Example of Systematic Review for an Adult nursing research paper

 

Example of an Introduction to the assignment:

Nursing research is an analytical process using disciplined methods to answer questions concerning nursing practice, the ultimate goal being an expansion in knowledge (Polit and Beck, 2008). Research is an important part of nursing as it provides the nurse with an evidence base for their clinical practice, ensuring patients are provided the safest and most effective care. Black et al. (2015) stated that nurses practicing in an evidence based manner improves the outcomes for patients. Evidence based practice (EBP) is a term that is recognised throughout the nursing profession and the Nursing and Midwifery Cuncil (2015) states that nurses must practice in accordance with the best available evidence to them in order to provide safe and effective care. It has been defined as, “a problem-solving approach to clinical care that incorporates the conscientious use of current best practice from well- designed studies, a clinician’s expertise, and patient values and preferences.” (Fineout- Overholt et al. 2005 p.335). Hoffmann et al. (2013) claimed that the purpose of EBP is to assist in clinical decision making through integrating information. EBP begins with questioning current practice and concludes with the application of the findings into the clinical setting.

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This assignment will identify a gap in current nursing practice through the development of a question using the PICO (Patient, Intervention, Comparison, Outcome) framework. A search strategy will be conducted in order to find research papers related to the question, followed by application of the critical appraisal skills programme tool (CASP, 2013) which will be used to critically appraise the chosen papers. An evaluation of the findings will be undertaken in order to identify some recommendations for best practice, and to establish how they can be put into practice. Possible difficulties and barriers that may prevent implementation of best practice will also be discussed.

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Example of the justification of choice of topic, and search strategy: 

The topic of this essay is the use of high-flow nasal cannulation (HFNC). There are some preliminary studies that show the potential benefits of this method, such as Parke et al (2011) which concluded that “[Nasel high-flow] oxygen therapy may be more effective than [high-flow face masks] in treating mild to moderate hypoxemic respiratory failure.” and Wagstaff et al (2017) which has similar reports. However, despite these studies, HFNC has not fully come into mainstream practice in the instance of a deteriorating adult patient in the NHS. A research question will be formulated in order to discover if nursing practice should be changed based on the evidence that is discovered. The research question for this essay is: “What effect does high-flow nasal cannulation have on the holistic care of an adult patient with acute respiratory problems, when compared to other methods of oxygen delivery?”

A search was carried out using the online databases, CINHAL, MEDLINE, Cochrane and the British Nursing Index. The search strategy implemented the Boolean operator ‘OR’ for keywords describing the intervention as advised by Fink (2014). This included the phrases “high flow nasal oxygen” OR “high flow nasal cannulation”. This search was expanded to cover different descriptions of the same treatment, using keywords like “heated” and “humidified” and the OR logic was also used to search for potential brand names like “Optiflow”. The Boolean operator ‘AND’ was used to refine the search to the chosen area, of patients with respiratory failure or those that are postextubation. The search was also restricted to articles published from 2012 or later. Plenty of articles were found within this range which ensures that some of the most recent technology is being tested and that the research is built on top of previous works. The most recent study is brand new, published in May 2017 (Fernandez, 2017).

There were 194 results, and 158 once duplicates were removed. Articles were excluded based on the title and abstract in order to ensure that the data was relevant to nursing practice in this research topic. According to the PICO derived research question, the criteria was that they compared HFNC to usual oxygen delivery methods. They must also involve adult patients in standard care pathways such as Acute Respiratory Failure and postextubation. This phase removed 116 articles, leaving 42. Finally, a consideration of the full text and results excluded articles that weren’t in the form of a randomised control trial with extractable data. This phase removed 31 articles, leaving 11.

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Example of Appraisal and synthesis of identified research evidence and findings

 

(The chosen question is, ‘What is the best evidence practice in providing artificial hydration to terminally ill patients with advanced cancer?’)

