Medical and Surgical Nursing Research Proposal
Medical and surgical nursing has long been considered the foundation of nursing. Care of the adult is the keystone of medical-surgical nursing. This care can be in the acute care setting, in the home, in outpatient settings, or in the community. The care provided is holistic and is rooted in health promotion, disease prevention, health restoration, and health maintenance ( 2005).
Medical-surgical nursing focuses on nursing care of the adult client and is recognized as the bedrock of nursing practice. Nursing care in this specialty is not centered on a setting or a body system, but encompasses the domain of nursing care of adults. Medical-surgical nursing care is provided to adults around the world. In many situations, medical-surgical nurses are the only specialty nurses available to provide care for adults (2005).
This paper focuses on the problems surgical medical nurses face. Research on the increasing incidence of complications or infection after surgical tracheostomy and other surgical procedures are performed in critically ill patients in nursing care settings will be critiqued as well as how this problem can be solved by providing solutions designed for the apparent cause of the problem. The tools to be used to explore the issue will include researching many reading materials regarding the topic and put it together in a meaningful whole. A personal analysis on the problem will also be presented and as well as recommendations on how the quality of care can be improved regarding the particular problem in surgical medical nursing.
In a nationwide study focusing on the state of research utilization in the United States, it revealed that the culture of healthcare institutions does not value research utilization. The study noted that nurses without a baccalaureate degree did not fully understand or value research, while some of the baccalaureate-prepared nurses who had classes on research in their program complained that the way in which nursing research was taught in the schools turned them off (2003).
These are just some examples that depict the increasing lack of awareness and utilization of many health care professionals. The purpose if this paper is to identify the main reasons why nurses do not utilize research in their practice; discuss three of these reasons and why they exist; and make evidenced based recommendations for future nursing practice to overcome each of these three barriers.
There are two major approaches to investigating diverse phenomena in the field of nursing research. These approaches originate from different philosophical perspectives and use different methods for collection and analysis of data.
Quantitative research progresses through systematic, logical steps according to a specific plan to collect numerical information, often under conditions of considerable control, that is analyzed using statistical procedures. The quantitative approach is most frequently associated with positivism or logical positivism, a philosophical doctrine that emphasizes the rational and scientific. Quantitative research is often viewed as “hard” science and uses deductive reasoning and the measurable attributes of human experience (2004).
The qualitative approach is often associated with naturalistic inquiry, which explores the subjective and complex experiences of human beings. Qualitative research investigates the human experience as it is lived through careful collection and analysis of narrative, subjective materials. Data collection and its analysis occur concurrently. Using the inductive method, data are analyzed by identifying themes and patterns to develop a theory or by identifying themes and patterns to develop a theory or framework that helps explain the processes under observation (2004).
Research Article Critique (Complications of Tracheostomy Performed in the ICU: Subthyroid Tracheostomy Vs Surgical Cricothyroidotomy)
Problem statement and or hypothesis
The purpose of the study was to compare the complications attributed to both surgical techniques used for tracheostomy in critically ill patients. Accordingly, we sought to prospectively determine the incidence and severity of complications associated with conventional subthyroid tracheostomy and surgical cricothyroidotomy that are performed at the patient's bedside in the ICU.
Tracheostomy refers to an opening into the trachea where an artificial airway (the tracheostomy tube) is inserted. This is usually performed to protect the patient from accidentally inhaling food, fluid or saliva. Such an airway may be necessary for patients when prolonged ventilation is required, or when an extended coma is anticipated. It may also be placed surgically to maintain the structure of the trachea--when threatened by cancer, infection or trauma, Placement of a tracheostomy is mainly used during the acute phase of an illness and later removed (2005).
A client may have a tracheostomy to bypass an upper airway obstruction, prevent aspiration, manage tracheobronchial secretions, or allow for prolonged mechanical ventilation. Whatever the reason for tracheostomy, the client should be provided standardized care in tracheostomy management. Lately, the rising incidence of chest infections in patients undergoing tracheostomy in my place of employment had been largely blamed on the part of the nurses. Such poor quality of practice is a no-no in the healthcare field. If nurses are not aware of the recommended and safe procedure, then the lives of clients are in jeopardy.
