causes in different contexts and for different patients. Conclusion Alarm fatigue is dangerous, and organizations should implement practices that minimize the effect of an excessive number of alarms that are not clinically relevant on patient safety. Intensive care nurses need to be aware of the potential risks for patients associated with alarm fatigue. Our study focused on 2 nursing actions: preparing the skin for and changing ECG electrodes daily. Our results showed that the number of alarms was reduced during a shift when these nursing actions were implemented in the ICU at a community hospital. Future work should evaluate these interventions in other clinical settings. ACKNOWLEDGMENTS The authors acknowledge the students in the Ergonomics and Applied Statistics Laboratory at Clemson University for reviewing the manuscript, and Puneeth Kalavagunta for his early work on this project. This work was conducted at Greer Memorial Hospital within the Prisma Health System (Greer, South Carolina) and at Clemson University (Clemson, South Carolina). FINANCIAL DISCLOSURES None reported. AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2020, Volume 29, No. 5 www.ajcconline.org SEE ALSO For more about alarm management, visit the Critical Care Nurse website, www.ccnonline.org, and read the article by Nguyen et al, “Double Trouble: Patients With Both True and False Arrhythmia Alarms” (April 2020). REFERENCES 1. Sincox AK, Nault DS. Raising the alarm: patient care at risk from too many . . . bells, beeps & buzzers independent study. Mich Nurse. 2014;87(2):11-15; quiz 15-16. 2. Cho OM, Kim H, Lee YW, Cho I. Clinical alarms in intensive care units: perceived obstacles of alarm management and alarm fatigue in nurses. Healthc Inform Res. 2016;22(1):46-53. 3. Lawless ST. Crying wolf: false alarms in a pediatric intensive care unit. Crit Care Med. 1994;22(6):981-985. 4. Harris RM, Manavizadeh J, McPherson DJ, Smith L. Do you hear bells? The increasing problem of alarm fatigue. Pa Nurse. 2011;66(1):10-13. 5. Keller JP Jr. Clinical alarm hazards: a “top ten” health technology safety concern. J Electrocardiol. 2012;45(6):588-591. 6. The Joint Commission. Sentinel event alert 50: medical device alarm safety in hospitals. Published April 8, 2013. Accessed May 14, 2019. https://www.jointcommission.org/ resources/patient-safety-topics/sentinel-event/sentinelevent-alert-newsletters/sentinel-event-alert-issue-50medical-device-alarm-safety-in-hospitals/ 7. Sendelbach S, Funk M. Alarm fatigue: a patient safety concern. AACN Adv Crit Care. 2013;24(4):378-386. 8. Graham KC, Cvach M. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care. 2010;19(1):28-34. 9. Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily electrode change and effect on cardiac monitor alarms: an evidence-based practice approach. J Nurs Care Qual. 2013; 28(3):265-271. 10. Welch J. Alarm fatigue hazards: the sirens are calling. Patient Safety Qual Healthc. 2012;9(3):26-33. 11. Bell L. Monitor alarm fatigue. Am J Crit Care. 2010;19(1):38-38. 12. Korniewicz DM, Clark T, David Y. A national online survey on the effectiveness of clinical alarms. Am J Crit Care. 2008;17(1):36-41. 13. Honan L, Funk M, Maynard M, Fahs D, Clark JT, David Y. Nurses’ perspectives on clinical alarms. Am J Crit Care. 2015;24(5):387-395. 14. Ruppel H, Funk M, Clark JT, et al. Attitudes and practices related to clinical alarms: a follow-up survey. Am J Crit Care. 2018;27(2):114-123. 15. Allan SH, Doyle PA, Sapirstein A, Cvach M. Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU. Jt Comm J Qual Patient Saf. 2017;43(2):62-70. 16. Imhoff M, Kuhls S, Gather U, Fried R. Smart alarms from medical devices in the OR and ICU. Best Pract Res Clin Anaesthesiol. 2009;23(1):39-50. 17. Chambrin MC, Ravaux P, Calvelo-Aros D, Jaborska A, Chopin C, Boniface B. Multicentric study of monitoring alarms in the adult intensive care unit (ICU): a descriptive analysis. Intensive Care Med. 1999;25(12):1360-1366. 18. Schoenberg R, Sands DZ, Safran C. Making ICU alarms meaningful: a comparison of traditional vs. trend-based algorithms. Proc AMIA Symp. 1999:379-383. 19. Edworthy J, Hellier E. Fewer but better auditory alarms will improve patient safety. Qual Saf Health Care. 2005;14(3):212-215. 20. Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. Daily electrode change and effect on cardiac monitor alarms: an evidencebased practice approach. J Nurs Care Qual. 2013;28(3):265-271. 21. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol. 2000;10(5):361-374. 22. American Association of Critical-Care Nurses (AACN). AACN practice alert: alarm management. Crit Care Nurse. 2013; 33(5):83-86. To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 3622050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org. Copyright of American Journal of Critical Care is the property of American Association of Critical-Care Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. EVIDENCE-BASED NURSING The Research-Practice Connection FOURTH EDITION Sarah Jo Brown, PhD, RN Consultant Emeritus Evidence-Based Practice Norwich, Vermont World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 info@jblearning.com www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online ­booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www .jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com. Copyright © 2018 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. 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Subjects: | MESH: Evidence-Based Nursing | Nursing Research Classification: LCC RT81.5 | NLM WY 100.7 | DDC 610.73--dc23 LC record available at https://lccn.loc.gov/2016030106 6048 Printed in the United States of America 20 19 18 17 16 10 9 8 7 6 5 4 3 2 1 Contents Lead-In xi PART I NURSING RESEARCH 1 Chapter 1 The Research–Practice Connection 7 Research to Practice Clinical Care Protocols Evidence Evidence-Based Practice Short History of Evidence-Based Nursing Practice Your Path to Evidence-Based Practice References 7 8 9 10 12 14 15 Research Evidence 17 Building Knowledge for Practice Findings from an Original Study Conclusions of a Systematic Review Recommendations of an Evidence-Based Clinical Practice Guideline Going Forward References 18 19 22 Chapter 2 23 25 26 iii iv CONTENTS Chapter 3 Chapter 4 Chapter 5 Chapter 6 Reading Research Articles 27 Starting Point Format of Study Reports Reading Approach Wading In References 28 29 37 37 38 Qualitative Research 39 Research Traditions Qualitative Description Uniqueness of Qualitative Studies Exemplar Profile & Commentary References 40 43 46 47 48 51 Quantitative Descriptive Research 53 Methods Study Variables Good Data Extraneous Variables Target Population and Sampling Surveys Results Exemplar Profile & Commentary References 53 55 58 62 64 70 71 73 74 81 Correlational Research 83 Defining Relationship Measuring a Relationship Correlational Design Profile & Commentary References 83 84 94 99 103 Contents Chapter 7 Chapter 8 Chapter 9 v Experimental Research 105 Chapter Map Section 1: Experimental Methods Key Features of Experimental Studies Measurement of the Outcome Variables Limitations of Randomized Experiments Quasi-Experimental Designs Exemplar Profile & Commentary: Why and How Section 2: Study Results More Effective? Outcome Reported as a Mean Attainment of an Outcome Both Perspectives Opinion Regarding Reporting of Outcomes Exemplar Profile & Commentary: Results References 105 106 106 119 119 120 121 133 137 137 137 145 147 149 150 150 151 Cohort Research 153 Design Data Analysis and Results Confounding Other Limitations Case-Control Studies Wrap-Up Exemplar Profile & Commentary References 153 155 155 155 156 157 158 166 173 Systematic Reviews 175 Types of Systematic Reviews Close and Distant Relatives of SRwNS The SR Production Process 175 177 178 vi CONTENTS Chapter 10 Use of SRwNS Umbrella SRs Exemplar Profile & Commentary References 186 188 188 206 208 Evidence-Based Clinical Practice Guidelines 211 Forerunners to Care Protocols EbCPG Production Guideline Formats Comorbidity Guideline Producers Profile & Commentary References 212 214 222 223 223 239 241 PART II EVIDENCE-BASED PRACTICE 243 Chapter 11 Asking Clinical Questions 249 Triggers Questions Not Answerable by Research Evidence Forming a Useful Project Question References 249 251 253 257 Searching for Research Evidence 259 Health Science Databases Nonprofit, International Organizations Professional Specialty Organizations Wrap-Up 260 262 263 264 Appraising Research Evidence 265 Appraisal Systems Appraisal in General Practical Considerations Already Appraised Evidence Resources 266 267 272 273 274 Chapter 12 Chapter 13 Contents Chapter 14 Chapter 15 Chapter 16 Chapter 17 vii Appraising Recommendations of Clinical Practice Guidelines 275 Synopsis Credibility Clinical Significance Applicability Appraisal Guide Format Your Turn References 276 276 278 279 280 280 281 Appraising Conclusions of Systematic Reviews with Narrative Synthesis 283 Synopsis Credibility Clinical Significance Applicability Your Turn References 284 284 286 286 286 287 Appraising Findings of Original Studies 289 Is This a Qualitative or Quantitative Study? Broad Credibility Issues Appraisal of the Findings of a Qualitative Study Appraisal of the Findings of a Quantitative Study Your Turn Across-Studies Analysis Wrap-Up