Critically reviewing research studies

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Critically reviewing research studies Zevia Schneider

Key terms

Learning outcomes

analysis understanding comprehensive understanding criteria critical analysis critical review guidelines preliminary understanding synthesis understanding

After reading this chapter, you should be able to: • identify the reasons why it is necessary to critically analyse studies • list the criteria used to review qualitative studies • list the criteria used to review quantitative studies • identify the strengths and weaknesses of a research report • discuss the implications of the findings of a research report for nursing and midwifery practice • understand why it is important for consumers of research to critically analyse studies.

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Introduction This chapter is designed to introduce you to the critical review guidelines for qualitative and quantitative studies and the stages of understanding relating to critical reading. Nurses, midwives and other health professionals have long appreciated the purpose and value of research in providing the evidence that informs practice. Evidence-informed practice is a key component contributing to patient care. Research gives us the unique opportunity of viewing health-related concepts and issues from the viewpoint of both researcher and participant. Importantly, research provides us with evidence of the effect of our interventions. The critique or critical review is the process of objectively and critically analysing a research report’s content for scientific merit and application to practice or theory. It requires some knowledge of the subject matter, knowledge of how to read critically and how to interpret appropriate criteria. It is above all a clear, stringent cognitive process requiring a basic understanding of the research process and relevant terminology. The critical review guidelines provide a structured approach with specific information to facilitate reading research articles. Two research articles, namely a qualitative approach by Elmir et al. (2010) and a quantitative design by Considine and McGillivray (2010), presented in full in this chapter, will be analysed using the critical review criteria for each approach. Criteria necessary to adequately review an article are any measures, standards, evaluation guides or questions used to judge (critique) a product or behaviour. The reader, in analysing a research report, must evaluate each step of the research process and ask questions about whether the explanation of each step of the process meets or does not meet these criteria. For instance, one objective of a literature review is to determine gaps, consistencies and inconsistencies in the literature about a subject, concept or problem. Two questions to guide the reviewer are: ‘What gaps or conflicts in knowledge about the problem are identified?’ and ‘How does this study intend to fill those gaps?’ Search strategies for accessing the relevant articles are explained in Chapter 3 (skimming and scanning), as well as a preliminary section on critically ‘skimming and scanning’ the literature to identify the main points of studies, before in-depth critical review occurs. Once articles have been selected and acquired, the process of review begins.

Critical reading Through reading, recognition and understanding of previous unfamiliar concepts and steps of the research process gradually become increasingly clearer and more accurate. This facilitates the next stage, which is to read critically. Critical reading has been described as ‘an active, intellectually engaging process in which the reader participates in an inner dialogue with the writer’ (Paul & Elder 2001). A critical reader therefore actively looks for assumptions, key concepts and ideas, reasons and justifications, supporting examples, parallel experiences, implications and consequences in the written text (Paul & Elder 2006). Critical reading involves making a judgment about the content

of an article, that is, how the evidence provided is used, argued and interpreted. A critical reading of research articles requires the reader to assess how the author’s purpose is developed and argued. Critical reading is often difficult for the beginning research consumer and may be somewhat frustrating at first (Box 15.1). To accomplish the purpose of critically reading a research study, the reader must have skilled reading, writing and reasoning abilities. These skills are experiential and cumulative — the more practice and experience, the higher the skill level. It is quite common for a research article to require several readings. At first, it is suggested that a minimum of three or four readings, with a research textbook by your side, will facilitate an

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15 • Critically reviewing research studies

Box 15.1  Highlights of critical thinking and reading strategies a) Read primary research articles from refereed journals. b) Read secondary research (critique/response/commentary) articles from refereed journals. c) Obtain primary and secondary articles (photocopy or print copies) and make notations directly on the copy. d) While reading articles: • keep a research text and a dictionary by your side • list key variables at the top of the article • highlight or underline new terms, unfamiliar vocabulary and significant sentences • look up the definitions of new terms and write them on the article copy • review old and new terms before subsequent readings • highlight or underline identified steps of the research process • identify the main idea or theme of the article — state it in your own words in one or two sentences • continue to clarify terms that may be unclear on subsequent readings • make sure you understand the main points of each reported step of the research process you identified before you critique the article. e) Determine how well the study meets the criteria: • ask fellow students to analyse the same study using the same criteria and compare results • consult faculty members about your evaluation of the study. f) Type a one-page summary and critical review of each study: • cite bibliographical information of the reference at the top of the summary according to relevant reference style (e.g. APA, Harvard, Vancouver) • briefly summarise each reported research step in your own words. • briefly describe strengths and weaknesses in your own words (bibliographical databases allow you to write a narrative for each paper reviewed).

effective review and are necessary to do the following: • identify concepts • clarify unfamiliar concepts or terms • question assumptions and rationale • determine supporting evidence (Paul & Elder 2006). No matter how difficult it may seem, read the entire article and reflect on it. Critically read for the levels of understanding described below. Most importantly, draw on previous knowledge, commonsense and the critical thinking skills you already possess. As you become more adept and skilled at critically appraising studies, the process will become more assured, natural and quicker.

• Preliminary understanding is gained through a light or skim reading; scanning is a refinement of skim reading and is useful when looking for specific information in the article. • Comprehensive understanding relates to a recognition of relationships between different parts. • Analytical understanding and reading involves breaking the content into parts to facilitate processing the information. • Synthesis understanding requires joining the parts to make a comprehensive whole.

Preliminary understanding Preliminary understanding is gained by quickly or lightly reading an article to familiarise 287

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yourself with its content and to get a general sense of the material: the title and abstract are read carefully but the content is skimmed. Skimming includes reading the introduction, major headings, one or two sentences under the heading and the summary or conclusion (see Chapter 3). Research in brief When reading the article by Hutchinson et al. (2010), it is important to know that in order to explore the nature of bullying in the Australian nursing workplace, in-depth, semi structured interviews were conducted with nurses who had experienced bullying in two Australian health services. Ethics approval was obtained. Content analysis of the interviews identified the following behaviours: personal attack, erosion of professional competence and reputation, and attack through work roles and tasks. Insight is provided into bullying behaviours and tactics, however, the subtle nature of many of the tactics make it difficult for observers and those managing these behaviours to detect hostile intent.

Comprehensive understanding: content in relation to context The purpose of comprehensive understanding is to understand the article — to see the terms in relation to the context or the parts of the study in relation to the whole article; the reader should be able to identify core concepts and themes. Reading for comprehension requires an understanding of the terminology and being able to state the main idea in your own words. Research in brief Jones et al. (2011) evaluated a curriculum drive to incorporate an in-depth post-graduate critical appraisal skills program in the School of Nursing, Midwifery and Indigenous Health at the University of Wollongong. Face-to-face and online teaching modules used structured analysis tools for critically appraising and debating the study design of research literature. Pre- and post-tests of the students’ performance demonstrated notable improvement in their critical appraisal skills.

Analysis understanding: breaking into parts The purpose of reading for analysis is to break the content into parts in order to understand each aspect of the study and, ultimately, a deeper understanding of the content. Some of the questions to ask during analysis of the research article include: • Can the main idea or theme of this article be captured in one or two sentences? • How are the major parts of this article organised in relation to the research process? • What is the purpose of this article? • How was this study carried out? Can it be explained step by step? • What are the main conclusions of the author(s)? • Is each section understood and can it be summarised or paraphrased into your own words? In a sense you are determining how the steps of the research process are presented or organised in the article and what the content related to each step is all about. You are beginning the process of critically analysing the merit of the study. It may require some knowledge of the subject matter, but the most important consideration is to read critically.

Synthesis understanding Synthesis involves combining parts into a complex whole. The purpose of reading for synthesis is to make sense of the whole. It is during this final step that you decide how well the study meets the criteria, its contribution to nursing and/or midwifery and how useful it is in practice. Reading for synthesis is facilitated by the following strategies: • reviewing your notes on the article on how each step of the research process measures up against the established criteria • briefly summarising the study in your own words: the components of the study and the overall strengths and weaknesses • limiting your summary to one page, including the citation at the top of the page in the specified reference style, and stapling the summary to the photocopied article.

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15 • Critically reviewing research studies

  Points to ponder Read whole sentences to gain an overall understanding of the idea/content before concentrating on single words. Think about the concepts in the text: how are they defined and used? Your ability to summarise text content indicates understanding of the concepts.

personal and birth data, and data on domestic violence, social support and maternal role development. Following bivariate analysis, social support was shown to be the most important factor in maternal role development. Health professionals need to understand the significance of role development to assist women in their transition to motherhood. The requirement that all health professionals engage in critical reading to enhance their understanding of the research process, and the format of research articles, becomes clear.

Consumer perspective Nurses, midwives and other health professionals recognise the importance of using research on which to base their practice. Evidence-informed practice is a key factor in contributing to accountability and benchmarking by providing answers and evidence to questions about current and traditional practices and processes. Furthermore, evidence-based practice should be viewed as a quality improvement process (Pravikoff et al. 2005). Not all nurses and midwives are committed to conducting research and some may think that they therefore do not have to read and analyse the literature, but unless they understand and evaluate the literature and the challenges and rewards that evidence-based research can offer, they will lack credibility in motivating for practice change. Being able to critically read and understand research articles is different from conducting research and remains crucial to the improvement of patient care, management and administration. DiCenso et al. (2004) define evidence-based nursing as ‘the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences and values, in the context of available resources’. The same concepts and contexts apply to midwifery-orientated evidence-based practice (evidence-based midwifery) (Pairman et al. 2010 p 85). Emmanuel et al. (2008) conducted a prospective study exploring maternal role development among Australian women following childbirth at three antenatal clinics in Queensland. Ethics approval was obtained. A total of 605 women completed a survey at 36 weeks gestation and 12 weeks postpartum. A self-report questionnaire was used to collect

Research in brief The purpose of the article by Teate et al. (2011) was to present the findings of the Australian CenteringPregnancy Pilot Study. The experiences of the women who participated in the CenteringPregnancy program are described. The aim of the pilot study was to determine whether it would be feasible to implement this model, which combines assessment, education and support in group settings, as a model of antenatal care in Australia.

Critical appraisal of a corpus of research literature Before moving on to the next sections that critically appraise and evaluate single studies from each of the main research paradigms, it is important to consider that this can be a limited exercise even if done very well. For most readers who have searched and reviewed the research literature previously, they will generally have collected a critical mass (corpus or body) of research literature studies (see Chapter 3). This will especially be the case for academic assignments and, as indicated previously, for evidence-based and practice change tasks. In essence, practice would not be changed on the basis of a single critically reviewed study, and good grades for assignments will only be obtained if a wide range of comparative research studies were included in the review. Spenceley et al. (2008) noted that when ‘one-off’ studies are reviewed it leads to a predominantly descriptive level of analysis. O’Leary and 289

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Mhaolrunaigh (2011) share this view. For most practice-change and assignment tasks we are usually considering clinical issues and topics that are already well researched. Through systematic searches (see Chapter 3), many research studies can usually be found. What we often find too, as would be expected, is that many of the studies are of a similar nature and methodology. Systematic reviews, meta-syntheses and metaanalyses utilise highly structured and systematic research approaches to do a similar thing — they tend to compare and contrast ‘like with like’. Where this type of process occurs, it is possible to conduct an even more critical appraisal. So, for instance, when exploring a clinical topic, it is important to evaluate the quality and credibility of gathered research studies (comparing like with like). A hypothetical example will illustrate the point. For example, Smith and Jones (2010) had a population size of 200 participants that excluded females. In comparison, the study by Jones and Smith (2011) utilised 500 participants and included both females and males. The study by Smith et al. (2009) had a population size between the two other studies but excluded participants over the age of 50. Other factors, such as statistical process, suggest that the study by Jones and Smith (2011) provided the most compelling evidence for the generalisation of findings. Sometimes, it is not always easy to find comparative studies, especially from a methodological perspective. For instance, a search may yield one randomised controlled trial (RCT), one cross-sectional survey and one qualitative descriptive study. While it would not be recommended to try to compare the methods used for these studies, as they are designed to do completely different things, one could still compare the contexts and the concepts of the clinical issue or topic overall. As Whittemore (2005 p 61) states of gathered primary literature, ‘The analysis stage should be explicit, with conclusions demonstrating thoughtful consideration of all studies’. For convenience and chapter space, the following critical reviews do critically appraise single studies and do so by drawing out the main points of the two selected studies in isolation of other comparable studies.

