Literature Exploring Role of Cardiac Nurses - Assignment Example

A Critical Review of the Literature Exploring Role of Cardiac Nurses THE OF SHEFFIELD SCHOOL OF NURSING AND MIDWIFERY SAMUEL FOX HOUSE, NORTHERN GENERAL HOSPITAL, HERRIES ROAD, SHEFFIELD, S5 7AU By Introduction Outstanding technological advances in healthcare have influenced the roles of all healthcare professionals, and nurses in all practice settings are no exception. Since cardiac nursing involves advanced academic learning and advanced practice roles, the educational and training programmes are necessary to be suited with these. The standards of practice and competencies would need to be developed in order to understand what is required to practice in a cardiac care environment, which are acknowledged to be complex and technologically intricate. For the cardiac nurses, to be able to do this efficiently, knowledge, skills, and attitudes are all that is needed. The term cardiac nursing is a broad term, and this encompasses care in different clinical areas. These areas may include areas of cardiac nursing in the cardiothoracic surgery, interventional cardiology, general medical cardiology, cardiac imaging and diagnostics, intensive and critical care units, pediatric cardiology and cardio-surgery, electrophysiology laboratory or pacemaker units, primary care, home care, and even community care. The care provided may need technological knowledge and expertise about the use of complicated instruments, implants, and procedures; ability to interpret data from sophisticated monitoring devices and investigations; capability to critically analyse biological manifestations about conditions, researching evidence from literature, and synthesize them to arrive at a medical decision and nursing care plan; dexterity to manage different critical and life-threatening cardiac situations in diverse environments; knowledge to intervene and educate patients to reduce cardiac risks; and ability to manage a care even in areas ranging from primary, home, and community settings. Research in these areas is diverse and voluminous. Therefore, identification of informative research in this area of practice is important, and to be able to extract useful findings, it would be legitimate to critically review the available relevant research. In this assignment, a critical literature review will be undertaken to that purpose so implications for clinical cardiac practice can be identified through evidence. The process of the literature search and findings from the review has been presented below. Literature Search To build a scientific basis of evidence, a comprehensive literature search was undertaken and then evaluated critically. For the purpose of the review of literature to support the rationale, need, and continuation of the project, this author conducted a literature search across databases. Those accessed for information included: CINHAL, Medline and Pubmed along with the Google Scholar internet search engine. Moreover MEDLINE, EMBASE, and CINAHL and Cochrane databases were searched to identify relevant literature on prevention of pressure ulcers. HighWire Press was also searched. The key words in the search included "cardiac nursing", "cardiac nurses", "role", "cardiovascular nursing", "intensive care nursing", "critical care nursing", "cardiac intervention nursing", "pacemaker units", "nursing," "clinical trials", "home cardiac nursing", "cardiac surgery nursing", "primary care cardiac nursing", "cardiac imaging nursing," "emergency cardiac nursing", "cardiac nursing education", and "cardiac patient education" published in the last 10 years. Inclusion criteria for each article reviewed were answers to the following questions: 1. Was the article a valid research article 2. Did the article's study include role of cardiac nursing in area of cardiac medicine practice and applied to nursing practice in that area 3. Was the article published within the past 10 years 4. Did the article have some identification with nursing practice and healthcare delivery related to cardiac care Each article must answer "yes" to all of these four questions. Based on these criteria, out of about 250 initial articles, only 17 latest research articles that fit the criteria described above were selected to be critically reviewed to synthesize evidence relevant to nursing practice. Those which were review, conversation, editorial, poster presentation, or letters to the editor were excluded. To further narrow the search, a combination of search words were used with an aim to narrow the search so specific areas of cardiac nursing are reflected in the research. Although this would miss the literatures that involve combinatorial cardiac nursing roles, this would generate articles that focus on nursing care in specific practice settings. Only 3 articles could fit this narrowed search that encompasses almost all possible areas of cardiac nursing. For this assignment, these three articles will be critically reviewed, and the findings have been presented. Literature Review Although nurses know that smoking has a negative impact on health, especially cardiovascular health, most fail to provide a smoking cessation intervention. Successful smoking cessation interventions usually have behavior modification as a core component. Behavioral modification skills include identifying areas of concern for patients, teaching patients strategies to cope with difficult situations, and role playing strategies with patients to allow them to practice their new coping strategies (Fridlund, 2002, 15-18). These behavioral modification skills usually are not part of most nursing school curricula. Even when they are taught, there is rarely an opportunity for practice, feedback, and development of confidence in performing these skills. Therefore, cardiac nurses