References 289 290 292 293 297 297 300 300 Evidence-Based Practice Strategies 303 Research–Practice Lag Embedding Evidence-Based Practice in Quality Improvement Translating Evidence into Practice Evaluate the Impact 303 305 307 312 viii CONTENTS Information Technology Present and Future Recap References 313 315 315 316 Evidence-Based Practice Participation 319 Capstone Project Contribute to a Patient Care Conference Join a Project Team Make a Poster Present an Idea or Concern Build Your EBP Knowledge and Skills Reference 319 320 322 323 324 325 326 Point-of-Care Adaptations 327 Individualized Care Story Point-of-Care Evidence-Based Practice Story From Mobile Devices The Information Intersection My Ending—Your Beginning References 327 329 330 333 334 335 Appendix A Appraisal Guide: Recommendations of a Clinical Practice Guideline 337 Appendix B Completed Appraisal: Recommendations of a Clinical Practice Guideline 341 Appendix C Appraisal Guide: Conclusions of a Systematic Review with Narrative Synthesis 347 Appendix D Completed Appraisal of a Systematic Review with Narrative Synthesis 351 Chapter 18 Chapter 19 Contents ix Appendix E Appraisal Guide: Findings of a Qualitative Study 357 Appendix F Appraisal Guide: Findings of a Quantitative Study 361 Appendix G Completed Appraisal of the Findings of a Quantitative Study 365 Appendix H Completed Findings Table 369 Glossary 373 Index 385 Lead-In “Evidence is stronger than argument.” —from The Celebrity by Winston Churchill, 1897 H ealthcare professionals apply specialized knowledge and skills in the interest of patients. This text is about the production and use of new knowledge produced by research. As a professional nurse, you should know something about how knowledge for practice is produced and how to use that knowledge in what you do every day. Aims In the first part of the text, the focus is on how clinical knowledge is ­produced—from original studies, to research summaries, to the translation of research evidence into practice guidelines. Just enough of the basics of conducting research are explained so you can understand research reports, research reviews, and evidence-based guidelines published in clinical journals. Then in the second part of the book, the use of research in practice settings is examined. This includes locating, appraising, and translating research evidence into clinical protocols and standards of care. Features of Note ■■ Emphasis on Using Research Evidence Systematic research reviews and evidence-based clinical practice guidelines receive considerable attention as the most ready-to-go forms of research evidence. Basing care on one or even several individual studies is viewed as the fallback xi xii LEAD-IN position—for reasons that are explained early on. In the second part of the text there is a strong emphasis on developing skills in appraising the quality and applicability of the various forms of research evidence. ■■ Easy to Read An online reviewer of the third edition said it was easy to understand because it was written almost like a blog. Although some persons may view these descriptions as an indication that the book is not “academic,” I feel good about them because I have made considerable effort to write so that complex information is conveyed in a clear and de-jargonized way. I hope you find it readable and clear—even interesting. ■■ Format In Part I, a profile and discussion is provided for each exemplar research report you read; this material is presented in a ­consistent WHY-HOW-WHAT format to assist you in breaking a research article down into its key parts. ■■ Exemplars As in previous editions, actual research reports are used to illustrate the different types of research evidence. Careful reading of these exemplars is essential to acquiring understanding of how nursing research is conducted and reported. Four exemplars are printed in full, whereas the citation and abstract are provided for the other three. We are unable to print these three in full here due to copyright restrictions. The full reports should be easily obtained through college, university, and medical center libraries. ■■ Statistics You will note that there is not a chapter about statistics; instead specific statistical tests and their interpretations are incorporated into the explanations of results of the exemplar reports. Students have told me that learning about a statistical test in the context of an actual study is quite helpful. The index indicates the page(s) on which each statistic is explained. ■■ Gender References As with all texts that include examples with unknown persons, there is the she-her/he-him conundrum. There are various ways to deal with it, but I have chosen to sometimes refer to the nurse as she and other times as he—the same with references to an individual patient. Sarah Jo Brown, PhD, RN P A R T I Nursing Research 1 2 3 4 5 6 7 8 9 10 The Research–Practice Connection Research Evidence Reading Research Articles Qualitative Research Quantitative Descriptive Research Correlational Research Experimental Research Cohort Research Systematic Reviews Evidence-Based Clinical Practice Guidelines 1 PART I Nursing Research T he level of knowledge required to understand research reports published in clinical journals is somewhat akin to being a savvy computer user. To be a competent computer user, you do not have to understand binary arithmetic, circuitry, program architecture, or how central processing units work. You just need to know some basic computer language and be familiar with the features of the hardware and software programs you use. Similarly, as a professional nurse in clinical care, you do not need to know all the different ways of obtaining samples, how to choose an appropriate research design, or how to decide on the best statistical test. But you do need to be able to read study reports with basic understanding of the methods used and what the results mean. The goal of the first part of the text is to introduce you to research methods and different kinds of research evidence. To accomplish this, seven research articles have been chosen as exemplars of each major research method. The use of exemplar articles allows me to explain research methods and results by pointing them out in the context of an actual study. For reasons explained in the Lead-In, an abstract and citation is provided for the first three exemplars; the next four are reprinted in full. I strongly recommend that you read all the articles in full, whether they are reprinted in full herein or not. Getting to the full articles for the first three articles using your college or university library access should not be difficult. Admittedly, you might get by reading just the abstract. But if you really want to acquire the knowledge and skills needed to become a nurse who is able to read and put into practice professional health literature, you will have to read the exemplar articles in full. Doing so will help you acquire: (1) understanding of research methods and results, (2) the ability to extract key information 3 4 PART I Nursing Research from research reports; and (3) skill in evaluating whether the research evidence is trustworthy and applicable to your practice. The abstract is just a sketch and lacks the details needed to acquire the needed knowledge and skills. Courtesy of Abby Laux, Landscape Artist of Indiana, U.S.A. One other advisory: Research and evidence-based practice knowledge is built piece by piece from the simple to the more complex across the text. If you don’t master early information, you will struggle when more complex information is presented later in the text. For readers who like to know where their learning will take them, an overview of the text’s learning progression is graphically displayed in F ­ igure PI-1. The main learning goals are in the chevrons on the left side. More specific learning issues associated with each goal are shown to the right. PART I Nursing Research 5 • Why Goal: Understand research • How Synopsis • What • Credibility Goal: How to appraise research evidence • Clinical significance Decision re: Use • Applicability • Clinical protocols Goal: How to use evidence Figure PI-1 • EBP-QI projects Evaluate outcomes • Individual practice Overview of the Text’s Learning Progression C H A P T E R O N E The Research–Practice Connection E ffective nursing practice requires the application of knowledge, information, judgment, skills, caring, and art to take care of patients in an effective and considerate way. An important part of the knowledge used in making decisions about care is produced by research findings. Ideally, all key decisions about how patients are cared for should be based on research evidence (Institute of Medicine, 2001). Although this is not a completely attainable goal, large bodies of healthcare research provide considerable guidance for care. This text introduces you to the basics of how knowledge is produced by conducting research studies and to the application of that knowledge to nursing practice. Research to Practice In the healthcare professions, research is conducted to develop, refine, and expand clinical knowledge about how to promote wellness and care for persons with illness. The development of clinical knowledge about a clinical issue plays out over time proceeding from a