Principles of Nursing Culture Change - Essay Example

? Evidence based practice in the operating department Evidence based practice in the operating department Evidence based practice in the operating department The culture change in nursing expects nurses to do research and to base their practice on the latest evidence from research (Polit and Beck, 2008). The evidence would be the best available clinical evidence for safe patient care. Polit and Beck defined research as “the systematic enquiry using disciplined methods to answer questions or solve problems” ((2008). The aim was to develop a research from the evidence provided in previous research, refine it to selected situations and expand the body of knowledge so that future researchers could build on it. The research usually elaborated on the practice, educational aspects, informatics and administration. Trustworthy evidence would be obtained for improvement of the health and maintenance of quality care of the patient (Polit and Beck, 2008). Nursing research previously enabled the nurses to do research but denied them the opportunities for clinical care (Newell, 2006). A change had been noted in recent researches; they focused on the experiences and educational systems for nursing. In effect it was the patients who were to be benefited. Research helped a nurse to be equipped to participate in the multidisciplinary team which functioned to provide a safe and quality care to patients (Newell, 2006). It was essential that nurses understood the code of professional conduct thoroughly. Participation in research needed to be a commitment preserving the principles of confidentiality. Nursing research had to be sanctioned by the appropriate body. The rights of the patients had to be safe-guarded and protected. The nurse researcher had to be well-informed about ethical policies and procedures (Newell, 2006). Evaluation and description of the principles and methods of scientific enquiry that made up evidence based practice. Qualitative research with different approaches This emergent research had many different approaches which were named differently but had some features in common. The research generally sought a large number of truths and generalization was usually not possible in another setting (Ryan, Coughlan and Cronin, 2007). Discovery and description constituted the main aims and occasionally verification. Details of the social context were obtained in this inductive approach. The social world was understood in the views of the participants or the patients and this was termed the emic perspective. The researcher and participants had a relationship which produced better data. The sample was usually small and consisted of people who spoke well and provided information. They were in some way related to the aim of the research either as patients or educational personnel. Data were soft data or words of the participants (Ryan, Coughlan and Cronin, 2007). Techniques for data collection were through interviewing, observation of participants and by looking through personal documents and printed matter. Analysis usually was presented in a narrative form. Rigour was determined by assessing credibility, transferability (fittingness), dependability, confirmability and goodness (Ryan, Coughlan and Cronin, 2007). The types of qualitative research or research approaches were generic qualitative research, phenomenology, ethnography and hermeneutics. Generic qualitative research used a purposive or convenience sampling. Data collection was usually through semi-structured interviews. Data analysis used some tools. The findings of the generic analysis described the phenomenon being studied (Ryan, Coughlan and Cronin, 2007). The phenomenological study investigated the lived experiences of participants. The literature review was usually done after the analysis of the study had been completed. This enabled the researcher to ground the data (Ryan, Coughlan and Cronin, 2007). The philosophy of phenomenology was to view the subjective experiences of the participants, these being the aims of the research. The studies with these experiences were then obtained from the literature review. The lived experiences or phenomena being studied were described, interpreted and understood. The sample selected was purposive (Ryan, Coughlan and Cronin, 2007). The interviews were multiple and unstructured but formal. Written texts like diaries could be used. Tools were used according to the philosophy selected. Findings were described or interpreted. Hermeneutics was a related approach which understood lived experiences and connected them to behaviors of a particular period in history or politics or culture or social context. Ethnography was another qualitative research approach which described or interpreted the cultural behavior. Written text was compiled by the researcher. The researcher collected the information during fieldwork by observation, information and by examination of documents. The cultural behavior was described, analysed and interpreted (Ryan, Coughlan and Cronin, 2007). The culture was presented in the words of the members. The research in broadly defined cultures was known as macroethnography. Studies with narrowly defined cultures were known as microethnography. Grounded theory was another research approach in qualitative research which originated in symbolic interactionism and social sciences (Polit and Beck, 2008). Many middle range theories were associated with grounded theory. Theory was derived from