have important roles to play in health education. Bolman et al. in their study examined the effectiveness of a nurse-managed minimal contact smoking cessation intervention for the hospitalized patients, admitted due to cardiac disease. This research was done in a pre-test post-test quasi-experimental design in a randomised group of 789 patients across 11 hospitals with stop smoking intervention that involved a short bedside consultation with the nurse as an important element with the objective to know whether these interventions result in smoking cessation in an effective manner. The most frequently used quasi-experimental design is the nonequivalent control group pretest-posttest design, which involves an experimental treatment and two groups of subjects observed before and after its implementation. The authors have established the rationale of this design from an excellent literature review where the feasibility of nursing intervention of strategy has been established. Since it has been observed that smoking cessation with newly established CHD reduces the mortality after 1 year by 50% and 20 to 60% of cardiac patients smoking prior to the hospital admission persistently smoke even after the hospital discharge, the nursing intervention on admission to cardiology ward can have a chance of greater success due to personal vulnerability, high motivation, and greater receptivity to smoking cessation advice. It has been found that although usually cardiologists advise the patients on smoking cessation, the required support in the cessation process is seldom given to these patients (Gies et al., 2008, 6-21). The nurses' participation in this process is usually partial, with only 10% of these coronary care nurses assisting their patients to quit. The authors chose a minimal contact brief intervention of smoking cessation advice since a needs-assessment study revealed the willingness of the nurses to spend only 15-30 minutes per patient. Another need assessment from the patients' point of view only revealed that the patients are not willing to participate in the formal intervention. Moreover, many reviews have been sited in this study indicating within existing hospital practice, the efficacy of a protocol comprising of stop smoking advice, brief counseling, self-help, and brief followup care are considerably acceptable to the patients (Allison and Keller, 2004, 31-48). Thus the intervention consisted of a protocol where there was a stop smoking advice from the cardiologist, a short bedside consultation with the nurse, administration of self-help materials, and aftercare by the cardiologist (Bolman, de Vries, and van Breukelen, 2002, 99-116). The Transtheoretical Model classifies smokers into four categories or stages based on their desire to quit smoking and their smoking status. The stages include precontemplation, contemplation, action, and maintenance. Smokers in the precontemplation stage are not seriously considering quitting within the next 6 months. Research on the processes of change in people who quit on their own without intervention from health care providers has shown that subjects in the precontemplation stage have fewer negative emotional reactions to their smoking and do little to change their focus on smoking (Kviz et al, 1995, 201-212). On the other hand, smokers who are in the contemplation stage are more open to information about smoking and to responding to feedback and education as sources of information about smoking. Research has also identified a strong correlation between the stage a patient is in and his or her self-efficacy expectations. Self-efficacy is defined as the smoker's level of confidence that he or she could refrain from smoking in various challenging situations such as social situations. Few randomized clinical trials of smoking cessation intervention have been conducted in patients with established CHD. Most of the studies have been observational or cross-sectional, using primarily physician advice, education, or group counseling to help patients quit smoking. This study is unique from that angle since this study is a randomized trial with a quasi-experimental design in order to assess the effectiveness of nurse-managed minimal contact smoking cessation interventions for patients hospitalised for CHD. The tool of intervention that has been used in the study is both a reliable and valid tool in terms of efficacy and feasibility although it has been adapted on the original Minimal Intervention Strategy tool. The reliability of a quantitative instrument is a major criterion for assessing its quality and adequacy (Kviz et al, 1995, 201-212). An instrument's reliability is the consistency with which it measures the target attribute. Validity is the degree to which an instrument measures what it is supposed to measure. Since this is a process, the authors incorporated a process validation in the intervention protocol to assess the quality of implementation and utilisation of the process. However, it can be argued that many studies also have shown that a short-contact intervention is less likely to be successful. In spite of these limitations, some studies do suggest that physicians and other health care professionals can have a positive impact on smoking behavior (Chyun et al., 2003, 302-318). The expected cessation rate in the general population is approximately 6% per year when simple advice is provided by physicians. Group programs using behavioral methods may achieve yearly cessation rates as high as 26% to 40%. In the CHD population in particular, the strong stimulus provided by a CHD event results in rates of smoking cessation that are higher than in most studies conducted in the general population. In particular, studies on those patients having coronary artery bypass graft surgery show smoking cessation rates of