An interventional approach for patient and nurse safety - Dissertation Example

? Critical Appraisal of An Interventional Approach for Patient and Nurse Safety” (Scott, L. D., Hofmeister, N., Rogness, N., and Rogers, A. E, by Critical Appraisal # 1 Theoretical Framework a. Theoretical Model The theoretical framework that was used in this study was the model of impaired sleep developed by Lee et al. (2004). The framework is based on a scientific theory (Burns & Grove, 2009) as it uses previous research linking sleep quality with errors and lack of alertness. b. Theoretical Model Discussion The theoretical framework is clearly discussed as having a direct significance with the research topic. It is stated impaired sleep consists of either sleep deprivation (inadequate sleep) or sleep disruption (fragmented sleep). The model implies that impaired sleep results in cognitive, behavioural, physiological, social, and emotional responses. The paper elaborates how a targeted fatigue countermeasures program for nurses (FCMPN) can intervene and prevent or alleviate the cognitive and behavioural impacts (like sleep duration, daytime sleepiness, and alertness) and reduce patient-care errors. The following figure from the paper captures the conceptual and the theoretical framework employed: The framework is therefore discussed well to outline what variables are to be measured pre and post the FCMPN intervention. 2. Major Study Variables Research Variables: 1. Sleep Quality 2. Sleep Duration 3. Daytime Sleepiness 4. Vigilance 5. Risk for Accidents and Errors 6. Short Term Memory 7. Problem Solving and Coping. Conceptual Definition Sleep Duration was defined as the time duration that participants spent in uninterrupted sleep. Sleep Quality was clearly conceptualized to mean sleep which is not fragmented and which is of adequate duration. While the remaining variables were not clearly defined, conceptually they could be understood to mean the following: Daytime Sleepiness – tendency to doze during the daytime work-hours Vigilance – Drowsiness and Unplanned Sleep Episodes during work hours Risk for Errors – Any perceived deviations from standard practice Short Term Memory – Recall of errors Problem Solving and Coping – How errors were managed Operational Definition Sleep Duration was measured using the log book entries made by the participants. Sleep Quality was measured using the Pittsburgh Sleep Quality Index PSQI (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989). Daytime Sleepiness was measured using Epworth Sleepiness Scale (Johns, 1991) while other variables (Vigilance, Risk for Accidents and Errors, Short Term Memory, Problem Solving and Coping) were measured using the log book entries using the self-report method 3. Sample and Setting a. Sample Inclusion/Exclusion Criteria Full-Time Hospital Staff Surgical nurses were used as the sample. In addition, the selection criteria included that the nurses should be working at least 36 hour per week. Advanced practice nurses, nurse managers, or nurses in specialized roles such as discharge planning were excluded. b. Sampling Method The paper mentions using three surgical nursing units in Michigan using convenience method for selection, though the rationale or the specific factors that led to the selection of the method is not listed. The qualifying nurses were contacted using the official mailing list and out of the 126, 62 consented to participate in the research. c. Sample Size 62 Power analysis indicated that 30 sample size would be sufficient to establish the impacts of FCMPN on the variables that are researched. d. Refusal to Participate Number and Percentage 62 out of the 147 full-time hospital staff nurses (43%). e. Sample attrition or Mortality Number and Percentage Out of the 62 selected for participation, 15 (24%) did not continue with the study for the complete duration. f. Informed Consent Process/Institutional Review Board The 147 nurses that comprised of the qualified the inclusion criteria were sent a preliminary survey to provide demographic information and give their interest to participate. Once the intent of participation was obtained, these were provided with detail information about the research and their enrolment sought. The details of what information was provided to the prospective participants are missing from the paper, though the enrolment agreement is implied to mean that the nurses consented voluntarily. The consent of the institutional review board at Grand Valley State University was also obtained. g. Study Setting. The research was conducted in medical-surgical units in three major acute care Michigan hospitals. 4. Measurement Methods Statistical Analysis a. Analysis Techniques The sample was described using percentages of prospective candidates that actually participated, and percentage of attrition. Power analysis was used to establish the validity of the sample size. The variables were described using frequencies of occurrence (accidental errors, unscheduled sleep episodes, short term memory and problem solving), duration (sleep duration), summative measures (daytime drowsiness) and subjective scores for quality of sleep. The relationship between variables were not established using any statistical measure. The difference in pre and post test measures were represented by analyses of variance, paired t tests, or McNemar tests (sleep duration, sleep quality, and daytime sleepiness) and chi-square tests (episodes of sleep on duty). Error reduction after the use of the FCMPN was examined using generalized estimating equations for repeated-measures categorical data (time vs. error presence or absence). Statistical significance was set at .05 for all the above measures. b. The data analysis was linked with the study purpose and the hypothesis. Findings a. Representation of the Findings The interpretation