Evidence Based Practice - Essay Example

?Introduction The purpose of this paper is to explore the implications of a piece of quantitative research by Brezis et al (2008) as part of evidence-based practice, and to explore how well this paper fulfils its purpose. The research by Brezis et al (2008) covers the quality of informed consent procedures for invasive surgery, evidently an important topic for someone working as an anaesthetic nurse. Surgical procedures need informed consent from the individual to comply with any ethical, moral or religious reasons they may have for wanting to abstain, therefore gaining informed consent from the patient or a relevant family member is important. The reasoning behind choosing this paper is therefore obvious: it is necessary to examine how well informed consent is gained prior to surgical procedures. To analyse the data from Brezis et al (2008), this review will use the Critical Review Form for Quantitative Studies (Letts et al, 2007), a tool which guides analysis of a quantitative paper such as this one to ensure that all areas of research are analysed accordingly. This paper will focus on three main areas of evaluation as identified by Letts et al (2007): the methods, the sampling and the data collection. The methods will be analysed as they are evidently important – using the wrong type of method could mean that there is bias in the responses or the information being studied is not actually collected. The sampling is important to analyse because the participant group needs to be large and representative enough so that it can be generalized to all of nursing practice. Finally, the data collection methodology is important as it is another stage in which bias or confounding variables could be introduced into the results. These three sections will be analysed giving a detailed appraisal. Finally, the paper will show how gaining proper informed consent should be a priority in nursing practice to help avoid the findings of Brezis et al (2008), and that this should be patient-specific to ensure that it is appropriate to practice. Critique To properly understand the implications that the research of Brezis et al (2008) has for nursing practice, it is necessary to examine whether the results represent a solid piece of quantitative research. This is to prevent research that is not appropriate or representative being incorporated into nursing (Munhall, 2011), which could cause harm to the patients (Woolf et al, 1999). One of the most important aspects of a piece of research is the method used. The method used by Brezis et al (2008) was to survey a variety of patients who were undergoing invasive procedures using a structured questionnaire with some open questions. For many patients, these questions could be seen as confusing and therefore false answers may be given (Fowler, 1995), so Brezis et al (2008) avoided this problem by providing a surveyor as a figure to explain unclear questions. These surveyors were medical students who were involved in some area relevant to the study. There is the potential that these surveyors could introduce bias into the results by guiding the participants in their answers (Munhall, 2011), although this effect should be reduced by the number of surveyors (n=30) involved in the study. One of the major benefits of using a quantitative design such as this is that it allows for more responses to be collected (as time and money is saved in the analysis), and the responses fit neatly into patterns that can be presented in a graphical manner (LoBiondo-Wood & Haber, 2005). However, Brezis et al (2008) have incorporated open-ended questions and claim to want to explore quantitative data as part of the design. This seems legitimate as responses for this type of issue can often be more complicated than limited answers on a questionnaire (Elo & Kyngas, 2008). However, bearing this in mind it may have been more informative and useful for the study design to have a mixed-method where qualitative and quantitative data was collected. This study is quantitative and therefore falls high on the hierarchy of experimental data, but could be described as an analytic observational study and therefore can be considered to provide the weakest evidence (The Canadian Best Practices Portal for Health Promotion and Chronic Disease Prevention-Public Health Agency of Canada, 2011). The sampling methods are also important for collecting data that can be used for evidence-based practice in a clinical setting. The sample size for the study is large (n=613) and were analysed over a period of two years. The importance of having such a large sample size cannot be downplayed, as more participants leaves less room for bias found in a small group (Sandelowski, 1995) and therefore the results can be more easily generalized to the population as a whole. One negative part of this study is that the large sample size was not justified within the study itself, but it is a common piece of knowledge that larger sample sizes are more useful in quantitative studies (Munhall, 