Differences Between Accident and Emergency Nurses - Book Report/Review Example

RESAERCH QUESTIONS Key issues What are the results Are the results of the study valid Will the results help locally Research questions Answers Whatis the research question or hypothesis Is the research question important for nursing In what way will the research contribute to nursing practice or the care of patients Are the key concepts and variables defined Is it clear who and what the researchers are investigating Is it clear whether the study tried to identify a harmful or beneficial effect Does the research make any supposition about the result The research questions were based on three hypotheses. It investigated whether there were any difference in Accident and Emergency Nurses' (A and E Nurses) attitude to deliberate self-ham (DSH) patients who after an harming attempt have attended the A and E to receive management. If there is a different attitude to such patients, this research was designed also to investigate whether these attitudinal differences were related to the nurses' age, A and E experiences, and attendance to in-service educational programmes about DSH. This is a very important question for nursing practice, since the findings may serve to be evidence base in practice. If this study is able to refute the null hypotheses that the authors suggested, this would indicate that the A and E nurses would need to be employed with a specific age recommendations, would have to be experienced, and would need in-service training for handling DSH cases. Since the findings of the research can modify nursing practice, the research question is important for nursing practice. The authors establish the rationale in the introduction of this study, and in the literature review section, they discuss the evidence from other studies, where the reader can reach a conclusion that this study would contribute to the nursing practice and in the care of the patients. There is a strong relationship between DSH and suicide. If the DSH patients do not get adequate care in the form of appropriate assessment and sufficient management in the A and E when they present, it is highly likely that these patients may end up committing a suicide that could have been prevented. The existing literature and real-life findings are that the A and E nurses are often the point of first contact with these patients. They need a very positive attitude towards these patients that they often lack in practice. They are also reported to lack appropriate assessment and interpersonal skills to care for them. This study proposes to find out whether these are true or not, and if true programmes of professional development that cater attitude building, assessment skill development, and development of interpersonal skills to handle these patients at first presentation in the A and E, so many DSH cases may not have catastrophic suicidal events as an outcome. In this study, the authors present a section called definitions where they define all the involved variables in this study. While defining them, they also explain the key concepts so the reader can start the study of this literature from that baseline of knowledge. Since this study is about the patients who presented with DSH, the authors have used Auditor General of Western Australia's definition of DSH that includes patients that had intentional poisoning or self-injurious activities irrespective of the underlying cause. This last element of the definition also includes psychiatric patients who could repeat such behaviours in future and are at risk of committing suicide. Since the age of the nurses is considered to be a variable, the cut-off point of the age has been defined as 35, above which, the nurses of 36 years or over have been defined as older and those 35 years or below are younger. Although this is an acceptable cut-off point of age segregation, the authors do not provide any rationale for such division. Also, one may argue that those who started their career at an early age may be experienced or matured enough to provide serious weightage to the patients even though they are young and vice versa. Similarly, the experience has been pointed out to be 5 years, where A and E experience of more than six years would be counted as experienced. Experience again is a facet of attitude and insight, and that is not necessarily a variable connected to the duration of work. The variable that defines attendance in in-service education programme related to DSH has no ambiguity, and this definition is very reasonable. The authors have explicitly explained and mentioned in a clear and discrete fashion, who are the study subjects. They have tabulated the criteria of the participants in table 1 and have indicated their number in each category. They have calculated their percentages, and the reader can have an idea of the sample size even without reading the associated text and the number of participants in each category of variables described above. The authors also mentioned in the discussion in the definition section, what they were investigating. In this sample population, the authors have utilized a questionnaire of 29 closed items to study sociodemographic, education and practice guidelines, attitudes, and practice intentions of these nurses. The questionnaire was designed and adapted from the Suicide Opinion Questionnaire by McLaughlin. This instrument was used to study the impact of the nurses' age and experience on attitudes towards patients with DSH. It is distinctly clear that the study attempts to identify the beneficial effects of educational intervention in changing the attitudes of the A and E nurses towards the DSH patients over the harmful effects of negative attitudes of these nurses towards prevention of DSH and suicide. The authors provide support from literature that nurses; attitude towards patients of DSH can influence their willingness to attend and care for these patients, and this reluctance may lead to negative care outcomes. If benefit is a target, then this can be achieved through attitude change of the nurses. This can be accomplished through ongoing support, provision for appropriate training, training in formal assessment of such patients to improve skills, and introduction of a comprehensive framework of care. In these