Evidence Based Practice and Applied Nursing Research

Evidence Based Practice and Applied Nursing Research

C361 Task 1

My full Name

Western Governor’s University

For this Quantitative article review section of task 1, I have chosen an article published in the Journal of Critical Care in 2016.

ARTICLE: Nolan, M. E., Yadav, H., Cawcutt, K. A., &Cartin-Ceba, R. (2016). Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. Journal of Critical Care, 31(1), 238-242. doi:10.1016/j.jcrc.2015.09.024

A1. Background / Introduction.The article is entitled “Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit” (Nolan, Yadav, Cawcutt&Cartin-Ceba, 2016). In this article, the researchers retrospectively reviewed cohort studies and compared the complication rates in peripherally inserted central catheters (PICCS) with the complication rates of centrally inserted central catheters (CICCS). They begin with an abstract that discusses very concisely their purpose or why they are studying this topic and why it is clinically relevant. In this case they are comparing the rates of complications because it would seem that the previous studies are outdated and there is little data out there that is up to date. The abstract also discusses the methods including the numbers of patients that were included in the cohort study, what types of PICC lines and CICC lines were included, the length of time that the PICCS and CICCS were indwelling and the complications suffered by the patients during that time. It discusses that the review included 200 PICCS and 200 CICCS that were inserted and used at Mayo Hospital in Rochester in 2012 and 2013. They followed these patients from insertion time through hospital discharge as a primary analysis and then insertion time through Intensive Care Unit (ICU) discharge as a secondary analysis. It also presents information on the two types of complications they were reporting on: catheter-related deep vein thrombosis (CRDVT) rates and central line-associated blood stream infections (CLABSI) rates and how they defined those complications. When I’m reviewing this article, even as a knowledgeable healthcare worker, it is important for each of these to be adequately defined and explained. This article’s validity can clearly be measured by the methods they used to review these items. The abstract then gives a section for results where it details the exact numbers. Days that the PICC lines and CICC lines were indwelling were referred to as PICC days or CICC days. The study reviewed 1730 PICC days and 637 CICC days and compared the CRDVT rates and CLABSI rates with those indwelling days. The conclusion then explains that the researchers found that not only were the incidence rates of CRDVT’s and CLABSI’s extremely low, but that there wasn’t much difference in the complication rates of PICCS as compared with CICCS.

The researchers then continue with a formal introduction. The introduction gives the reader an overview of central venous access, why it is necessary and what it used for. They go on to further explain their purpose for this study by talking about the limited amount of current data available on the subject of complications of the two types of central lines. It also talks about how modern practices and modern PICC lines have basically made the previous studies obsolete. As the healthcare industry has made great strides to improve not only the practice of PICC line and CICC line insertion using sterile techniques, but has also improved the physical PICC and CICC lines themselves making them less likely to create complications.

A1 Review of Literature. In reviewing the literature, the researchers reference 33 peer-reviewed journal articles and compare their findings with those previous authors and articles. The researchers created a section entitled: Discussion. In this section, the researchers give a thorough overview of the study presenting the trends that they noted and then explaining the clinical significance of those trends, again comparing to previous articles. For instance, they report that because of their chosen study parameter of primary outcome per central catheter rather than using the overall indwelling time, it may have different results. It also explains the reasoning for the referenced articles to find different results by noting the distinctions between their course of study and other article’s courses of study. The researchers also use this section to further define the criteria they used and reference the Centers for Disease Control (CDC) recommendations as a reliable source so that the reader may also go back and research the recommendations. The review of literature also has sections specifically for discussing the strengths and limitations of this study. These sections allow the researchers to reflect on the limitations and or issues with their own study while pointing out the strengths and justifying the results section (Day, 1998). Acknowledging those limitations and strengths also points to the thoroughness of the researchers and allows the reader to review the literature with an “eyes wide open” view.

A1 Discussion of Methodology. The materials and methods section of this article breaks down into several smaller subsections that discuss the study population and the catheter type, the catheter insertion technique and the maintenance protocols, the data collection methods, the methods for calculating the outcomes, the definitions used to say whether a complication actually occurred or note and then the measurement of statistics and how they decided if the data was clinically significant. The study included all adult patients over the age of 18 years that were admitted to the Rochester medical ICU and that agreed to be included in general retrospective research studies. The researchers identified 200 patients that received PICC lines and 200 patients that received CICC lines by starting at their start date of June 30, 2013 and working backward in the data until they reached their target of 200 patients with each type of line. They talk about which catheters were excluded from the study and why. The researchers also talk about the specific catheters that this ICU uses giving all the information so that a future researcher reviewing this article could actually attempt to duplicate the study.