2011). However, the participants were not chosen at random but were participating consecutively (Brezis et al, 2008), meaning that bias could be found in the type of procedure that was most common at the time (Munhall, 2011). For example, participants could be less likely to receive informed consent about some invasive procedures that were more common in the consecutive period, altering the results and making it more likely that the results would suggest less informed consent before a procedure. However, the fact that the study was taken over two years would reduce this likelihood (Fitzpatrick et al, 1991). There are some significant problems with the sampling information given in the study write-up. For example, there are no demographics given for the sample. This means that the majority of these patients could be male or female, making it hard to generalize to the hospitalized population as a whole (Polit & Beck, 2010). The participants were also all taken from one hospital in Israel, again making it difficult to generalize the results to the UK hospital population, although this is still an industrialized nation. There is also no information about the type of invasive procedure that the patients were undergoing, which could have an impact on the results. There were also some non-reported participants, which are covered in the sampling section of the report. It is stated that these participants were not including in the decision-making analysis for the paper because of a slightly different question being included, but details are not given. A final important part of the paper is the data collection. The data itself was collected by the patients themselves answering the questionnaire, although as previously mentioned there was a surveyor present to help guide them on more difficult questions (Brezis et al, 2008). Interestingly, the patients were all surveyed within one or two days of them signing the informed consent, but this included a variety of pre- and post-surgery responses (Bresiz et al, 2008). Information was not detailed about which responses were most likely in which questionnaire-answering situation, which makes it hard to judge whether the surgery itself could have an effect on participant’s memories of being informed about their procedures and their decision-making process. However, using patients who were interviewed before and after the surgery does mean that there is a wide variety of responses being used and this can be useful for judging informed consent procedures from a variety of angles (Munhall, 2011). Overall, the questions on the survey were generally appropriate, with the majority of them being closed questions that were simple to answer. However, it does seem strange to include the opportunity for open-ended answers which would provide qualitative data in a quantitative study (Covell et al, 2012), and again suggests that a mixed-method design may have been more appropriate (Munhall et al, 2011). There are advantages to both closed and open questions. Closed questions allow for data to be gathered which represent the hypothesis that the study is trying to analyse (Cresswell, 2012), meaning that answers will all represent information that is necessary for the study. However, it does limit the amount of information that a patient can give (Munhall, 2011). Open questions can be more useful for giving full responses that accurately represent the patient experience, but again can lead the responses away from the hypothesis and introduce complications and confounding variables (Cresswell, 2012). Implications Despite the fact that there are some limitations to the study, which are partially acknowledged by Bresiz et al (2008), it can still provide important implications for the clinical setting as a whole. Firstly, informed consent procedures do appear to be sub-optimal in this hospital, and patients seem to prefer being involved in the decision-making process (Bresiz et al, 2008). Informed consent is necessary in hospital settings (Mayo & Wallhagen, 2009), and therefore this should be carefully monitored by nursing staff and perhaps even properly analysed on a regular basis in the hospital setting. It must also be noted that there are suggestions that comprehension of informed consent prior to the surgical procedure can often be low, due to a number of factors (Fink et al, 2009). This means that the new-style informed consent procedures as suggested by Bresiz et al (2008) need to be delivered in a style appropriate to the procedure. Mahjoub & Rutledge (2011) found that nurses and patients often have differing perceptions of the informed consent procedure, with patients often feeling confused with the amount of information being given and nurses finding their style appropriate. Backed up by the findings of Bresiz et al (2008), this suggests that nursing practice should provide information in a patient-centred way which is appropriate to the patient themselves. The major implication for practice here is that informed consent may not be appropriate, and therefore could lead to the