  Point to ponder Imagine that you had just critically appraised a single study that you thought presented an excellent finding. Would you change your or other colleagues’ practice on the basis of it? If you answer ‘yes’, could this be a case of ‘putting all your eggs in one basket’?

Research in brief A self-administered questionnaire, the Public Health Nurse Professional Competency Scale, was posted to 1534 full-time public health nurses (response rate 67.3%) in Taiwan for the purpose of developing an instrument to measure public health nurse competencies and to test its psychometric properties (Lin et al. 2010). Ethics approval was obtained. The scale had strong content validity and good test-retest reliability. Three factors were identified following factor analysis: basic care, community health management, and combined teaching and self-development competencies. The scale can be used to assess the competencies of Public Health Nurses in Taiwan and improve the quality of clinical services provided.

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Tutorial Trigger Describe the levels or stages of understandings involved in reading critically.

Critical review of qualitative research studies A careful reading of the qualitative approaches in Chapters 6, 7 and 8 will highlight issues of data collection, analysis, interpretation and rigour in these approaches. In general, a critical review of qualitative research studies requires an examination of the: • title and abstract • identification of the phenomenon • structuring of the study • research question and design

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15 • Critically reviewing research studies

• participants • data analyses • description of the findings • researcher’s perspective. Notwithstanding the difference in terminology, qualitative studies require a different kind of critical analysis from quantitative designs. Suggestions for critique appear in Box 15.2.

  Points to ponder While qualitative research findings may be specific to particular patients, the information contributes to enhancing our understanding of the phenomenon and to nursing’s and midwifery’s knowledge base. Qualitative research findings can be used to generate nursing and midwifery interventions; interventions can then be tested in practice.

Evidence-based practice tip In-depth interviewing is a qualitative datagathering technique that permits exploration of a person’s feelings, ideas and thoughts.

Introduction to critical reviews The article ‘Against all odds: Australian women’s experiences of recovery from breast cancer’ (Elmir et al. 2010) is critically reviewed for its design and contribution to healthcare and nursing knowledge. The critical review guidelines appear in Box 15.2. Title and abstract

The title identified the participants, their nationality (Australian women) and their physical condition (recovering from breast cancer). The abstract provided the motivation for the study; that is, to generate insight into how younger women experienced their recovery from breast-cancer-related breast surgery, and also to contribute to the knowledge base in this field. No objective was stated. Specified were the background, the participants, design, method of data collection and data analysis. Findings and their relevance to clinical practice were stated.

Identifying the phenomenon/phenomena of interest

The phenomenon of interest is the lived experience of younger Australian women with cancer who were recovering from breast-cancerrelated surgery. This topic is relevant to all areas of nursing, midwifery and women’s health. Structuring the study

The participants are living the phenomenon of interest; recovering from breast-cancer-related surgery. Related literature is used to provide background and motivation for the study, that is, the perceived lack of studies specifically dedicated to women younger than 50 years, thus filling a gap in the literature. The theoretical framework, a phenomenological approach that focuses on lived experience, is clearly stated and fits the research question. Face-to-face interviews were used to collect the data. Data analysis was clearly specified. Research question and design

Motivation for the study was explicitly stated, that is, little literature and lack of information on the experiences of women younger than 50 years recovering from breast-cancer-related breast surgery. In-depth interviews were appropriate for exploring the experiences of the women and reflect the framework of the study, a phenomenological approach. Data analysis was described using Van Manen’s (1990) three approaches: holistic, line by line and selective. Four major themes and sub-themes were identified following the thematic analysis. Participants

Women meeting the inclusion criteria — that is, diagnosed with breast cancer followed by surgery, under 50 years of age and able to converse in English — were asked to make contact by email or phone to arrange a meeting. They were recruited through advertisements in local and metropolitan papers, information posters and an announcement on a local radio station. Pseudonyms were used to identify the women and assure confidentiality and anonymity. The women were given an opportunity to ask questions, a participant information sheet was provided and informed consent obtained. Measures taken by the researchers to address ethical issues were: interviews were conducted in 291

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Box 15.2  Critical review guidelines for qualitative studies Title and abstract

Participants

a) Is the title of the research paper concise, clear and congruent with the text?

a) How were the participants and setting selected (e.g. sampling strategies)?

b) Were the aims and/or objectives stated? What are they?

b) How was confidentiality of the participants assured?

c) Did the abstract contain sufficient information about the stages of the research process (e.g. aims, research approach, participants, data collection, data analysis, findings)?

c) How was the anonymity of participants assured?

Identifying the phenomenon/phenomena of interest a) Is the phenomenon focused on human experience within a natural setting? b) Is the phenomenon relevant to nursing, midwifery and/or health? Structuring the study a) Is it clear that the selected participants are living the phenomenon of interest? b) How is published literature used in the study? c) Does the question identify the context (participant/group/place) of the method to be followed?

d) What ethical issues were identified in the study? e) How were the ethical issues addressed? Data analyses a) How were the data analysed? b) Is the analysis technique congruent with the research question? c) Is there evidence that the researcher’s interpretation captured the participants’ meaning? d) Did the researcher say how the criteria for judging the scientific rigour of the study were maintained in terms of credibility, auditability, fittingness and confirmability? Describing the findings

d) Is the theoretical framework clearly stated?

a) Does the researcher demonstrate to the reader the method (e.g. audit trail) by which the data were analysed?

e) Does the theoretical framework fit the research question?

b) Does the researcher indicate how the findings are related to theory?

f) Is the method of data collection and analysis clearly specified?

c) Is there a link between the findings to existing theory or literature, or is a new theory generated?

g) Does the qualitative method of data collection chosen fit the research question (e.g. grounded theory, ethnography)? h) Are the limitations of the study stated? Research question and design a) Was the research question determined by the need for the study? How was this determination made? b) Are the data collection strategies appropriate for the research question?

Researcher’s perspective a) Are the biases of the researcher reported (e.g. researcher/participant expectations, researcher bias and power imbalance)? b) Are the limitations of the study acknowledged? c) Are recommendations suggested for further research? d) Are implications for healthcare mentioned?

c) Do the data collection strategies reflect the purpose and theoretical framework of the study (e.g. in-depth interviewing, focus groups)? d) Can the data analysis strategy be identified and logically followed?

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15 • Critically reviewing research studies

a private room at a convenient time for participants, participants were informed that the interview would be audio-taped, they could withdraw from the interview at any stage, they had the right to refuse to answer any questions, and anonymity was assured through the use of pseudonyms. Psychological support was made available to the women. Data analyses

Data were audio-taped, transcribed and thematically analysed. Transcripts were read several times while listening to the tapes to identify gaps in transcribing the data and to become more familiar with the narratives. Participants were contacted by phone for clarification when needed. Data were analysed using three approaches described by Van Manen (1990); the holistic approach, the line-by-line approach and the selective approach. Themes and sub-themes emerged from the data. No further information about the analysis is provided. The method of data analysis was congruent with the research question. The themes and sub-themes reveal the participants’ experiences and feelings. An important omission is the lack of evidence for judging the scientific rigour of the study in terms of credibility, auditability, fittingness and confirmability. Describing the findings

Thematic analysis produced four major themes and several sub-themes. These are described with exemplars from the interviews and in a diagram (audit trail). The link between the findings of the study and other studies is discussed providing examples of similarities. The findings support literature showing that younger women with breast cancer experience psychological as well as emotional upheaval potentially affecting quality of life and prognosis. Also, younger women can become overwhelmed by their diagnosis, multiple role demands in the home and in the paid workforce. Researcher’s perspective

No researcher biases are reported and there were no conflicts of interest. Limitations of the study

are acknowledged: small sample size, non-English speaking women excluded, and participants were all of middle to high socioeconomic status. Implications for health professionals are: (1) the importance of having insight into the lives of younger women with breast cancer; and (2) increased awareness of their specific needs. Future directions are necessary for research into support from health professionals in the provision of care for younger women who have undergone breast surgery. Care should be individualised and there should be a recognition of differences between younger and older women who have had breast surgery. Research in brief Carlson and Plonczynski (2008) used Cooper’s guide for integrated literature reviews to analyse 45 studies using the BARRIERS Scale to determine: (a) if the identification of perceived barriers to research utilisation influence nurses’ use of research; (b) if the extent of nurses’ perceived barriers to research utilisation and most frequently cited barriers have changed over the past 15 years (1991– 2006); and (c) if nurses’ most frequently cited barriers to research utilisation differ across countries. Studies were included if they were in English, used the entire BARRIERS Scale and reported data on nurses’ responses separate from other categories of respondents. Only two studies had pre- and post-test designs and show that the interventions were successful in reducing nurses’ perceptions of barriers to using research in practice. When considering all the studies, the most common barriers identified related to characteristics of the organisation: insufficient time to implement new ideas was cited in 33 (73%) of the studies; not having enough time to read was cited in 17 (38%) studies; and lack of authority to change patient care procedures was cited in 22 (49%) studies. The authors conclude by suggesting that continued use of descriptive research designs using BARRIERS Scale appears to be unproductive in increasing nurses’ use of evidence-based practices.

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PATIENT PERSPECTIVES

Against all odds: Australian women’s experiences of recovery from breast cancer Rakime Elmir, Debra Jackson, Barbara Beale and Virginia Schmied

Aim. The aim of this study was to generate insight into younger women’s experiences of recovery from breast cancer-related breast surgery and to contribute to the knowledge base for clinicians practising in this field. Background. Despite the abundance of literature concerning the impact of breast cancer and breast loss on older women over 50 years of age, fewer studies have been conducted specifically with women younger than 50 years focusing on the recovery from breast cancer and related breast surgery. The effects of breast cancer on younger women differ to those of older women; younger women may have difficulty coming to terms with loss of fertility, perceived loss of femininity, sexuality and may experience body image disfigurement. Younger women may face these issues as a result of the treatment and surgery they have received to confine the breast cancer and attempt to improve their chances of survival. Design. A phenomenological qualitative methodology was used to capture the true essence and lived experience of four Australian women under the age of 50, who had undergone surgery as a result of being diagnosed with breast cancer. Methods. Tape-recorded semi-structured face-to-face interviews. Results. Thematic analysis revealed four major themes. These were ‘It absolutely encompassed me,’ ‘Being overwhelmed,’ ‘Living with fear and uncertainty’ and ‘Finding strength within.’ Conclusions. Findings of this study shed light on the experiences of recovery from breast cancer-related surgery in women under 50. Relevance to clinical practice. This research study will assist clinicians in understanding the needs of younger women undergoing breast cancer-related breast surgery, who may require counselling in relation to fertility and relationship issues and assistance in coping with the demands of work and home life. Key words: breast cancer, breast surgery, nursing, qualitative research, women’s health, young women Accepted for publication: 27 October 2009

Introduction Breast cancer is one of the leading causes of deaths in Australian women, and each year, approximately 10,000 women are diagnosed with breast cancer with a further 25,000 dying annually of the disease (Cancer Council 2006). Authors: Rakime Elmir, Grad Cert Clinical Teaching, RN, RM, BN, PhD Candidate, School of Nursing and Midwifery, University of Western Sydney; Debra Jackson, PhD, RN, Professor, School of Nursing and Midwifery, University of Western Sydney; Barbara Beale, RN, Lecturer, School of Nursing and Midwifery, University of Western Sydney; Virginia Schmied, RN, PhD, Associate Professor, School of Nursing and Midwifery, University of Western Sydney, Sydney, Australia

The risk of developing breast cancer in younger women is statistically low, with approximately 1% of all breast cancers occurring before age 30 and about 10% occurring before age 50 (Stephens 2001). In Australia, each year, approximately 700 women under the age of 40 years are diagnosed with breast cancer (Australian Institute of Health and Welfare Correspondence: Rakime Elmir, PhD Candidate, University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith South DC, NSW 1797, Australia. Telephone: (02) 46203355. E-mail: [email protected], [email protected]

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2531–2538 doi: 10.1111/j.1365-2702.2010.03196.x

2531

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AIHW 2005). It is estimated that 72% of women aged between 20–29 years and 80% aged 30–39 years will live for approximately five years after diagnosis of breast cancer (AIHW 2005). It has been noted that there can be a delay in diagnosis in younger women, and this is attributed to a misconception that they are too young to be diagnosed with breast cancer. This delay results in a poorer prognosis as a result of the delay in detection and diagnosis (Komen 2005). There is scant literature on younger women’s experiences of breast cancer; in particular, little is known on younger women’s experiences of recovery from breast cancer-related breast surgery.