approximately 50%. Depending on severity of the condition on admission, the compliance increases. In this connection, it can be stated that nurse-managed smoking cessation interventions are known to be very effective when they begin in the hospital and then continue with telephone follow-up after discharge from the hospital. The effectiveness of this type of intervention has been demonstrated in patients after MI, admitted to the hospital (Reimer et al., 2002, 87-94). From the discussion of intervention, it is apparent that the nurses can very effectively deploy measures to promote cessation of smoking. This intervention by the nurses must be preceded by a stop-smoking advice by the cardiologist. Since a large section of these patients are known to relapse after discharge, a followup must be incorporated (Cakir and Pinar, 2006, 190-209). As discussed in the theoretical framework, the success of any cessation programme depends on generation of contemplation and maintenance of it, nurses may play the vital role of supporting the cessation following advice. The survey of measures through questionnaires at different phases ensured that both baseline and outcome measures were available. Since the results of this study suggested effectiveness of this protocol in implementing smoking cessation, the details of this protocol is important to build nursing practice. Following advice from the cardiologist, a ward nurse assessed the smoking behaviour of the patient, degree of addiction, and motivation to quit. Further counseling by the nurse would depend on the patients' readiness to change (Barnett-Damewood and Carlson-Catalano, 2000, 24-31). If the patient is unmotivated, steps should be taken to motivate them. If found to be motivated and the patient appeared to have self efficacy, the nurse must address the barriers to cessation through boosting of coping strategies. It is evident that nurses have great role to play in this intervention; however, implementation of this intervention is dependent upon the knowledge, dexterity, expertise, and time on the part of nurses. The training must be adequate, and there must be time and intent to deploy such measures in the clinical area. Alex et al. in their study assess the role of surgical cardiothoracic nurse assistants and the impact of their works in many cardiothoracic surgery centres across UK. This study was chosen because this demonstrates another very effective role of cardiac nurses across the spectra of cardiac nursing care. Cardiothoracic surgical nursing is undergoing immense change currently (Tranmer and Parry, 2004, 515-532). These changes could happen due to recent changes in National Service Frameworks in 2000 and associated NHS plan. Moreover, a growing number of older people are undergoing surgery. This shift in practice has led to great demands on the service and service providers to accommodate an increased number of patients for surgery. The consequent enhancement in workload needs to be catered, although this has been facilitated by shift of care towards greater patient acuity in hospital and more specialist care in the community, and improved technology and drug therapy (Scott and MacInnes, 2006, 502-508). With tremendous development in cardiothoracic surgery, the previously considered high risk in surgery is no longer there. The teamwork that is involved in cardiothoracic surgery is highly skillful, and the skill of the team needs to grow to accommodate these changes. Traditionally, for cardiothoracic surgical nurses, these have led to development of acute care skills and learning of new techniques to manage and support the unique postoperative course of these patients, where the current goal is to perform surgery with less risk of complications, shorter hospital stay, and a quicker return to an active life (Riley, Brodie and Shuldham, 2005, 15-21). A newer dimension of cardiac nursing is cardiothoracic nurse assistance. In the United Kingdom, these nurse assistants are playing increasing roles in many cardiothoracic centres. The authors undertook this study to know the comparative quality of their service and the impact of this new role of these nurses on the service provision (Alex et al., 2004, 111-115). The current roles of the nurses in relation to this assistance practice are a little limited, in the sense that they have worked in cardiac catheterization laboratories. Nurses working in cardiac catheterization laboratories fill many roles. In some laboratories, the nurses scrub and assist in the procedure; in others, they are responsible for monitoring pressure and cardiac rhythm, assisting with hemodynamic studies such as CO determination, and administering IV conscious sedation (Stables et al., 2004, 53-59). The nurse may visit the patient before the procedure to teach and help in preparing the patient. The nurse ideally has a background in intensive or coronary care and a thorough knowledge of cardiovascular drugs, arrhythmias, the principles of IV conscious sedation, sterile technique, cardiac anatomy and physiology, pacemakers, and the concepts of catheter flushing and clot and embolus formation and prevention. Changes in the patient's emotional status, alertness, vocal responses, and facial expressions are important indices of the patient's tolerance of the procedure. The nurse's alertness to these clues and early intervention with reassurance or appropriate medication may help to prevent more serious events, such as vasovagal reactions and coronary artery spasm. However, in this study, the audit has been mainly directed towards a new role which is not very prevalent in the current practice. This study was retrospective analysis of the patient data where the outcomes of surgeries were compared between two groups. One group comprised of patients whose surgeries were assisted by nurse