In the insertion technique and maintenance protocols section, the researcher further describes how the PICCS and CICCS are inserted, what type of ultrasound machine is used, the sterile techniques used, the policies and protocols in place at the time of insertion, the training that the healthcare providerhas undergone prior to attempting insertion as well as the maintenance routines that the entire medical team follow on a daily basis.

The data collection section describes how the researchers were able to collect the data using an electronic database that collects data on several different levels including demographics, outcome data and procedural data. Each case that appeared to meet the criteria for inclusion was then manually reviewed by the researchers to further verify whether or not it met the inclusion/exclusion criteria as well as to verify indwelling time of the PICCs and CICCs. The method of manual reviews of the data is also listed as a strength in the review of literature as the process of manually reviewing each chart allowed the researchers to further substantiate their data and add weight to the validity of the data.

The outcomes section describes the end-points used for incidence rates. The definition sections further clarifies how the research team defined CRDVTs and CLABSIs referencing the CDC’s definition which is more universally accepted definition and again adds to the validity of the study.

A1 Data Analysis. The data in this article is analyzed using several different methods. The researchers used a 2-sided Student t test and then reported that data using a nonparametric Wilcoxon rank sums test. They compared data using a Pearson X2 test or Fisher exact test and then analyzed all the data a statistical software from JMP (Version 9.0.3; SAS Institute, Cary, NC). They present the analysis of their data in 4 different tables and 2 figures that include a flow chart and a graph. The first is a table to review the baseline characteristics of each PICC and CICC including the demographics of the patients, the acuity of the patient illness, where they were admitted from and their lengths of stay. The second table compares the PICC line and CICC line sites in the body. Table 3 reviews the complication rates for PICCs and CICCs from insertion to hospital discharge and the last Table reviews the complication rates from insertion to ICU discharge. The flow chart presents an easy to read study flow diagram that walks the reader through the data collection process and criteria used by the researchers. The final figure is a graph that represents a comparison of the PICC lines and CICC lines indwelling catheter duration showing that PICCs were in place an average of 7-8 days where CICCs were in place an average of 2-3 days. The results section of this article clearly explains each table and graph, justifying that there were 2300 total ‘catheter-days’ of data used with 1730 days of PICC data and 637 days of CICC data. Overall, 4% of PICC lines and 1% of CICC lines developed symptomatic CRDVT, P= .055. Only 1 CLABSI was identified out of the total PICCs and CICCs together (400 in all) and it occurred 34 days after the PICC was inserted and after the patient was discharged from the ICU to the medical surgical floor. The data also suggests that the patient’s underlying condition may have also led to the complication. The data that is presented clearly supports the researcher’s conclusion.

A1 Researcher’s Conclusion. The researcher’s conclusions concisely summarize the results. They conclude that although it initially appeared that PICCs had a higher incidence of DVTs as compared to CICCs when looking at the length of time from insertion to hospital discharge, upon further examination when looking at the length of time from insertion to ICU discharge the difference in complications between PICCs and CICCs was not significant. The researchers again advocate for removal of all central line catheters as soon as they are no longer needed.

A2 Critique of the evidence presented. Overall, the researchers present their findings in an easy to read and uncomplicated manner. It is well organized and the structure is easy to follow. The abstract is concise and to the point, drawing the reader in and capturing their attention to not only summarize the study but to also tell why it is clinically relevant. Each section of the article serves to support and add validity to the researchers claims that PICCS do not present a significant increased risk over CICCs for vascular access. The introduction gives a brief summary of the findings presenting evidence that supports the conclusion. The review of literature compares this study’s findings to that of previous studies and points out the differences in the previous clinical research available, further supporting the need for this study to update clinicians with new and relevant information based on modern practice and modern technology. The methodology used in this study was really a strength for the article. The researchers painstakingly reviewed each central line case by hand to ensure the accuracy of the information they were using. Polit and Beck (2010) advise that in order to consider a research study credible, “a careful analysis of the study’s methodological and conceptual limitations and strengths is required”. The researchers in this study, used reliable methods that are replicable and they acknowledged the limitations of the study which were few and they maximized the credibility of the study by reviewing each case manually. The presentation of the limitations of the study also allow for other researchers to begin other related analysis. The results were clear and justified. The data was presented clearly and was easily measurable. The analysis of the data was done using statistical software and by utilizing X2 tests