Background Literature review Breast cancer is the most commonly occurring cancer among women in Australia (Australian Institute of Health and Welfare AIHW 2005) and is a disease that can cause dread, fear and apprehension among women (Thewes et al. 2004). The literature asserts that young women (aged < 50 years) with breast cancer have a more advanced disease and worse prognosis than older women (Lee 2002). It remains unclear why less promising and positive outcomes are seen in younger women diagnosed with breast cancer. Cancer survivorship is viewed as a dynamic and continually changing process that begins at the time of diagnosis and continues for the balance of life (Dirksen 2000). The psychological effect of surviving breast cancer has been of particular interest to investigators, given the observation that some women clearly adjust to survivorship better than others (Dirksen 2000). It is estimated that between 20–38% of women diagnosed with breast cancer experience high levels of psychological distress in the first year of diagnosis (Baider et al. 2003). Ferrell et al. (1998) explained that breast cancer in younger women resulted in emotional distress, anxiety, depression and a sharp decrease in morale, making women emotionally vulnerable. Bredin (1999) conducted a study with three women aged between 25–65 years. This study suggested that body image can profoundly impact on the ‘whole’ of one’s being. Women who have undergone breast surgery may experience distress because of a fear of stigma and as a consequence of living in a society where womanhood is associated with having a perfect body and a pleasant appearance (Bredin 1999). Bredin (1999) comments if the loss of a breast or both breasts results in changes in the woman’s self-image, so that she dislikes, or is unable to tolerate herself, her experience of femininity can become affected. Several studies (Kraus 1999, Crouch & 2532

McKenzie 2000, Avis et al. 2004) suggest that women, who believed their breasts were important to their feelings of femininity and attractiveness and who valued their physical appearance, experienced greater dissatisfaction with body image after mastectomy. In a study of six young breast cancer survivors, Coyne and Borbasi (2006) found women were fearful of the treatment they received, consequently limiting their choices in life, especially surrounding issues of fertility. Breast loss for younger women could be more difficult to accept, because of their youth and their perceived effects on future childbearing, thus being the catalyst for a personal identity crisis (Avis et al. 2004). The diagnosis of breast cancer can have an impact on quality of life by causing disruptions in a woman’s relationships, including sexual and intimate relationships (Thewes et al. 2004). Hughes (2000) states a healthy sexual relationship can contribute to the overall quality of life of an individual. Breast cancer may have a debilitating effect on a woman’s capacity to develop or sustain fulfilling sexual interactions. Many women struggle to cope with the psychological impact of the diagnosis and the knowledge that their breast a major symbol of their femininity and sexuality is going to be distorted (Crouch & McKenzie 2000, Avis et al. 2004). Some authors have reported the changes in quality of life and the effect of social functioning following breast cancer. In one study, it was found that patients withdrew from social interactions and reduced their engagement in social relationships with colleagues, neighbours and friends (Luoma & Hakamies-Blomqvist 2004). Similarly, Dunn and Steginga (2000) claim breast cancer has social and psychological ramifications that will not only alter a woman’s health but her relationships, her way of life and her appearance. The support of family and friends is an essential aspect in the healing of women with breast cancer. Social support can be a powerful force, which is identified as being a facilitator to successful coping for breast cancer survivorship (Connell et al. 2006). Support from health professionals is also important. The clinician is often the key source of information, especially around issues of diagnosis, treatment and prognosis. Research indicates that up to 66% of patients with cancer prefer key information from a hospital specialist (National Health and Medical Research Council 2003). As several researchers have noted, the usefulness of a particular type of support depends on who is providing it. Women consider the support received from health professionals to be more valuable in the healing and towards the recovery process. Coyne and Borbasi (2006) explored the experience of breast cancer diagnosis on women under the age of fifty, and although the research has produced important insights on the experiences of younger women, gaps in the literature

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remain on the experiences of younger women recovering from breast cancer and subsequent breast surgery.

Aim of the study This study aims to provide insight into younger women’s experiences of recovery from breast cancer-related breast surgery and to contribute to the knowledge base for clinicians practicing in this field.

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of illuminating the richness of women’s experience, the sample size is deliberately kept small. Holloway and Wheeler (2002) comment that a sample size between 4–40 is considered sufficient for qualitative research, although it should be noted that sample size is not an indicator of the study’s relevance or the quality of the data generated from participants narratives. Furthermore, the nature of the lived experience is one of low incidence, thus a small sample size for this study is appropriate because of a small research population.

Methods Phenomenology was the most appropriate qualitative methodology for this study as it focuses on lived human experience (LoBiondo-Wood & Haber 2002). An holistic perspective and the study of experience as it is lived serve as the foundation for phenomenological enquiry. Speziale and Carpenter (2003) elucidates that phenomenological method explores subjective phenomena in the belief that essential truths about reality are grounded by individual experiences in their life-world. This study aimed to gain insight and make meaning from the lived experience of women recovering from breast cancer-related breast surgery. A phenomenological approach provided an avenue for women to express the essence and nature of their experience.

Demographic profiles of participants Pseudonyms have been used to identify participants to protect their identity: Jane: 31 years old, married, works full-time, treatment included mastectomy, chemotherapy, radiotherapy and breast reconstruction. Kelly: 37 years old, de facto, works full-time, treatment included lumpectomy and chemotherapy. Denise: 48 years old, single, works part-time, treatment included lumpectomy and chemotherapy. May: 42 years old, married, works part-time, treatment included mastectomy, chemotherapy and radiotherapy.

Data collection and analysis Recruitment procedures The inclusion criteria for participation required that women be: diagnosed with breast cancer that resulted in breast surgery; under 50 years of age; and able to converse in English. Following ethics approval, recruitment proceeded using information posters, advertisements in local and metropolitan papers and an announcement on local radio station. Women meeting the inclusion criteria were invited to make contact by either email or direct phone call to arrange for a time to meet and verify and clarify information. They were given the opportunity to ask questions, were given a participant information sheet, and following informed consent procedures, they were recruited into the study. Prior to the start of the interview, all the participants were informed that the interview would be audio-taped and were made aware that they were able to withdraw from the interview at any point if they felt uncomfortable. Interviews were in depth and semi-structured. Participants were also aware of their right to refuse to answer any questions. A total of four women aged between 31–48 years were recruited into the study. Although a sample size of four participants may be regarded small, in keeping with the aim

Rich descriptive narrative was gathered via phenomenological face-to-face interviews (Talbot 1995). Interviews were conducted at a time most convenient to participants in a private room, and measures were put into place to avoid disruptions. Women were asked to describe and discuss their recovery from breast cancer-related breast surgery and concerns and feelings that arose for them as a result of having to undergo such surgery. Some of the questions included were as follows: • How did the experience of having breast cancer and breast surgery affect you psychologically and emotionally? • How did breast surgery affect your relationship with your family? How did it affect your role in the household? Data were audio-taped, transcribed and thematically analysed (Van Manen 1990). Transcripts were read several times, and tapes were listened to simultaneously to identify gaps in the transcription of data and to become more familiar with the narratives. Participants were contacted by phone to clarify narratives where needed. Data were analysed using three approaches as described by Van Manen (1990); the wholistic approach, the line by line approach and the selective approach. Psychological support was made available to participants.

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Results

Well, I was completely and utterly shocked…I was quite angry

Analysis of the narratives reveals that breast surgery related to breast cancer was a life-changing experience with emotional and social as well as physical ramifications for these women. Participants conveyed the significance of support from their family and friends and how heavily this support impacted on their recovery from breast cancer. Thematic analysis revealed four major themes and several sub-themes, which are represented in Fig. 1 and are expanded below.

‘It absolutely encompassed me’ All the women in this study described the powerful emotional response to being diagnosed with breast cancer, regardless of whether they had a family history of breast cancer or whether they were the first person in their family to be diagnosed with breast cancer. The women stated that the initial emotional backlash was as a result of the revelation of being diagnosed with breast cancer, which was experienced as sudden and all consuming. Jane recalls the day she received the news of being diagnosed with breast cancer: It absolutely encompassed me you know like, all I could think about was I have cancer, I have cancer, I have cancer. It was the last thought of a night and the first thing in the morning and all day, it was just shocking. (Jane)

actually as well because when I was diagnosed, the doctor seemed to be saying to me that, that was quite expected that I would have breast cancer, because 20 years prior to my breast cancer I had Hodgkin’s disease… (May)

‘Being overwhelmed’ All the women in this study described being overwhelmed by having to manage all their day-to-day responsibilities even while facing up to the news that they had breast cancer and were undergoing breast surgery in conjunction with other treatments. Each participant had to continue to manage both paid and household work. While all the women shared the experience of ‘being overwhelmed’, each dealt with it differently. Sub-themes to this theme were identified, and these are: ‘dealing with household activities’ and ‘coping with the external workforce’. Dealing with household activities Kelly described her role in the home and her almost singular contribution to the household work. Despite having a partner, Kelly continued to perform household chores such as mowing the lawns. Although this affected her personal wellbeing, she felt the need to be doing this because of her nature of being self-caring most of her life: Still doing everything by myself, although I have been self-reliant my

May was distressed about the fact that doctors were telling her the diagnosis of her breast cancer was to be expected because of her history of Hodgkin’s disease:

whole life…. Like I was still mowing my own grass. It would have been nice if someone could have come over and mowed the grass for me. It used to take me 4 hours to cut the grass while having chemo and I was pretty ill…. (Kelly)

Theme 1: 'it absolutely encompassed me' – Having breast cancer

Theme 2: 'Being overwhelmed' – Dealing with household activities – Coping with the external workforce

Narratives from women's lived experience Theme 3: 'Living with fear and uncertainty' – Uncertainty & making changes in life – Fear of losing attractiveness and desirability

Theme 4: 'Finding strength within' – Finding strength and being strong – Strength through support from family and friends – Strength through support from doctors and nurses

May describe how her role in the household as ‘mother’ was altered as a result of the breast surgery: ...It did alter my role in the family because I wasn’t around, like I was in and out of hospital it was awful…I think once that mastectomy was over I was able to come back into that role of mother… (May)

Coping with the external workforce All the women were in the paid workforce during their breast cancer treatment. Three participants were on reduced hours because of their treatment, one participant was forced to work because of financial constraints, despite receiving treatment. Kelly expressed the need to continue to work to pay off a mortgage and in the event of her death, her own funeral: I was still working I had a lot of time off, work was pretty good but having to take medicines and I was paying my own home at that

Figure 1 Themes of the study.