single study about the issue, to several similar and related studies, to a systematic summary of the finding of the several studies, to a translation of the summary conclusions into a clinical action or decision recommendation. Thus, research evidence develops as a progression from knowledge that has limited certainty to greater certainty and from limited usefulness to greater usefulness. Actually, clinical nursing knowledge is quite variable with some issues having been examined by only one or two studies and other issues having been 7 8 CHAPTER 1 The Research–Practice Connection studied and summarized sufficiently that research-based recommendations have been issued by respected organizations and associations. The end users of research evidence are healthcare delivery organizations and individual care providers. The healthcare delivery organization could be nurses on a particular unit or ward of a hospital, a nursing department, a multidisciplinary clinical service line, a home care agency, a long-term care facility, or a rehabilitation team; in short: a group of providers or an organization with a commitment to basing the care they deliver on research evidence. Use of research evidence by provider groups and organizations often takes the form of clinical protocols that are developed using the research evidence available. In contrast, individuals use research evidence in a softer, less prescribed way—meaning that they incorporate it into their own practice as a refinement or slight change in how they do something. After reading a research summary about patient education methods for children learning to give themselves insulin, a nurse might alter her teaching approach; or after reading a study about sleep deprivation in hospitalized adults, a nurse working the night shift might pay more attention to how often patients are being awakened and try to cluster care activities to reduce interruptions of sleep. Clinical Care Protocols Clinical protocols are standards of care for a specified population that are set forth by caregiving organizations with the expectation that providers will deliver care accordingly. A population is a group of patients who have the same health condition, problem, or treatment. A population can be defined broadly, for example, as persons having surgery; or narrowly, as elderly persons having hip replacement surgery. Some clinical protocols set forth a comprehensive plan of care for the specified population; for example, perioperative and postoperative care of elderly persons having hip surgery, whereas others address just one aspect of care such as body temperature maintenance in the elderly having hip surgery. Still others are even narrower and could be called a clinical procedure, for example, blood salvage and transfusion during hip surgery. Generally, multidisciplinary groups produce protocols that address many aspects of care, whereas nursing staff members produce protocols that address clinical issues that nurses manage, such as preventing delirium in ICU patients. Evidence 9 Clinical protocols are set forth in various formats: standardized plans of care, standard order sets, clinical pathways, care algorithms, decision trees—all are guides for clinicians regarding specific actions that should be taken on behalf of patients in the specified population. PROTOCOLS ■■ Standardized plans of care ■■ Standard order sets ■■ Clinical pathways ■■ Care algorithms ■■ Decision trees ■■ Care bundles Evidence To produce effective and useful clinical protocols, project teams combine research evidence with other forms of evidence, including: ■■ Internal quality monitoring data ■■ Data from national databases ■■ Expert opinion ■■ Scientific principles ■■ Patient/family preferences There is wide agreement among healthcare providers that research findings are the most trustworthy sources of evidence and that clinical protocols should be based on research evidence to the extent possible. However, when research evidence is not available or does not address all aspects of a clinical issue, the other forms of evidence come into play. In recognition of the fact that multiple sources of knowledge and information are used to develop clinical protocols, they are commonly called evidence-based protocols. Research evidence is an essential ingredient, although, as you will learn, the strength of the research evidence will vary. From here forward I will use the descriptor evidence-based, often abbreviated e-b, to describe protocols and care actions that are based to a major degree, but maybe not entirely, on research findings. 10 CHAPTER 1 The Research–Practice Connection Evidence-Based Practice When research findings are used to develop a protocol and the protocol is followed in daily practice, everyone involved (patients, healthcare professionals, the caregiving organization, third-party payers, and accrediting agencies) can have confidence that patients are receiving high-quality care. This is the case because the recommended actions have been scientifically studied, and people with expertise in the field have considered their application. In addition, the consistency of care achieved with standardized e-b protocols reduces variability and omissions in care, which enhance even further the likelihood of good patient outcomes. Research Evidence EvidenceBased Protocol EvidenceBased Practice Using Clinical Protocols In any care setting, care protocols do not exist for every patient population and every care situation. Healthcare organizations develop protocols to promote effective clinical management and to reduce variability in the care of their high-volume and high-risk patient groups. If a protocol exists, it should be followed unless there is good reason for not doing so. Protocols should be adhered to but with attentiveness to how they are affecting individual patients. Nurses are patient advocates and as such look out for patients’ welfare; this requires that nurses be constantly aware of patients’ responses to protocols. If a nurse observes that a protocol is not producing effective results with a patient, a clinical leader should be consulted to help determine whether a different approach to care should be used. A protocol may be evidence-based and may work well for most patients; however, it may not be right for every patient. Scenario Suppose you are providing care to a patient 2 days after he had a lumbar spinal fusion and you observe that he does not seem as comfortable Evidence-Based Practice 11 as he should be even though the postoperative protocol is being followed; he has no neurological deficit and the surgeon’s notes indicate that there are no signs of complications. You should then ask yourself questions such as, “Why isn’t he getting good pain relief? Should we get a different pain medication approach? Would applying ice packs to his lower back reduce muscle spasm that could cause his pain? Is he turning in bed and getting up using proper technique? Should he be sitting less? Should he use his brace more?” The advisable course of action would be to talk with the patient and then with your nurse manager or a clinical leader about how to supplement or change some aspect of his care. Protocols Þ Recipes So, now you know a bit about how research evidence contributes to good patient care. In the rest of Part I of this text, I will walk you through the methods used to develop clinical practice knowledge. In later chapters of Part II, I will turn your thinking once again to e-b protocols and to how you as an individual can locate research evidence when there is no protocol for a clinical condition or situation. As a Staff Nurse After you have been in the staff nurse role for a while, you may be asked to participate in a project to develop or update a care protocol or procedure. Often, your organization will be adapting an evidence-based guideline that was issued by a professional association, leading healthcare system, or government organization. Other times, an evidence-based guideline will not be available, but a research summary relative to the clinical issue will have been published, and its conclusions will be used in developing the protocol. To contribute to a protocol project, you will need to know how to read and understand research articles published in professional nursing journals and on trustworthy healthcare Internet sites. Scenario You are working in a pediatric, urgent care clinic and are asked to be a member of a work group revising the protocol for evaluating and treating children with fever who are suspected of a having a urinary tract infection. You may be asked to read, appraise, and report to the group about an evidence-based clinical guideline produced by a leading pediatric 12 CHAPTER 1 The Research–Practice Connection hospital. To fulfill this assignment, you should be able to formulate a reasonably informed opinion as to the extent to which the guideline recommendations are evidence based (e-b) and were produced in a sound manner. If the recommendations are deemed credible, then the protocol work group will rely heavily on them while developing their protocol. In this anecdote, do note that the protocol project team was building on the works of others who had produced an e-b guideline on the issue. E-b guidelines and protocols may sound similar but they are