Through the Nursing and Midwifery Council (NMC) code of professional conduct (NMC, 2004) nurses supply high standards of care to patients and clients. One code nurses adhere to is clause 6 which pronounces nurses must maintain professional knowledge and competence, have a responsibility to deliver care based on current evidence, best practice and validated research (NMC, 2004). Validated research involves critiquing and acquiring the skills of synthesis and critical analysis, this enables nurses to distinguish the relationship between theory and practice in nursing (Hendry & Farley 1998).
This assignment will critique the research paper “Patients’ case – notes: look but don’t touch” written by Bebbington, Parkin, James, Chichester and Kubiak (2003) (Appendix 1) using Benton and Comack’s (2000) framework (Appendix 2). This was selected because of the publicity that surrounds hospital acquired infection (Barrett, 2005).
TitleThe framework suggests the title should be concise, informative, clearly specify the content and indicate the research approach. The title of the paper is concise; however it gives no information of content or research subject.
Moreover the research approach is unidentified consequently the reader is unsure what kind of research has been performed, perhaps an alternate title could have been “Case notes, do they pass infection: A quantitative study”. This may indicate that the authors have not used a standard format which Benton (2000) states reports should follow; nevertheless the title captured the imagination of the reader and warrants further reading.
AuthorsAccording to the framework, the author(s) should possess appropriate academic and professional qualifications and experience; this according to Carter & Porter (2000) establishes integrity. The qualifications and experiences of the authors are not documented. This could indicate the authors have no relevant qualifications or experiences in this field. However further reading identifies where the authors work which could be relevant to their subject, although there is no indication of their occupation. However the reader performed an online search and found the authors have had previous papers published suggesting research experience, which gives confidence in their abilities.
AbstractThe framework states an abstract should be included, should identify the research problem, state the hypotheses, outline the methodology, give details of the sample subjects and report major findings. The abstract is included and is outlined which makes it distinctive and captures the attention. Burns and Grove (2003) states this helps to influence the reader to read the remainder of the report. Additionally a distinctive abstract is beneficial for a rapid summary (Parahoo, 1997). The search question is included and is noticed immediately on the first line. Also incorporated are the methodology, sample subjects and major findings. Yet they do not state the hypothesis. The abstract is clear and precise which gives the reader belief in the capability of the researches.
IntroductionThe framework indicates the introduction should clearly identify the problem, include a rationale and state any limitations. The problem is identifiable and the rational is included, nevertheless the reader would have liked to see these presented earlier in the introduction. Dempsey & Dempsey (2000) concur and states the research problem should be identified early and Polit & Beck (2004) add that readers profit from learning the problem immediately. The authors did not indicate any limitations which could suggest inexperience or could question their professional responsibility (Polit & Beck, 2004), however the reader perceives a limitation as being only one study of hospital inpatients notes have been reported thus only one study to compare findings.
Literature reviewThe, framework indicates the literature review should be current, identify the underlying theoretical framework, produce a balanced evaluation of material and to look for absent references. The authors’ literature reviews produce twelve references which range from 1967 to 2002, four were classed as outdated (Burns & Grove, 2003) and nine were classed current. Although the reference from 1967 is outdated it is reasonable the authors included it since it is the only research paper found on their particular subject. However this causes the reader to speculate the reason this subject was studied. Because the authors and the reader did not discover any other literature concerned with the subject this, could indicate that the authors’ literature search was comprehensive which could prove validity of the study. However it is wondered if other researches believed case notes were irrelevant compared to other objects in the hospital or if this is ground breaking research. Improvement could have been made by the authors including the search engines they had used as this would allow replication and evaluation of the paper.
The literature the authors cited used a quantitative approach as did the authors themselves thus identifying and employing the underlying theoretical framework and giving credibility to the paper. Cutlcliff & Ward (2003) suggests the literature review guides the researcher in discussing the results of the study in terms of agreement or non agreement with other studies, however there is no evidence of evaluation of material that supports or challenges the position being proposed .This suggests the researches appear to have only reported the finding of other studies and not examined the material, which, Peat (2001) states is essential for making decisions about whether or not to change practice on the basis of published report.
The outcome is a research paper without critical analysis which Beyea & Nicoll (1998) states is central to the delivery of evidence based patient care. Following duplication of the researches literature search using their keywords the reader could find no important references omitted which leads to the belief that they performed the search methodically. However it was discovered that one important reference in the text (Semmelweis) had been omitted in the reference list. This leads the reader to question if other things may also have been omitted resulting in an unsound paper.
The hypothesisThe framework asks if the hypothesis is capable of testing and if the hypothesis is unambiguous. There is no hypothesis in the paper only a research question. Cormack (2000) states that hypothesis can only be stated for studies which predict a relationship between two variables. Polic & Becks (2004) concur and believe hypotheses are predictions of expected outcomes. Since the authors do not state an expectation of the outcome they did not need to incorporate a hypothesis. This could suggest an understanding of research giving the reader faith in their capabilities.
Operational definitionsThe framework suggests the terms used in the research problem should be clearly defined. The terms that the author’s employ are clearly defined and can be found effortlessly. Nevertheless they are very limited in respect of the paper and the reader speculated how they found eleven of the twelve references using the keywords since they related to other objects. This could indicate that they decided upon key words prior to performing the literature research, thus limiting their search (Tarling & Crofts, 2002) which questions the validity of the paper. The reader searched Blackwell Synergy using own keywords such as hospital equipment, contamination and bacteria. Many more articles were discovered indicating the authors did not perform an adequate literature search.