findings shown in Bresiz et al (2008). Fink et al (2010) found that using a repeat back method may allow nurses to deliver information more appropriately, again perhaps leading to the findings in Bresiz et al (2008) when informed consent is not delivered in this way. The implications are again that informed consent may not really be informed and should be adjusted to reflect findings in the literature. Findings & Practice As an anaesthetic nurse working in operating theatres, informed consent plays a big role in patient care in my current field. If a patient believes they have given informed consent but are unsure about the procedure, this could be seen as non-informed consent and therefore I could be breaching their needs and desires during the operating theatre activity (Ulrich et al, 2012). Additionally, I am always told that the patient has given informed consent, and therefore it could be misleading if they haven’t received enough information or have not had their information delivered in an appropriate way (Gaudine et al, 2011), putting my own beliefs and needs about the procedure at jeopardy. The fact that patients do not always believe their informed consent and decision-making process have been carried out correctly therefore have huge implications for anaesthetic nursing in general and therefore evidence-based practice could be improved by the findings by Bresiz et al (2008). There are several ways that the findings by Bresiz et al (2008) could be used to improve anaesthetic nursing. As patients found some of the informed consent procedures to have “major omissions” (Bresiz et al, 2008, p356), this suggests that procedure needs to be improved before coming into the operating theatre to maintain the mental well-being and safety of the patient. Anaesthetic and theatre nurses are often involved in the preoperative phase of surgery, in which an assessment of the patient is undertaken and the informed consent procedure begins (Leclercq et al, 2010). The nurse’s role in this situation is therefore to ensure that the patient has enough information about the surgery and its risks to allow them to make a judgement about the procedure before undergoing surgery (Leclercq et al, 2010). The fact that Bresiz et al (2008) found that this information was not always adequate means that theatre nursing could be improved by analysing the problems that occur during communication of these issues between nurse and patient. Additionally, Mahjoub & Rutledge (2011) found that the nurse’s perception of the informed consent procedure often differs from the patient’s perception. This could lead to the results found in Bresiz et al (2008), and therefore nurses could benefit from asking the patient to repeat back the information that they’ve heard or ensuring more thoroughly that they understand the information they have been given. Patients should also be encouraged to ask questions about the procedure (Gardiner et al, 2010) to ensure that the information that they have for decision-making is appropriate for their own worries and fears about the procedure (Mandaver et al, 2012). It has also been shown that the ability to ask questions to the anaesthetic nurse who will be present during surgery builds trust between the patient and the nurse and can help the procedure and recovery go more smoothly (Schenker et al, 2011). There is a major dilemma for operating theatre nurses which have been brought up in the discussion of the study by Bresiz et al (2008). Patients have a right to know about the risks involved in their surgery, including the likelihood of complications or fatality (Schenker et al, 2011). This can often be shocking or frightening to the patient, and therefore nurses may feel it more appropriate to leave this information about the informed consent procedure from the discussion (Krumholz, 2010). There needs to be a balance between informing patients and ensuring that they are not so scared that they put off necessary procedures out of fear. One solution proposed by Bresiz et al (2008) is to simply ask the patient how much information they require about the procedure to ensure that they have the experience appropriate for themselves. This approach could be used to improve my practice as it would allow a balance between giving all the information possible and giving the information that promotes patient well-being. If informed consent procedures are not good enough for patients as suggested by the findings of the study, then improving them in the ways suggested above could improve practice significantly. Firstly, there would be less moral issues because the informed consent would be properly informed and patients would be able to make the right decisions for their own health and safety (Krumholz, 2010). Secondly, patients would be happier with the choices that they make, and would have a more pleasant experience of surgery. Improving the experience would also improve trust in the nurse and therefore patients and their families would feel safer during the surgical procedure. Thirdly, giving proper informed