assistants and the other group, whose surgeries was assisted by surgical trainees. The authors studied data from 1300 consecutive cases of elective and expedite first-time coronary artery bypass grafting cases. These also state the inclusion criteria since cases other than these, which were emergency, urgent, expedite, and redo cases were excluded from the study. It was fround that in 233 cases, the surgical nurse assistants participated, and in 1067 cases, surgical trainee assisted the cases. The available data were categorised into numerical and categorical data. The anesthetic technique, consultant expertise and skills, cardiopledic solution, rewarming techniques, and other technical aspects of the surgeries between the two groups were chosen to be equivalent. The patients undergoing surgery were also comparably equivalent; however, the patients belonging to group B were found to be at significantly higher risks. The criteria for operative outcome were predesigned from relevant literature, and statistical analysis showed no statistically significant difference between the outcomes between these two groups. Obviously, in this study, the authors designed a research in order to compare between the outcomes of these two groups. Comparisons are often the central focus of a study, but even when they are not, they provide a context for understanding the findings. While describing the categorical parameters of this study, the reader can have knowledge of the contexts of this study in terms of the variables involved in the anaesthetic techniques, cardioplegia, ventricular fibrillation, sequence of grafting, and technique of performing the bypass. The authors have studied extensive literature, although the details are missing in this article, to establish the outcome parameters and risk stratification. As has been done in this case, it is usually advantageous to design a study with as many relevant comparisons as possible. In nonexperimental studies, multiple comparison groups can be effective in dealing with self-selection, especially if the comparison groups are selected to address competing biases (McKendry et al., 2004, 258-263). This study has very important implications for a cardiac nursing role. Moreover, as indicated earlier, by the Health and Safety legislation, development and creation of new roles and posts for nurse practitioners and surgical nurse assistants is mandatory. This role seems effective as the results of this audit suggests, and like in any other discipline, despite the patient profile and intensity of multidisciplinary perioperative care being critical, there is a felt need and scope for these new roles for cardiac nurse practitioners. This area has the potential to inspire the nurses to step up and acquire operative and surgical assistant skills, where already many NHS trusts are offering courses based on didactic skills and competence (McKendry et al., 2004, 258-263). The role of cardiac nurses has been elaborated by many studies; most of them are descriptive and qualitative studies. The patient's cardiovascular function requires careful monitoring during the initial period of the recovery, and definitely during the intensive care phase of the recovery. In current practice, monitoring continues for 24 hours, and is then discontinued based on a general assessment of the patient. If all normal cardiovascular parameters are met, with no support, and the patient has not displayed dysrhythmias, the monitoring can be discontinued. Arterial pressure is usually monitored via an indwelling radial artery catheter or, occasionally, by a femoral artery catheter. The pressure is displayed digitally and in waveform on the bedside monitor. The monitoring is important since establishment of haemodynamic status post cardiac surgery is indicative of a favourable outcome. Usually, in the postoperative care unit cardiac nurses take charge of these patients. McKendry and coworkers designed a study to determine whether a nurse-led flow-monitored protocol could be effective in optimisation of haemodynamic status of the postcardiac surgery patients and whether this would be effective in reducing complications and shortening the hospital and ICU stay. It was a randomised control trial done in an intensive care unit and cardiothoracic unit in a teaching hospital. In such patients, hypertension or hypotension is avoided by the management of blood volume and drug therapy. The most important parameter that needs to be detected early and treated in a rapid fashion is hypovolemia since after cardiac surgery decreased tissue perfusion may lead to other complications and morbidities leading to extended stay in the hospital (McKendry et al., 2004, 258-263). Different monitoring methods are in use to guide the nurse in such situations, and most methods are invasive, and interpretation is difficult and complex. In most situations, intervention from the medical staff becomes necessary (Riley et al., 2003, 283-290). The authors propose a noninvasive method using a protocol for administration by nurses without additional input from the physicians and study the effectiveness of such method. The authors state the inclusion and exclusion criteria clearly and include the patients who have undergone cardiopulmonary bypass surgery in this university centre and exclude all patients with chances of very unstable haemodynamic status. The authors have also included a treatment algorithm that would be followed by the nurses. If this care would be effective, then most of the patients in the intervention group would have less stay in the intensive care unit due to optimisation of circulatory status quickly and could be discharged from the hospital early in comparison to the routine care group. Thus it is seen that the details of the design fit accurately with the hypothesis