Nurses are instrumental in helping tracheostomy patients cope through symptom management, emotional support, and patient education. By increasing their awareness of this disorder and the challenging nature of its diagnosis, nurses can help identify patients needing care.
Risk management is important. It is about identifying, measuring and controlling those risks that threaten quality or performance in the delivery of patient care (Metcalfe, 2002). Every day, nurses help patients through education, empowerment and expertise to avoid the recognized complications associated with tracheostomy care. They give practical advice and support to people with who underwent tracheostomy to manage risky situations such as an episode of chest infections, encouraging the patient and the family to learn from the event and employ tactics to prevent recurrence. This is a proactive risk management strategy that involves the recognition and identification of things that can go wrong as part of a systematic approach to patient care. Patients are empowered to respond appropriately in a risky situation.
Theoretical and conceptual framework
While the existing literature points to the deep impact that surgical tracheostomy can have on patient’s lives, there is nonetheless a scarcity of research on the particular issues of infection after tracheostomy. Although surgical tracheostomy has become a procedure that is commonly performed in critically ill patients, the morbidity of the different surgical techniques currently used in ICUs is not well-known. For this reason the medical and mental health communities are unaware of the best way to assist surgical tracheostomy patients with infection in their recovery.
To address this gap in the literature, this particular study was conducted which specifically explored the incidence and severity of complications and infections associated with subthyroid tracheostomy and cricothyroidotomy when performed in the ICU.
For this proposal, the author employed a combination of qualitative methods. This study examined individual consecutive patients who were undergoing elective tracheostomy rather than experimental manipulation of these variables. Attending physicians elected the timing and technique of the tracheostomy. All procedures were performed at the bedside. A complete laryngeal examination was performed before ICU discharge, prior to decannulation, and 6 months after the tracheostomy. Over a 2-year period, all patients hospitalized in the 22-bed ICU of Limoges University Hospital (France) who underwent an elective tracheostomy were studied. Exclusion criteria included the following: (1) having undergone an emergency tracheostomy and (2) a history of previous tracheostomy, neck surgery, cervical irradiation, or laryngeal disease.
In each patient, the following parameters were noted: age; sex; body mass index; APACHE (acute physiology and chronic health evaluation) II score on ICU admission; reason for admission to the ICU; length of ICU stay; indication for tracheostomy; duration of mechanical ventilation prior to tracheostomy; number of endotracheal intubations prior to tracheostomy; duration of cannulation; as well as different factors that could result in a technically challenging surgical tracheostomy, including the presence of a distorted neck anatomy or coagulopathy. The ICU morbidity and mortality at 6 months after ICU discharge also were recorded.
Patients were divided into two groups, according to the technique of tracheostomy used (subthyroid tracheostomy vs surgical cricothyroidotomy). Randomization was not performed since the technique of surgical tracheostomy was chosen by each attending physician based on anatomic or functional factors that are known to influence the feasibility of the procedure. Cricothyroidotomy was performed in the presence of at least one of the following criteria: (1) severe distortion of neck anatomy; (2) morbid obesity; or (3) patients with poor prognoses. In the absence of these criteria, a conventional subthyroid tracheostomy was usually performed.
The main limitation of this study is that the tracheostomy technique was chosen by the referring physicians based on anatomic and functional factors, rather than by randomization. This may have introduced a substantial bias since surgical cricothyroidotomy was more frequently performed in the presence of criteria that traditionally have been associated with the performance of technically difficult conventional subthyroid tracheostomies. However, with the exception of age and body mass index, both study groups were comparable for all other characteristics. In addition, the power analysis showed that the size of our study population was adequate to detect a difference of 20% in the incidence of major complications between groups.
The data is of high quality since it can be used for decision-making and planning of the nurses, which can ultimately improve the effectiveness of nursing care and health outcomes in patients with infections and complications from surgical tracheostomy.
Patients’ characteristics and the incidence of tracheostomy complications were compared between both groups (subthyroid tracheostomy group vs surgical cricothyroidotomy group). Qualitative variables were compared using a [chi square] test, or a Fischer Exact Test when appropriate. All quantitative parameters were compared using a Mann-Whitney rank sum test. Results were expressed as the mean [+ or -] SD. For all comparisons, a p value of < 0.05 was considered to be statistically significant.