different in an important way. E-b guidelines (1) draw directly on the research evidence, (2) are produced by experts from a variety of work settings, and (3) consist of a set of e-b recommendations that are not intended for a particular setting. In contrast, clinical protocols are produced by providers in a healthcare setting for that setting; often they are translations of an e-b guideline that keep the essential nature of the guideline recommendations but tweak them to fit into the routines and resources of the particular setting. GUIDELINE: A set of recommendations for the care of a patient population that is issued by a professional association, leading healthcare center, or government organization. Guidelines are not setting specific. PROTOCOL: A set of care actions for a patient population that has been endorsed by the hospital, agency, clinic, or healthcare facility. Protocols are setting specific. Short History of Evidence-Based Nursing Practice The nursing profession has been conducting scientific research since the 1920s, when case studies were first published, and calls for research about nursing practice were first issued in the American Journal of Nursing. Now, nursing research is being conducted in countries around the world, and reports of clinical research studies are published in research journals and clinical journals in many languages. In many countries, nursing research is funded by the government, and over 50 countries have doctoral programs in nursing. The growing cadre of nurses with doctoral degrees has propelled both the quantity and quality of clinical nursing research being conducted. In the United States, the National Institute of Nursing Research (www.ninr.nih.gov), a component of the National Institutes of Health, is a Short History of Evidence-Based Nursing Practice 13 major source of funding for nursing research. Many other countries have similar organizations. In the mid-1970s, visionary nurse leaders realized that even though clinical research was producing new knowledge indicating which nursing methods were effective and which were not, practicing nurses were not aware of the research. As a result, several projects were started to increase the utilization of research-supported actions by practicing nurses. These projects gathered together the research that had been conducted on issues such as preoperative teaching, constipation in nursing home residents, management of urinary drainage systems, and preventing decubitus ulcers. Studies were critiqued, evidence-based guidelines were developed, and considerable attention was paid to how the guidelines were introduced into nursing departments (Horsley, Crane, & Bingle, 1978; Krueger, Nelson, & Wolanin, 1978). These projects stimulated interest in the use of nursing research in practice throughout the United States; at the same time, nurses in other countries were also coming to the same recognition. By the 1980s and 1990s, many research utilization projects using diverse approaches to making nurses aware of research findings were under way. During this time, interest in using research findings in practice was also proceeding in medicine. In the United Kingdom, the Cochrane Collaboration at Oxford University was formed in 1992 to produce rigorous research summaries with the goal of making it easier for clinicians to learn what various studies found regarding the effectiveness of particular healthcare interventions. At the McMaster Medical School in Montreal, Canada, a faculty group started the evidence-based practice movement. This movement brought to the forefront the responsibility of the individual clinicians to seek out the best evidence available when making clinical decisions in everyday practice. The evidence-based practice (EBP) movement in medicine flowed over into nursing and reenergized the use of research by nurses. Three other things were happening in the late 1990s and early 2000s: ■■ Considerably more clinical nursing research was being conducted. ■■ The EBP movement was proceeding in a somewhat multidisciplinary way. ■■ National governments in the United States, the United Kingdom, ­ anada, and many other countries funded efforts to promote the C translation of research into practice. Today, high-quality evidence-based clinical practice guidelines and research summaries are being produced by healthcare organizations around 14 CHAPTER 1 The Research–Practice Connection the world, and nursing staffs are increasingly developing clinical protocols based on those guidelines and summaries. Also, individual clinicians are increasingly seeking out the best available evidence to use as a guide for the care they provide to patients. The most recent development is an area of research called implementation research or translational research. These studies examine how to implement evidence-based innovations in various practice settings so the changes are taken up by direct care providers and become part of routine care. Your Path to Evidence-Based Practice I want to emphasize that the point of this text and of the course you are taking is not to prepare you to become a nurse researcher, but rather to help you be an informed consumer of nursing research, i.e., a true professional clinician. The exemplar research articles you will be reading were published in clinical journals, not research journals. They were written for clinicians; thus they do not go into the fine points of research methodology. In Part I you will start by learning about individual studies, then about research summaries, and last about clinical practice guidelines—the three major forms of research evidence. Your goal in reading about them will be to grasp why the study/summary/guideline was done, how it was done, and what was found. Because this text is a primer, only the most widely used and important types of research are presented. Also, the information provided is selective, which means that it is not a comprehensive reference source regarding research methodology. It does not delve deeply into methodological issues; it does not explain all research designs, methods, and statistics. However, it does provide an introduction to research methods and results that serves as a foundation for making a judgment about the credibility of a study/ summary/guideline. In Part II you will learn about using research evidence in nursing practice. You will revisit the studies/summaries/guidelines you read in Part I, to learn how to critically appraise their soundness, and consider their applicability to a particular setting. You will also learn about how organizations use research evidence to develop clinical protocols and how to use research evidence in your own individual clinical practice. References 15 You, the Learner The exploration of evidence-based nursing in this text assumes that you (1) have had an introduction to statistics course; (2) have some experience in clinical settings; and (3) are committed to excellence in your professional practice. Other Learning Resources In reading this text, and indeed in your reading of research articles once you have graduated, you may want to have a statistics book handy to look up statistical terms and tests you have forgotten or never learned. Your statistics text need not be new. Earlier editions are often available very inexpensively—and statistics do not change much from edition to edition. Do make sure you use a basic book, not an advanced one written for researchers. If in doubt, ask your instructor for a suggestion. For a full suite of learning activities and resources, use the access code located in the front of your text to visit this exclusive website: http:// go.jblearning.com/brown4e. If you do not have an access code, you can obtain one at the site. References Horsley, J. A., Crane, J., & Bingle, J. (1978). Research utilization as an organizational process. Journal of Nursing Administration, 8, 4–6. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy of Sciences. Retrieved from http://www.nap.edu/html/quality_chasm/reportbrief.pdf Krueger, J. C., Nelson, A. H., & Wolanin, M. O. (1978). Nursing research: Development, collaboration, and utilization. Germantown, MD: Aspen. C H A P T E R T W O Research Evidence T he term research evidence needs to be defined. First, perhaps obvious, scientific research is the methodical study of phenomena that are part of the reality that humans can observe, detect, or infer; it is conducted to understand what exists and to acquire knowledge about how things work. More particularly, nursing research is the study of phenomena in and relevant to the world of nursing practice; nursing phenomena can be grouped into five categories (adapted from Kim, 2000). The categories and examples of phenomena within each are: ■■ The Client as a Person (motivation, anxiety, hope, exercise level, and adherence to treatments) ■■ The Client’s Environment (social support, financial resources, and peer group values) ■■ Nursing Interventions (risk assessment for skin breakdown, patient teaching, and wound care) ■■ Nurse–patient Relationship and Communication (person-centered talk, collaborative decision making) ■■ The Healthcare System (access to health care, quality of care, cost) In brief, nursing phenomena are personal, social, physical, and system realities that exist or occur