cases, the most appropriate and satisfactory care can be achieved to nurses' education on psychosocial assessment that needs time, patience, and attitude of the nurses. This research does not make any supposition about the results, but makes null hypotheses and lists them. The reader, however, while going through the literature review can have the feeling that the authors are confident that better nursing care of the DSH patients in A and E can culminate into reduction of the suicide cases in these hospitals. The authors cite some conflicting evidences from studies whether age and clinical experience are factors determining nurses' attitudes. Also, the reader must remain aware that attitude of the nurses matter, but the disease condition, DSH and suicidal tendency are complex and multidimensional, and there are no significant relationships between duration of clinical experiences of the nurses and their attitudes. If the null hypothesis is refuted, the opposite becomes true and will be considered as the findings of this study. Study design Answers What is the method that is being used Is this quantitative or qualitative design Is it prospective or retrospective Is this longitudinal or cross-sectional research Is there an intervention, if so, what is it What type of measurement tool was used What other method (s) could have been used Would this method have been more appropriate or can you see why it was not favoured Does the method used address the study question The authors have used a questionnaire interview study before an educational intervention about DSH in an A and E Department in a blinded fashion. These were framed in 29 closed items and related to attitude issues. Since the data were collected in a Likert scale giving numerical values to the descriptive Answers, it can be stated that descriptive or qualitative data were converted to quantitative data for the purpose of statistical analysis. Therefore this can be termed as a quasi-qualitative design. This quantitative method is very suitable to study behavioural change processes. This is a prospective study in the sense that in a prospective study, subjects are sampled based on input variables that are believed to influence the outcomes. In this study, the authors arranged educational intervention classes for the nurses about DSH, and they studied attitudinal and practice intentions through interview questionnaire that was completed before the education intervention began, and completion of the questionnaire was not a prerequisite for entry to the education session. Thus, this is a prospective study in the sense that the authors held staff education classes before the data collection began. The authors ensured the accuracy of the data collection before the study. This is a cross-sectional study in the sense that this relies on the memory and experience of the nurses about their care processes on DSH patients while on duty in the A and E. The researchers did not identify any group of nurses who might have been having attitudinal problems or demonstrating lack of adequate care to these patients, rather, they gathered data from everyone at a time. After gathering data, the authors analyse them to find out what factors are responsible for such intent in practice. Similar information about the nurses demonstrating caring attitudes to these patients can be compared to arrive at a conclusion. The intervention that was used in this study was an educational intervention that deals with the ideal attitude, its importance in clinical practice, and how attitude changes in the nurses can influence the outcome of care in these patients. The measurement tool that was used was an interview questionnaire that contained 29 closed items in four parts. This tool is known as Suicide Opinion Questionnaire that incorporated 14 attitudinal statements from highly significant items from another research. The responses were recorded in a Likert scale ranging from 1 to 5, where 1 means strongly agree and 5 means strongly disagree. A descriptive method could have been used in this study. It would list all the variables of the defined sample. Descriptive studies require a thorough and careful description of the sample. This would not compare between the two groups, young and old, attendee and non-attendee, or experienced and inexperienced. Readers can then understand the differences from their own experiences. However, in that, the limitations are that the findings from the study would have lacked generalizability, so application in practice to change practice would have been difficult. Furthermore, the authors not only want to know the effects of attitudinal changes in the care outcome of DSH patients in terms of prevention of suicidality, they also intend to know the effect of the demographic variables and educational interventions in such practice. Therefore, depending on the thesis question, the authors have chosen the most suitable design for such study. This method addresses the study question most completely with adequate reliability. They have studied the siociodemographic, education and practice guidelines, attitudes, and practice intentions of the nurses. The authors used this same instrument to replicate the impact of nurses' age and experience on their attitude towards such patients. In this way, the authors take care of the entire hypothesis made in this study. Recruitment and sampling Answers What is the research population What method was used to select the sample from the population Was this appropriate Did the sampling strategy introduce any bias Was the sample representative of the population Was everyone included who should have been If a group of people were excluded did that have an effect on whether the sample was representative of the population If the sampling strategy introduced bias do the researchers acknowledge this Did anyone opt out If so why Are the characteristics of those who did not take part different from those who did Will this affect the results Is the sample size large enough How did the researchers arrive at the sample size Can the results be generalised to the population Sample of A and E nurses consisted of 43 nurses. Convenience sampling was used to select these nurses from the population. Since the study was done in a single hospital A and E Department, this was