The first paper, an observational cohort study, was carried out in Sweden by Fritzson et al. (2013). According to Andermann (2013) a cohort study is placed at level 4 in the hierarchy of evidence. The aim of the study was to determine whether or not dying patients receiving parental fluids (PF) suffer more or less symptoms than patients who did not receive PF. These symptoms included presence of dyspnoea, respiratory secretions, anxiety, nausea and confusion. 530 patients were reported to have died expectedly between 1 January 2011 and 30 June 2012. 280 patients were identified by stratified randomisation, within this 140 cases were registered to have received PF and 140 had not. Patients were excluded if they received sedation during the last 24 hours of life or if they had a length of stay of less than 24 hours. Information was obtained through their medical notes where the remaining 251 patients were then divided into 4 sub-groups of those which received PF during the last 24 hours and 7 days of life and those who did not.

The results of the study showed that there is an association between PF and documented dyspnoea which Oneschuk et al. (2012) described as an uncomfortable awareness of breathing. 51% of patients receiving PF during the last 24 hours of life presented with dyspnoea compared with 22% who did not receive PF. When examining the difference between respiratory secretions for patients receiving PF during the last 24 hours of life the difference is 49% who did but 44% developed the symptom and were not receiving PF. Contrasting this with the results of patients who received PF during the last 7 days of life this difference widens with 50% experiencing respiratory secretions and 33% who did not. None of the analysed symptoms appear to be significantly higher in the non-PF groups leading to the argument that providing PF during the last days of life may not be of benefit to patients.

The internal validity of this paper can be questioned as it is a retrospective study involving a cohort selected from the past and the authors have measured the subsequent outcomes.

The disadvantage of this is that there is little control over the nature of the sample selection and design, or the nature of the measurements (Chiappelli, 2014). The measurements of this paper were the symptoms experienced by the patients. As this was obtained from medical data there is a share of subjectivity as it was down to the staff members to decide whether to document a symptom or not. Therefore, the results were dependent on the correctness of documentation, effecting the generalisability of the study. However, the authors state that

due to this study being retrospective, no staff were aware of the purpose of this study, consequently reducing any potential bias. The findings highlight that whether a dying patient should receive PF is a complex issue and one which can only be made following careful assessment. The authors express the need for more research, stating that randomised controlled trials are the preferred method of data collection.

Next, Bruera et al. (2013) carried out a placebo controlled randomised trial (RCT) in America in order to determine the effect of hydration on symptoms associated with dehydration.

According to Andermann (2013) RCT’s are placed at level 2 on the hierarchy of evidence due to their shield against bias as a result of known or unknown factors. Eligible patients were recruited from 2007-2011 and exclusion criteria consisted of severe hydration, identified as low blood pressure or a decreased level of consciousness. 129 patients from six hospices were randomly assigned to receive parental hydration (PH) of either 1L normal saline (n=63) per day over four hours or the placebo (n=66) of 100mls per day over four hours. Changes were noted between day 4 and baseline and day 7 and baseline. Blinding was ensured by having a separate infusion nurse to the one carrying out the research.

Blinding was further assured by the use of identical backpacks carrying the same weight of 900g. The rate of the infusion pump was covered with tape. Monsen and Van Horn (2007) declared that the placebo treatment must be identical to the experimental treatment in appearance and administration.

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The findings of this trial showed that PH at 1L per day was not superior to the placebo of 100ml per day in improving symptoms of dehydration. 56% of the PH group were reported to have felt better compared with 54% who received the placebo. Only 3% of the placebo group reported to have felt worse after comparison with their baseline and day 4, increasing to 10% on day 7. A trend was observed for less deterioration of the patient’s mental status in the hydration group. However, patients with delirium were excluded from this study and it could be argued that these patients would have benefitted the most. High doses of strong opioids such as oral morphine are used as pain relief for patients with advanced cancer and Sykes et al. (2008) advocated for the use of hydration alongside opioid management in order to improve opioid-induced delirium. Internal validity was affected in this trial as originally the trial was set to use 150 patients however only 129 patients were used due to funding issues. The generalisability of this study has also been effected as oral intake was not accounted for therefore patients could have had a higher fluid intake than their allocated amount, thus effecting the results.

Next, a prospective observational study was conducted by Nakajima et al. (2012) to explore the influence of hydration on terminally ill cancer patients in the last three weeks of life.