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time…and I have a brother who’s close but as he has testicular cancer

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Patient perspectives he’s frightened he doesn’t want to admit anything. Like the other day I said to him, ‘I have to pay off a funeral,’ and he said, ‘Whose funeral?’ and I said, ‘Mine.’ (emotional) (Kelly)

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In a similar way, May talks about her inability to feel desirable and attractive towards her husband as a result of her breast surgery: … I was going to be deformed…I thought he won’t like me anymore

‘Living with fear and uncertainty’ Living with fear and uncertainty because of the possibility of recurrence of breast cancer was prominent in all of the women’s stories. The women’s fear of recurrence was influenced by their prognosis and type of surgery. They talked about how these fears led them to make changes in their lives. They also feared becoming unattractive and undesirable to men, in particular their partners. Sub-themes to this theme were identified, and these are: ‘uncertainty and making changes in life’ and ‘fear of losing attractiveness and desirability’. Uncertainty and making changes in life All the women felt they needed to change something in their life as a result of having breast cancer and the accompanying feelings of uncertainty. The women made changes to themselves as individuals. They also made changes in their lives to benefit their families and expressed the feeling that they did not want to die not knowing what was going to happen to their families. Jane decided she needed to make changes in her life as she felt uncertain of whether or not she would get the opportunity to experience life in the way she wanted to: I want to go to Africa, I want to go to Vietnam and I keep saying to my husband I want to do this, I want to do this and he says yeah you have time to do that but I’m still not sure if I have that time. Yeah, people say you can be hit by a bus tomorrow but I’ve seen my bus, I’ve seen the driver…Things are more urgent that I want to do because I’ve had that brush, that brush of death. (Jane, emotional)

Fear of losing attractiveness and desirability Three of the women talked about changes to their body image with respect to their femininity and sexuality, as a result of their surgery. At the same time, their concerns and thoughts about men’s perception towards them as women were revealed through their narratives. Kelly expressed issues of body image disfigurement because of having breast surgery: …I didn’t know how I was going to look like… I just used to think well if I go out with anybody new and it looks like it is going to lead to a long term relationship, I didn’t know if I am going to be able to get undressed in front of them…how can I take my top off in front of anybody that is a new partner... (Kelly)

and I’m going to look horrible…initially I didn’t think I was going to be feminine anymore particularly with no hair…you don’t feel desirable or your husband would want you anymore…it was me that didn’t want to partake in any sort of sexual relationship…I was quite frightened and scared… (May)

‘Finding strength within’ Despite the physical and emotional turmoil, the hardship and anguish that women experienced during their recovery and treatment, it was evident from all the women’s narratives that they held the belief that breast cancer and related breast surgery had made them stronger individuals. The women further elaborated on their ability to find strength in themselves and being strong. All the women noted that family and friends were a good source of support and that liaising with health professionals contributed towards the way they perceived their disease process. Sub-themes to this theme were identified, and these are: ‘finding strength and being strong’, ‘strength through support from family and friends’ and ‘strength through support from health professionals’. Finding strength and being strong All the women talked about the ways in which they found strength and how this made them strong. The women’s ability to be strong was directly influenced by their life experiences hence aiding to an optimal quality of life. Jane communicated her experience of breast cancer and related breast surgery and how it has made her ‘stronger,’ enabling her to believe she can beat the disease and survive: …it probably made me realise how strong I am and how strong my body is and the human body is designed to survive, no matter what you do to it, it keeps on trying to come back to survive….I have been through an amazing transformation, an amazing experience that nothing can compare to. It’s made me stronger and more confident of who I am. (Jane)

Strength through support from family and friends All the women talked about the support they received from family and friends throughout the period of breast cancer diagnosis and the period of having and recovering from breast surgery. They felt as though this support network endeavoured to accelerate the recovery process, contributing to their overall feeling of happiness and their sense of strength

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and vitality. Denise conveys her experience of receiving support from family and friends: Oh it was great, I worked in a community of caring people and they were really supportive and the family was great. (Denise)

Strength through support from health professionals Women identified the support they received from doctors and nurses assisted them to find strength in themselves. Expert advice from health professionals was considered to be essential to their care and overall adjustment to the diagnosis of breast cancer. May explained how her General Practitioner organised everything and took charge of the situation, which according to May is exactly what she needed. She said it helped her to cope a little better with being diagnosed with cancer. May also mentions the immense support and encouragement she received from the breast care nurse: …My GP….she was actually great….she organised everything, brought us in after surgery hours explained everything, came to my house the next day, had made appointments with the oncologist…. The surgeon he was great…. when I went to have my surgery the person that I thought was the anaesthetist was actually the breast care nurse…. we had a really good rapport, she explained everything that was going to happen to me that day in much detail than the surgeon had….gave me an idea of what to expect in the end, was there when I woke up from surgery and rang me the next day…my family and I could not have been able to cope without them…. (May)

Discussion The findings of this study have shown that these younger women experienced emotional turmoil and concerns associated with body image, sexuality and femininity following surgery and treatment for breast cancer. The feelings and concerns expressed by participants became a routine part of life from the moment of diagnosis through their surgery and thereafter, during the recovery process. These feelings were associated with the diagnosis of breast cancer and living with fear and uncertainty of the recurrence of breast cancer. Participants identified that valuable sources of support were derived from family and friends and doctors and nurses. Our findings resonate with another qualitative Australian study conducted by Coyne and Borbasi (2006) who described women’s feelings of shock at the diagnosis of breast cancer and emotional turmoil. Women in the Coyne and Borbasi (2006) study considered the family unit to be significant and expressed the vital role clinicians held in helping them adjust to the disease. However, the current study adds important insights into younger women’s experiences of sense of self 2536

and body image following surgery. This study also emphasises the impact of breast surgery on the recovery of younger women. Participants revealed that the diagnosis of breast cancer precipitated an emotional response. The ‘sudden’ news of their cancer resulted in emotional responses described by women as: ‘shock’, ‘disbelief’, ‘anger’, ‘fear’, ‘anxiety’, ‘numbness’ and ‘panic’. Women considered their diagnosis as being a stressful time, as they regarded it to be a lifechanging phenomenon. Baider et al. (2003), Dunn and Steginga (2000) and Harcourt and Rumsey (2001) support the findings relating to the emotional distress caused by the diagnosis of breast cancer. Harcourt and Rumsey (2001) also highlight the emotional distress associated with having to undergo surgery following the diagnosis of breast cancer. Women felt overwhelmed having to juggle day-to-day responsibilities along with the news of being diagnosed with breast cancer and its potential treatment and sequels. The women faced having to manage household-related chores as well as work outside the home, causing immense pressure and physical exhaustion. Studies by Sammarco (2001), Luoma and Hakamies-Blomqvist (2004), Thewes et al. (2004) all support the current findings. Luoma and Hakamies-Blomqvist (2004) investigated the meaning of quality of life of patients with advanced breast cancer. They suggested that women diagnosed with breast cancer can find it distressing as they experience limitations to physical functioning associated with activities of daily living, such as driving, walking, housework, family and leisure activities and self-care. Sammarco (2001) comments younger women sometimes inevitably have to cope with the multiple role demands including cooking, cleaning and having to go to work. This can sometimes add enormous pressure on women with breast cancer, as they have to meet the demands of their illness, hence placing them at risk of psychological morbidity. Thewes et al. (2004) agrees with the findings pointing out that younger women find it challenging working and attending to domestic household chores during their recovery from breast cancer. Fear was triggered because of the risk of recurrence of breast cancer, and women experienced uncertainty of what the future held for them. Findings by Avis et al. (2004) support these findings and suggest that a diagnosis of breast cancer is not necessarily a death sentence; however, it does trigger thoughts of death and dying, thus bringing various life issues into perspective. Avis et al. (2004) adds that such a diagnosis causes a prompt recognition of the person we are and the changes we may want to make to our lives. Additionally, for the women in the present study, living with fear and uncertainty also encompassed the fear of losing

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attractiveness and desirability. Women felt that breast surgery changed their body image and affected their femininity and sexual relations with men. Pelusi (2006) suggests that many women experience body image disfigurement prior to the diagnosis of breast cancer. It is possible that an alteration in body image could be experienced as a consequence of breast cancer itself, as well as a consequence of its treatment, or both. The women found strength in themselves as individuals as a result of being diagnosed with breast cancer and having undergone breast-related surgery; this resulted in the women having an overall optimistic perspective on life. They also indicated they received support from family and friends and health professionals. Women valued this source of support as it contributed towards their feeling of inner strength. Family and friends provided praise, encouragement and guidance. In a similar manner, health professionals empowered them in terms of involving the women in the decision-making process and enabling them to be an active partner in their care. Authors such as Landmark and Wahl (2002) and Coyne and Borbasi (2006) explain the power of strength and its significance in terms of healing and surviving.

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English speaking women were excluded from the study, as the essence of their narrative may have been lost in the translation process. Women in this study were all from middle to high socioeconomic status, and therefore, women affected by poverty were not included.

Relevance to clinical practice This study has highlighted the lived experience and recovery of a group of women under 50 who were diagnosed with breast cancer and have undergone breast-related surgery. As the findings have illustrated, health professionals provide a significant source of support, and it is therefore important that health professionals have insight into the lives of younger women with breast cancer and to have increased awareness of their specific needs. This research highlights future directions for research into support from health professionals when providing care for younger women who have undergone breast surgery. Health professionals should deliver care that is individualised and understand the physical and psychological disparities among younger and older women who have undergone breast surgery and not treat all women with breast cancer as a homogenous group.

Conclusion Findings of this study have concurred with previous literature that suggests younger women diagnosed with breast cancer and who are recovering from breast-related surgery experience a multitude of issues. These issues include body image disturbance, femininity and sexual difficulties. The findings have supported extant literature that asserts younger women with breast cancer experience psychological as well as emotional upheaval, potentially affecting their quality of life and prognosis of their disease. The findings contribute to the literature, asserting that younger women with breast cancer can become overwhelmed with their diagnosis, having to meet the multiple role demands in their household and in the paid workforce. The feelings of fear and uncertainty among breast cancer survivors are also prominent in the literature. Participants in this study narrated that this fear and uncertainty was related to the risk of recurrence of breast cancer and what the future held for them. The findings have further supported the literature that asserts a valuable source of support was derived from family and friends and health professionals, from whom the women gained strength.

Limitations of the study A limitation of the study is the small size. However, the sample size was sufficient to meet the aims of the study. Non-

Contributions Study design: RE, DJ, BB; data collection and analysis: RE, DJ, BB and manuscript preparation: RE, DJ, BB, VS.

Conflict of interest There are no conflicts of interest.

References Australian Institute of Health and Welfare AIHW (2005) Breast health: evidence based information for women and their families. Retrieved from http://www.breasthealth.com.au/statisticsresearch/ index.html. Avis EN, Crawford S & Manuel J (2004) Psychological problems among younger women with breast cancer. Psycho-Oncology 13, 295–308. Baider L, Andritsch E, Uzielt B, Ever-Hadani P, Goldzweig G, Hofmann G & Samonigg H (2003) Do different cultural settings affect the psychological distress of women with breast cancer? A randomised study European Journal of Cancer care 12, 263–273. Bredin M (1999) Mastectomy, body image and therapeutic message: a qualitative study of women’s experience. Journal of Advanced Nursing 29, 1113–1120. Connell S, Patterson C & Newman B (2006) Issues and concerns of young Australian women with breast cancer. Supportive Care in Cancer 14, 419–426.

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R Elmir et al. Coyne E & Borbasi S (2006) Holding it all together: breast cancer and its impact for younger women. Contemporary Nurse 23, 157–169. Crouch M & McKenzie H (2000) Social realities of loss and suffering following mastectomy. Health 4 196–215. Dirksen RS (2000) Predicting well-being among breast cancer survivors. Journal of Advanced Nursing 32, 937–943. Dunn J & Steginga KS (2000) Young women’s experience of breast cancer: defining young and identifying concerns. Psycho-Oncology 9, 137–146. Ferrell B, Grant M, Funk B, Otis-Green S & Garcia N (1998) Quality of life in breast cancer: part two: psychological and spiritual wellbeing. Cancer Nursing 21, 1–9. Harcourt D & Rumsey N (2001) Psychological aspects of breast cancer reconstruction: a review of the literature. Journal of Advanced Nursing 35, 477–487. Holloway I & Wheeler S (2002) Qualitative research in Nursing, 2nd edn. Blackwell Science, Oxford. Hughes M (2000) Sexuality and the cancer survivor: a silent coexistence. Cancer Nursing 23, 477–482. Komen SG (2005). Facts for life: young women and breast cancer. Retrieved from http://www.komen.org. Kraus P (1999) Body image, decision making and breast cancer treatment. Cancer Nursing 22, 421–427. Landmark B & Wahl A (2002) Living with newly diagnosed breast cancer: a qualitative study of 10 women with newly diagnosed breast cancer. Journal of Advanced Nursing 40, 112–121. Lee W (2002) Frequent loss of BRCA1 nuclear expression in young women with breast cancer: an immunohistochemical study from an area of low incidence but early onset. Applied Immunohistochemistry and Molecular Morphology 10, 310–315.