Interpretation of results
Data gathered from the study shows that the reasons for admission to the ICU were as follows: acute medical condition, 57 patients (48%); postoperative complications, 16 patients (14%); and multisystem trauma, 45 patients (38%). Tracheostomy was performed for prolonged ventilation in 73 patients (62%), because of difficulty in weaning from the ventilator in 25 patients (21%), because of an advanced stage of chronic respiratory insufficiency in 14 patients (12%), and due to severe facial trauma in the remaining 6 patients.
Research Article Critique (Health and Economic Impact of Surgical Site Infections Diagnosed After Hospital Discharge)
Problem statement and or hypothesis
The purpose of the study was to describe the impact of infections diagnosed after discharge, which constitute the majority of surgical site infections (SSIs). Although surgical site infections (SSIs) are known to cause substantial illness and costs during the index hospitalization, little information exists about the impact of infections diagnosed after discharge, which constitute the majority of SSIs.
Wound site infections are a major source of postoperative illness, accounting for approximately a quarter of all nosocomial infections. Postoperative surgical site infections remain a major source of illness and a less frequent cause of death in the surgical patient. These infections number approximately 500,000 per year, among an estimated 27 million surgical procedures. Infections result in longer hospitalization and higher costs (2001).
Evidence-based practice is critical to patients, nurses, health care providers, and the health care system (2000), and this could significantly help improve the quality of care provided to patients with SSIs. Guidelines should be set in order for nursing care be improved.
Recent improvements in antibiotic prophylaxis, including the timing of initial administration, appropriate choice of antibiotic agents, and shortening the duration of administration, have established the value of this technique in many clinical surgical settings (2001).
Theoretical and conceptual framework
Given the high costs and adverse patient outcomes associated with SSIs, quantifying the clinical and economic impact of SSIs recognized after discharge from the hospital is important. Several studies have focused on the direct medical costs borne by the hospital or insurer, but to the author’s knowledge, no study has assessed the full societal impact of SSIs, which includes indirect costs, such as lost patient productivity and diminished functional status. Additionally, no study has addressed the costs of SSIs that arise from most of these infections which now occur in the postdischarge setting and for which patients are not readmitted to the index hospital. The magnitude of these costs might not be known if ascertainment were left solely to the index hospital's information systems. To address this gap in the literature, this particular study was conducted.
For this research, the author employed a matched cohort design to compare the costs and illness of patients with an SSI to matched patients who had surgery during the same period but in whom an SSI did not develop. The study population was drawn from adult members of Harvard Vanguard Medical Associates. Study participants were those who had undergone a nonobstetric inpatient or outpatient operating room procedure at Brigham and Women's Hospital from May 18, 1997, through October 31, 1998.
In this study, a patient questionnaire was used and administrative databases are assessed for clinical outcomes and resource utilization in the 8-week postoperative period associated with SSIs recognized after discharge.
Each patient provided a signed consent form before completing the questionnaire and being enrolled in the study. The Harvard Pilgrim Health Care institutional review board approved this study.
Data collection procedures
Participants were enrolled 5-7 weeks after surgery. All case-patients and matched pairs were mailed a 49-item questionnaire, an explanatory letter, and a consent form. The questionnaire is divided into three sections which the participants are going to answer. Four administrative databases were also used to determine provider-level resource use associated with the 8 weeks after discharge from the operation that led to entry into the cohort.
Data gathered and analyzed can be used by health care professionals in knowing the impact of surgical site infections diagnosed after discharge. By knowing this, health care professionals could come up with a way of how to minimize these infections therefore cutting costs for the patients and the health care system as well.
Student t test, Wilcoxon rank-sum test, or Fisher exact test were used, where appropriate, for univariate comparisons. Outcomes are presented as medians with interquartile range, means with standard deviations, or proportions. Cases and matched controls were compared by using the Wilcoxon signed-ranks test for continuous outcomes with non-normal distributions, continuous linear regression by forcing the matching variable into the model for normally distributed variables, or the Cochran-Mantel-Haenszel for matched binary variables. Almost all assessed utilization outcomes, including all charges, were non-normally distributed so both medians with interquartile range and means with standard deviation are reported. Multivariable unconditional logistic regression was used to control for confounding variables in the analysis of the questionnaire data, and all matched variables were forced into the model to account for the matching process. All data collected were combined into one dataset for final analysis, after which all unique identifiers were removed.