that nurse-administered protocol-driven flow-Doppler dependent haemodynamic monitoring in the post bypass surgery patients actually improve care. Randomization is the most effective method of controlling individual extraneous variables. The primary function of randomization is to secure comparable groups, that is, to equalize groups with respect to extraneous variables. A distinct advantage of random assignment, compared with other control methods, is that randomization controls all possible sources of extraneous variation, without any conscious decision on the researcher's part about which variables need to be controlled. For the purpose of equalization, the nonintervention group was provided standard care through physician and care team determined care and monitoring as applicable to the severity of the case. Moreover, by excluding cases that are complicated, the chosen nonintervention group can be equated in terms of baseline condition, so the actual outcome between these two groups can be compared, which was decided to be length of stay and incidence of complications. The data had been collected and had been presented in tabulated form. A power calculation for validity and generalizability of the results yielded the sample size to be 170. Quantitative researchers need to pay careful attention to the number of subjects needed to test research hypotheses adequately. A sophisticated procedure known as power analysis can be used to estimate sample size needs. This study established that the post cardiac surgery complications associated with prolonged hospital stay and perioperative tissue hypoxia can be prevented by optimisation of the intravascular volume in a 4-hour period following surgery can reduce this, and this can be achieved successfully through a protocol-guided nurse administered minimally invasive device that can monitor flow volume. Conclusion These three studies have been selected due mainly to reasons that these cover three important areas of cardiac nursing. The first study reveals nurse administered smoking cessation advice to patients admitted for cardiac causes, works, and the nurse must continue to support these patents' smoking cessation through followup. This is the area where the nurse would provide education and health promotion to the patients with a view to modify the lifestyle associated risk factors. With advance of technology, the nurses are gradually being able to assume different roles in cardiac care, and operative assistance in cardiac bypass surgery that involves knowledge, dexterity, and skills on the part of the nurses can be successfully done by the nurses when they are trained. This can open up one more ramification of cardiac nursing role where cardiac nurses may fit with congruency matching the regulations and requirements by NHS. In the third article, the effectiveness of nurse administered protocol-driven noninvasive flow volume monitoring in reducing complications and hastening recovery without input from the medical staff indicates their abilities and roles to act as postoperative nurses in the high-skill area of post CABG nursing. Many other possibilities exist, the nurses may take up all these roles; however, preparation from their end is a must to assume all these roles. Reference List Alex, J., Rao, VP., Cale, ARJ., Griffin, SC., Cowen, ME., Guvendik, L., (2004). Surgical nurse assistants in cardiac surgery: a UK trainee's perspective. European Journal of Cardio-thoracic Surgery; 25: 111-115 Allison, MJ. and Keller, C., (2004). Self-Efficacy Intervention Effect on Physical Activity in Older Adults. Western Journal of Nursing Research; 26; 31-48. Barnett-Damewood, M. and Carlson-Catalano, J., (2000). Physical activity deficit: a proposed nursing diagnosis. Nursing Diagnosis; 11(1): 24-31. Bolman, C., de Vries, H., and van Breukelen, G., (2002). Evaluation of a nurse-managed minimal-contact smoking cessation intervention for cardiac inpatients. Health Education Research; 17: 99 - 116. Cakir, H. and Pinar, R., (2006). Randomized Controlled Trial on Lifestyle Modification in Hypertensive Patients. Western Journal of Nursing Research; 28: 190 - 209. Chyun, DA., Amend, AM., Newlin, K., Langerman, S., and Melkus, GD., (2003). Coronary heart disease prevention and lifestyle interventions: cultural influences. Journal of Cardiovascular Nursing; 18(4): 302-18. Fridlund, B., (2002). The role of the nurse in cardiac rehabilitation programmes. European Journal of Cardiovascular Nursing; 1(1): 15-8. Gies, CE., Buchman, D., Robinson, J., and Smolen, D., (2008). Effect of an Inpatient Nurse-Directed Smoking Cessation Program. Western Journal of Nursing Research; 30; 6-21. Kviz F, Clark M, Prohaska T et al, (1995). Attitudes and practices for smoking cessation counseling by provider type and patient age. Preventive Medicine. 24: 201-212. McKendry, M., McGloin, M., Saberi, D., Caudwell, L., Brady, AR., and Singer, M., (2004). Randomised controlled trial assessing the impact of a nurse delivered, flow monitored after cardiac surgery protocol for optimisation of circulatory status. BMJ; 329;258-263. Riley, JP., Bullock, I., West, S., and Shuldham, C., (2003). Practical application of educational rhetoric: a pathway to expert cardiac nurse practice European Journal of Cardiovascular Nursing; 2(4): 283-90. Riley, J., Brodie, L., and Shuldham, C., (2005). Cardiac nursing: achieving competent practitioners. European Journal of Cardiovascular Nursing; 4(1): 15-21. Reimer, WJS, Jansen, CH., de Swart, EA., Boersma, E., Simoons, ML., and Deckers, JW., (2002). Contribution of nursing to risk factor management as perceived by patients with established coronary heart disease. European Journal of Cardiovascular Nursing; 1(2): 87-94. Scott, C. and MacInnes, JD., (2006). Cardiac patient assessment: putting the patient first. British