the existing data. The sample included people who contributed to the information obtained. Information was gathered from interviews, participant observation, diaries and other documents. Comparative analysis was done. The emergent theory was then described. The information obtained showed how people solved the problem at hand. Both the research problem and the process were obtained during the research. Constant comparison revealed the themes (Polit and Beck, 2008). Case studies provided information by focusing on the participants. Plenty of descriptive information was obtained (Polit and Beck, 2008). The case was the central focus. An intrinsic case was one that was given while an instrumental study started out with a question and then a suitable case was found. Quantitative research and Statistical Analysis The question which addressed the purpose of the study was well-defined in quantitative research. The research would be confirming hypotheses about phenomena. A more rigid style was followed for the process and design was equally rigid. There was a logical style for the research report. Structured methods were followed in the questionnaires, surveys and observation. Question format was close-ended. The objectives were to analyse quantitative variation, predict causal relationship and provide characteristics of a population. The quantitative research dealt with the numerical data and was slightly more difficult to perform. It consisted of data collection, its tabulation, summarization and analyses for answering hypothetical questions (Fitzpatrick et al, 2011). Nursing studies were mostly quantitative. Statistical methodology was used frequently. The numerical data needed to be converted into meaningful text through statistical analysis. At the beginning of the research, the researcher had to determine how he was going to quantify the variables. There were dependent and independent variables. Random sampling was usually done to eliminate bias. Three scales were used for measurement: nominal, ordinal and continuous. Usually Likert scales or Guttman scales were used for measuring opinions, attitudes and other psychological measurements. The outcomes of nursing care and its effectiveness were measured by the quantitative research (Fitzpatrick et al, 2011). Randomised clinical trials used the quantitative research. Quasi-experimental research This was just like the experimental research which also had an independent variable but with a few differences like not having a control group or a random selection or random assignment or any active manipulation (Fitzpatrick et al, 2011). This research was useful for testing causality. The threat to internal validity was a disadvantage in quasi-experimental designs. Quasi-experimental research was of 3 kinds: pre-experimental, nonequivalent control group and interrupted time-series design. Mixed researches Recently nursing researches had turned to mixed methods (Sandelowski, 2000). Combinations could occur at the method level (qualitative or quantitative), paradigm level (design), technique, data collection (survey, interviews) or data analysis. The power of analytic studies and versatility were increased in the mixed methods. Results also could be versatile. Survey A survey was performed using a questionnaire and provided straight-forward textual data on experiences, perceptions and observations. The information could be rich data which could be used for future improvements within the nursing practice for a particular situation or group of people. Surveys could be classified according to size of sample, type of sample, method of data collection (mail surveys, telephone surveys) and content (pre-election survey, health survey, housing survey etc.). Panel design was used when the same participants had to be interviewed several times. Case control and case cohort studies Case control and case cohort studies were used to study the epidemiology of illnesses and known as epidemiological designs (Sato, 1994). In case control studies, all cases of an illness were selected. The controls would be the people who did not suffer the illness at the end of the risk period. Retrospectively, the history of exposure could be taken. Then the comparison of the cases and controls were done. It was difficult to determine the proportion of incidence or risk ratio. The design of studies using the case controls and the fixed cohort was known as hybrid epidemiological design. In fixed cohort the cases and non cases were selected at the beginning of the risk period. Here the risk ratio could be calculated (Sato, 1994). Randomised controlled trial A cause-effect relationship between treatment and outcome could be rigorously determined using a randomized controlled trial (RCT). The cost effectiveness of a treatment could also be determined. The allocation to intervention groups was random (Sibbald, 1998). Double-blinding studies were those where the patients and trialists were unaware of the treatment. However double blind studies were not always appropriate. All intervention groups had the same treatment except for the experimental one. Patients were analysed within the group they were allocated. Associations between an intervention and an outcome could be determined through a non-randomised controlled trial (Sibbald, 1998). The non randomized controlled trial could not eliminate the possibility of a third factor associated with both the intervention and outcome. The outcomes assessment could not be biased in RCT by the