Interpretation of results
SSI recognized after discharge was confirmed in 89 (1.9%) of 4,571 procedures. One hundred seventy-eight patients with similar age, procedure types, and surgical duration were matched to the SSI patients in a ratio of one case-patient to two controls. There are no significant differences in age, gender, or surgery type between case-patients and matched controls were noted. Surgery duration was significantly longer for SSI patients, despite having been matched for procedure duration. This was expected by the author because procedure duration is an important risk factor for infection.
Today, nurses are actively generating, publishing, and applying research in practice to improve client care an enhance nursing’s scientific knowledge base (2004). Research provides a solid foundation on which health care professionals base their practice. The scientific knowledge base for professional health care practice is developed through scholarly inquiry of the research literature, use of existing research findings, and the actual conduct of research ( 2004).
Healthcare professionals should care about the existence of this guidelines and quality care in medical / surgical nursing practice. First and foremost, documents that recommend practices that are based on the extant research evidence and knowledge regarding medical and surgical nursing must be implemented in health care environments. Research or evidence based practices supply a foundation for providing best practice in the prevention of medical and surgical complications and infections. Each patient expects to receive the best care, regardless of the health care setting, and as recipients of care, each individual deserves the best level of care.
Medical-surgical nurses have unique knowledge and skills that are the basis of the excellent care they provide for adults. They are supported by a well-derived knowledge base and a body of adult health nursing research. They have defined competencies in the specialty and numerous mechanisms to maintain cutting-edge knowledge in the advances of care of the adult (2005).
But although research and evidence based practices are recommended, there are many factors that hinder such. Although interest in research-based practice seemed to be present among a majority of the health care professional population, the reality of the situation suggests that it is not occurring as frequently as desired. The statistical section of a research study could be intimidating to the beginning researcher.
There are several studies focusing on the barriers to research utilization and awareness among nurses but few on attitudes toward research. Researchers noted that where ability was higher, attitudes toward research activities were more positive, and vice versa. Attitude and availability of research reports were related to research utilization.
Barriers limit the potential of identifying clinical outcomes in nursing care (2004). However, recognizing and acknowledging the existence of these barriers enable to implement change in practice in a timelier manner.
Integrating the findings of research to improve clinical practice should be a vision for most health care professionals - the nurses, who form the largest proportion of care providers at the bedside. There is a need to search for the missing link between the dissemination and implementation of research findings for evidence-based practice among nurses (2003).
The gap between research and its translation to practice in the healthcare arena became a focus for policy discussion in some healthcare organizations in the last decade. Studies have continued to reveal that the gap between research and practice seems to be most obvious in the nursing profession. It is disheartening, however, to note that regardless of the millions of dollars spent on funding clinical research, the integration of the findings into practice has been relatively slow among nurses (2003).
If nurses are to use research, they must first learn to conduct a critical appraisal of research reports published in the literature. A research critique enables the nurse as a research consumer to evaluate the scientific merit of the study and decide how the results may be useful in practice. Critiquing involves intensive scrutiny of a study, including its strengths and weaknesses, statistical and clinical significance, and the generalizability of results (2004).
By critiquing the two research articles, I have learned that the use of research has further improved the quality of care that nurses and other health care professionals offer to the patients. Other than that, by critiquing the research articles, I have used critical thinking skills which are essential in the nursing profession.
Nursing professional development is a very important aspect of the nursing profession. It is a lifelong process and it does not stop once nurses get a job. There should be active participation by nurses in learning activities that assist in developing and maintaining their competence, enhance their professional practice, enhance the quality of patient care that they can offer, and support achievement of their career goals.
Evidence-based practice move nursing professionals towards providing the best care for their clients. This is not only true for the nurses but for other health care professionals as well who are in the front line of providing care to individuals. What is best for the patient more often is best for the health care practitioners and the clinical setting.
Each of the nurses and health care professionals alike has a responsibility to know and use the latest research related to their respective clinical practice. Surgical and medical nurses should see to it that they are up-to-date with the current research findings in their field. They can do this by reading research journals or actively participate in research studies. Evidence-based practice synthesize research findings, make recommendations, and ultimately be able to come up with better quality of patient care. Every patient deserves best practice regardless of the practice setting and every nurse has the responsibility to know the best practice for the clients under his or her care.