of the findings was clear and followed a logical structure. All the results of the statistical analysis from the data gathered pre and post trial were presented in a comprehensive manner. a. Findings Link with the Framework The findings reveal that there are positive gains in sleep quality, sleep duration, reduction in accidental errors, reduction in daytime drowsiness and increase in alertness after FCMPN has been introduced. These findings relate to similar studies conducted in other sectors and settings. These also relate to the conceptual model of impaired sleep developed by Lee et al. (2004), which states that sleep quality and duration have a direct correlation with behavioural and cognitive outcomes. b. Expected Findings The research found that sleep quality and duration improved with FCMPN, which on the basis of the impaired sleep model (Lee et al., 2004) should lead to reduction in daytime sleepiness, improvement in alertness, reduction in errors, increase in discovered errors and intercepted errors. The same was validated by the research findings. c. Unexpected Findings An unexpected finding was that while there were significant improvements in the sleep quality and duration, daytime sleepiness was not improved significantly in 18 out of the 47 participants. Another finding was that overall the quality of sleep was low, in spite of the gains achieved through FCMPN intervention. Additional finding was that the participants showed a reluctance to indulge in strategic naps as they consider these as inappropriate. d. Consistency of the Findings with Previous Research While the research does not list much background research in the subject area, it was noted that sleep quality and duration has a direct impact on the subjects’ cognitive and behavioural performance. Several studies in diverse industries have already established the implications of long shift hours and lack of sleep quality on the health of the workers and their jobs. This research therefore provided consistent results for the case of nursing sector. Study Limitations The researcher identifies the limitation as the convenience sampling and lesser number of nursing units that participated in the research and hence making it of limited scope. Generalization of Findings The researchers used several generalizations to support the case for FCMPN. As the main study outcome, FCMPN was pronounced to have positive benefit to overall nursing effectiveness and quality. Further, the researchers made suggestions on how to ensure that FCMPN was integrated into nursing practice, by changing culture and attitude, by ensuring that nurses do not have to work at double jobs, and by suggesting enhanced remuneration for them. Implications of the Findings for Nursing Practice The findings have wide reaching implications for nursing practice as these revealed that majority of the nurses suffer from low quality sleep and daytime drowsiness, issues which lead to detrimental errors and jeopardize the patients health and safety. The research also provided evidence that introduction of FCMPN protocol and by changing some cultural inhibitions and modifying the HRM policies, there is scope to improve nurses’ sleep quality and duration and improve their alertness and reduce errors. The research therefore points out a path for further exploring the techniques through which nursing errors can be avoided, and also provides a practicable example for clinics to emulate to improve their nurses’ performance. Suggestions for Further Study The researchers suggest that a more expansive study spanning a larger geographical area could bring in more information and provide a better starting point for making changes in the HRM policies in nursing. Critical Appraisal 2 Strengths and Weaknesses Purpose/Problem The research problem is clearly identified as the impact that long working hours, coupled with insufficient sleep and fatigue have on the nurses performance and errors. The significance of the problem is also highlighted as Scot et al (2010) provide statistics from previous research (Rogers, Hwang, Scott, & Dinges, 2003) which indicates that majority of the registered nurses struggle to stay awake on their shifts, and hence are at a higher risk to make errors and undermine the health of patients entrusted in their care. The reason that Scot et al (2010) cite for the above problem situation is that registered nurses working hours are not at par with those of the industrial workers, in spite of the fact that nurses too spend long hours on their feet and are exposed to chemicals. Additionally, the problem is made more acute by the fact that there is an increased evidence of single parenthood among nurse population, as well as staff shortage in the sector, both the factors adding to less sleep time for the nurses. The purpose of the study is defined at the end of the Introduction of the study by Scot et al (2010), as to evaluate the feasibility of a fatigue countermeasures program for nurses (FCMPN) for reducing fatigue and patient care errors among registered nurses. The purpose of the study derives from the fact that there has been little research directed at exploring the utility of FCMPN to reduce Nurse fatigue and improve sleep quality. Scot et al’s (2010) study is therefore aimed to fulfil the gap in knowledge and develop a program that can be used to provide practical support to the registered nursing staff. The purpose of the study is feasible as the subjects and the facilities to conduct the research are available and the researchers competent (Grove, 2007). The purpose of the study could have been more clearly established by stating which specific variables (sleep deprivation/fatigue/working hours) were to be targeted for improvement using which FCMPN method, and also by defining the specific variables (nursing errors, sleep quality) that