views of subjects and clinicians. Systematic review Systematic review was a reliable source of evidence for clinical practice guidance (Clarke, 2011). A summary of the researches included in the review provided the answer to the research question. It was sometimes called secondary research being a research on other researches. Guidelines development usually required systematic reviews. The rigour of the systematic review was usually the same as that of the participant researches (Hemingway and Bereton, 2009). Systematic reviews needed to be based on peer-reviewed protocol so that the study could be replicated. They synthesised the findings and made interpretations. Interpreting results Qualitative data were words and observations. To understand the data, analysis and interpretation was done (Taylor-Powell and Renner, 2003). Open-ended questions, written comments, testimonials, individual interviews, focus group interviews, logs, journals, diaries, field observations, documents, reports, stories and case studies were the sources of qualitative data (Taylor-Powell and Renner, 2003). The analysis of these narrative data was systematic. A systematic approach was needed to understand the data. Rereading the text or listening to the audio-tapes repeatedly provided understanding of the data. The data could not always be of high quality. Focusing the analysis to a few key questions that needed answering helped the thematic analysis of the data. Identification of the themes and categorizing them was the final stage of qualitative analysis. Preset categories were set before the analysis. Emergent categories evolved during analysis. When the two were combined, the pre-set categories were noted and then more were added as the analysis proceeded. Identification of patterns or connections between and within the categories constituted the next step. Attaching significance to the themes provided meaning and then they were brought together. The final step involved was the cutting and the sorting (Taylor-Powell and Renner, 2003). Quantitative data analysis used descriptive statistics which described data as numerical counts or frequencies or percentages, means, modes or medians, or range, standard deviation or variance. The summary of the data was seen from different directions. Summarising the data into charts and tables helped in analyzing them. Validity Validity decided whether a research had performed what it set out to measure and the truthfulness of the results. It was significant in both quantitative and qualitative research. The trustworthiness of the research was proved by validity. A research was good if it was valid and reliable. Internal validity measured the legitimacy of the results of the study (e.g. mean difference between treatment and control groups). External validity was the ability to generalize the results. Reliability Reliability was a common threat to internal validity. If the test provided the same result always, the research was reliable (Handley, NATCO). Reliability was at risk if the research took a long time to complete. The threats to validity and reliability were reduced by a team approach. Pvalue Random fluctuations or errors of sampling indicated the p value as a probability in the observed findings by being a chance occurrence. If the p value was 0.01, the probability was 1 out of 100 that the finding was a chance event. The interpretation was that we could say with 99% confidence that observed finding was meaningful. Skew values “Skewness is a measure of distributional asymmetry” (Lovric, 2010). If the distribution had a longer tail on the right, the skewness was positive or rightward. If the tail was on the left, it was leftward or negative. Some values remained positive like weight, response time, time to failure, income, wealth and prices as these did not take values below zero. Left skewness was rare unless the variable was close to maximum. Evaluation of the appropriateness of the different methods in relation to operating department practice. The use of antiseptic agents at two points in time with an interval of 4 years was investigated in questionnaires at 6 significant hospitals in Japan (Shiraishi et al, 2006). Guidelines had been published in 2000 by the Center for Disease Prevention and Control after evidence-based practice had been explored. The survey was for finding out the amount of disinfectant used in the operating rooms over a one-month period in 2000 and 2004. It was found after the surveys that lesser disinfectant was used in 2004. Large reductions were noted for amphoteric and glutaral products in the 6 hospitals by more than 90% (Shiraishi et al, 2006). Povidone iodine was used lesser by 23.4% at an overall average while 3 hospitals showed an increased use. The applications of Povidone iodine on the operation site were not reduced. However the site was left to dry more in 2004. The frequency of using the scrub brush was the same in 2004 as in 2000. However time for scrubbing was shorter in 2004. The changes advocated in the guidelines had brought about changes in the measures for infection control in the operation theatres of the six hospitals (Shiraishi et al, 2006). The hospitals used brush scrubbing and alcohol-based scrubs. Environmental disinfection had been controlled and the rash use of disinfectants had been reduced. The guidelines had discouraged the unnecessary use of disinfectant in the hospital environment and for wiping the floor. Alcohol hand-rubs were also used (Shiraishi et al, 