within the realm with which nursing is concerned. As a student new to the science of nursing, when mention is made of research evidence, you will naturally think of the findings of a scientific 17 18 CHAPTER 2 Research Evidence study. However, as you proceed through this course, you will come to see that research evidence can take several forms, namely: ■■ Findings from a single, original study ■■ Conclusions from a summary of several (or many) original studies ■■ Research-based recommendations of a clinical practice guideline Building Knowledge for Practice A finding of a single original study is the most basic form of research evidence. Most studies produce several findings, but each finding should be considered as a separate piece of evidence because one finding may be well supported by the study whereas another finding may be on shaky ground. Although a finding from an original study is the basic building block of scientific knowledge, clinical knowledge is really more like a structure made up of many different kinds of blocks. E-B Guidelines Systematic Research Reviews Findings from Individual Studies Building Practice Knowledge Building Practice Knowledge Findings from several/many soundly conducted studies are necessary to build reliable knowledge regarding a clinical issue. Insistence on confirmation of a finding from more than one study ensures that a knowledge claim (or assertion) is not just a fluke unique to the patients, setting, or research methods of one study. If a finding is confirmed in several different studies, clinicians have confidence in that knowledge because it held up across diverse settings, research methods, patient participants, and clinician participants. Findings from an Original Study 19 There are several recognized ways of summarizing findings from two or more studies; as a group these methods are called systematic research reviews, most often shortened to systematic reviews. Conclusions from systematic reviews may then be translated into evidence-based recommendations by expert panels. A group of e-b recommendations is called an evidence-based clinical practice guideline. Although one could make a case that evidence-based recommendations are technically derivations of research evidence, when they are true to the underlying research results they are considered research evidence for practical purposes. In this chapter, each of these forms of research evidence is introduced briefly in turn. Later in the text, each is considered in depth. Findings from an Original Study Most people think of a research study as involving (1) a large number of subjects who are (2) randomly assigned to be in one of several intervention groups; (3) research environments that are tightly controlled; and (4) data that are meticulously obtained and then analyzed using statistics to produce results. In fact, research using these methods is common and valuable; however, it is only one type of scientific study—there are many other kinds. The most common way of thinking about research methods is to categorize them as qualitative and quantitative. Qualitative Research Qualitative research can be used to study what it is like to have a certain health problem or healthcare experience. Qualitative research methods are also used to study care settings and patient–provider interaction. The following are examples of phenomena a nurse researcher might study using qualitative methods: 1. The experience of being a physically disabled parent or the experience of recovery from a disability. 2. The interpersonal support dynamics at a social center for persons with chronic mental illness. 3. How intensive care unit (ICU) staff members interact with family members of unconscious patients. 4. How a family who has entered a family weight loss program makes changes in eating and physical activity over time. 20 CHAPTER 2 Research Evidence These kinds of social experiences and situations are typically tangles of issues, forces, perceptions, values, expectations, and aims. They can be understood and sorted out best by methods of inquiry that will get at participants’ perceptions, feelings, daily thoughts, beliefs, expectations, and behavior patterns. Qualitative researchers have an overall plan for how they will approach potential informants and position themselves in situations of interest. However, they are also committed to going where the data leads them and following up leads suggested by prior informants. Data collection methods such as in-depth interviewing, extended observation, diary keeping, and focus groups are used to acquire insights regarding subjective and social realities. Qualitative data consists of what people say, observational notes, and written material. The data are analyzed in ways that preserve the meanings of the stories, opinions, and comments participants offer. The goal of qualitative research is understanding—not counting, measuring, averaging, or quantifying in any way. Qualitative research is described in more depth in Chapter 4. Quantitative Research Quantitative research methods provide a different perspective on how the world works. Quantitative researchers assume a basic understanding of phenomena that allows numerical measurement of them. They then use numerical measurements to confirm the level at which phenomena are present and explore the nature of relationships among them under various conditions. For instance, the quantitative measurement of body temperature using a degree scale on a thermometer is a precise way of determining body temperature at a point in time and tracking it over time. It is also makes possible the study of the relationship between body temperature and blood alcohol level by 2-axis graphing and by statistical analysis. Measurement is also used to test how well a nursing intervention works compared to another intervention by measuring the outcomes achieved by both intervention groups to determine if there is a difference. Quantitative researchers have specific study questions they want to examine; most often the questions involve several phenomena. For example, a researcher whose main interest is preoperative anxiety may ask a research question pertaining to how patients’ levels of perceived risk for a bad outcome affect anxiety. Perceived risk and preoperative anxiety are the phenomena that make up the research question. In research lingo, Findings from an Original Study 21 however, the phenomena of interest are called variables because they are not ­constants—they exist at more than one level and vary in time, place, person, and context. Variables are phenomenon that exist at more than one level The following are examples of study purposes that could be studied using quantitative research methods: ■■ The strength of relationship between health-related phenomena (e.g., between mothers’ hours worked outside the home and mothers’ level of fatigue). ■■ Test a hypothesis about the effectiveness of an intervention (e.g., A smoking cessation program delivered to small groups of sixth graders by a school nurse will result in a lower level of smoking in 3 years than will an interactive computer program delivered and evaluated in the same time frame. The intervention in this study is one variable (it is a variable because it has two forms); level of smoking at 3 years is the other variable. ■■ Predict good or bad health outcomes (e.g., Determine predictors of re-hospitalization within 30 days for persons discharged on newly prescribed anticoagulants. Several predictor variables could be tested, such as: type of anticoagulant, frequency of blood level monitoring, age, or lives alone. Re-hospitalization (yes/no) is the outcome variable). Researchers then choose a research design that will produce answers to their questions. A research design is a framework or general guide regarding how to structure studies conducted to answer a certain type of research question. The four quantitative research designs used most often in nursing research are: 1. Descriptive designs 2. Correlation designs 3. Experimental designs 4. Quasi-experimental designs (Burns & Grove, 2009) After choosing a design that will answer their research questions and is feasible given their resources, they develop a detailed study plan that spells out specifically how their study will be conducted—sample size, how 22 CHAPTER 2 Research Evidence participants will be recruited, data to be collected, statistical analysis that will be done, etc. Mixed Methods Research Researchers sometimes use qualitative and quantitative methods in combination with one another. Using mixed methods may produce a more complete portrayal of an issue than can one method alone. For instance, researchers used mixed methods to identify health concerns in an African American community; they conducted focus groups and analyzed the results of a community health survey. They concluded that “Although quantitative approaches yield concrete evidence of community needs, qualitative approaches provide a context for how these issues can be addressed” (Weathers et al., 2011, p. 2087). Conclusions of a Systematic Review Systematic reviews are an important and useful form of research evidence. A systematic review is a research summary that produces conclusions by bringing together and integrating the findings from all available original studies. The process is often referred to as synthesis because it involves making a new whole out of the parts. The integration of findings from several or many studies can be done using tables and logical reasoning and/or with statistics. To reduce bias resulting from the process used to produce the conclusions, the methods used for conducting a systematic review are rigorous and widely agreed upon. Systematic reviews, when well done, bring to light trends and nuances regarding the clinical issue that are not evident in the findings of individual studies. I suggest that now you take a look at an abstract of a systematic review, because reading and using the conclusions of systematic reviews is one of the destinations on your learning path, and looking at one will give you a sense of this important learning destination. 