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LoBiondo-Wood G & Haber J (2002) Nursing research: methods, critical appraisal and utilisation. Mosby, St Louis. Luoma M & Hakamies-Blomqvist L (2004) The meaning of quality of life in patients being treated for advanced breast cancer: a qualitative study. Psycho-Oncology 13, 729– 739. National Health and Medical Research Council (2003) Clinical practice guidelines for the psychological care of adults with cancer. National Breast Cancer Centre, Camperdown. Pelusi J (2006) Sexuality and body image. Research on breast cancer survivors documents altered body image and sexuality. American Journal of Nursing 106, 32–38. Sammarco A (2001) Psychological stages and quality of life of women with breast cancer. An International Journal for Cancer Care 24, 272–277. Speziale SH & Carpenter RD (2003) Qualitative research in nursing, 3rd edn. Lippincott Williams and Wilkins, Philadelphia. Stephens F (2001) All about breast cancer. Oxford University Press, New York. Talbot AL (1995) Principles and practice of nursing research. Mosby, St Louis. The Cancer Council. (2006). Understanding breast cancer. Retrieved from http://www.cancercouncil.com.au. Thewes B, Butow A, Girgis A & Pendlebury S (2004) The psychological needs of breast cancer survivors; a qualitative study of the shared and unique needs of younger versus older survivors. PsychoOncology 13, 177–189. Van Manen M (1990) Researching lived experience: human science for an action sensitive pedagogy. State University of New York Press, New York.

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(Source: Elmir R, Jackson D, Beale B, Schmied V 2010 Against all odds: Australian women’s experience of recovery from breast cancer. Journal of Clinical Nursing 19:2531–38.)

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Nursing and Midwifery Research 4e

Critical review of quantitative research studies The following review process for quantitative studies (Box 15.3) is not exhaustive. As you read research papers or chapters in this book, additional pertinent questions may occur to you. Consider the size of the sample and remember that samples have to be large enough to permit the assumption of normality. If the sample is small, say, five to ten subjects, the assumptions necessary for inferential statistics may have been violated. The important question is whether the researcher has provided enough justification to use the statistics presented. As you read the ‘Methods’ section consider the level of measurement and statistical tests used to measure important variables. Evidence-based practice tip If the level of measurement was interval or ratio, the statistics most likely to be used will be parametric; however, if the variables are measured at the nominal or ordinal level, the statistics used should be non-parametric (see Chapter 13).

Finally, consider the results as they are presented. The first place to begin to critique the statistical analysis of a research paper is with the hypothesis. The hypothesis should indicate to you what statistics were used. If the hypothesis predicts that a relationship between the variables will be found, you should expect to find indices of correlation. If the study is experimental or quasi-experimental, the hypothesis would indicate that the author is looking for differences between the groups studied and you would expect to find statistical tests of difference between means or proportions. There would be serious implications for the study if the stated aims and hypotheses are written in a vague way. There should be enough data presented for each hypothesis studied to determine whether the researcher actually examined each hypothesis (see Chapter 4). The tables, procedures, analysis and text should be congruent. For example, the text should not indicate that a test reached statistical significance while the tables indicate that the probability value of the test was above 0.05.

2

Tutorial Trigger

Beverley is in her postgraduate year of nursing. She works as a full-time theatre nurse and would like to conduct research in her clinical area. She has read a few articles on the topic she wishes to research. Beverley has been asked to present a short research proposal. What information should she include?

There are two other aspects of the data analysis section that the reader should review. The paper should not read as if it were a statistical textbook. The results in the text of the paper should be clear enough to the average reader so that determinations can be made about what was done and what the results were. In addition, the author should attempt to make a distinction between practical and statistical significance. Some results may be statistically significant, but their practical importance may be doubtful. If this is so, the author should note it. Alternatively, you may find yourself reading a research report that is elegantly presented, but you come away with a ‘so what?’ feeling. Such a feeling may indicate that the practical significance of the study and its findings have not been adequately explained. Note that the critical analysis of a research paper’s statistical analysis is not done in a vacuum. The adequacy of the analysis must be judged in relation to the other important aspects of the paper: the problem, the hypothesis, the design, the sample and the data collection methods. For example, a researcher may sometimes use a non-parametric statistic when it appears that a parametric statistic is appropriate. Because parametric statistics are more powerful than non-parametric statistics, the result of the parametric analysis may not have been what the researcher expected. However, the non-parametric result might be in the expected direction, so the researcher reports only that result, but this would be misleading (see Chapter 13). Evidence-based practice tip Use whatever opportunities you can to examine and evaluate your clinical practice. Then, generate questions about your practice and share them with colleagues.

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15 • Critically reviewing research studies

Box 15.3  Critical review guidelines for quantitative studies The title and abstract a) Is the title of the research paper congruent with the text? b) Were the aims and/or objectives stated? What are they? c) Did the abstract contain sufficient information about the stages of the research process (e.g. aims, hypothesis, research approach, sample, instruments and findings)? Structuring the study a) Is the motivation for the study demonstrated through the literature review? b) Is the literature cited current, relevant and comprehensive? Are the references recent? c) Are the stated limitations and gaps in the reviewed literature appropriate and convincing? d) How was the investigation carried out? e) Is the hypothesis stated? f) Which hypothesis is stated: the scientific hypothesis or the null hypothesis? g) Does the hypothesis indicate that the researcher is interested in testing for differences between groups or in testing for relationships? The sample a) Is the sample described? b) Is the sample size large enough to prevent an extreme score from affecting the summary statistics used? c) How was the sample size determined? d) Was the sample size appropriate for the analyses used? Data collection

f) How were the data collection instruments validated? g) How was the reliability of the measurement instruments assessed? h) Were ethical issues discussed? Data analysis a) Are descriptive or inferential statistics reported? b) What tests were used to analyse the data: parametric or non-parametric? c) Were the descriptive statistics/inferential statistics appropriate to the level of measurement for each variable? d) Were the appropriate tests used to analyse the data? e) What is the level of measurement chosen for the independent and dependent variables? f) Were the statistics appropriate for the research question and design? g) Are there appropriate summary statistics for each major variable? h) Were the statistics primarily descriptive, correlational or inferential? i) Identify the outcome of each statistical analysis. j) Explain the meaning of each outcome. Findings a) Were the findings expected? Which findings were not expected? b) Is there enough information present to judge the results? c) Are the results clearly and completely stated? d) Describe the researcher’s report of the findings.

a) How were the data collected (questionnaires or other data collection tools)?

e) Identify any limitations or gaps in the study.

b) Who collected the data? c) Are the data adequately described?

g) Did the researcher mention the implications of the study for healthcare?

d) What is the origin of the measurement instruments?

h) Was there sufficient information in the report to permit replication of the study?

f) Were suggestions for further research made?

e) Are the instruments adequately described?

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Nursing and Midwifery Research 4e

Weller et al. (2010) used an RCT to estimate: (a) the difference in mean sub-bandage pressures of inelastic and elastic compression bandage systems at rest, standing, exercise and recovery; (b) the difference in mean stiffness between bandage types; and (c) the difference in mean amplitude of sub-bandage pressures between bandage systems during exercise. Inelastic and elastic compression bandages were randomised to the opposite limbs of 42 healthy adult volunteers. Ethics approval was obtained. The same wound care nurse applied the bandages in a clinical laboratory simulation ward. A pressure transducer measured sub-bandage pressures and median, interquartile range and overall range of sub-bandage pressures were recorded. Findings showed that inelastic bandages resulted in an increased mean interface sub-bandage pressure when resting and recovering and further increased when standing or exercising. Bandage stiffness and amplitude were also greater in inelastic compared with elastic bandages.

3

Tutorial Trigger

Some of the nursing and midwifery students in your research group argue about the necessity of having to know how to critically analyse and interpret research articles when they don’t intend to conduct research. Explain to your peers why it is important that as research consumers they need to know how to critically read research articles.

The next article ‘An evidence-based practice approach to improving nursing care of acute stroke in an Australian Emergency Department’ (Considine and McGillivray 2010) is critically reviewed for its design and contribution to healthcare and nursing knowledge. Critical review guidelines appear in Box 15.3.

Title and abstract The title indicates the approach (evidence-based practice), the reason (improving nursing care), the type of patient diagnosis (acute stroke) and the venue (an Australian emergency department). The aim is clearly stated: to improve emergency nursing care of acute stroke by enhancing the use of evidence relating to the prevention of early complications. A pre-test/

post-test design was used; the intervention was a guideline for emergency department (ED) nursing management of acute stroke. The study intervention was evaluated. The participants were not mentioned. The findings show a significant improvement in triage decisions, an increase in frequency of assessment rates, documentation of pressure area interventions and nil orally status, swallow assessment, speech pathology assessment in ED and a decrease in time to speech pathology assessment for admitted patients.

Structuring the study The literature review is limited to a detailed account of the Australian setting; in particular, the perceived variability in management of patients with stroke, waiting times in the ED at The Northern Hospital and the pernicious effects of stroke. Observations of current practice of the hospital identified variability in management of patients with stroke in their ED. Care for patients with ED discharge diagnosis of stroke was also various. No hypothesis is stated. Ethical approval was obtained. Data were collected using the medical record audit. The intervention was supported with tutorials. The intervention (guideline) was based primarily on the Institute for Clinical Systems Improvement (ICSI) Diagnosis and Initial Treatment of Ischemic Stroke Guideline. The ICSI evidence was enhanced by evidence-based recommendations from other key documents related to stroke management. Tutorials were provided for the emergency nurses on eight occasions and involved 48 emergency nurses.

The sample Participants were patients with an ED discharge diagnosis of stroke: pre-test data were collected from participants with an ED discharge diagnosis of stroke (n = 63) from 1 January to 31 March 2007. The guideline was implemented and a period of one month allowed for normalisation of practice. Post-test data were collected for all patients with ED discharge diagnosis of stroke from 1 August to 31 October 2007 (n = 41). No indication is given for determining sample size.

Data collection One of the researchers collected the medical record audit data: demographic data; ED system

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15 • Critically reviewing research studies

data; specialist referrals; nursing assessment data; frequency of oral intake assessment; and risk management documentation. The intervention for the study was a guideline implemented in 2007 for the emergency nursing management of stroke. The guideline was based primarily on the Institute for Clinical Systems Improvement (ICS) Diagnosis and Initial Treatment of Ischemic Stroke Guideline. The (ICSI) guideline included recommendations of key document related to stroke management and designed to be a summary document that accompanied usual ED nursing documentation. Specific details of tool reliability and validation are not provided. The study was approved by the ethics committee.

Data analysis Descriptive statistics (percentages, means, standard deviations) were used. These were appropriate to describe the data. Data were not normally distributed and medians and interquartile ranges are presented. Data were compared using chi-square and Mann-Whitney U-tests and independent samples t test. Pre-test and post-test data were compared to determine if prevention of early complications improves ED management of stroke. There were no significant differences in the gender or age distribution of both groups: males made up 49.2% of the pre-test group (n = 31), and 56.1% (n = 23) of the post-test group (χ = 0.472, df = 1, p = 0.492). Patients in the pre-test group had a median age of 75 years (IQR = 59–82), and post-test group patients had a median age of 66 years (IQR = 58–77) (U = 1087.0, p = 0.174). The between-group difference in median age was not statistically significant. There was also no significant between-group difference in the number of patients arriving by ambulance (54.0 vs. 53.7%) (χ = 0.0001, df = 1, p = 0.975) or who required interpreting services (27.4 vs 14.6%) (χ = 2.326, df = 1, p = 0.127). The three major findings are presented in the tables. There was also a significant 21.4% increase in triage in category 2 following implementation of the stroke guideline and a significant 15.6% decrease in triage 21.4% to category 4. There was increased frequency of repeated assessments of respiratory rate, heart rate, blood pressure and oxygen saturation, and a non-significant number of Glasgow coma score

assessments. There were significant improvements in risk management; a 43.3% increase in patients who underwent a swallow assessment prior to oral intake (p = 0.0003) and 13.8% increase in documentation of nil orally status. There was a significant 28.85% increase in the frequency of documentation or pressure area interventions (p = 0.0006), the speech pathology assessment in ED increase by 16.1% (n = 3, 9.7 vs 26.1%, n = 6) (χ = 2.390, df = 1, p = 0.122) and median time to speech pathology assessment decreased by 93.5 minutes. Median time for speech pathology assessment for the pre-test group was 25.7 hours (IQR = 17–52.9) and 24.1 hours (IQR = 14.6–66.7) for the post-test group (U = 332.000, p = 0.816).