2006). . A qualitative focus group interview with 7 theatre nurses, with several years of experience in a teaching hospital in London, revealed their perceptions of communication skills in the operation theatre (Nestel and Kidd, 2006). The key features as well as other unique features of communication were investigated. The data were collected and transcribed. Content analysis produced common themes. Listening, clear speech and politeness were features of good communication that were agreed upon by most of the nurses. Conflict in role perception and issues of organisational nature were found to be drawbacks in the communication. When nurses were assigned other roles, the communication suffered. Barriers to communication also occurred when collaborative team work was lacking (Nestel and Kidd, 2006). These barriers to good communication would never have been found if research had not been done; the working of the operation theatre would not have been optimal then. The discovery of the barriers promoted changes in the theatre and helped the nurses to achieve satisfaction as they were the ones who were not happy with the communication in the operating theatre. The same research could be repeated in other operation theatres with the aim of improving their functioning. Clinical safety would be achieved by role clarity and effective teamwork (Nestel and Kidd, 2006). Patient safety was assessed in operation theatres using aviation pilots of the crew resource management team for training the theatre personnel on the shared mental model of communication that pilots were familiar with (Gore et al, 2010). A pre-interventional survey and a survey 6 months after the training revealed a big improvement in some questions of the survey questionnaire: 3 questions of team work, 1 of reporting of errors and 3 on the patient safety climate. Scoring was by the Likert scale. The crew resource management training had proved useful for improving patient safety in the operation theatre (Gore et al, 2010). The architectural aspects of the physical environment of the operation theatre including the general layout of the nursing unit, the position of nurses’ station (whether central or not), position of staff areas, design of the patient room and the interior design aspects which included the lighting, acoustics, ventilation and ergonomics greatly influenced the work of the staff in maintaining the safety culture and preventing errors in nursing and medication. Chaudhury et al studied literature for designs affecting the safety culture and investigated the situation in three hospitals through focus group interviews for medication errors caused by architectural design (2009). The researchers discovered four principles which were design-related and which could be changed for better patient safety and less errors. Changes in design were advocated for making patient accessibility better and decreasing disruptions, using machines to help in the safety process, reducing workload by keeping the nurses’ station close to the patients and also by promoting the safety culture (Chaudhury et al, 2009). The literature review allowed the researchers to obtain only a few articles for discussion. The focus group interviews however provided the actual practical problems currently being experienced. The ample information provided ideas for correction of the architectural and interior decoration design to promote safety culture. Research had provided the answers to a big question of patient safety. The mini-ethnographic study by Gillespie et al (2008) provided information on the characteristics of the organizational culture within the eight operation theatre-complex in a large hospital in Australia. The highly specialized environment provided three themes. The significance of the competence and educational knowledge of the nurses was understood from the perceptions and behaviours of the nurses in the words of the nurses, orderlies, trainees, surgeons and anaesthetists and it comprised the first theme which influenced the organizational culture. The social order and the situational control were the other themes which had their influence. Role expectations were high and could have influenced the nurses’ attrition. Nurses had to keep their competency robust in the operation theatre and the difficulty to remain so had caused their attrition (Gillespie, 2009). A case study analysis by Finn (2008) was used to study the ethnographic study of Eisenhardt (1998) in an operating theatre in Midlands University. The ethnographic study had included 5 months of observation of the various staff. The findings however were against the usual assumption that teamwork was beneficial to the patient safety. Teamwork had been perceived to trigger contests between the staff of different categories and produce conflicts in turn. The divisive effects of teamwork were obvious (Finn, 2008). Enhancing collaborative teamwork could have had disastrous effects on safe patient care if it produced competition among the staff at the risk of impinging on the safety culture. So merely enhancing collaborative teamwork was insufficient for patient safety. The collaborative teamwork needed to always keep the patient safe (Finn, 2008). Research used different techniques and approaches to identify problems in the operation theatre. The identification of problems was faster and solutions could be rapidly incorporated in the management of the functioning of the theatre. The organisational culture for the healthcare of patients