1. Go to the CINAHL database in your library’s website or go online to PubMed (http://www.ncbi.nlm.nih.gov/pubmed). PubMed is a free, online database of healthcare articles. 2. Type the following text in the search box: “facilitated tucking Obeidat” and click on the Search button. (Facilitated tucking involves holding or swaddling an infant so his arms and legs are slightly flexed and close to his body.) Recommendations of an Evidence-Based Clinical Practice Guideline 23 3. That should bring up the citation and abstract for a systematic review of five studies about facilitated tucking of preterm infants during invasive procedure to modulate their responses to pain; the review was conducted by Obeidat, Kahalaf, Callister, & Froelicher and published in 2009. 4. Note that the abstract provides information about how many articles were included in the review, the outcomes that were examined, and the main conclusion of the review. Remember: You are reading a very short synopsis of the review, not the entire report. From this quick look at the abstract of a systematic review, you should get a sense of the groundwork that has been done by the persons who did this review. In the process of doing the review, they did the following: ■■ Searched for articles ■■ Sifted through them for relevant studies ■■ Extracted information from each study report ■■ Brought the findings together in a coherent way Clearly, this saves clinical nurses a great deal of time when they are looking for the research evidence about an issue in care. You will delve more deeply into systematic reviews in later chapters. Recommendations of an Evidence-Based Clinical Practice Guideline The third form of research evidence is the recommendations of an evidence-based clinical practice guideline. A clinical practice guideline consists of a set of recommendations, and when the recommendations are based on research evidence, the whole guideline is referred to as an evidence-based clinical practice guideline. These guidelines are most often developed by organizations with the resources (money, expertise, time) required to produce them. I think it will be informative for you to now briefly look at a guideline to get a feel for how the recommendations and supporting research evidence are linked. (You will be examining a guideline in more depth in Chapter 10.) 1. Go to the website of the Registered Nurses’ Association of Ontario (RNAO; http://www.rnao.org ). 2. Click the Best Practice Guidelines tab; scroll down to the search box, enter “dyspnea,” and click Search. The search result will bring up the 24 CHAPTER 2 Research Evidence guideline Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease. 3. Double click to open the page for the guideline. 4. Low on the page under Related File(s), you will see COPD Summary. Open that by double clicking and you will see a list of recommendations. The developers of this guideline looked at the research evidence regarding nursing assessment and management of stable, unstable, and acute dyspnea associated with COPD. Based on the evidence, they derived the recommendations listed. (I suggest that you look at the Practice Recommendations [1–5] and ignore the Education Recommendation and Organization & Policy Recommendations that follow.) The strength of the evidence supporting each recommendation is indicated in the right column, and definitions of those levels are provided at the end of the table; do not get caught up in that right now, although you should know that level Ia is very strong research evidence whereas level IV evidence was obtained from expert opinion evidence (i.e., no research exists, so consensus of an expert panel was the best available evidence). The evidence levels that support the recommendations are mostly either Ia or IV, indicating that considerable research evidence is available for some issues but none for quite a few others. Remember that you are looking at part of a much larger report. The other document, the complete 166-page guideline (viewable by clicking on Free Download tab), presents more specific guidance and detailed review of the evidence that led to each recommendation. It also informs the reader how the search for evidence was conducted and how the 2010 update of the original 2005 guideline was done. As you can see, evidence-based clinical practice guidelines are even more ready to go for use in practice than systematic reviews and definitely more ready to go than tracking down the original research articles and trying to get an overall sense of them. For time-pressed protocol development teams, evidence-based clinical practice guidelines and systematic reviews are the short roads to evidence-based protocols, as portrayed in Figure 2-1. If starting the development of a care protocol by retrieving individual research articles is like baking a cake from scratch, and systematic reviews are like using a cake mix, then starting with an evidence-based clinical practice Going Forward 25 E-B Protocol Develop Develop Adapt E-B Guideline Summarize Retrieve Original Studies (1–?) Systematic Review Start Figure 2-1 Roads to E-B Protocols guideline is like buying a cake at the bakery and adding a personalized topping or presentation. Going Forward In Chapter 3, you will begin to learn how to read research reports of individual studies. Then in Chapters 4 through 8, you will be guided through reading of exemplary articles reporting five different types of research (one qualitative study and four types of quantitative studies). After that, you will read a systematic review and learn how one type of systematic review is conducted, and then you will read an evidence-based clinical practice guideline and learn how they are produced. Note that this order is the reverse of the order in which care design project teams search for research evidence—they first look for evidence-based guidelines and systematic reviews. If they exist and are well done, the team can build on them rather than reinventing the wheel. The order of presentation in this book is reversed because proceeding from original studies to systematic reviews to evidence-based clinical practice guidelines is a more natural learning order. 26 CHAPTER 2 Research Evidence References Burns, N., & Grove, S. K. (2009). Practice of nursing research: Conduct, critique, and utilization (6th ed.). St. Louis, MO: Elsevier Saunders. Kim, H. S. (2000). The nature of theoretical thinking in nursing (2nd ed.). New York, NY: Springer. Obeidat, H., Kahalaf, I., Callister, L. C., & Froelicher, E. S. (2009). Use of facilitated tucking for nonpharmacological pain management in preterm infants: A systematic review. Journal of Perinatal and Neonatal Nursing, 23(4), 372–377. Weathers, B., Barg, F. K., Bowman, M., Briggs, V., Delmoor, E., Kumanyika, S., . . . Halbert, C. H. (2011). Using a mixed-methods approach to identify health concerns in an African American community. American Journal of Public Health, 101(11), 2087–2092. C H A P T E R T H R E E Reading Research Articles T o get the most out of a research article one has to be intellectually engaged. One way to be intellectually engaged is to annotate or mark your copy of the article: underline, circle phrases, highlight, or jot comments in the margin—whatever helps you keep track of important information and connect the various parts of the study. When reading a pdf file in Acrobat Reader, you can click “Comment” on the tool bar and use the Comment and Annotation tools. Also, some people prefer to make notes in a file on their computer—fine, whatever works for you. I tend to annotate right on my paper copy of articles. I write something like “n = 54” in the margin so I can quickly locate the sample size, underline important definitions, outcomes or findings, circle abbreviations that will be used in the report and the parts of a table that are most important or unexpected. I put question marks where a statement does not fit with what was said earlier or does not make sense. When reading a pdf file electronically, I use the sticky note feature and/or the highlight and underline tools. Of course, it is possible to over-annotate and in so doing produce clutter. However, if you annotate selectively, you will be able to find important information easily when you return to the article at a later time. In this chapter, I make suggestions about how to read reports of individual studies. At this point in your learning, the goals in reading a research article about a study are to