A3 Protection of Human subjects and cultural considerations. The subjects used in this study were all patients of the Mayo medical ICU unit in Rochester, MN. They were chosen based on the criteria that that were adult patients greater than age 18 years of age who had given consent for general retrospective research at that institution. Some patients were excluded because although they had received a PICC line or CICC line, they had not given consent to participate in the research. The researchers also presented the study to the Mayo Clinic institutional review board who approved of the study and waived the requirement for written informed consent.

A4 Strengths and Limitations. The strengths and limitations of the study are clearly written in the review of literature section entitled: Discussion. The researchers point to the integrity of the data that is supported by their intense data collection practice as a huge strength for the study. It further points out that their hands-on approach to this type of data collection is rare when compared to previous studies and that they found irregularities in the data that would have otherwise been overlooked in automated data abstraction. They also point to using a specific population, such as ICU patients, as a strength as it reduced the variability as compared with previous studies.

The limitations of the study are also well explained. The researchers found several limitations including limitations with using a retrospective review of the data. By using a retrospective review, they weren’t able to do real time observations of the data and or ask questions in real time. This made it difficult to include cases that didn’t include enough information, for instance, they were unable to assess the specific indication for each line placement which limited their ability to analyze specific differences. Also CRDVT’s are difficult to identify without symptoms and since CICCs are generally removed after 48 hours which is before the thrombus has time to truly be recognized those cases would often not be found. Whereas PICCs are used in smaller veins with a smaller catheter-to-vein ratio and generally stay in longer giving the thrombus more time to grow and cause symptoms the bias is clearly against PICC lines. There was also a limitation to the detection of CLABSI in CICCs related to the shorter indwelling time. This study also excluded patients who had received PICCs or CICCs that had a primary diagnosis of active malignancy or were recent solid organ or bone marrow transplant patients because for Mayo, these patients are not treated in the medical ICU. Patients with those comorbidities are at higher risk and so in duplicating this study, other hospitals should be aware of the limitation to generalize the data for their use. The researchers certify that they have no conflicts of interest that would further hinder the validity of the study.

A5 How this Evidence Informs Nursing Practice. The evidence presented in this article informs nursing practice as it studies an often-questionedquery. I specifically chose this topic because I had been asked the question of “which central line was safer and provided less risk to patients?” and I didn’t have an answer. Because PICCs and CICCs have changed over the years and because our insertion practices, sterile techniques and reporting practices have also improved dramatically, the previously studied data was outdated and needed to be reviewed. Having current, evidence-based research is extremely important so that nurses can improve their practice through the application of real science. Although this was a relatively small study, the researchers clearly explained their methods so that the study could be replicated using larger groups for further analysis. The evidence in this study, although it points to a relative similarity in risk between PICCs and CICCs, should help to answer the question of “am I providing the safest and best care for my patient?” which is truly why we as nurses should be using current evidence to direct our practice. Having reliable research with clear evidence to direct our care is extremely important as is outlined in the Institute of Medicine’s definition of quality healthcare: the “Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”(IOM, 2013).Having articles like this one help nurses, physicians and even hospital administrators make informed quality improvement decisions for better healthcare.

For this Qualitative review section of task 1, I have chosen an article published in the Open Journal of Nursing, 2013.

ARTICLE: D’Souza, M. S., Venkatesaperumal, R., Radhakrishnan, J., & Balachandran, S. (2013). Engagement in clinical learning environment among nursing students: Role of nurse educators. Open Journal of Nursing, 03(01), 25-32. doi:10.4236/ojn.2013.31004