consent could also reduce the likelihood of complications because the nurse would have more information from the patient as to why they do not believe they should have the surgery (Miller & Colloca, 2011). This again would significantly improve nursing practice. The results of the study could also be used to help improve the practice of others. It could improve the practice of long-term or palliative nurses because their patients may need surgery (Hosie et al, 2011). These nurses could give information over a longer period of time prior to any surgical needs (Hosie et al, 2011), which would improve the likelihood that patients absorb and understand all the information being given to them. Additionally, the practice of all the clinicians (the surgeon, the anaesthetist) would be improved because they would not be performing a procedure that the patient is not happy with or does not have enough information about to make a proper decision. Overall, the findings of the Bresiz et al (2008) study have far-reaching implications for many areas of surgical and non-surgical practice if improved in the way that the study suggests. Conclusion The Bresiz et al (2008) study is important because it outlines some of the ways that informed consent can often be inadequate for the needs of the patient and can often be confusing for them. Overall, the study is of a good quality because it involves many of the aspects of a good quantitative study. The method of the study is interesting because it used a survey design with both open and closed questions, suggesting that a mixed method may be more interesting to allow some qualitative answers. The sample size was large but the consecutive method of sampling and the lack of demographic data may be problematic for generalizing the findings to practice in other hospitals. Finally, the data collection methods were strong as there are the benefits of using both closed and open questions in gathering data. As the study suggests that informed consent procedures are often not adequate for the patient’s needs, there are implications for all areas of nursing practice, especially as an anaesthetic theatre nurse. Part of the pre-operative procedure is providing information to allow the patient to give informed consent, and the study shows that this information may not be adequate or delivered in an appropriate way. This means that improving the delivery style using a repeat back method or allowing the patient to ask more questions about the procedure could benefit both patient and nurse. Additionally, patients may appreciate being given a choice about how much information they are given about the risks of surgery. Overall, the implications of the study could improve patient nurse relations, patient well-being and surgical procedures dramatically. References Brezis, M., Israel, S., Weinstein-Birenshtock, A., Pogoda, P., Sharon, A., Tauber, R., 2008. Quality of informed consent for invasive procedures. International Journal for Quality in Health Care 20, 352–357. Canada, T.C.B.P.P. for H.P. and C.D.P.-P.H.A. of, 2011. Canadian Best Practices Portal - Public Health Agency of Canada [WWW Document]. URL http://66.240.150.14/intervention/evidence-eng.html#quantitative (accessed 5.26.13). Covell, C.L., Sidani, S., Ritchie, J.A., 2012. Does the sequence of data collection influence participants’ responses to closed and open-ended questions? A methodological study. International journal of nursing studies 49, 664–671. Creswell, J.W., 2012. Qualitative inquiry and research design: Choosing among five approaches. SAGE Publications, Incorporated. Elo, S., Kyngas, H., 2008. The qualitative content analysis process. Journal of advanced nursing 62, 107–115. Fink, A.S., Prochazka, A.V., Henderson, W.G., Bartenfeld, D., Nyirenda, C., Webb, A., Berger, D.H., Itani, K., Whitehill, T., Edwards, J., Wilson, M., Karsonovich, C., Parmelee, P., 2010a. Enhancement of Surgical Informed Consent by Addition of Repeat Back. Annals of Surgery 252, 27–36. Fink, A.S., Prochazka, A.V., Henderson, W.G., Bartenfeld, D., Nyirenda, C., Webb, A., Berger, D.H., Itani, K., Whitehill, T., Edwards, J., Wilson, M., Karsonovich, C., Parmelee, P., 2010b. Predictors of Comprehension during Surgical Informed Consent. Journal of the American College of Surgeons 210, 919–926. Fitzpatrick, E., Sullivan, J., Smith, A., Mucowski, D., Hoffmann, E., Dunn, P., Trice, M., Grosso, L., 1991. Clinical nursing research priorities: a Delphi study. Clinical Nurse Specialist 5, 94–99. Fowler, F.J., 1995. Improving survey questions: Design and evaluation. SAGE Publications, Incorporated. Gardiner, C., Barnes, S., Small, N., Gott, M., Payne, S., Seamark, D., Halpin, D., 2010. Reconciling informed consent and “do no harm”: ethical challenges in palliative-care research and practice in chronic obstructive pulmonary disease. Palliative medicine 24, 469–472. Gaudine, A., LeFort, S.M., Lamb, M., Thorne, L., 2011. Clinical ethical conflicts of nurses and physicians. Nursing Ethics 18, 9–19. Hosie, A., Fazekas, B., Shelby-James, T., Mills, E., Byfieldt, N., Margitanovic, V., Hunt, J., Phillips, J., 2011. Palliative care clinical trials: how nurses are contributing to integrated, evidence-based care. International journal of palliative nursing 17, 224–230. Krumholz, H.M., 2010. Informed consent to promote patient-centered care. JAMA: The Journal of the American Medical Association 303, 1190–1191. Leclercq, W.K., Keulers, B.J., Scheltinga, M.R., Spauwen, P.H., van der Wilt, G.