MethodologyThe framework indicates that the methodology should clearly state the research approach, appropriate to the research problem and if strengths and weaknesses are noted. Although the authors do not identify the study as quantitative the reader understands that it is since it uses findings that can be measured and deals with quantity of results as opposed to interpretation (Munhall, 2001). Additionally the reader believed it is a deductive study since the authors looked at cross infection and objects in the hospital setting and narrowed it down to cross infection and case notes. No strengths or weaknesses were acknowledged, which, Byrne (1998) states is needed so the reader can ascertain if the research is valid.
Furthermore the authors state they sampled the spine of the case notes because this is where most hand contact occurs while reading them, however perhaps it could have been suggested sampling the inside since in, my experience, this is where most hand contact occurs. The researches also stated they did not wash their hands until the last set of notes had been tested because it simulates the typical daily handling of notes by HCW’s. However the Department of health (2000) state before and after patient contact hands should be washed, consequently the validity of their approach is questionable. Finally the reader would have liked the researches to explain why the notes were incubated at 37 degrees since an assumption could be made that they are simulating a hospital environment.
SubjectsThe framework suggests the subjects should be clearly identified in the title abstract and methodology. In this paper there are no subjects only case notes. However the reader would have liked there to be a rationale why the authors chose case notes as this according Polit & Beck (2004) gives the reader an understanding of the strengths and weaknesses of the sampling plan.
Sample selectionThe framework suggests the selection approach is congruent to the methodology, clearly stated and if sample size is clearly stated. It appears that convenience sampling was utilised though this is not clear; Burns & Grove (2003) suggest this approach should be avoided however as it provides the opportunity for bias. Since the sample selection method is unclear, it may have been inappropriate, denoting further flaws which affect the remainder of the paper. The sample size is clearly stated however but should have been included in the methodology giving the reader a reference when reading it.
Data collectionThe framework asks if the data collection procedures are adequately described. The authors describe the data collection procedure as recorded and analysed. This gives the reader no understanding of how the data was collected, who document it, who interpreted it and where it was stored. This could have implications on the results since there may have been weaknesses in these areas such as the reliability of the collection tools, if the people who recorded and analysis it had training and if there could there be any contamination to the notes.
Ethical considerationsThe framework asks if the study involves humans has the study received ethics committee approval, if informed consent was sought, if confidentiality was assured and anonymity guaranteed. Although the study does not directly involve human subject’s research involving personal information relating to human subjects requires the approval of the local ethics committee. (Cormack, 2000)(Royal college of physicians, 1998) The authors make no reference these three ethical codes so it is unknown if the patients agreed to their case notes being tested. This implies no consideration of ethical issues from the authors and questions what other considerations they have overlooked.
ResultsAccording to the framework the results should be clearly presented, internally consistent, have sufficient detail to enable the reader to judge, and asks how much confidence can be placed in the finding. The results that the authors present are unclear and misleading since the first two lines state 227/228 case notes contained bacteria; however it continues to inform that most were “environmental”. The authors use a table to portray their results which Crooks & Davis (1998) suggests is all that is needed to convey information. However the table appears complex, confusing and impossible to understand; therefore the reader would question the internal consistency. In addition since the results are difficult to interpret the reader can not judge the reliability of the findings.
Data analysisThe framework states the approach should be appropriate to the type of data collected, statistical analysis should be correctly performed, should be sufficient analysis to decide whether significant differences are not caused by differences in other relevant variables and if the complete information is reported. The authors approach was appropriate to the type of data collected since no other approach would be suitable. Nevertheless the researches do not state how they analysed the statistics so the reader can not judge any limitations.
DiscussionThe framework states the discussion should be balanced, drawn on previous research, weaknesses of the study acknowledged and clinical implications discussed. The discussion is not balanced since it focus upon the findings of pathogenic bacteria on case notes and subsequently formulates assumptions about MRSA surviving on case notes without research to back this up. It vaguely draws upon the only previous research and mentions the result, which contradicts their own findings. No failings or limitations of the study or literature review are recognized implying no review or evaluation of the literature, which, according to Benton & Cormack (2000) is central to the research process. One clinical implication is discussed briefly however the reader should remember that the authors have not proved the transmission of bacteria on case notes to HCW’s hands only the potential.
ConclusionThe framework asks if the conclusions are supported by the results obtained. The conclusion the authors established was the possibility of transferring bacteria, however since the results are indecipherable it is impossible to determine if the conclusions are supported by the results.
RecommendationThe framework states the recommendations should suggest further areas for research, and identify how any weaknesses in the study design could be avoided in future research. There is no suggestion for further research; no weaknesses in the study design mentioned and no recommendations on how issues can be avoided. Therefore the reader believes this paper does not establish contamination from case notes, so is unreliable and lacks validity.
Application to practiceThe Department of Health (2005) states Clinical governance is the system through which National Health Service organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. Elcoat (2000) adds evidence-based practice and evidence-based nursing have very strong positions in the Clinical Governance agenda of quality improvement. Evidence-based practice can be defined as using contemporaneous best evidence ensuring actions are clinically appropriate cost effective and result in positive outcomes for patients (Trinder & Reynolds, 2000). Therefore every healthcare team member has to critique evidence, assess its reliability and application before combining it with their own clinical expertise (DePoy & Gitlin, 1998).
Before knowing how to critique I did not understand why nurses had to review articles and I would have taken them on face value, however since critiquing this article I have realized it is a very important part of my practice and taking articles on face value is unsafe practice. The authors discussed some important issues concerning cross infection and as a consequence I have reflected more on cross infection in my clinical area. This leads me to believe that every research paper is of value and has something to give to the reader. However the article will have little impact on my practice since the recommendation of hand washing before and after patient contact is already integrated in my nursing practice.
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