identify (1) why the study was done, (2) how it was conducted, and (3) what was found. After you are have mastered extracting these aspects of a study, you will add the goals of (4) determining whether the study was soundly conducted, and (5) relevant to the care of patients to whom your agency or unit provides care. 27 28 CHAPTER 3 Reading Research Articles GOALS IN READING A RESEARCH ARTICLE 1. Determine the purpose of the study 2. Understand how the study was done 3. Understand what was found 4. Appraise the credibility of the findings 5. Determine if the findings are relevant to the care of your patients The emphasis in this chapter and in all of Part I of the book is on understanding the why, how, and what of a study (goals 1–3). As you read you may wonder whether the data really showed what the researcher claimed it did or think about the patients to whom the results would and would not apply. That’s fine—just put your thinking about credibility and applicability (goals 4 and 5) on the back burner for now and we’ll take them up in Part II when we revisit the studies with the aim of appraising them. Also, in reading this chapter, you may see a few terms that are unfamiliar to you. For now, just look them up in the glossary to get a sense of what they mean; they are explained in full as you proceed through the first part of the text. Starting Point Is this a report of an original research study? This seems like it should be an easy question to answer, but at times it is not. Some articles read like research articles, but they are in fact other kinds of reports. An article with tables and percentages may lead you to think you are reading a research study, but the article may just be providing numerical data to describe a clinical program. Such data is anecdotal and naturally occurring with no control over its quality or the conditions under which it was collected. As you will learn, it takes more than numerical data to call an evaluation report research. Most often, the author of a research report, which is often referred to as a research article, will refer to “the study” early in the report, but sometimes you have to read quite far into an article to determine that it has the essential elements of a study. The essential elements of a research study include the following: ■■ A specified research question, hypothesis, or purpose ■■ Specified, systematic methods of data collection ■■ Data analysis and results Format of Study Reports 29 ■■ Findings (interpreted results) ■■ Conclusions If all these elements are present, then the likelihood that you are reading a research study report is very high. Remember, however, that there are many types of research methods and designs, and the essential elements of each type look quite different. Most quantitative studies address specific research questions or hypotheses, whereas qualitative studies may have a broad aim or purpose. Quantitative studies report results with tables, graphs, and statistics, whereas the data of qualitative studies consist of extended quotes and narrative descriptions. Qualitative studies often have small sample sizes (e.g., N = 6); most quantitative nursing studies use moderate sample sizes (e.g., N = 40–200). In short, research articles are diverse but should include at a minimum a clear purpose statement, a description of methods used to collect and analyze data, results and/or findings, and conclusions. Format of Study Reports Research reports of original studies are organized in a very logical way, and the formats used are similar from one journal to another. This standardization of format helps you as a reader because you will learn where to expect, and later locate, various kinds of information about the study. The following is a brief orientation to the format of research reports. Title and Abstract The title tells the reader what the study examined and often the patient group of interest. These are your first clues as to whether the report is likely to be of interest to you. However, titles can be misleading because a phrase or term used in the title may be different from the one used in your practice setting. Abstracts almost always precede the main body of the article. An abstract provides a brief summary of the study—typically 300 words or less. The section headings used in the abstract are similar but not identical to those used in the full report. The abstract distills the main points of the study, and after reading it you should know whether the study is of interest. Let us assume that you have decided to read the whole study. Rather than read straight through the first time, you might want to read the introduction and then jump to the discussion section. The discussion summarizes the important findings and places them in the context of findings 30 CHAPTER 3 Reading Research Articles from earlier studies. Having read the introduction and the discussion, you should have a sense for the context of the study—and be ready to read the article from start to finish in its entirety. Introduction In the introduction of a research study report, the researcher presents a view of the current state of knowledge regarding the issue or problem being investigated; this includes what is known and what are the gaps in knowledge. Study purposes are often set forth in the introduction section. Mark them in some way because they are important and you will want to refer to them. Theoretical Framework In the introduction section of a research study report, a theory that has been used to organize thinking about the issue and that serves as a conceptual context for the study may be specified. A theory is made up of assumptions, concepts, definitions, and/or propositions that provide a cohesive, although often tentative, explanation of how a phenomenon in the physical, psychological, or social world works. Propositions are suggested linkages among the concepts of the theory that have not yet been proven. THEORY Concept Definition Concept Definition Concept Definition Concept Definition Propositions Assumptions To make the preceding paragraph a bit more rooted in the real world, consider the following illustration. The theory of community empowerment was developed to provide direction for improving health in communities (Persily & Hildebrandt, 2008). Consider two propositions from this theory: 1. Involving lay workers in a community health promotion program extends access to health promotion opportunities. 2. Access to health promotion information leads to adoption of healthy behaviors. Format of Study Reports 31 Lay workers, access, health promotion opportunities, and adoption of healthy behaviors are concepts of the theory. A researcher conducting a study about improving the health of elders living in their own homes might use the theory of community empowerment as a source of ideas for the study. By translating the two theoretical propositions into more concrete terms, the following two study hypotheses are formed: 1. Trained volunteers who collect healthy living questions from elders once a month at the weekly senior lunch and deliver answers the following week will increase access to health promotion information. 2. Health promotion information of personal interest will produce changes in health-related behaviors. The questions submitted are given to a nurse practitioner who answers them via video recording shown at the next week’s lunch. Adoption of new health behavior outcomes will then be measured at 3-month intervals for 1 year. Thus, the theory has served the research by bringing into a trial program a component that otherwise might not have been included and by providing a knowledge context for the findings. At the same time, the study acts as a test of the theory because the study has translated the abstract concepts of the theory into concrete realities that can be examined. If the study hypotheses are supported, the theory is supported because the hypotheses represent the theory. THEORETICAL PROPOSITIONS Lay workers Health promotion opportunity Adoption of healthy behavior RESEARCH HYPOTHESES Trained volunteers at lunch Opportunity to ask healthy living questions Performance of healthy behaviors Not all study reports stipulate a theoretical framework; many researchers, particularly those testing physiological hypotheses, do not locate their studies within a theoretical framework; instead, they locate their study in a review of what is known from previously conducted research and what 32 CHAPTER 3 Reading Research Articles is still not known with certainty. Clearly, much more could be said about the relationship between theory and research; however, doing so would be a diversion from the topic of this chapter, which is how research articles are formatted. Study Purposes A reason for doing a study may be stated as a purpose statement, aims, objectives, research questions, or as hypotheses that will be tested by the study. Purpose words and phrases you will encounter in nursing study reports include: ■■ Acquire insights about . . . ■■ Understand ■■ Explore ■■ Examine ■■ Describe ■■ Compare ■■ Examine the relationship/association between . . . ■■ Predict ■■ Test the hypothesis that . . . In the early stages of studying an issue, research is directed at acquiring understanding of the various aspects of the issue—the problems