Findings This study was the trial of an intervention. There is sufficient information to judge the results which are clearly described. The researchers’ report identifies three major areas of practice change following implementation of the ED stroke guideline: First, a significant shift in triage decision-making to ATS category 2, and decreased triage to ATS category 4. These findings suggest increased perception of urgency of stroke care by emergency nurses. Second, there was increased frequency of repeated physiological assessment, and third, there were significant improvements in risk management, particularly in regard to safe swallowing.

Limitations and recommendations The researchers advise caution when interpreting the findings for the following reasons: (1) it is a relatively small study conducted in one ED limiting generalisability; (2) the method was reliant on nursing documentation as a proxy for care delivery and it may not reflect actual practice; observations of clinical practice suggest that documentation is under-representative of nursing care; and (3) the use of pre-test/post-test design has limitations given that data collection occurred over two different periods in time. It was recommended that evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the management of acute stroke. There is sufficient information to permit another similar ED to implement the guidelines. 305

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Nursing and Midwifery Research 4e

CLINICAL ISSUES

An evidence-based practice approach to improving nursing care of acute stroke in an Australian Emergency Department Julie Considine and Bree McGillivray

Aims. The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence regarding prevention of early complications. Background. Preventing complications in the first 24–48 hours decreases stroke-related mortality. Many patients spend considerable part of the first 24 hours following stroke in the Emergency Department therefore emergency nurses play a key role in patient outcomes following stroke. Design. A pre-test/post-test design was used and the study intervention was a guideline for Emergency Department nursing management of acute stroke. Methods. The following outcomes were measured before and after guideline implementation: triage category, waiting time, Emergency Department length of stay, time to specialist assessment, assessment and monitoring of vital signs, temperature and blood glucose and venous-thromboembolism and pressure injury risk assessment and interventions. Results. There was significant improvement in triage decisions (21Æ4% increase in triage category 2, p = 0Æ009; 15Æ6% decrease in triage category 4, p = 0Æ048). Frequency of assessments of respiratory rate (p = 0Æ009), heart rate (p = 0Æ022), blood pressure (p = 0Æ032) and oxygen saturation (p = 0Æ001) increased. In terms of risk management, documentation of pressure area interventions increased by 28Æ8% (p = 0Æ006), documentation of nil orally status increased by 13Æ8% (ns), swallow assessment prior to oral intake increased by 41Æ3% (p = 0Æ003), speech pathology assessment in Emergency Department increased by 6Æ1% (ns) and there was 93Æ5 minute decrease in time to speech pathology assessment for admitted patients (ns). Relevance to clinical practice. An evidence-based guideline can improve emergency nursing care of acute stroke and optimise patient outcomes following stroke. As the continuum of stroke care begins in the Emergency Department, detailed recommendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the management of acute stroke. Key words: Australia, emergency nursing, nurses, nursing, stroke Accepted for publication: 12 March 2009

Introduction Stroke is a significant and increasing health issue. World Health Organisation data shows that 15 million people worldwide suffer a stroke very year. Of these, five million Authors: Julie Considine, RN, RM, BN, GradDipNurs, MNurs, PhD, FRCNA, Senior Research Fellow, Deakin University – Northern Health Clinical Partnership, Burwood; Bree McGillivray, RN, BN, GCertEmergNurs, Clinical Nurse Specialist, Emergency Department, The Northern Hospital, Epping, Vic., Australia

138

people die from stroke and five million people are left with permanent disability placing a burden on families and communities (Mackay & Mensah 2004). Awareness and modification of risk factors such as hypertension and smoking has resulted in a reduction in the incidence of stroke Correspondence: Julie Considine, Senior Research Fellow, Deakin University, 221 Burwood Hwy, Burwood, 3125 Vic., Australia. Telephone: +61 3 9244 6175. E-mail: [email protected]

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15 • Critically reviewing research studies

Clinical issues

however the absolute number of strokes continues to rise as a result of ageing populations and increased life expectancy (Mackay & Mensah 2004). In the Australian context, 48,000 Australians have a stroke each year (Victorian Department of Human Services 2007). Of these strokes, 70% are first ever strokes and 30% of these people will have another stroke within one year (Victorian Department of Human Services 2007). Of those who survive initial stroke injury, 9000 Australians die within one month of stroke, one-third of patients with stroke die within 12 months and 78% of deaths from stroke occur in patients older than seventy-five years (Victorian Department of Human Services 2007). In the next 10 years more than half a million people in Australia will suffer a stroke (National Stroke Foundation 2006). In addition, stroke is a leading cause of disability in Australia (National Stroke Foundation 2006). During 2005/2006 Victorian public hospitals managed almost 12,000 episodes of stroke and just over 2800 episodes of Trans-ischaemic attack (TIA) (Victorian Department of Human Services 2007). It is predicted that the incidence of acute stroke will continue to increase by 2Æ7% annually (Victorian Department of Human Services 2007). An important part of acute stroke management and decreasing stroke-related mortality is preventing complications within the first 24–48 hours (Bhalla et al. 2001, Pendlebury & Rothwell 2004, Lees 2005, Anderson et al. 2006). The current climate of prolonged time spent in the Emergency Department (ED) means that many aspects of stroke management are now the responsibility of emergency nurses. The ED at The Northern Hospital (TNH), Melbourne, Australia manages over 65,000 patients per year (Northern Health 2007). Observations of current emergency nursing practice at TNH suggested variability in management of patients with stroke in our ED. Further assessment of 2006 ED data for 113 patients with ED discharge diagnosis of stroke confirmed variation in care. For example, triage category allocation was spread across all five Australasian Triage Scale categories (Cat 1 = 4Æ4%, Cat 2 = 19Æ5%, Cat 3 = 51Æ3%, Cat 4 = 21Æ2% and Cat 5 = 3Æ5%) suggesting variability in perceived urgency of treatment and potentially significant knowledge deficits among triage nurses. There was also variability in terms of waiting times to see medical staff: 80% of patients (n = 90) were seen within one hour and 70% of patients (n = 80) were seen within 30 minutes. The average length of ED stay was 11 hours however 20% of patients were in the ED for over 20 hours before transfer to an inpatient unit highlighting the need for prevention of complications to commence in the ED and for ED management of acute stroke to be evidenced-based. Observations of current practice also showed variability in frequency of vital

Evidence-based practice in improving nursing care of acute stroke

sign monitoring and that the intervals between vital sign assessment increase the longer the patient is in the ED. It is important to note that the focus of this paper is on emergency nursing management of acute stroke. Although the use of thrombolysis as a treatment option for acute stroke is discussed in most stroke guidelines (Royal College of Physicians 2004, Anderson et al. 2006, Adams et al. 2007, National Stroke Foundation 2007, Victorian Department of Human Services 2007), most current evidence does not support the use of thrombolysis in acute ischaemic stroke beyond three hours (Hacke et al. 1995, Clarke et al. 1999, 2000, Kothari et al. 2001, National Stroke Foundation 2003) to 4Æ5 hours after symptom onset (Hacke et al. 2008, Wahlgren et al. 2008). Further, it may be argued that for patients who are ineligible for thrombolysis, the management of fundamental aspects of stroke care is vital to optimising outcomes for stroke survivors.

Aims The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence regarding prevention of early complications.

Methods Study design A prospective pre/post-test design was used. The outcome measures were elements of emergency nursing care known to impact on outcomes of stroke survivors. Data were collected using by medical record audit. The intervention for the study was a guideline for the emergency nursing management of stroke, the implementation of which was supported with tutorials. Pre-test data were collected from January–March 2007 and post-test data were collected between August– October 2007. Setting The study was conducted at The Northern Hospital: a peripheral hospital 30 km north of Melbourne, Australia. TNH is a 300 bed acute care campus of Northern Health. The ED at TNH manages over 65 000 patients per year (Northern Health 2007). During 2005/06, Northern Health managed 404 admissions for acute stroke (Victorian Department of Human Services 2007). The ED at TNH does not routinely offer thrombolysis as an emergency treatment option for acute ischaemic stroke due to lack of specialist neurology and neurosurgical services, specialist neuroimaging capability and high dependency unit facilities.

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Nursing and Midwifery Research 4e

J Considine and B McGillivray

Pre-hospital triage of patients with stroke by paramedics tends to result in transport of patients who may be eligible for thrombolysis to specialist centres. As a result of pre-hospital triage, patients with stroke who present to TNH tend to be older with a high incidence of pre-morbid risk factors, particularly diabetes and smoking. Participants Participants were patients with an ED discharge diagnosis of stroke (ICD-10 code I64). Pre-test data were collected for all patients with an ED discharge diagnosis of stroke from 1 January–31 March 2007 (n = 64). The guideline was implemented in July 2007 and a period of one month was allowed for normalisation of practice. Post-test data was collected for all patients with ED discharge diagnosis stroke from 1 August–31 October 2007 (n = 41).

Ethical considerations This study was approved by the Human Research and Ethics Committee at TNH.

debate about changes to practice and this level of interaction facilitated emergency nurses’ understanding of the rationale for the recommendations made in the guideline. It was also important for the tutorials to emphasise the important influence of nursing care of outcomes for patients with acute stroke. Tutorials were used previously in ED at TNH by Considine and Brennan (2006) to promote uptake of evidence and change practice related to paediatric fever management practice in the ED at TNH. Adaptation of the ICSI Guideline (Anderson et al. 2006) and development of the tutorial occurred in conjunction with the ED Clinical Nurse Educators, Emergency Physicians, allied health personnel (speech pathologists, physiotherapy and dieticians) and physicians from the inpatient medical unit that specialises in stroke management. The tutorial was delivered on eight occasions and captured 48 emergency nurses. The guideline was also placed in the nursing communications folder and on the desk top of all computers in the ED and was promoted by the researchers and ED Clinical Nurse Educators.

Procedure/data collection Intervention The intervention for the study was a guideline for the emergency nursing management of stroke that was implemented in June 2007. Details of the guideline development and content are presented elsewhere (McGillivray & Considine 2009). The guideline was based primarily on the Institute for Clinical Systems Improvement (ICSI) Diagnosis and Initial Treatment of Ischemic Stroke Guideline (Anderson et al. 2006). The evidence presented in the ICSI Guideline was augmented by evidence-based recommendations from other key documents related to stroke management: Australian National Stroke Foundation Guidelines (National Stroke Foundation 2003), metaanalyses related to stroke management (Hajat et al. 2000), outcome studies (Weir et al. 1997) and local pressure injury and venous thromboembolism assessment and prophylaxis policies that supported the ICSI recommendations. The guideline was designed to be a summary document that accompanied usual ED nursing documentation: this decision was pragmatic and aimed to increase clinical utility of the guideline. Guideline implementation which was supported by a tutorial on stroke care delivered during nursing education time. An overview of the evidence contained in the guideline was presented during the 30 minute tutorial and the rationale for changes in emergency nursing care of stroke discussed. Importantly, the tutorials provoked robust discussion and 140

One of the researchers (BM) collected following data by medical record audit: • demographic data: patient age and gender; • ED system data: time of arrival, triage category, waiting time, mode of arrival and ED length of stay; • specialist referrals: assessment by stroke unit, speech pathology, physiotherapy, dietician and occupational therapy; • nursing assessment data: vital sign assessment, oxygen saturation and blood glucose monitoring, IV fluid regimes; • frequency of oral intake prior to swallowing assessment; • risk management: documentation of nil orally status, timing of swallow assessment, IV fluid regimes, venous thromboembolism risk assessment and interventions, pressure injury risk assessment and interventions.