the best possible choice. The sample strategy did not introduce any bias, since completion of the questionnaire was not mandatory to attend the educational session. The sample was representative of the population since 81.4% were female, more than half were aged 35 years or below, 67.4% of the respondents had 5 years or less experience in the A and E Department, and 32.6% had more than 6 years of experience. Only 8 respondents have attended any in-service educational session of 1-2 hour duration. From experience, this is picture in any A and E Department nursing pool. Nobody opted out of the study. This question is not applicable. This question is also not applicable. The sample size, 43 is a good number that is more than 35, and a sample size of more than 35 establishes the reliability. However, multicentric studies involving more nurses could provide more validity, reliability, and generalizability to the results. The researches arrived at the sample size by convenience sampling. With an extent of limitations, these results can be generalised to the population since these reflect the structure of the nursing workforce in almost any A and E Department, not only in terms of number, but also on the basis of age, experience, and exposure to educational intervention. Their awareness about the guidelines were minimal, which is the care in reality, and very few have read the guidelines. Those who have read the guidelines claimed that they nearly follow the guidelines indicating the effect of educational interventions in practice irrespective of age and experience. Although the researchers believe that the attitudinal items accurately reflected the then Australian beliefs, it is a fact to be recognised that the non-probability samples were drawn from a group of registered nurses in only one emergency department. This might limit the generalizability of the findings, although it is certain that this would provide insight into the issues associated with the care of the patients with DSH. Data collection Answers What tool(s) have been used for the collection of data Have the tools been validated and tested for reliability Are the tools appropriate for this study Were the tools piloted before they were used in the study Was any data missed that would have been helpful Who collected the data and what training did they have What is the relationship between the data collector and researcher Is there any undue influence because of that relationship (e.g. senior colleague, manager, lecturer, patient and doctor) Where did the data collection take place and was this appropriate What were the circumstances under which the data collection was made and could those circumstances have caused any pressure or bias Did the data collection cause burden for any of the participants McLaughlin's adaptation of Domino's Suicide Opinion Questionnaire was used. The tool had been validated and tested for reliability in other studies outside Australia, but in this study, the authors mention about no validity and reliability tests although this is a very known and established tool for the researchers in this area. There is no evidence of piloting of the tool in this study, but if one takes evidence from other studies from which this tool has been adopted is taken into account, one can take those as adequate evidence of piloting. All the data have been taken into account appropriately with no evidence of any requisite data missing. The participants did not know the data collector, and the researchers just appointed the data collector, and this has helped to avoid bias. One of the researchers was employed in the hospital where the study was taking place. There may be some indirect influence on participation due to this factor. The data collection took place in an A and E Department in a major city hospital in Australia. It was appropriate since there is no harm in conducting a study in the hospital setting where the nurses are habituated to work. The circumstances in which the data collection was done were ideal, adequate, and appropriate. The questionnaire was completed before the education intervention began, and the nurses could participate in the education session without completing the questionnaire. The participation in the education session was voluntary indicating no scope of pressure or bias in responses. There were no coercion whatsoever to participate in the study. There is no evidence in this study as to whether the data collection caused any burden for the nurses, since all 43 nurses completed the questionnaire, indicating spontaneous response, and no one opted out. Have the authors identified all the confounding factors Answers Have the authors identified all the important confounding factors What have they missed Have the authors controlled for confounding factors or corrected the results in anyway What did the researchers do to control for (or account for) factors that might influence the results The number of variables were less, and the authors used a tool that used questions designed in a manner to take care of any possibility of any confounding factor. In my opinion, the authors have not missed any confounding factor, and study had few variables to be confounded. The authors applied statistical analysis by means and standard deviations for attitudinal scores to statistically manipulate the data so individual variations are taken care of. Apart from testing the hypothesis by a paired-t test depending on the standard deviations, the statistical analysis was simple enough so as not to need corrections of the data. It was simple analysis of the Likert scale scores of interview questionnaire by statistical means, and there was no statistical factor involved that could influence data or results. The nurses' responses were the main mode of data, and this was designed to be obtained out of spontaneous and free will. To avoid bias, the data collector was not known to the participants, although the there is no evidence that the authors did anything to avoid the influence of the researcher who was an employee of that hospital. There was no other factor identified that might have influenced the results. Data analysis Answers Do the descriptive statistics describe the study sample completely and succinctly Do the descriptive statistics compare the sample to the