Friday, December 30, 2011

change management

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The purpose of this assignment is to demonstrate competency in searching and

reviewing the available research literature for a chosen nursing intervention. The rationale for choosing the particular nursing intervention will be given, then a short explanation of what evidence based practice is and why it is so important in nursing will be offered. The method involved in accessing the databases and carrying out the literature search will then be explained. Three articles will be chosen from the larger body of research evidence found in the literature search, and a critical appraisal of each one will be provided, highlighting the results and how they affect practice. Discussion will then be offered regarding any barriers to the implementation of evidence-based practice in nursing today, and why it is problematic.

The nursing intervention chosen for the purpose of this assignment is the bedside hand-over. This subject has been chosen for the focus of the assignment as during a surgical placement this method of handing over the report between shifts was implemented. It was wondered how the patients themselves felt about it and whether they thought that it lacked confidentiality. I wanted to access the research literature to see for myself whether or not it was best practice based on evidence. Also was there any evidence to suggest that the patients suffered as a result of it?

The term ‘evidence based practice’ has only been in use since the early 10’s when different disciplines noticed that practice was not being based on the best evidence available. There was a switch towards promoting evidence-based practice from then on in the form of education, training initiatives, publications, policy directives and debate (Le May 1). Once the term was in use, definitions were offered such as the one from Sackett et al (16) which proposed that evidence based medicine was the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This definition includes the term best evidence, which has always been emphasised as coming from research (Long 16, in Le May 1). However Le May (1) acknowledges that best evidence can come in the form of evidence based on experiences, theory that is not research based, evidence gathered from clients or their carers and evidence passed on by role models and experts. He also suggests that to enable us to base our practice on evidence we need to consider how we can put the definition into operation. This can be done through a series of stages which are; deciding what we want to find evidence about, accessing the evidence, appraising the evidence, using the best available evidence and evaluating the impact of the evidence. Only when each of these steps is successfully completed, will practice become evidence based.

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The Department of Health (16) and the NHS Executive (18) have highlighted how important it is for clinical effectiveness to be underpinned by evidence based practice. This clinically effective care can benefit the patients, nurses and the NHS with reduced time wasted on inappropriate treatments, increased consistency of care, increased understanding of investigations and treatments, increased confidence in practitioners and increased value for money. These benefits also apply to nurses as well as the other major benefit that the accountable nurses have evidence on which to base their practice which would stand up in a court of law should any problems arise.

In order to access research articles on the chosen topic of bedside hand-over it was necessary to do a literature search. Literature searches can be done manually by using the OPAC system and reading through journals in the library, or can be carried out online using the internet to link to a medical data base where articles can be accessed from a home computer. In this instance the online search was carried out using the OVID database. The database consists of a selection of different journal sites such as MEDLINE and CINAHL. To initiate the search, a specific site was selected. It was decided for this search that each database site would be visited using the same search criteria working down the list of sites. The keyword entered into the search box was bedside hand-over. The MEDLINE databases came up with no hits for this search, so keeping the same keyword phrase the database was changed and the same search was carried out. This was repeated for each of the different databases, and the results of the search were saved. The nursing databases came up with most citations; this is understandable as the subject of bedside hand-over is a nursing one rather than a medical one. Some of the citations did not match exactly the criteria I was looking for. Abstracts were read from those that did match the criteria and the best most applicable ones were printed out. Once this process was completed it was repeated using the term bedside reporting and then nursing hand-over. The nursing sites offer full text of their journals, so it was possible to print out the ones that were of most interest to read in detail. From the search three articles were chosen for appraisal.

The articles were chosen because they had very similar titles. Two of the articles were qualitative and one was quantitative which was interesting as they were researching the same subject of patient perceptions of the bedside hand-over.

The first article to be appraised is by Cahill (18) is a piece of qualitative research, which was published in the Journal of Clinical Nursing. The study clearly states the aim of the research, which is to describe and provide an analysis of the perceptions of the bedside hand-over. The researchers were trying to find out more about patient perceptions of the bedside hand-over as they found that there was very little research on this subject.

Qualitative methodology is a suitable approach for this study as it seeks to illuminate which elements; patients express either satisfaction or dissatisfaction with. The research design employed the grounded theory method of data collection and analysis (Glaser & Strauss 167), the advantage being that it allowed the complexity of the bedside hand-over in a surgical care setting and the richness of such an everyday life practice to be captured.