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Andermann (2013) placed this at level 4 on the hierarchy of evidence. A total of 75 terminally ill patients were classified into two groups: the hydration group (n=32) received 1L or more of artificial hydration (AH) over three weeks and the non-hydration group (n=43). Patients included in the trial had an estimate life expectancy of less than 3 months. It was decided that physicians would assess and document signs of dehydration and fluid retention every week as opposed to every day due to the burden this would place on patients and their relatives. Physicians were not blinded to the treatment and agreements were made between the responsible physician and nurse to avoid bias. The medical team assessed for dehydration through moisture on the mucus membranes, dry skin and sunken eyes. The severity of peripheral oedema, pleural effusion, ascites and respiratory secretions were also assessed and documented.

The results revealed a statistical difference between dehydration symptoms with 13% in the hydration group compared with 35% in non-hydration. This contradicts the RCT carried out by Bruera et al. (2013) who found that the same infusion of 1L parental hydration per day did not improve symptoms associated with dehydration. The presence of oedema was significantly different between the two groups with the group receiving AH, 57% developed oedema compared with 33% in the non-hydrated patients. Respiratory secretions were also higher in the hydrated group (41%) in comparison with non-hydrated (19%). This is similar to the findings of Fritzson et al. (2013) with 50% of participants also reporting an increase in respiratory secretions. There was minimal statistical difference between the two groups for pleural effusion and agitation and delirium.

The internal validity of this study is called to question as the primary physicians were not blinded to the treatment. Awareness of the allocation may influence data recording practices due to the expectation that treatment, in this case hydration, will produce certain side effects (Peat et al. 2009). The generalisability of this study is limited as cancer patients with abdominal malignancies only were used and this study could have been more relatable had patients with different cancers been used. This study does suggest the need for further research on the overall effect of patients’ subjective well-being. It is important to include patient’s in this decision and to have the knowledge of how having hydration, or not, made them feel.

The following study examined what influences patient’s decisions on AH at the end of life. The study was carried out in the United Kingdom by Malia and Bennett (2011). This form of study is placed at level 6 on the hierarchy of evidence due to its qualitative nature (Andermann, 2013). The study wanted to identify factors that patients believe are most important to them when regarding artificial hydration (AH) at the end of life. 20 patients with

 

advanced diseases were given a set of 37 statements and they divided them into piles according to whether they agreed, disagreed or felt neutral about each statement. The study took place over a 10-week period, 17 participants completed the Q-sort process, 3 withdrew due to drowsiness and fatigue. Of the 20 participants that started, 17 had advanced cancer.

The findings revealed that 6 of the patients believed in quantity of life at all costs and felt that the provision of AH would prolong their life. These patients were not influenced by their family’s opinions and they would rather have the medical staff make the decision in the provision of AH. 5 of the patients did not wish to be a part of the decision making and would rather medical staff made the decision on their behalf. These patients wanted AH to be discussed with them but wished for AH only if it was to improve quality of life. The remaining participants did not wish for medical staff to make decisions on their behalf and wished AH to be discussed with them in advance at a time when they were fit enough to be involved in the decision making.

This study was only undertaken in one hospice in the UK and most patients were of white British ethnicity. Generalisability is difficult to ascertain and would be improved with patients from a variety of ethnical backgrounds. Only a small sample size was used which also affects generalisability. Roe and Webb (2008) argued that research samples need to be of adequate size in order to draw sound interpretations of a population so that the results are generalisable. What the study does show is the importance of communication and education when it comes to discussing AH with patients and their families. Medical staff must draw on evidence based practice when conversing with patients to ensure that they have all the information about AH before making a decision.

The following qualitative study focused on nurse’s perception of the provision and non- provision of hydration during end of life in Australia. This study is also placed at level 6 on the hierarchy of evidence (Andermann, 2013). Higgins et al. (2013) conducted three focus group meetings with ten nurses working in an acute care setting from medical, oncology and haematology. Four themes were developed during the interviews; limited involvement in decision making, comfort vs. discomfort, uncertainty and the comfort of withdrawing treatment. Participants stated that doctors usually made the decision regarding end of life care and some did not feel the need to be involved in the discussion. Nurses acknowledged that if they had a good rapport with the patient and their family they felt comfortable to discuss end of life issues. When discussing withholding AH nurses felt that absence of IV lines creates a comfort space for the patient. This is similar to Malia and Beck (2011) who stated that AH may be withheld at the end of life as it is perceived as a burden on patients and their families. The participants believed that IV fluids helped family members come to

terms with the situation and if patients developed pulmonary oedema from the fluids, medication could be given.