B1. Background / Introduction. The article is entitled “Engagement in clinical learning environment among nursing students: Role of nurse educators” (D’Souza, Venkatesaperumal, Radhakrishnan, & Balachandran, 2013). This study was done at the College of Nursing (CON) Sultan Qaboos University located in Al Khoudh in the Muscat Governorate in Oman.In this article, the researchers began with the usual abstract that presented a brief overview of the study. The researchers describe their purpose was to study the engagement levels of student nurses in the clinical environment from the perspective of the nurse educator. As this study takes place in Oman, which is culturally very different from the United States of America, I was particularly interested to understand what the Omani student’s clinical experience looked like. The abstract discusses why this research is significant in the Arab world but goes on to state why this research is so valuable for all clinical educators in planning educational experiences for their student nurses so that they can be engaged in improving the overall quality of healthcare. The introduction gives some background as to why the researchers felt the need to study this topic. There is a brief high-level overview of the goals and competencies for the baccalaureate nursing program including: patient centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics and safety (D’Souza, Venkatesaperumal, Radhakrishnan, & Balachandran, 2013). They describe the BSN program as being very difficult emotionally for student nurses as the students are required to go through many clinical experiences and deal with patients in various situations, various social and racial backgrounds and psychosocial issues. The researchers describe the problems of this emotionally draining experience as being so difficult that the student nurses are unable to remember the basic anatomy and physiology and are unable to reason clinically in such a stressful environment. This truly sets the stage for why this nursing research needed to be done. The job of the introduction section of the article is to get a little deeper into the study than the abstract did, explain a little more why this research is so relevant and to draw the reader in. This introduction does all of these things. The researchers set up the background for the study by defining student engagement (SE) as the students’ wiliness to actively participate and the extent of their involvement in the clinical learning process (D’Souza, Venkatesaperumal, Radhakrishnan, & Balachandran, 2013). They also go on to further explain the elements of a supportive clinical learning environment. The researchers describe the value of this study with fact that there is no prior research regarding the process of SE in the clinical environment for Omani student nurses.

B1 Review of Literature. In the review of literature, the researchers reviewed the educational recommendations for student nursing and key principles used in effective teaching that have been known to achieve engagement of students. They reference 49 sources for student engagement, positive educational relationships and their relation to learning outcomes as well as their application in the real world of nursing healthcare after education. They also reported a review of over 305 studies, although those are not individually referenced; the summary idea being that positive clinical learning environments promote learning.

B1 Discussion of Methodology. In this article there is not a section entitled “Methodology” as I have found in many other articles, however, researchers employed methods of interviewing students, interviewing nurse-educators, reviewing curriculum plans and student and nurse-educator reports. Nurse educators used several different tactics to promote SE in the clinical setting including incorporating strategies that required active learning. The researchers defined active learning as not only the active care of nursing, but also the actions of reflecting, researching evidence-based references, outlining and summarizing lecture or study information and participating in clinical discussions. In order to achieve this active learning situation, the College of Nursing set up a clinical course specifically designed to engage the students in active learning. The nurse educators utilizedteaching-learning strategies using simulated scenarios, concept mapping, evidence-based projects, e-learning with interactive chat sessions, and reflective practice as well as exposure to diverse clinical environments from 2009-2012. There was much time and effort placed into creating positive relationships for students with their peers and nurse educators. The goal is for the nursing students to grow and develop with a mindfulness that they are involved in a dynamic learning process with an understanding that they are ever evolving through active learning. The researchers also identified several measurable outcomes which coincided with students’ level of engagement, including personal growth and development of cognitive, intellectual and psychosocial skills which also reportedly carried lifelong benefits.

B1 Data Analysis. The data collected in this study was collected by means of interviews both with the student nurses and with the nurse educators. However, the researchers did not include a specific questionnaire or standard interview questions that were used in this collection, they may or may not have had one. Without a better understanding of how the data was collected, it makes it hard to quantify the results. The researchers may have used open and closed-ended questions or surveys to accompany their research. They used Omani nursing students enrolled in the College of Nursing (CON) Sultan Qaboos University during 2009 to 2012. Although the researchers do not spell out their methods for data analysis, it is clear that the researchers used a systematic approach and were able to recognize themes and trends and then organize the data and present it to the reader in a logical format. The researchers identified the topics of active learning, student-faculty interactions, shared-learning opportunities and diversity experiences. The researchers likely used a manual approach to data analysis rather than a software based system.