Theoretical sampling was employed for this study i.e. specific sampling decisions evolved during the research process. The sample was not predetermined before embarking on the study. Ten informants were recruited for the study but there was no discussion of the type of patients they were. As with the appraisal of article three, there is the issue of gender, age, race and social class, all of which can have an effect on the validity and reliability of the results.

The data from the study was collected in the form of unstructured in-depth interviews using open and closed questions. The interviews were tape-recorded and a method known as constant comparative analysis was used to generate the grounded theory (Glaser & Strauss 167). Good description was given as to what this method of analysis entailed and how many themes emerged. However no steps seemed to have been taken to test the credibility of the findings. As Woodgate & Kristjanson (16, in Parahoo 17) suggest, help could have been enlisted from others to read the transcripts in order to ensure rigour and validate their results. During this study the author has made no comment on the possibility that his own potential bias and influence may have an effect on the results. It was brought to the reader’s attention that the setting for the study was a surgical ward. Data was collected there from the sample population one day before discharge after having had the interview agenda explained. Previous to this ethical considerations had been addressed including anonymity and the chance to opt out at any time.

From the original transcripts ten themes quickly emerged, then after more careful analysis these themes were broken down into six, then finally three categories of findings which were discussed in detail. There was no clear statement of findings but they appeared to be embedded in the discussion of each of the three categories of patient perceptions. The author states that no definite conclusions can be drawn from this study as it is no more than the beginnings of a more comprehensive grounded theory study. However it does support findings from earlier work of other researchers and it does highlight some important points for consideration. These are that the staff maintained professional dominance over the patients. The patients in the study stated that although they wanted to be involved in the hand-over they felt that they were unable to converse with the large volume of staff. This was because they felt that they did not have enough knowledge about the medical jargon used, their illness or the nursing care that should be carried out.

The second article to be appraised is a piece of quantitative research in the form of a survey. It was carried out by Timonen (000) and was published in the Journal of Clinical Nursing. The study addresses three research questions and gives a good outline of the content of the study. The research questions were, ‘what is the aim of bedside reporting, how actively do patients participate in bedside reporting by taking part in conversation and what factors promote or prevent patient participation?

A literature review had been carried out prior to the study, which referenced many other studies on the subject of patient hand-over. However, no acknowledgement was made by the author to suggest that the survey had been commissioned by a particular agency or group. From this review the author noted that there was a need for a more generalised insight into both nurse’s and patient’s opinions of bedside reporting.

Good description was given of the design of the study, which was in the form of a questionnaire. A sample of both nurses and patients received the same questionnaires in order to compare their views. Different sets of questions were related to each of the research questions and responses used a four point Likert scale for attitudinal statements. The alternatives strongly agree, agree, disagree and strongly disagree were combined for the analysis. The results were displayed as frequencies and the chi-square test was used to test for significant differences between the groups.

The sample was selected by purposefully choosing six hospitals. A total of eight wards were chosen for the research, four abdominal-surgical and four orthopaedic wards were included, all of which were found to be using the bedside hand-over method of reporting. For patients on these wards to be accepted for the study they had to be over eighteen years old, be able to fill in the questionnaire and have been involved in a bedside hand-over at least once. These people are part of a captive population and as such become volunteers in a convenience sample. Parahoo (17) suggests that this is the weakest form of sampling. He states that the researcher should question whether or not the participants really volunteered, or whether they felt they had to take part due to moral obligation, gratitude for the care they were receiving or for fear of being labelled uncooperative. 146 nurses and 18 patients were given the questionnaire and an 81% response rate was received from both groups. Polit & Hungler (15) have stated ‘the larger the sample the more representative of the population it is likely to be’. Details were given as to the gender and age of the patients but not the nurses; also the care setting was described i.e. how many patients shared a ward or whether they were in single rooms etc. However, there was no mention of social class or race, which could have an effect on the results, for instance there is a good probability that patients from an upper class white background will answer the questionnaires differently to Ethnic minorities from the lower end of the social class scale.

The researchers suggested that the question of validity had been addressed by ensuring that patients were aware of what they had been asked to comment on and that they had understood bedside reporting. The authors accepted that the reliability may be questioned because the sample was one of convenience and it was not known how the sick patients would have assessed the bedside hand-over as they had been excluded from the study.