Journal of Nursing; 15(9): 502-8. Stables, RH., Booth, J., Welstand, J., Wright, A., Ormerod, OJ., and Hodgson, WR., (2004). A randomised controlled trial to compare a nurse practitioner to medical staff in the preparation of patients for diagnostic cardiac catheterisation: the study of nursing intervention in practice (SNIP). European Journal of Cardiovascular Nursing; 3(1): 53-9 Tranmer, JE. and Parry, MJE., (2004). Enhancing Postoperative Recovery of Cardiac Surgery Patients: A Randomized Clinical Trial of an Advanced Practice Nursing Intervention. Western Journal of Nursing Research; 26: 515 - 532. THE UNIVERSITY OF SHEFFIELD SCHOOL OF NURSING AND MIDWIFERY SAMUEL FOX HOUSE, NORTHERN GENERAL HOSPITAL, HERRIES ROAD, SHEFFIELD, S5 7AU APPENDIX ONE RESEARCH SUMMARY SHEETS RESEARCH SUMMARY Reference Bolman, C., de Vries, H., and van Breukelen, G., (2002). Evaluation of a nurse-managed minimal-contact smoking cessation intervention for cardiac inpatients. Health Education Research; 17: 99 - 116. Themes/ key words Nurse, manage, cardiac inpatients, intervention, effectiveness, coronary heart disease. Principle findings 1. A low-contact smoking cessation intervention in hospitalised cardiac patients and support programme executed by the nurses is effective in comparison to the control group. 2. The patients feel that conversations with the nurses have motivated them. 3. If the nurses are trained they administer the interventions to the cardiac patients needing smoking cessation. Ethics The research project was subject to ethical scrutiny. The Medical Ethics Committee of all the participating hospitals approved the study, and the participants provided informed written consent. Thirty-eight patients refused to participate, but the reasons of refusal were not able to be obtained since ethical policies did not allow this. Sample This study clearly describes the inclusion and exclusion criteria of the patients. Smoking patients with coronary heart disease who have been admitted to the hospital were included in the study. Both pre-test and post-test samples were drawn, one group having designed intervention and the other group served as control with no intervention randomly. Previous research was used to serve as a guide, and it was assumed that 40% of the control group would quit, against 50% in the intervention group. For a one-tailed significance level of 0.05 and a power of 80% led to a required sample size of 650 patients. The authors assumed a 20% dropout, thus making the required number to be 815 smoking patients. Out of selected 891 hospitalized patients, 38 dropped out. Since filling up the questionnaire completely was necessary 64 patients did not fill up 30% or more of the questions, thus this number may be considered as attrition. Taking into consideration the attrition of other participants, the rate lost was 22% of the final number. The aim of research typically is to reveal enduring relationships, the understanding of which can be used to improve human health and well-being. The adequacy of the sampling design determines external validity or generalizability, and therefore this attrition would have affected the generalizability of the study. Design Quantitative Quasi-experiment Qualitative Since the study is looking at independent variables and looking forward at the effect, the design is prospective. This design is trustworthy since this prospective design incorporates covariates in the independent variables, and logistic regression analysis has been used to test the effectiveness of interventions. Since there are a number of variables in different phases, the authors have corrected their baseline differences through inclusion of covariates, and this has reduced unexplained variance. However, although randomisation was the intent in the beginning by designing intervention and nonintervention groups, the fact that the hospital groups selected intervention or nonintervention has led to a situation of apparent bias, this could have compromised the study design. This is also apparent that the attrition occurred in a selective basis. Since there are many parameters in a decision to quit smoking, and it involves behavioural intervention, there remains doubt as to whether a short intervention would work or not. Therefore from the evidence, it can be stated that even though many directions regarding nursing practice has been revealed through this study, further research is needed to gather more evidence. Data collection The followup was done through interviews. Clinical data have been used at the baseline through records entered by nurses as to the reason for admission. Questionnaires were used for different parameters of intervention. Proximal cognition and parameters in the motivational phase was measured with ASE scale. The reliability of these was sufficient as indicated by the Cronbach alpha of greater than 0.60. Data Analysis Quantitative Chi-squared test Logistic regression analysis They are parametric Greater than 0.21 Qualitative How has the data been dealt with How trustworthy do you feel this is Clinical significance The researchers have looked at the clinical as opposed to the statistical significance of the findings. RESEARCH SUMMARY Reference Alex, J., Rao, VP., Cale, ARJ., Griffin, SC., Cowen, ME., Guvendik, L., (2004). Surgical nurse assistants in cardiac surgery: a UK trainee's perspective. European Journal of Cardio-thoracic Surgery; 25: 111-115 Themes/ key words Coronary revascularization; Surgical nurse assistant; Outcome; European working time directive; Training Theme is feasibility of a new role of cardiac nurses as assistants in the cardiothoracic surgery unit. Principle findings If the cardiac nurses are trained, the quality of service they provide as surgical nurse assistants in cardiothoracic surgeries are comparable