are to be improved. Literature Review Scot et al’s (2010) paper does not contain a separate section on Literature Review. However, the first few paragraphs of the paper, develop a background for the research problem and purpose based on what appears to be a preliminary literature review. This review of the literature is tightly knit around the studies that have established that nursing staff suffers from long work hours and sleep deprivation (Rogers, Hwang, Scott, & Dinges, 2003), as well as some studies that have researched the impact of sleep deprivation and long working hours on subjects, not necessarily belonging to the nursing population (Barger et al., 2005; Powell et al., 2007; Scott, Rogers, et al., 2006). The information however is more suitable towards developing a background and understanding of the problem under study, rather than as a review of the literature. A well structured review of the available literature could have included a review and critical appraisal of the research that have been undertaken on the implementation of FCMPN programs in nursing settings (Burns & Grove, 2009). The methodologies used and the findings obtained from previous similar research could have benefited in the development of Scot et al (2010) own research methodology. Further, a review of any available research undertaken on nursing errors or studies that have researched the causes of nursing errors could have benefited Scot et al paper’s premise for introducing FCMPN program to combat the causes that lead to nursing errors. Additionally, a review of literature on the concepts and measures used for variables like sleep quality, sleep deprivation, types of nursing errors, impacts of sleep deprivation is also lacking. Scot et al paper therefore lacks from a serious omission of a critical review of the available research on the subject of their study. Framework The paper identifies the model of impaired sleep (Lee et al., 2004) as the conceptual framework. This model postulates that sleep quality is dependent on sleep disruption which is related to sleep fragmentation and sleep deprivation or inadequate sleep. The FCMPN model that is used as the intervention in the pilot study, targets the improvement of these two areas of sleep quality. The model of impaired sleep also states that there is a direct impact of low sleep quality on cognitive and behavioural factors like decrease sleep duration, increase daytime sleepiness, decrease alertness or daytime drowsiness (Vigilance) and increased accidents or errors. The improvements in the sleep quality via the FCMPN were therefore expected to bring about positive results in these factors. Scot et al (2010) therefore used this model to arrive at four measurable variables (sleep duration, daytime sleepiness, alertness or daytime drowsiness (Vigilance) and accidents or errors) that are the outcomes of sleep quality. However, the conceptual framework lacks in conceptual literature on how these measurable four variables, which determine the sleep quality, can be improved. Or rather, a framework on improving sleep quality, which could have guided the development of the FCMPN that was finally used by the study. Instead of developing a rationale and framework that could have justified the use of the selected FCMPN, the authors chose simply to pick some elements from two FCMPN programs - National Aeronautics and Space Administration Ames Research Center’s Fatigue Countermeasures Program (National Aeronautics and Space Administration Ames Fatigue Countermeasures Group, 2002) and Sleep, Alertness, and Fatigue Education in Residency Program (American Academy of Sleep Medicine, 2006) - and use them direct in the study without any evaluation or comment on the appropriateness or utility of the choice for their case. Objectives, Questions, Hypotheses The research defines the objective as evaluation of the feasibility of FCMPN for improving sleep duration, sleep quality and reducing daytime sleepiness, and patient care errors. “Specific goals of the study included an evaluation of hospital staff nurse sleep patterns and alertness before and after the implementation of an FCMPN and a comparison of the frequency and type of errors and near errors reported by hospital staff nurses before and after the implementation of an FCMPN” (Scot et al, 2010, p. 251). While within the paper, an additional factors – vigilance, short term memory, and problem solving and coping are also measured as factors FCMPN impacts upon, these are not defined or stated at the onset. The paper lacks a clear development of the research objectives that could give a comprehensive idea of what the researchers want to measure specifically – which is needed in the introduction section for the reader to form expectations from the paper. A tentative statement of the hypothesis is presented, “It was hypothesized that adoption of a standardized fatigue intervention program used in many other industries would improve nurses’ alertness and therefore decrease the number of near errors or actual patient care errors.”