Statistical significance results in this study are poor. The p value was used when showing results for some of the questions but not for others. Discussion of the strengths and weaknesses of the study was included in the article but the results could have been documented in a way that was easier for the reader to pick them out rather than having to read through pages of text to see what the results were. The conclusion led on from the results and summarised very loosely what they had shown, however it did not appear from reading the article that the original three research questions had actually been answered. The results stated that all of the nurses in the study saw bedside reporting as a source of information for both nurses and patients but only 64% of patients agreed. Nurses felt that communication with patients was more interactive than the patients did; the nurses felt that they encouraged the patients to participate in the hand-over whereas the patients felt that this was not the case.

The third article by Greaves (1) is a piece of qualitative research, which was published in the Nursing Standard. The paper states that the aim of the research is to explore how patients perceive the practice of nurses handing over care at their bedside. However the author did not state why the research was carried out or what the relevance of it was.

The qualitative method seems appropriate as a research design as it ensures that the research is focused on the perspectives of the participants, allowing them to talk about their feelings towards bedside hand-over. Parse et al (185) state that because a qualitative approach to research identifies the perspectives of the research participants and uncovers their characteristics and experiences.

It is not clear from this piece of research where the sample population was chosen from or how they were chosen. It simply said that patients who had a history of frequent admission to hospital were chosen but there was no mention of whether the sample was random, volunteer or convenience. Four groups of people were excluded from the sample. These were, patients awaiting transfer to another ward, dysphasic patients, withdrawn patients and those patients who spoke English only as their second language. The final sample, because of constraints on time consisted of only four patients forcing the research to become nothing more than a pilot study. The research did not include any description of the type of care setting the sample was from i.e. the type of ward. Also there was no description of the demographic variables of the sample population, and this could have an effect on their experiences i.e. race, gender, age and social class (Parahoo 17).

Explanation was offered as to the method of data collection, which consisted of semi-structured interviews using open-ended questions. The interviews were taped and transcribed verbatim; however it was not clear where the interviews had taken place or how long each one had lasted.

The research gives brief description of how the data analysis was carried out. Significant statements from the transcripts relating to hand-over were coded and themed into ten categories. The logic of this process was not brought to the reader’s attention, but the credibility and validity of the findings were tested by means of an independent colleague also coding the transcripts, the results of which were that he also identified similar themes. Although ten main categories were addressed there is no mention as to whether other information brought up at the interview were taken into account and included in the findings.

The article included a token sentence stating that the study received approval from the ethics committee and that patients could withdraw at any time. It stated that at each stage of the study, issues of validity, reliability and bias were considered but there was no proof of this being the case. So how reliable are the results?

The findings are clearly stated and easy to understand, they suggest that patients like the bedside hand-over although they feel the need to be involved and be talked to, rather that talked about. The patients did not appear to be worried about confidentiality as they stated that they spoke to each other about their illnesses anyway.

From this research it would be wrong to assume that the findings were generalisable and that bedside hand-over should be implemented everywhere. Patients in this particular research setting may have liked this method of hand-over but others may not. For instance if you work on a gynaecology ward it would not be sensible to base your practice on research that was carried out on a geriatric ward, therefore it would have been helpful for the setting of the study to be described.

The author does state that more research needs to be carried out and that due to the small sample and selection of informants used it is not possible to generalise the findings of the study to other areas and it only serves as a pilot study.

From these appraisals offered it appears evident that the results of these studies are less than reliable. Some are better that others and do have good points. However for a study to be worthy of having its findings implemented into practice it has to be carried out with the utmost care and attention covering every research issue.

Although it would be unwise to take the results of these studies at face value there are many other pieces of good research worth implementing. Unfortunately a lot of it is not being used. There are many suggested reasons put forward by several writers why this may be the case, including the way research is encoded, transmitted, received, interpreted and accepted by nurses (Brown 15). Barriers to the utilisation and implementation of research in nursing are increasingly being researched and written about in order to find out reasons why the best research evidence is not always put into practice. Nelson (15) suggests that a lack of a positive research culture within the wards and units plays a part in why research evidence is not integrated into clinical practice. Pearcey (15) has similar views blaming it on lack of knowledge about how to access and critique research papers. Whereas Retsas (000) suggested that the greatest barrier was the lack of organisational support in relation to providing time to use and conduct research. Many nurses who were trained before research became popular, may not have the skills necessary to utilise the available evidence. As Clark (187) states, ‘they lack research awareness’, which hopefully will not be a problem for the nurses of tomorrow.

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