in terms of outcome when they are assigned to assist cases that are comparatively less complicated. There is no statistically significant difference in immediate postoperative outcome. Ethics There is no mention of any ethical review in this study. However, it is evident a study of this magnitude cannot be performed without appropriate ethical clearance. Sample The population under study has been described. The sample drawn from the population was a convenience sample of retrospective data from PATS database. Since it was a data analysis of retrospective sampling, there was no question of response rate. These data were divided into two groups of cardiothoracic surgery cases comprising of 233 consultants and surgical nurse assistants as opposed to 1067 consultants and surgical trainees. No question of dropping out or attrition rate arises, and therefore external validity of the study has not been affected. Design Quantitative Correlational Survey Qualitative The study was retrospective based on prospectively entered data into the patient analysis and tracking system. Depending on the hierarchy of presented data, it appears trustworthy. Data collection The data has been collected from the care records and clinical data. The method utilized verification of the internal consistency of the catergorised data by statistical tests, and the two groups were matched for uniformity of the data. The variables in each category were further compared for any significant difference. Thus the data collection was both valid and reliable. Data Analysis Quantitative Chi-square test and Fisher's test were used for categorical data while the Student's t-test was used for numerical data. These were both parametric and nonparametric. Level of significance was less than 0.05 Qualitative Clinical significance The researchers have looked at the statistical and clinical significance of the data. RESEARCH SUMMARY Reference McKendry, M., McGloin, M., Saberi, D., Caudwell, L., Brady, AR., and Singer, M., (2004). Randomised controlled trial assessing the impact of a nurse delivered, flow monitored after cardiac surgery protocol for optimisation of circulatory status. BMJ; 329;258-263. Themes/ key words Nurse-delivered protocol, optimisation, circulatory status, cardiac surgery Principle findings Optimisation of intravascular volume in the first four hours postoperatively reduces complications and bed usage. Nurses could deliver a flow monitor protocol through usage of a minimally invasive device by themselves without intervention from doctors. Ethics This study was approved on ethical parameters by the ethics committee of the University College London Hospitals NHS Trust. No obvious problems otherwise. Sample The population under the study was described. The participants were patients on the intensive care and postoperative cardiothoracic units of the University College London Hospitals NHS Trust, undergoing cardiopulmonary bypass surgery who had provided preoperative informed consent. The basis of the selection was exclusion criteria that indicate complicated cases. Of these patients who fit the inclusion criteria, 179 patients were included. All consented for the study with a response rate of 100%. Five patients could not fulfill criteria in the postoperative entry phase, and they were excluded later, making a protocol group of 89 and 85 in the control group. The attrition rate was 4.3%. This has not affected the external validity of the results since a power calculation revealed a sample requirement of 85 in both the control and the intervention groups with a power of 0.9. Design Quantitative RCT Qualitative This is a prospective design since this study wanted to measure the effect of the protocol on the patients in comparison to the control group. Data collection The baseline characteristics of the patients were recorded from care records. Clinical data and manual recording of the standard haemodynamic variables, intravenous fluid and drug requirements were made. Followup data were collected through observation by the study nurses including complications, time to extubation, and length of stay in intensive care and hospital. This is a valid method since the authors incorporated a blinding technique on both the patients and nurses where both were unaware of the group assignment. The groups were also matched based on demographic parameters ensuring uniformity of the intervention, protocol, or observation. Data Analysis Quantitative Differences in postoperative measurements were tested using two sided t tests. Two-sample Wilcoxon rank sum test to test for differences in non-normally distributed variables including outcomes. Confidence intervals were constructed by bootstrapping within treatment groups. Intention to treat analysis. Pearson's chi-square test was used to compare complications between treatment groups. These are parametric data The P value was 0.02 Qualitative Clinical significance The researchers looked at the clinical as opposed to the statistical significance of the findings APPENDIX TWO MATRIX RESEARCH MATRIX Author/Date/Source Summary of findings Ethics Sample type/size Design Data Collection Tests/ Analysis Discussion Bolman, C., de Vries, H., and van Breukelen, G., (2002). Evaluation of a nurse-managed minimal-contact smoking cessation intervention for cardiac inpatients. Health Education Research; 17: 99 - 116. A low-contact smoking cessation intervention in hospitalised cardiac patients and support programme executed by the nurses is effective in comparison to the control group. The patients feel that conversations with the nurses have motivated them. If the nurses are trained they administer the interventions to the cardiac patients needing smoking cessation. The research project was subject to ethical scrutiny. The Medical Ethics Committee of all the