population or non-responders What variables were measured What level of measurement were these variables reported in Was this reported in the text What statistics tests were performed on the data Were these tests appropriate Did the authors provide a rational for their choice Which of the results were statistically significant Were there any results that were not statistically significant but could be clinically significant Do the authors discuss this point if it is relevant Were tables used appropriately to summarise information The descriptive statistics have been presented in a complete, succinct manner so a logical flow remains throughout the description, and the reader has no problems understanding the data. It should also be mentioned that they have been tabulated in according to category and order that had been mentioned in the text. Along with the description, the authors also provide explanations for these findings. There were no nonresponders, and therefore no question of comparing the data with the nonresponders arises. Since the study was done to study different parameters and their influence on specific practice, there is also no reason to include comparison with the population. The authors measured demographic variables such as age ranges, sex, experience, knowledge about practice guidelines, and attendance in in-service education. Apart from those, the attitudinal parameters were measured along with the intent to practice. The designed questionnaire also measured the changes in attitudinal parameters of the nurses to the DSH patients depending on their demographic, experiential, and training variables. These measurement data were tabulated in details, and the text also describes these measurements. The authors also explain the measurements while discussing the results in the text so the reader has no problem in understanding the implications of these results. All the collected data were analysed using SPSS version 12. This is a statistical software that analyses the significance of the collected data. The demographic data were utilised to calculate the frequencies and percentages. Means and standard deviations for attitudinal scores were calculated. Independent t-tests were performed to test the hypothesis. These tests were appropriate in this study, since the authors in the first place wanted to know the effect of experience, age, and in-service education in handling patients with DSH in the A and E. Therefore demographic frequency is the right parameter. Descriptive statistics are best recorded in a Likert numerical scale, and if the scores from those data are statistically calculated, one can have clear numeric inference about these descriptive statements. The t-test is a well known hypothesis testing statistical tool, and the authors are right to use this tool. However, the authors did not provide any rationale for these choices of statistical tests. Most were female nurses with most having less than 5 years experience in A and E Department, where only 18.6% of the respondents attended any educational programme with many even not knowing that there is practice guideline in such patients. A 33.3% of these nurses did not read the guidelines even knowing that they exist. However, 95.5% of the nurses who knew about the guidelines followed them. Nurses were mostly in agreement that those who survived suicide attempt needed to be cared. There were significant difference between the nurses on the basis of age, length of clinical experience, or previous in-service education for seven of the 14 items, and the null hypothesis mentioned earlier were not supported. The magnitude of the differences of opinion between older and younger nurses were indicated by differences in means were large with a 13% variance in the attitudinal difference with regard to paying serious attention to the complaints of the DHS patients. Another variable was the probability of further attempt at suicide after survival from initial attempt. The young and the older group varied with a mean difference of 11%. The other areas of similar significant differences were people who attempted suicide were less religious, those who threatened suicides actually ended up ending their lives. The level of attendance in educational programme was also a significant criterion where the groups varied in a statistically significant manner in areas of suicide behaviour interpretation in the A and E settings. The extents of differences were large so one can perceive the influence of attending education sessions. Unfortunately, there were no items that were not statistically significant, and all these factors happen to be clinically significant also. Since there were no such items, the authors discuss none, but they discuss about the improvement of attitude of the nurses towards these patients. This change of attitude has a clinical significance since the effects would be perceived in practice. The reason for this, as the authors have suggested, may be increased education or a reflection of public awareness on suicide and depression. The tables were appropriately summarized and labelled. The data display was precise and clear. The Table 1 displays the Participants data; Table 2, Mean and standard deviation for attitudes towards DSH; Table 3, Mean and t-test of younger and older A&E nurses' attitudes towards DSH; Table 4, Mean and t-test of less and more experienced A&E nurses' attitudes towards DSH, and Table 5, Mean and t-test of attendance at DSH education and A&E nurses' attitudes towards DSH. There is no repetition of the data in the text. The statistical results and the numerical data all are displayed with statistical analysis. What are the results of this study Answers What are the bottom line results How have the results been reported Are the results clear Are all the results included in the paper Have all the results been reported and discussed Does the discussion include any results that re not published in the section The results do not support null hypothesis. The age is an important factor that shapes a nurse's attitude. Although this finding is consistent with the finding from other relevant studies in this area, but in this study, it may mean that life experiences and increasing maturity somehow interact to reinforce the development of positive attitudes