(Scot et al, 2010, p. 251). A more elaborate and comprehensible hypothesis statement is provided in the data analysis section, where the researchers want to show what variables are used – “It was hypothesized that the FCMPN would improve sleep quality, increase total sleep duration, and decrease severity of sleepiness and frequency of unplanned sleep episodes while on duty” (Scot et al, 2010, p.254). However, from the objectives, much remains to be desired as there is no mention of how sleep quality may be impacting on these variables, and if FCMPN used in the study targets sleep quality improvement. Thus, it is seen that the objectives are not identified to be rooted in the conceptual framework or the theory of impaired sleep. It is also not clear if the study is to be pre and post facto study (which is the case) It is nevertheless clear from the objectives it is clear that the researchers intend to measure the impact of FCMPN on at least some of the variables from among the total they finally measure in their study (Burns & Grove, 2009). Definition of Variables The conceptual definition of all the variables is not well written, and actually omitted in most cases. There also appears some confusion in the concepts of sleep deprivation (which, along with sleep disruption makes up sleep quality) which is defined as inadequate sleep and sleep duration. The two appear to be same on the face value, and hence there was a need to discuss them in a discriminating manner. For example, the researcher may have stated that by sleep deprivation, they mean ‘not sleeping for continuous long hours’ while sleep duration means the ‘total time spent in sleep’. It is essential to express this distinction as sleep deprivation may be wrongly interpreted as ‘very less time spent in sleep’, while in reality it means that a person may not get down to sleep for long intervals; which is not same as the amount of time spent in being asleep. Moreover, the paper lacks in conceptual framework and understanding of several additional variables that are involved in the research. For example, there is no background information on variables like vigilance, problem solving and short term memory and how these may be impacted by sleep quality or how these may relate to work-related errors. The operational definitions of only two variables, sleep quality and daytime sleepiness are clearly defined as these are contained in the discussion of the standard instruments that are used to measure the two. For the remaining variables, the researchers simply mention that the nurses use log books to note their activities. Only for log book entries related to errors, the researchers give insights about what comprised of errors by mentioning that the nurses were asked to provide details of any medication or other errors that they made or almost made during the course of the day. For sleep duration, the participants were asked to keep records of their rest times, while for vigilance, they were asked to record incidences of unplanned sleep during work and drowsiness during driving. For other variables like short term memory and problem solving, there was no elaboration of the constructs or measurements used to assess these variables. The paper therefore lacks on clarity on what activities, aspects and factors are actually used to measure the majority of the other factors. Scot et al (2010) could have improved the paper by including, as part of appendix, the sample of log book entries or given some details about how they structured the collection of this mode of self-reported data. Study Design The research design is outlined clearly, but it misses out on important details. The researchers mention that restriction of small sample size and convenience sampling method, but they do not discuss how these restrictions were compensated for. The research protocol received the consent of the institutional review board at Grand Valley State University and hence the established the validity of the research. The research lacks construct validity as there is little linkage between the conceptual understanding of the measures and how they are actually measured. There is also lack of protocols to contain the scope of errors and bias that could occur due to the survey method of data collection where the participants used self-reporting. Additionally, the research design does not include a mention of the ethical considerations or sources of additional bias or errors that could have confounded the research findings (Burns & Grove, 2007). Intervention The FCMPN model that is used in the study is based on a modified program that uses the National Aeronautics and Space Administration Ames Research Center’s Fatigue Countermeasures Program (National Aeronautics and Space Administration Ames Fatigue Countermeasures Group, 2002) and Sleep, Alertness, and Fatigue Education in Residency Program (American Academy of Sleep Medicine, 2006). The actual FCMPN program was not clearly delineated and hence it is not easy to understand what activities of FCMPN were aimed towards the achievement of which specific factor. Sampling Process The paper details that the research was conducted in three surgical-clinical facilities in Michigan, but it does not give details about why these specific facilities were selected or how the decision was made. The researchers report acquiring the database of all the prospective candidates (surgical nurses who spent at least 36 hours per week) from the selected clinics, and then obtaining their willingness and consent to participate in the research. The sampling process therefore was based on convenience, rather than random sampling, which could have furnished data that is practicably applicable to the population. However, small sample size of 47 nurses was proved to be appropriate by the researchers by using a power analysis that indicated its suitability for the research purpose. Measurement Methods The measurement methods of using Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESQ) scales, are valid and reliable standard instruments for the measurement of sleep quality and daytime sleepiness. The log book entries, though not clearly elaborated in the research paper, are however are subjected to variance analysis, paired t test analysis, and chi-square tests to determine the gains between the pre-test and the post-test measurements. Moreover, the error reduction is determined using the generalized estimating equations using time vs. error method. All the measures are therefore valid and reliable. The study also included a measure of the power analysis that determines that the research sample of 47 was appropriate