Data analysis Data analysis was performed using the computer software  SPSS 14.0 for Windows (SPSS Inc., Chicago, IL, USA) Pretest and post-test data were compared to determine if prevention of early complications improves ED management of stroke. In addition to descriptive statistics (percentages, means, standard deviations), non-parametric data were compared using chi-square and Mann–Whitney U-tests and parametric data were compared using independent samples t-test (Polgar & Thomas 1991).

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15 • Critically reviewing research studies

Evidence-based practice in improving nursing care of acute stroke

Clinical issues

Results

Table 2 Median number of repeated nursing assessments by group

A total of 104 patients were recruited to the study: 63 patients in the pre-test group and 41 patients in the posttest group. As the study data were not normally distributed, medians and inter-quartile ranges are presented and non-parametric analyses were used to compare groups. There were no significant differences in the gender or age distribution of both groups: males comprised 49Æ2% of the pre-test group (n = 31) and 56Æ1% of the post-test group (n = 23) (v2 = 0Æ472, df = 1, p = 0Æ492). Patients in the pre-test group had a median age of 75 years [Inter-Quartile Range (IQR) = 59–82] and post-test group patients had a median age of 66 years (IQR = 58–77) (U = 1087Æ0, p = 0Æ174). This between-group difference in median age was not statistically significant. There was no significant between-group difference in the proportion of patients arriving by ambulance (54Æ0 vs. 53Æ7%) (v2 = 0Æ001, df = 1, p = 0Æ975) or who required interpreting services (27Æ4 vs. 14Æ6%) (v2 = 2Æ326, df = 1, p = 0Æ127). This study had three major findings following implementation of the ED stroke guideline. First, there was significant 21Æ4% increase in triage to Australasian Triage Scale (ATS) category 2 following implementation of the stroke guideline and significant 15Æ6% decrease in triage to ATS category 4 (Table 1). Second, there was increased frequency of repeated assessments of respiratory rate, heart rate, blood pressure and oxygen saturation (Table 2). There was also a non-significant increase in median number of Glasgow coma score assessments. Third, there were significant improvements in risk management. There was a 41Æ3% increase in patients who underwent a swallow assessment prior to oral intake (p = 0Æ003) and 13Æ8% increase in documentation of nil orally status (Table 3). There was no change in the frequency of risk assessments for venous thromboembolism or pressure areas however there was a significant 28Æ8% increase in the frequency of documentation of pressure area interventions (p = 0Æ006) (Table 3). In addition, the frequency of speech pathology assessment in ED increased by 16Æ1% (n = 3, 9Æ7 Table 1 Distribution of ATS categories by group Pre-test

ATS ATS ATS ATS

1 2 3 4

Post-test

n

%

n

%

p*

0 8 39 16

0 12Æ7 61Æ9 25Æ4

4 14 19 4

9Æ8 34Æ1 46Æ3 9Æ8

0Æ011 0Æ009 0Æ118 0Æ048

*Chi-square.

Respiratory rate Heart rate Blood pressure Temperature Glasgow Coma Score (GCS) SpO2 Blood sugar level (BSL)

Pre-test

Post-test

Mdn (IQR)

Mdn (IQR)

p*

8 8 8 4 4 5 4

12 11 12 4 7 10 4

0Æ009 0Æ022 0Æ032 0Æ310 0Æ163 0Æ001 0Æ310

(5–13) (5–12) (5–11) (2–5) (3–8) (3–10) (2–5)

(6–19) (5Æ75–19) (5Æ75–19) (2–6Æ5) (3Æ5–9Æ5) (5Æ5–19) (2–6Æ5)

*Mann–Whitney U.

Table 3 Risk assessment and interventions by group

Nil orally status documented Swallow assessment prior to oral intake VTE assessment VTE interventions Pressure area assessment Pressure area interventions

Pre-test

Post-test

n

%

n

%

p*

27

52Æ9

20

66Æ7

0Æ227

12

46Æ2

28

87Æ5

0Æ003

22 35 21 13

40Æ7 64Æ8 38Æ9 24Æ1

11 21 16 18

34Æ4 65Æ6 47Æ1 52Æ9

0Æ557 0Æ939 0Æ450 0Æ006

*Chi-square.

vs. 26Æ1%, n = 6) (v = 2Æ390, df = 1, p = 0Æ122) and median time to speech pathology assessment decreased by 93Æ5 minutes. The median time for speech pathology assessment for the pre-test group was 25Æ7 hours (IQR 17–52Æ9) and 24Æ1 hours (IQR 14Æ6–66Æ7) for the post-test group (U = 332Æ000, p = 0Æ816).

Discussion The results of this study highlight three major areas of practice change following implementation of the ED stroke guideline so the discussion to follow will focus on the importance of these changes in clinical practice for ED patients with acute stroke. The first major finding of this study was a significant shift in triage decision making with increased triage to Australasian Triage Scale category 2 (seen within 10 minutes) and decreased triage to Australasian Triage Scale category 4 (seen within 60 minutes). This finding is important as it suggests increased perception of urgency of stroke care by emergency nurses and acknowledgement that stroke is a medical emergency (National Stroke Foundation 2007). Further, triage of patients with actual or potential stroke as high acuity is the first step in facilitating early

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Nursing and Midwifery Research 4e

J Considine and B McGillivray

diagnosis, treatment and referral to specialist services: these factors are known to improve outcomes and prevent complications following stroke (Davernport & Dennis 2000, National Stroke Foundation 2003). The second major finding of this study was increased frequency of repeated physiological assessments. Increased physiological surveillance is a positive finding because control of abnormal physiological parameters may be a neuroprotective strategy following stroke (Bhalla et al. 2001). The median number of oxygen saturation assessments doubled in the post-test group despite no real differences ED length of stay suggesting increased frequency of assessment. Oxygen saturation monitoring is important following stroke as patients with acute stroke have lower oxygen saturation than matched controls (Elizabeth et al. 1993) and hypoxia increases cerebral injury following stroke (Bhalla et al. 2001, National Stroke Foundation 2003). Unfortunately, there were no major changes to temperature and blood glucose monitoring and this is an area of ongoing work for the ED. Temperature monitoring following stroke is important as hyperthermia is common in stroke patients due to infection preceding stroke, stroke related damage to the hypothalamus or as a result of thromboembolism (National Stroke Foundation 2003). Early hyperthermia in acute stroke increases risk of poor outcome, mortality and increased infarct size (Bhalla et al. 2001, Lewandowski & Barsan 2001, Anderson et al. 2006). One meta-analysis of hyperthermia and stroke outcomes showed a 19% increase in mortality for febrile patients (OR 1Æ19, 95% CI, 0Æ99–1Æ43) (Hajat et al. 2000) highlighting the importance of temperature control in patients with acute stroke. Hyperglycaemia following stroke is also associated with increased mortality and/or decreased functional outcome (Weir et al. 1997, Bhalla et al. 2001, Lewandowski & Barsan 2001, National Stroke Foundation 2003, Anderson et al. 2006) and blood glucose level over 8 mmol/l is a known predictor of mortality following stroke (adjusted for age, stroke severity and stroke type) (Weir et al. 1997). Finally, there were significant improvements in risk management, particularly related to safe swallowing. Documentation of nil orally status increased by 13Æ8% indicating increased awareness of nil orally status until swallowing is assessed. There was also a 41Æ3% increase in patients who underwent a swallow assessment prior to oral intake again highlighting the importance of safe swallowing following stroke. Impaired swallowing following stroke is associated with increased mortality (Lewandowski & Barsan 2001) and gag assessment is now known to be an unreliable indicator of swallowing (Lewandowski & Barsan 2001, National Stroke Foundation 2003). In addition, the frequency of speech 142

pathology assessment in ED increased by 16Æ1% and median time to speech pathology assessment decreased by 93Æ5 minutes. Although these differences in speech pathology assessment did not reach statistical significance, it may be argued that they are clinically significant. A key focus of the guideline used in this study was early referral to speech pathology and prior to guideline development, speech pathology referral was ad hoc and dependent on individual clinician knowledge and motivation. Speech pathology referral occurred mostly using telephone paging system which had major limitations out of hours when speech pathologists were not in the hospital. To coincide with implementation of the guideline, an electronic allied health referral system was activated on all ED computers. The increased incidence of speech pathology assessment in ED and decreased time to speech pathology assessment suggest that these changes were effective although there is scope for further improvement in facilitating speech pathology assessment. A further finding related to risk management was increased the frequency of documentation of pressure area interventions. Pressure ulcer risk assessment and prophylaxis are an important aspect of stroke care and patients with stroke are particularly prone to pressure ulcers as a result of increased age, immobility, incontinence, poor nutritional status, cognitive impairment and diabetes (National Stroke Foundation 2007). The ED stroke guideline used in this study highlighted existing organisational policies related to pressure ulcer prevention.

Limitations There are several limitations that should be considered when interpreting the study findings. First, this was a relatively small study conducted in one ED so the generalisability of findings may be limited. Second, the study method was reliant on nursing documentation as a proxy for care delivery and it may be argued that documentation does not accurately reflect actual practice. Observations of clinical practice would suggest that documentation is under-representative of nursing care; that is care is delivered but not documented. The findings of this study may therefore under-represent actual improvements in stroke management. Finally, the use of a pre-test post-test design has limitations given that data collection occurred over two different periods in time. Although there were no major changes in staff or ED policies during this time, the use of a control group would have been an ideal study design. The model of emergency nursing care delivery at TNH is team nursing: if staff were assigned to control and intervention groups the need to work together would make contamination of a control group unavoidable.

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15 • Critically reviewing research studies

Clinical issues

Conclusion Emergency nurses play a key role in acute stroke care and the role of ED staff in stroke care will expand as the burden of disease related to stroke results in increased service demand. Further, increased emergency demand and decreased access to inpatient beds may further increase the time patients spend in ED following acute stroke making emergency nursing management of acute stroke a fundamental factor in optimising patient outcomes following stroke. The results of this study have shown that an evidence-based guideline can improve stroke care in the ED and decrease clinical risk associated with acute stroke. Unfortunately, emergency nursing care is under-represented in many guidelines for the management of acute stroke and most guidelines focus on use of thrombolysis as the key to ED management of acute stroke. Irrespective of whether thrombolysis is a treatment option for acute stroke, sound emergency nursing management (accurate assessment and triage, rigorous physiological surveillance, management of physiological abnormalities and management of clinical risk) are fundamental to the health outcomes of patients with acute stroke. As the continuum of stroke care begins in the ED, detailed recommendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the management of acute stroke.

Acknowledgements This study was supported by a National Institute of Clinical Studies (NICS) Emergency Care Nursing Grant. NICS is an institute of the National Health and Medical Research Council (NHMRC), Australia’s peak body for supporting health and medical research.

Contributions Study design: JC; data collection and analysis: BM, JC and manuscript preparation: BM, JC.

References Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA & Wijdicks EFM (2007) Guidelines for the Early Management of Adults With Ischemic Stroke: a Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council and the Atherosclerotic Peripheral Vascular

Evidence-based practice in improving nursing care of acute stroke Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke 38, 1655–1711. Anderson D, Neacy K, Stead L, Koshnick R, Lee J, McRaith J, Haake B, Robinstein A, Lakshminarayan K, Wallace GJL, Hunteman T, Metfessel B & Suber S (2006) Health Care Guideline: Diagnosis and Initial Treatment of Ischemic Stroke, 5th edn. Institute for Clinical Systems Improvement. Available at: http://www.icsi.org/ knowledge/detail.asp?catID=29&itemID=166 last accessed October 2006, Minnesota. Bhalla A, Wolfe CDA & Rudd AG (2001) Management of acute physiological parameters after stroke. QJM: An International Journal of Medicine 94, 167–172. Clarke WM, Wissman S, Albers GW, Jhamandas J, Madden KP & Hamilton S (1999) Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. Journal of the American Medical Association 282, 2019–2026. Clarke WM, Albers GW, Madden KP & Hamilton S (2000) The rtPA 0 to 6 hour acute stroke trial, part A: results of a double-blind placebo-controlled multicenter study. Stroke 31, 811–816. Considine J & Brennan D (2006) Emergency nurses’ opinions regarding paediatric fever: the effect of evidence-based education program. Australasian Emergency Nursing Journal 9, 101–111. Davernport R & Dennis M (2000) Neurological emergencies: acute stroke. Journal of Neurology, Neurosurgery and Psychiatry 68, 277–288. Elizabeth J, Singarayar J, Ellul J, Barer D & Lye M (1993) Arterial oxygen saturation and posture in acute stroke. Age and Ageing 22, 269–272. Hacke W, Kaste M, Fieshchi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Hoxter G, Mahagne MH, Hennerici M & group ftEs (1995) Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. Journal of the American Medical Association 274, 1017–1025. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N & Toni D (2008) Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke. New England Journal of Medicine 359, 1317–1329. Hajat C, Hajat S & Sharma P (2000) Effects of Poststroke Pyrexia on stroke outcome: a meta-analysis of studies in patients. Stroke 31, 410–414. Kothari RU, Hanke W, Brott T, Dykstra EH, Furlan A, Koroshetz W, Marler J & Sayre MR (2001) Stroke. Annals of Emergency Medicine 37, S137–S144. Lees KWM (2005) Acute stroke and diabetes. Cerebrovascular Disease 20, 9–14. Lewandowski C & Barsan WG (2001) Treatment of acute ischemic stroke. Annals of Emergency Medicine 37, 202–216. Mackay J & Mensah G, eds (2004) The Atlas of Heart Disease and Stroke. World Health Organisation. Retrieved 9 April 2008 from http://www.who.int/cardiovascular_diseases/resources/atlas/en., Geneva McGillivray B & Considine J (2009) Implementation of evidence into practice: development of a tool to improve emergency nursing care

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J Considine and B McGillivray of acute stroke. Australasian Emergency Nursing Journal 12, 110– 119. National Stroke Foundation (2003) National Guidelines for Acute Stroke Management. National Stroke Foundation, Melbourne. National Stroke Foundation (2006) 10 Things You Should Know About Stroke. Retrieved on 13 January 2009 from http:// www.strokefoundation.com.au/facts-figures-and-stats. National Stroke Foundation (2007) National Guidelines for Acute Stroke Management. National Stroke Foundation, Melbourne. Northern Health (2007) Annual Report 2006/07. Northern Health, Epping. Pendlebury S & Rothwell P (2004) Stroke management and prevention. Medicine 32, 62–68. Polgar S & Thomas S (1991) Introduction to Research in the Health Sciences, 2nd edn. Churchill Livingstone, Melbourne.

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Royal College of Physicians (2004) National Clinical Guidelines for Stroke. 2nd edn. Prepared by the Intercollegiate Stroke Working Party. Royal College of Physicians, London. Victorian Department of Human Services (2007) Stroke Care Strategy for Victoria. Metropolitan Health and Aged Care Services Division, Department of Human Services. Retrieved 31 January 2008 from http://www.health.vic.gov.au/strokecare/stroke_care_ strategy.pdf, Melbourne. Wahlgren N, Ahmed N, Davalos A, Hacke W, Millan M, Muir K, Roine RO, Toni D, Lees KR & SITS investigators (2008) Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet 372, 1303–1309. Weir CJ, Murray GD, Dyker AG & Lees KR (1997) Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long term follow up study. British Medical Journal 314, 1303–1306.

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(Source: Considine J, McGillivray B 2010 An evidence-based practice approach to improving nursing care of acute stroke in an Australian Emergency Department. Journal of Clinical Nursing 19:138–44.)

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15 • Critically reviewing research studies

Summary

Evidence-based practice tip • A randomised controlled trial is the clinical equivalent of a true experiment and is used to determine cause and effect relationships. Participants are randomly assigned to experimental and control groups. • Randomisation is a key issue impacting on the validity of a study.

  Points to ponder Should findings that do not support the research hypothesis be reported? Should refereed journals publish studies that have not obtained ethical approval? How does the absence of study limitations affect the generalisability of the findings?

Research consumers need to have a clear understanding of the research process and major research approaches. Also required is the ability to read critically in order to objectively interpret and determine the usefulness and implications of a study for practice change. Critical reading involves reading for the levels of understanding. These are: preliminary; comprehensive; analysis; and synthesis understanding. Separate guidelines have been developed to assist in the critique of qualitative and quantitative studies. These guidelines provide a format for asking questions about the study and are useful in structuring a critical reading of qualitative and quantitative research studies.

Key points • The best way to become an intelligent research consumer is to have a clear understanding of the research process and the major research approaches. • The goal of synthesis understanding is to combine the parts of a research study into a whole. During this final stage the reader determines how each step relates to all the steps of the research, how well the study meets the criteria used to critique the study and the usefulness of the study for practice. • Critical reading involves active interpretation and objective assessment of an article, looking for key concepts, ideas and justification. • The most important point when analysing statistical procedures in a study is the relationship of the statistics used to the research question, design and method. • Clues to the appropriate statistical test to be used by the researcher should stem from the researcher’s hypothesis. • Ethical issues in qualitative research involve issues related to the naturalistic setting, emergent nature of the design, research–participant interaction and the ‘researcher as instrument’.

Learning activities 1. Nurses and midwives need to be able to critically read research articles because: a) all nurses and midwives should conduct research b) all nurses and midwives enjoy reading c) the knowledge will enhance their practice d) they will be able to base their practice on research evidence and improve patient care.

2. When planning your research study, a literature search is undertaken: a) to identify gaps and limitations in the published research b) to find a research topic c) because it is important to read many articles d) to see if other researchers like your topic.

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Nursing and Midwifery Research 4e

3. Synthesis understanding refers to: a) preliminary understanding b) seeing parts of the study in relation to the whole c) combining parts into a complex whole d) breaking the content into parts or sections. 4. Understanding a research article and seeing the terms in relation to the context relates to: a) preliminary understanding b) comprehensive understanding c) analysis understanding d) synthesis understanding. 5. The highest level of evidence for a therapy question is: a) a randomised controlled trial b) a descriptive design c) a correlational design d) a qualitative approach. 6. Ethical clearance from an HREC is necessary before commencing a study because: a) the HREC wants to know what your research is about b) the HREC wants to know when you intend to begin your research c) participants in the study can feel confident that they will be treated ethically if your study has been passed by a Human Research Ethics Committee d) participants want to tell their friends that they are taking part in a study. 7. Evidence-based practice is a quality improvement process because: a) you have critically analysed many research articles b) you have learned how to skim when reading research articles c) trial and error is still important in clinical practice d) evidence-based practice is a key factor contributing to accountability and benchmarking.

8. Stating recommendations for further research is important because: a) it indicates that you understand that further research would enhance the knowledge base of nursing or midwifery in that area b) it shows that you recognise the limitations of your research study c) readers like to get ideas about topics from research studies d) readers will think your research design was poor. 9. Writing about the implications of your study for healthcare is important because: a) readers like to know about health problems in the community b) a well-planned nursing or midwifery research study should have implications for healthcare c) it indicates a lack of careful planning before conducting the research d) people need to know what healthcare is about. 10. Providing an audit trail when analysing data is important because: a) it shows that you can audit your research b) it is useful to provide a trail for readers to follow c) it gives the reader information about the method by which data were analysed d) it makes the study more interesting.

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15 • Critically reviewing research studies

Additional resources Bannigan K, Watson R 2009 Reliability and validity in a nutshell. Journal of Clinical Nursing 18:3237–43 Dibley L 2011 Analysing narrative data using McCormacks Lenses. Nurse Researcher 18(3):13–19 Duffy J R 2005 Critically appraising quantitative research. Nursing and Health Sciences 7:281–3 Jiwe M 2011 Analysing qualitative data. Nurse Researcher 18(3):4–5 Kvale S, Brinkmann S 2008 Interviewing: Learning the Craft of Qualitative Research Interviewing, 2nd edn. Sage Publications, Thousand Oaks, California, USA Sandelowski M 2004 Using qualitative research. Qualitative Health Research 14(10):1366–86 Sandelowski M, Barroso J 2002 Finding the findings in qualitative studies. Journal of Nursing Scholarship 34(3):213–19 Sandelowski M, Barroso J 2003 Classifying the findings in qualitative studies. Qualitative Health Research 13(7):905–23 Saunders L D, Soomro G M, Buckingham J, Jamtvedt G, Raina P 2003 Assessing the methodological quality of non-randomised intervention studies. Western Journal of Nursing Research 25(2):223–37 Yardley L 2000 Dilemmas in qualitative health research. Psychology and Health 15(2):215–28

References Carlson C L, Plonczynski D J 2008 Has the BARRIERS Scale changed nursing practice? An integrative review. Journal of Advanced Nursing 63(4):322–33 Considine J, McGillivray B 2010 An evidence-based practice approach to improving nursing care of acute stroke in an Australian Emergency Department. Journal of Clinical Nursing 19:138–44 DiCenso A, Ciliska D, Cullum N, et al. 2004 Evidence-based Nursing: a Guide to Clinical Practice. Mosby, St Louis, USA Elmir R, Jackson D, Beale B, Schmied V 2010 Against all odds: Australian women’s experience of recovery from breast cancer. Journal of Clinical Nursing 19:2531–8 Emmanuel E, Creedy D K, St John W, Gamble J, Brown C 2008 Maternal role development

following childbirth among Australian Women. Journal of Advanced Nursing 64(1):18–26 Hutchinson M, Vickers M H, Wilkes L, Jackson D 2010 A typology of bullying behaviours: the experiences of Australian nurses. Journal of Clinical Nursing 19:2319–28 Jones S C, Crookes P A, Johnson K M 2011 Teaching critical appraisal skills for nursing research. Nurse Education in Practice 11:327–32 Lin C-J, Hsu C-H, Li T-C, Mathers N, Huang Y-C 2010 Measuring professional competency of public health nurses: development of a scale and psychometric evaluation. Journal of Clinical Nursing 19:3161–70 O’Leary D F, Mhaolrunaigh S N 2011 (in press) Information-seeking behaviour of nurses: where is information sought and what processes are followed? Journal of Advanced Nursing Pairman S, Tracy S, Thorogood C, Pincombe J 2010 Midwifery: Preparation for Practice. Elsevier, Sydney, Australia Paul R, Elder L 2001 Critical Thinking: Tools for Taking Charge of Your Learning and Your Life. PrenticeHall, Englewood, New Jersey, USA Paul R, Elder L 2006 The Thinker’s Guide on How to Read a Paragraph, 2nd edn. Foundation for Critical Thinking, Dillon Beach, California, USA Pravikoff D S, Tanner A B, Pierce S T 2005 Readiness of US nurses for evidence-based practice. American Journal of Nursing 105(9):40–51 Spenceley S M, O’Leary K, Chizaesky L L K, Ross A J, Estabrooks C A 2008 Sources of information used by nurses to inform practice: an integrative review. International Journal of Nursing Studies 45:954–70 Teate A, Leap N, Rising S S, Homer C S E 2011 Women’s experiences of group antenatal care in Australia — the Centering Pregnancy Pilot Study. Midwifery 27:138–45 Van Manen M 1990 Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. State University of New York, New York, USA Weller C, Jolley D, Wolfe R, Myers K, McNeil J 2010 Effect of elasticity on sub-bandage pressure of three tubular compression bandages in healthy volunteers: a RCT. Journal of Wound Care 19(10):417–23 Whittemore R 2005 Combining evidence in nursing research: methods and implications. Nursing Research 54:56–62

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