towards DHS patients. The results have been reported in a descriptive manner in such a way that it relates to the hypothesis in a categorised manner. In each category, the authors could derive a conclusion after a brief discussion of the findings, demonstrating how these conclusions can be derived from these findings. The results are very clear. Scale of difference in attitudinal opinions regarding the DSH patients considerably varied between the two groups of nurses, and more experienced nurses would give more attention to a suicide threat. These findings also refuted the null hypothesis that nurses' attitudes to DHS would not be affected by years of experience as a registered nurse in the A and E. All the results are included in this paper in a clear manner without omitting any. Experienced nurses held more positive attitudes towards people who self-harm; however, this may be related to the results of repeated exposure to such patients in work. All the results have been reported and discussed in a precise manner with possible explanations associated with it. For example, DHS in-service education attendees and non-attendees demonstrated significant differences on 3 of the 14 attitudinal items investigated, indicating the attendees have greater appreciation of the seriousness of a suicide attempt and the need for specialist treatment and the limitations of the A and E Department in providing this type of management. This discussion includes all the results published in this study and does not include any results that were not published in this study. Credibility and Generalisability Answers What are the indications that it is a credible set of results Can these results be applied to the local or UK population This is a credible set of results, since this corroborates with the findings of other studies on this topic. In all the three categories of the null hypothesis, the results refute them in this study, and similar results resonate in other studies in this area. The researchers believe that the attitudinal items accurately reflect the current Australian belief. This is one of the limitations of this study. The results can be applied to local or UK population with limitations. The reliability and validity of the questionnaire is not known to be validated locally or in the UK. Furthermore, the non-probability sample if drawn from a group of registered nurses in one ED, and this limits generalisability of the study despite the fact remaining that this being a representative sample from a major city hospital A and E is an eye opener to the issues related to A and E management of DSH patients. Discussion Answers Does the conclusion offer interpretation and discussion of all the important results Are the key findings easy to identify What evidence o the authors use to support their arguments Do the authors offer alternative explanations for their findings Do the authors discuss the limitations of their study In a very brief but precise conclusion, the authors have presented all the important results. The key finding is easy to identify. This is that the nurse participants hold supportive attitudes to the DSH patients, and increasing age, greater A and E experience, and attendance at DSH specific in-service education programmes, each play a part in development of positive attitudes towards these patients. The evidence that the author provide are supports from relevant literatures and statistical proof of null hypothesis getting refuted. In some cases, the authors provide alternative explanations. The knowledge about the framework and DSH management programme may be a result of public awareness or may be result of repeated exposure to such patients at work or may be a result of educational programme. The authors also discuss the limitations of their study that limits generalisability and clinical application of the results of this study in all hospitals anywhere. Implications Answers Do the authors discuss the implications of their findings Are the implications or suggestions for practice feasible The authors discuss the implications of their study in enhancing the education of the A and E nurses. Enhancing education has implications in introducing measures to improve both awareness and adoption of practice guidelines about DSH. The authors also suggest that this would improve the attitude of the A and E nurses towards these patients. These implications or suggestions have great application values in practice. Improvement of attitudes of nurses to these patients has implications in changing the outcomes of these patients. Arranging education in-service is one such manoeuvre that can change practice a lot. Over and above that the authors draw attention to the need for older and more experienced nurses to mentor young and less experienced nurses. In-service educations forums can guide the provision of effective and supportive assessment and interventions for patients with DSH. Ethics Answers Does the study address an important question Did all potential participants have an equal chance of participation Were the participants harmed in anyway Is there a potential for this study to do good Did the benefits outweigh the potential harms of the research Was there any coercion or undue influence Were the participants fully informed Was the privacy and confidentiality maintained Was the research reviewed and approved by an appropriate review board This study addresses an important question about the adequacy of treatment and attention that the DSH patients get from A and E nurses. All potential participants had an equal chance of participation. The participants were not harmed, rather benefited from this study. They received education about DSH and had a chance to explore their attitudes and beliefs and to corroborate them with the expectant standards. There were no questions of harm involved in this study, all were benefits. There were no coercion for participation and no known undue influence. However, one of the researchers were employed in the hospital, and that might have caused some undue influences, but that is not known certainly. All the participants were fully informed. Participants' privacy and confidentiality was totally maintained. University and Hospital ethics committee reviewed and approved this study giving ethical clearance. Read More