to measure a significant impact of FCMPN on the research variables. Data Collection The data was collected in two phases. The first phase, or the pre-test phase of the study lasted for 2 weeks (week 1 and week 2) and during this phase the researchers asked the participants to fill in log books, Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESQ) scales. After the 2-week period, the nurses were introduced to the FCMPN educational session. Following the education session, and with the implementation of FCMPN protocol during the next week (Week 3), the participants again completed log books, PSQI, and ESQ scales. All the data was collected via email and the participants were free to record their responses at their own convenience. This form of self- report method may have led to bias and omissions from the participants who may not be comfortable in recording their own errors. Similarly, in order to measure vigilance, the participants were expected to record incidents of unplanned sleep during work or drowsiness during driving. Here again, there is scope for wilful omission of incidences of unplanned sleep on job. Moreover, the log book entries are not clearly defined, and there is no mention of how these entries relate to the conceptual framework and hence, there is a question of establishing the validity of the measurements to relate to what the researchers wanted to assess in their study. Data Analysis The data analysis is conducted using the statistical tools of variance, paired t tests, McNemar tests and chi-sqaure tests to measure the changes in the research variables – sleep duration, sleep quality, daytime sleepiness, episodes of sleep on duty (vigilance), errors. The methods used for the analysis of the collected data were appropriate (Burns & Grove, 2007). However, as pointed out in this appraisal already, the researchers did not provide adequate information on two additional variables like short term memory and problem solving even in the data analysis section. Nevertheless, the data analysis involved statistical measures that are appropriate for establishing the strength and value of changes that occurred post the FCMPN intervention. Discussion Section The discussion section of the paper contains a summary of the main findings and links sleep quality and sleep duration with reduction in sleepiness, sleep episodes and reduction in errors. While not explicitly stating that the research hypothesis, (the FCMPN would improve sleep quality, increase total sleep duration, and decrease severity of sleepiness and frequency of unplanned sleep episodes while on duty) it does indicate that the hypothesis was validated. The discussion also highlighted issues of duration of sleep and lack of sleep quality for the nurses of Michigan, where there employment hours are expansive. It also hinted at the need to change the organizational culture so that the FCMPN interventions are adopted and embraced whole-heartedly by the nurses as well as their supervisors. The discussion is lucid but it does not provide any linkages with the conceptual framework or provides an overall closure for the research topics. Scot et al (2010) could have improved their discussion by bringing together the research objectives and the findings more explicitly, and relating then with the background literature and conceptual background. Evaluation Confidence The research is important for urging action from the hospital authorities to modify their work culture and nurse scheduling methods owing to the detrimental impact that nursing errors can have on patients. The study provides a practical solution to the problem, by introducing FCMPN and encouraging a culture change. While there are several weaknesses in the research design as well as conceptualization of the research variables, Scot et al’s (2010) research can serve as a starting point for further research in using targeted FCMPN programs to address the problem of nursing errors and nurse alertness. Consistency with previous research The research is consistent with previous research as it establishes successfully the positive impact of FCMPN on sleep duration, sleep quality, vigilance and reduction in nursing errors. The previous research has established that there is short sleep duration and low sleep quality are associated with daytime sleepiness and errors (Rogers, Hwang, Scott, & Dinges, 2003). Previous research has established that sleep deprivation and extended work hours lead to driving impairment (Barger et al., 2005; Powell et al., 2007; Scott, Rogers, et al., 2006) and several health problems (National Sleep Foundation, 2009; Patel et al., 2004). Readiness of findings for use in practice The research is based on a pilot study, and hence the findings ideally cannot be used in practice without replacing the research on a larger scale. Also, there are several problems, as highlighted throughout this appraisal, regarding the conceptualization and measurement of the research variables, that need to be worked out in more detail. The study nevertheless provides guidance for future, more detailed and expansive research to be undertaken in the topic. Contribution to Nursing Knowledge The study indicates that FCMPN should target all those activities that may hinder quality sleep as well as sleep duration. These activities include moderating nursing scheduling and shift-hours; educating the nurses on the tools and methods to ensure quality sleep; and changing the organizational culture to support the new methods. While it was only a pilot study, it contributes to academic nursing knowledge by highlighting the factors associated with culture (which encourages nurses to try to do too much in too little time, at the cost of their sleep) and employment terms (which dictate the scheduling and shift hours). 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