-J., 2010. A review of surgical informed consent: past, present, and future. A quest to help patients make better decisions. World journal of surgery 34, 1406–1415. LoBiondo-Wood, G., Haber, J., 2005. Nursing research: Methods and critical appraisal for evidence-based practice. Mahjoub, R., Rutledge, D.N., 2011. Perceptions of informed consent for care practices: hospitalized patients and nurses. Applied Nursing Research 24, 276–280. Mandava, A., Pace, C., Campbell, B., Emanuel, E., Grady, C., 2012. The quality of informed consent: mapping the landscape. A review of empirical data from developing and developed countries. Journal of medical ethics 38, 356–365. Mayo, A.M., Wallhagen, M.I., 2009. Considerations of informed consent and decision-making competence in older adults with cognitive impairment. Research in gerontological nursing 2, 103. Miller, F.G., Colloca, L., 2011. The placebo phenomenon and medical ethics: Rethinking the relationship between informed consent and risk–benefit assessment. Theoretical medicine and bioethics 32, 229–243. Munhall, P., 2011. Nursing Research. Jones & Bartlett Learning. Polit, D.F., Beck, C.T., 2010. Generalization in quantitative and qualitative research: Myths and strategies. International journal of nursing studies 47, 1451–1458. Sandelowski, M., 1995. Sample size in qualitative research. Research in nursing & health 18, 179–183. Schenker, Y., Fernandez, A., Sudore, R., Schillinger, D., 2011. Interventions to Improve Patient Comprehension in Informed Consent for Medical and Surgical Procedures A Systematic Review. Medical Decision Making 31, 151–173. Ulrich, C.M., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M., Grady, C., 2010. Everyday ethics: ethical issues and stress in nursing practice. Journal of advanced nursing 66, 2510–2519. Woolf, S.H., Grol, R., Hutchinson, A., Eccles, M., Grimshaw, J., 1999. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ: British Medical Journal 318, 527. Appendix Purpose of the study Was the purpose of the study and or research question stated clearly? Yes No This study looks at the quality of informed consent as given by nurses. The justification for the study is that patients require a good standard of informed consent to allow them to make the right decision, and nurses have an ethical duty to ensure that consent for surgery is given correctly. Study design Was the study design RCT Cohort Single case Cross sectional Longitudinal The study design was cross-sectional because it analysed these people at one point in their lives, either before or after their surgical procedure. Method used Which method was used experiment structured interviews survey observation The method used was a survey which was distributed to the patients to fill out themselves, although a surveyor was available to help them answer some questions. The survey consisted of open and closed answer questions. Sampling Was the process of selection described and are the participants described in adequate detail? Yes No The participants were those undergoing surgery at one hospital and 10 general clinics in Israel and were recruited sequentially. There is no demographic information about the sample given, despite the fact that this information was taken during the survey. The selection of the patients was also not described, as in we do not know if they were happy to take part in the study or were just recruited as part of their surgery. Data collection Is a clear account of the data collection given? Yes No The data was collected using a questionnaire with open/closed answer questions. The questions are provided in the paper to allow judgement on their appropriateness for the study. Data analysis Methods of data collection were adequately described Yes No The data was analysed using Chi-square testing but the justification for this method is not given. Justification is not given for combining two data sets. Results Were the results reported in terms of statistical significance? Yes No Was the attrition rate from the study reported? Yes No The findings of the study suggest that patients sometimes feel that informed consent procedures are not adequate and would like more involvement in the decision-making process. Ethical considerations Was informed consent obtained from the participants of the study? Yes No The ethical considerations for the actual study are not described in detail, as we are not told about how the patients gave consent for the study itself. However, asking these questions is said to not alter patient outcomes or put them in danger so this suggests the authors considered this aspect of ethics. Read More