within the operation theatre needed to be frequently assessed for promotional changes. Evaluation and critically analysis of an existing piece of research relating to the operating department, and demonstration of the ability to make a judgement based on the evidence. Nestel, D. and Kidd, J. 2006, Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview BMC Nursing 2006, 5:1 BioMed Central This qualitative research with exploratory design had a short precise title with no ambiguity about it. It was well written and grammatically correct and avoiding jargon. Both authors seemed well-educated and placed. Their educational qualifications had not been added. However Nestel was placed in the Department of Biosurgery and Surgical Technology in the Imperial College of London and Kidd was a Reader in Warwick University; both were well educated. So the believability of the research was confirmed. The abstract, with the background, methods, results and conclusions was fairly informative and impressed a reader. The study was for determining the inter-professional communication in the operation theatre through the perceptions of 7 nurses currently working in the operation theatre. The research problem and the sample had been given clearly. The statement of the phenomenon of interest had been identified: the communications between professionals in the operation theatre seen through the perceptions of the theatre nurses. The research question had not been expressed as a question but the paper was evidently talking about the inter-professional communications and the means of improving these in the operation theatre. The significance of the study had been highlighted and the rationale understood. The literature review also had been elaborate. It met the philosophical underpinnings of the study by providing relevant information and identifying specific ideas on methods of communication, areas of tension and the impact on novices. The aim of this paper was to explore nurses' perceptions and experiences of communication in the Operation Theatre that the nurses identified in the focus group interviews. Development of interventions was to be done using the evidence obtained in the focus group interviews. A framework or concept had not been identified but it was mentioned that the data would be obtained through prominent emerging themes of the perceptions by the nurses at the focus group interviews which were then subjected to thematic content analysis. The sample method was purposive and convenient (according to availability by the duty roster and from the specialist and general theatres) and size had been identified as seven. The participants were most suitable for informing the research. Only verbal consent had been obtained. The anonymity was safe and participants received a copy of the conclusions in the research. The data collection strategies had been mentioned. Analysis had been done repeatedly till emergent themes were recognized and negotiated between the two researchers. It was not evident that data saturation had been achieved. The rigour of the study had been established in the aspects of documentation, procedure and ethics. The findings had been placed appropriately in the context of the phenomenon studied. The original purpose had been addressed. The implications of the findings were significant. Nursing practice could utilize the findings in promoting the management of the operation theatre to be safe for the patients. Recommendations had been made for more research in future. The references had been all given. This study had been a good one with plenty of information for future use and research to produce changes in the operation theatre. Implications of research in future practice Nursing will continuously use evidence-based practice. The quality of studies, the understanding and critiquing of the evidence and the usage of the results for practice constitute the future research (Polit and Beck, 2008). Translational research or how evidence could be used in practice appears to be a significant approach. The rigor of the studies will be improved. Research designs which confirmed earlier findings through replication with different clients and settings could provide ample information of stronger evidence. Studies at multiple sites are another possibility. Systematic and integrative reviews help to put together evidence from many studies. This massive evidence and its exploration provide the basis of best practice guidelines (Polit and Beck, 2008). Localised research could provide answers for problems in a setting. This is especially useful for hospitals vying for Magnet status. Research could also focus on the multidisciplinary collaboration and its value for success mostly in the psychobiologic and behavioral therapies. Lifestyle and intervention therapies also need the collaborative efforts. Wide dissemination of result findings help other researchers to use these for their practice and also go onto more progressive research (Polit and Beck, 2008). References: Clarke, J. 2011, What is a systematic review? Evid Based Nurs 2011;14:64 Chaudhary, H, Mahmood, A and Valente, M. 2009, The Effect of Environmental Design on Reducing Nursing Errors and Increasing Efficiency in Acute Care Settings : A Review and Analysis of the Literature. 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Program Development and Evaluation, Board of Regents of the University of Wisconsin. Retrieved from http://learningstore.uwex.edu/assets/pdfs/g3658-12.pdf Read More