participating hospitals approved the study, and the participants provided informed written consent. Thirty-eight patients refused to participate, but the reasons of refusal were not able to be obtained since ethical policies did not allow this. Out of selected 891 hospitalized patients, 38 dropped out. Since filling up the questionnaire completely was necessary 64 patients did not fill up 30% or more of the questions, thus this number may be considered as attrition. Taking into consideration the attrition of other participants, the rate lost was 22% of the final number. Quasi-experiment The followup was done through interviews. Clinical data have been used at the baseline through records entered by nurses as to the reason for admission. Questionnaires were used for different parameters of intervention. Proximal cognition and parameters in the motivational phase was measured with ASE scale. The reliability of these was sufficient as indicated by the Cronbach alpha of greater than 0.60. Chi-squared test Logistic regression analysis They are parametric Greater than 0.21 The researchers have looked at the clinical as opposed to the statistical significance of the findings. Alex, J., Rao, VP., Cale, ARJ., Griffin, SC., Cowen, ME., Guvendik, L., (2004). Surgical nurse assistants in cardiac surgery: a UK trainee's perspective. European Journal of Cardio-thoracic Surgery; 25: 111-115 If the cardiac nurses are trained, the quality of service they provide as surgical nurse assistants in cardiothoracic surgeries are comparable in terms of outcome when they are assigned to assist cases that are comparatively less complicated. There is no statistically significant difference in immediate postoperative outcome. There is no mention of any ethical review in this study. However, it is evident a study of this magnitude cannot be performed without appropriate ethical clearance. The population under study has been described. The sample drawn from the population was a convenience sample of retrospective data from PATS database. Since it was a data analysis of retrospective sampling, there was no question of response rate. These data were divided into two groups of cardiothoracic surgery cases comprising of 233 consultants and surgical nurse assistants as opposed to 1067 consultants and surgical trainees. No question of dropping out or attrition rate arises, and therefore external validity of the study has not been affected. Correlational Survey The study was retrospective based on prospectively entered data into the patient analysis and tracking system. Depending on the hierarchy of presented data, it appears trustworthy. The data has been collected from the care records and clinical data. The method utilized verification of the internal consistency of the catergorised data by statistical tests, and the two groups were matched for uniformity of the data. The variables in each category were further compared for any significant difference. Thus the data collection was both valid and reliable. Chi-square test and Fisher's test were used for categorical data while the Student's t-test was used for numerical data. These were both parametric and nonparametric. Level of significance was less than 0.05 The researchers have looked at the statistical and clinical significance of the data. McKendry, M., McGloin, M., Saberi, D., Caudwell, L., Brady, AR., and Singer, M., (2004). Randomised controlled trial assessing the impact of a nurse delivered, flow monitored after cardiac surgery protocol for optimisation of circulatory status. BMJ; 329;258-263 Optimisation of intravascular volume in the first four hours postoperatively reduces complications and bed usage. Nurses could deliver a flow monitor protocol through usage of a minimally invasive device by themselves without intervention from doctors. This study was approved on ethical parameters by the ethics committee of the University College London Hospitals NHS Trust. No obvious problems otherwise. 179 patients were included. All consented for the study with a response rate of 100%. Five patients could not fulfill criteria in the postoperative entry phase, and they were excluded later, making a protocol group of 89 and 85 in the control group. The attrition rate was 4.3%. This has not affected the external validity of the results since a power calculation revealed a sample requirement of 85 in both the control and the intervention groups with a power of 0.9. This is a prospective randomised control trial design since this study wanted to measure the effect of the protocol on the patients in comparison to the control group. The baseline characteristics of the patients were recorded from care records. Clinical data and manual recording of the standard haemodynamic variables, intravenous fluid and drug requirements were made. Followup data were collected through observation by the study nurses including complications, time to extubation, and length of stay in intensive care and hospital. This is a valid method since the authors incorporated a blinding technique on both the patients and nurses where both were unaware of the group assignment. The groups were also matched based on demographic parameters ensuring uniformity of the intervention, protocol, or observation. Differences in postoperative measurements were tested using two sided t tests. Two-sample Wilcoxon rank sum test to test for differences in non-normally distributed variables including outcomes. Confidence intervals were constructed by bootstrapping within treatment groups. Intention to treat analysis. Pearson's chi-square test was used to compare complications between treatment groups. These are parametric data The P value was 0.02 The researchers looked at the clinical as opposed to the statistical significance of the findings, so a clinical decision is possible Read More