B1 Researchers Conclusion. In this article, the researchers unanimously conclude that achieving active student engagement is critical to positive outcomes in the clinical environment. They place responsibility on the nurse educators as conduits between the clinical learning environment and the student, explaining how important the role of the nurse educator is to the future of nursing in Oman: “Students learning experiences in the clinical environment determine their short and long term commitment and responsibility in the nursing practice and are vital to the preparation of future qualified nursing professionals in Oman” (D’Souza, Venkatesaperumal, Radhakrishnan, & Balachandran, 2013). The researchers repeat the strategies used by the nurse educators studied and recommend those innovative strategies for future educators looking to achieve the same favorable outcome with their students. They further conclude that through these innovative strategies, students were empowered with new perspectives and developed better self-awareness and better critical thinking skills.

B2Critique of the evidence presented. The conclusions presented in this qualitative study are much different than those presented in the previous quantitative study as the researchers seemingly give subjective proof of their conclusion. Because the responses from the students and nurse educators is difficult to quantify, the reader is left taking the researchers conclusion without solid objective information. In my mind, it is difficult to solidly prove the researcher’s conclusion. The explanation of methodology is lacking in this study as the researchers don’t give much information about their subjects and how they collected information from them. There is no demographic information on the subjects studied, other than to say that they were nursing students attending college during 2009-2013. There is an assumed lack of standardized questioning or survey in this study that may or may not be an actual limitation of the study. The researchers very convincingly present their results and make a passionate case for changing nursing program curriculums for the improvement of nursing outcomes and quality healthcare. Because of the lacking explanation of methodology it would be difficult for other researchers to replicate it which is a well-known key to scientific research.

B3 Protection of Human subjects and cultural considerations. This study does not report on the exact number of nursing students or nurse educators that were involved in the study. It also does not report if those participants gave informed consent. The identity of the students is protected and there is no demographic information given. I believe that the culture of the people participating in this study may have also contributed to why the study was being done. In the abstract, the researchers point to the importance of this research to the Arab culture as this culture had created an attitude and lack of student involvement in the clinical setting that was hindering engagement and therefore the learning outcome for students.

B4 Strengths and Limitations. The strength of this study is the researcher’s apparent passion for the future of nursing in Oman. This may sound like I am saying there was bias, but I don’t believe that there was as far as the study goes. The researchers may have a personal interest in the population and culture studied by seeing a lack of engagement or poorly prepared nurses in Oman that may have prompted the researchers to study the engagement level of the nursing students, however I do not believe that that bias influenced the strategies used by the nurse educators. One of the limitations I noted above was the lack of explanation of methodology. This lack makes it impossible to replicate the work. Another limitation is the apparent lack of standardized interview questions, or at least these were not shared in the article. It is also unclear from the article the exact number of students and nurse educators that were evaluated, again making it difficult to replicate the results.

B5 How this Evidence Informs Nursing Practice. The implications of the curriculum changes for the College of Nursing Sultan Qaboos University are that those nursing students will be better able to handle the stress and intense emotional shock of going into the actual clinical setting to practice as nurses. This will translate to improved quality of healthcare for the Omani people. How this will inform the practice of nursing will be seen in how it changes clinical education and nursing education not only in Oman but worldwide. Nursing education programs throughout the world could stand to benefit from the conclusions and recommendations of this study. I would like to see this study replicated in the United States with more quantified results available. If the conclusions are as evident and far reaching in another group as they were for the Omani nursing students, this could change nursing curriculum, nursing student outcomes and improve the quality of nursing healthcare worldwide.

References

Day, R.A. (1998). How to Write & Publish a Scientific Paper (8th ed.). Phoenix, AZ.: Pryx Press.

D’Souza, M. S., Venkatesaperumal, R., Radhakrishnan, J., & Balachandran, S. (2013). Engagement in clinical learning environment among nursing students: Role of nurse educators. Open Journal of Nursing, 03(01), 25-32. doi:10.4236/ojn.2013.31004

Institute of Medicine. (2013). Announcement. Crossing the quality chasm: The IOM health care quality initiative. Retrieved from: www.iom.edu/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx

Nolan, M. E., Yadav, H., Cawcutt, K. A., &Cartin-Ceba, R. (2016). Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. Journal of Critical Care, 31(1), 238-242. doi:10.1016/j.jcrc.2015.09.024

Polit, D.F. & Beck, C.T. (2010). Essentials of nursing research: Appraising evidence for nursing practice. Philadelphia, PA: Lippincott Williams & Wilkins.