The data from the interviews were analysed thematically with significant statements coded under relevant themed headings (Polit and Beck, 2005). This enhances the generalisability as feelings and experiences were captured using verbatim quotes (Parahoo, 2014).

However, the sample size, as discussed in the previous study, was small which may hamper the generalisability. The authors acknowledged this limitation and admitted that they were unable to recruit more participants. Lichtman (2013) argued that focus groups with less than six participants may result in insufficient interaction which could affect the results. Individuals who share a common experience will stimulate each other to talk and with a smaller number of participants, differing views might not be shared.

In answering the question, ‘what is the best evidence practice in providing artificial hydration to terminally ill patients with advanced cancer’, there was no clear cut evidence on whether AH should be provided to patients, and further research needs to be undertaken to determine the effect on overall patient well-being, particularly in the United Kingdom. Bruera et al. (2013) and Nakajima’s et al. (2012) studies alone showed differing results when assessing a patient’s dehydration status following 1L of parental fluid per day. However, through analysis of the chosen articles, themes emerged surrounding the provision or non- provision of artificial hydration which can be applied to practice. The themes comfort vs. discomfort, knowledge and education, communication and treating patients on an individual basis were developed.

 

Example of Recommendations, Difficulties in translating evidence into best practice, and Conclusions.

(The chosen question is, ‘How can palliative care and end of life care be improved for the homeless population?’).

All five themes discussed have given an insight into how palliative and end of life care can be improved for the homeless population. Some may be easier to implement in practice than others. Within nursing, we are bound by our code of conduct (NMC,2015) and have a duty of care for all, regardless of status, and must aim to promote trust. When it comes to improving the relationships between homeless patients and healthcare professionals, nurses are at the forefront of care and can be the profession that begins to break these barriers to effective care. Nurses can also play a part in improving knowledge and training within the healthcare profession regarding the complex care needs faced by the homeless population. As the code

of conduct states, in order to practice effectively nurses should maintain essential knowledge and skills, sharing experiences and striving to improve practice (NMC, 2015). Effective communication skills can begin to promote collaborative, inter-professional working between agencies to help support homeless persons effectively at the end of their life.

Other suggested interventions may be more difficult to implement. All discussed papers highlighted the urgent need for greater and more robust research to help find best practices in achieving better care for homeless individuals requiring palliative input. Moving palliative services into a hostel environment and introducing harm-free strategies are much bigger interventions that will require a lot more research to prove effectiveness and aid implementation, and some barriers, such as stigma and individual attitudes are a lot harder to overcome in practice (Parahoo, 2014).

Implementing evidence into nursing practice has its own barriers. Change is a concept that is often seen within healthcare as a negative, relinquishing old practices for the ‘unknown’ (Ellis, 2015). Ellis (2015) also argues that change and transitioning can cause emotional and psychological responses. This can cause a resistance to change and, consequently, implementing evidence into practice can prove difficult. Gerrish (2015) suggests the need to overcome these barriers before implementing change. One such method to achieve this to implement a change model, such as Kotter’s, to help guide the process of change and helping nurses to see the benefits of change before application Gerrish, 2015).

Palliative and end of life care is a concept that should not be reserved just for a select few. It is a service that should be available at the point of need for all, including marginalised populations, such as the homeless (DOH, 2009). The limited available research shows that there is a need for healthcare professionals, including nurses, to implement ways to improve fair access and adequate end of life care for the homeless population. Nursing research is vital in attaining an evidence-base to improve nursing practice and achieve a consistent high level of care in practice.

Additional advice

Please note that, for the last quarter of the assignment (roughly), you are encouraged to use a framework such as PARIHS to explore issues of implementation.

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