people with the condition are experiencing, social or psychological forces at work, and what the condition or experience means to individuals. Generally, these early studies use qualitative research methods. The following are study purposes from qualitative studies: ■■ “The research question in this qualitative study was: How do women experience miscarriage, conception, and the early pregnancy waiting period, and what types of coping strategies do they use during these periods” (Ockhuijsen, van den Hoogen, Boivins, Macklon, & de Boes, 2014, p. 267)? ■■ “The objective of this study was to examine how skilled nursing facility nurses transition the care of individuals admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions” (King et al., 2013, p. 1095). Note how both purposes set forth issues that will be examined, but they do not get highly specific about what they are looking for because they Format of Study Reports 33 want the study participants to highlight the important aspects of their situation and experiences. After the condition or situation is well understood at the experiential or social process level, subsequent studies may determine the frequency with which it occurs in different populations or measure the degree to which aspects of the condition or situation are present. Later, when several studies have been done and the situation is fairly well mapped, researchers will propose and quantitatively test associations between aspects of the situation or effectiveness of interventions directed at it. The following examples illustrate several ways of stating quantitative research purposes: ■■ “The specific research question was ‘What patient characteristics, clin- ical conditions, nursing unit characteristics, medical pharmacy, and nursing interventions are associated with falls during hospitalization of older adults’” (Titler, Shever, Kanak, Picone, & Qin, 2011, p. 129)? ■■ “The purpose of this study was to compare the time needed to reach a specified temperature and the efficiency of two warming methods— warm cotton blankets and a radiant warmer—for hypothermia patients in a postanesthesia care unit after spinal surgery” (Yang et al., 2012, p. 2). ■■ “The hypothesis is that the outcomes from nurse-led clinics will not be inferior to those obtained by the rheumatologist-led clinics, but at a lower cost and greater patient satisfaction” (Ndosi et al., 2011, p. 996). ■■ In a study of the association between depression and health-risk behaviors in high school students, two competing explanations became the hypotheses that were tested in the study: (1) Early depressive symptoms predict increases in risk behaviors over time; and (2) Early participation in health-risk behaviors predicts increases in depressive symptoms over time (Hooshmand, Willoughby, & Good, 2012). Methods In the methods section, the author describes how the study was conducted, including information about the following: 1. The overall arrangements and logistics of the study 2. The setting or settings in which the study was conducted 3. The institutional review board (IRB) that gave ethical approval to the study 34 CHAPTER 3 Reading Research Articles 4. How the sample was obtained 5. How data were collected 6. Any measurement instruments that were used (i.e., scales, questionnaires, physiologic measurements) 7. How the data were analyzed Each of these steps will be discussed in detail specific to different research designs later. Briefly here, I will just say that the information about the sample should be sufficient to inform the reader about the likelihood that the sample is a good representation of the target population or provide enough profile information about the sample to let readers decide to whom the results would likely apply. The information about how the data were obtained includes a statement about the organization that gave ethical approval to the study, procedures used to collect data, and descriptions of the measurement instruments used. For now, you should come away from reading the methods section of the reports with an understanding of the characteristics of the people who were included in the study, the sequence of steps in the study, and the data collected. Results/Findings In the results/findings section, a profile of the sample and the results of the data analysis are reported. The profile of the sample lists characteristics of the sample as its composition determines the population to whom the results can be generalized. Results are the outcomes of the analyses. In quantitative studies, results are shown in tables, graphs, percentages, frequencies, and statistics. There should be results related to each of the research questions, hypotheses, or aims. To illustrate, consider the following hypothetical statement that might be found in the results section of a quantitative study: “The t-test comparing the functional status scores of those in intervention group A and intervention group B indicated a significant difference (mean A = 8.4; mean B = 6.1; p = .038).” This is a result statement; it reports the results of the statistical analysis. The interpretation of a result is called a finding. A finding for the result statement just given would be stated something like, “The group who received nursing intervention A had a significantly higher functional level than did the group who received intervention B.” Note how the findings statement interprets the statistical result but does not claim anything more Format of Study Reports 35 than the statistical result indicated. Findings statements are usually found in the conclusions or discussion section of quantitative study reports. To illustrate further, consider the results and findings of a hypothetical quantitative study comparing the effects of a new method for osteoporosis prevention education to standard education among high school students. A t-test was used to compare the scores of the two groups on an osteoporosis prevention questionnaire; the result of that test was t = 1.99, p = .025. This result indicates that the statistical calculation comparing the scores of the two groups resulted in a t-value of 1.99, which is statistically significant at the p = .025 level. The finding was this: The new educational method on average produced higher osteoporosis knowledge levels than standard education did, and there is a very low chance that this claim would not hold up in other similar situations. The concept of p-values will be explained in detail in Chapters 6 and 7. Results → Findings → Conclusions In qualitative research reports, data (observations, quotes) and findings (e.g., themes) are often intermingled. Generally, qualitative study reports do not have a results section; rather, they have a findings section in which themes, narrative descriptions, or theoretical statements are presented along with examples of data that led to them. Chapter 4 provides more explanation of the analytical processes used by qualitative researchers. When you first begin reading research articles, you may have a tendency to skip over the tables and figures. However, you really should pay attention to them because that is where you will find the real meat of the results. Most authors highlight or summarize in the text what is in the tables, but others assume the reader will get the information from the tables, thus they do not restate that information. In examining tables and figures, it is important to carefully read their titles so you know exactly what you are looking at. Also, within tables, the column and row labels are critical to understanding the data provided. Reading tables is a bit like dancing with a new partner—with a bit of practice, you will quickly get good at it. Discussion and Conclusions In the discussion section, the researcher ties together several aspects of the study and offers possible applications of the findings. The researcher 36 CHAPTER 3 Reading Research Articles will usually open this section by stating the most important findings and placing them in the context of what other studies on the topic or question have found. In discussing the findings, many researchers describe what they think are the clinical implications of the findings. Here, they are allowed some latitude in saying what they think the findings mean. In the osteoporosis education for high school students example just given, the researcher might say, “The findings indicate that a short educational session is effective in increasing high school students’ knowledge regarding osteoporosis prevention.” This conclusion statement is close to the findings. On the other hand, if the researcher said, “Short educational sessions are an effective way of increasing osteoporosis prevention behaviors in high school students,” the findings statement would be beyond the results. Because the study only measured the outcome of knowledge, not behaviors, the author is adding an assumption to the results, namely, that knowledge produces behavior change—and that is a big assumption. Authors are also expected to consider alternative explanations for their findings. This would include noting how research methods may have influenced the results, such as “The sample size may have been too small to detect a difference in the treatment groups” or...

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