1Received: June 13rd 2020; Accepted: Aug. 4th 2020. Rev Rene. 2020;21:e44466.

Rev Rene. 2020;21:e44466. DOI: 10.15253/2175-6783.20202144466 www.periodicos.ufc.br/rene

Original Article

Knowledge about the use of potentially dangerous drugs among hospital health care nurses*

Conhecimento sobre uso de medicamentos potencialmente perigosos entre enfermeiros da assistência hospitalar à saúde

ABSTRACT Objective: to characterize the knowledge about the use of potentially dangerous drugs among hospital health care nurses. Methods: quantitative, descriptive-exploratory re- search, with the application of a validated questionnaire, translated and adapted in Brazil, on potentially dangerous medications, with 26 nursing assistants in a university hos- pital. Univariate and bivariate descriptive statistical analysis of the data was performed using the Statistical Package for Social Science, version 20. Scores ≥70% were considered as sufficient knowledge and insufficient knowledge scores <70%. Results: in the first domain of the questionnaire, called Medication Administration, the average percentage of correct answers was 64.6%. In the second domain, Clini- cal procedures, an average of 53.7% of correct answers was found. The use of electrolytes, chemotherapy and insulin were the main weaknesses in the knowledge of professio- nals. Conclusion: insufficient knowledge about the admi- nistration and clinical procedures of potentially dangerous drugs was identified among hospital care nurses in this sce- nario. Descriptors: Medication Errors; Potentially Inappropriate Medication List; Hospital Care; Patient Safety.

RESUMO Objetivo: caracterizar o conhecimento sobre uso de medi- camentos potencialmente perigosos entre enfermeiros da assistência hospitalar à saúde. Métodos: pesquisa quantita- tiva, descritiva-exploratória, com aplicação de questionário validado, traduzido e adaptado no Brasil, sobre medicamen- tos potencialmente perigosos, com 26 enfermeiros assisten- ciais em hospital universitário. Realizou-se análise estatís- tica descritiva univariada e bivariada dos dados, por meio do Statistical Package for Social Science, versão 20. Conside- raram-se como conhecimento suficiente escores ≥70% ou conhecimento insuficiente escores <70%. Resultados: no primeiro domínio do questionário, denominado Adminis- tração dos medicamentos, o percentual médio de acertos foi de 64,6%. No segundo domínio, Procedimentos clínicos, encontrou-se média de 53,7% de acertos. O uso dos eletróli- tos, quimioterápicos e de insulina foram as principais fragi- lidades no saber dos profissionais. Conclusão: identificou- -se conhecimento insuficiente sobre a administração e os procedimentos clínicos de medicamentos potencialmente perigosos entre os enfermeiros assistenciais hospitalares neste cenário. Descritores: Erros de Medicação; Lista de Medicamentos Potencialmente Inapropriados; Assistência Hospitalar; Se- gurança do Paciente.

*Extracted from the Course Conclusion Paper “Saberes e práticas dos enfermeiros acerca dos medicamentos po- tencialmente perigosos na assistência hospitalar à saúde”, Universidade Federal de Sergipe, 2017.

1Universidade Federal de Sergipe. Lagarto, SE, Brazil. 2Universidade Federal de Sergipe. São Cristóvão, SE, Brazil.

Corresponding author: Ingrede Tatiane Serafim Santana Universidade Federal de Sergipe. Av. Marechal Rondon, s/n - Jardim Rosa Elze, CEP: 49100-000. São Cristóvão, SE, Brazil. E-mail: [email protected]

EDITOR IN CHIEF: Ana Fatima Carvalho Fernandes ASSOCIATE EDITOR: Renan Alves Silva

Gilvan Oliveira dos Santos1 Anny Giselly Milhome da Costa Farre1 Ingrede Tatiane Serafim Santana2 Hertaline Menezes do Nascimento Rocha1 Adriana Andrade Carvalho1 Gleyce Kelly de Brito Brasileiro Santos2 Ana Liz Pereira de Matos1

How to cite this article: Santos GO, Farre AGMC, Santana ITS, Rocha HMN, Carvalho AA, Santos GKBB, et al. Knowledge about the use of potentially dangerous drugs among hospital health care nurses. Rev Rene. 2020;21:e44466. DOI: https://doi.org/10.15253/2175-6783.20202144466

Santos GO, Farre AGMC, Santana ITS, Rocha HMN, Carvalho AA, Santos GKBB, et al

Rev Rene. 2020;21:e44466.2

Introduction

Medication administration is a complex pro- cess in the daily practice of nursing professionals, which requires adequate knowledge about pharma- cology and technical skills for execution(1). In the hos- pital environment, drug therapy is widely used as a therapeutic approach to health recovery, the practice of which is associated with potential and real risks to patient safety(2).

Research has shown significant rates of medi- cation errors in a hospital environment(3-4). Medica- tion errors are preventable adverse events that can cause harm to the patient and, in critical situations, result in death. The occurrence of this type of failure can be associated with factors such as failures in the prescription and dispensing of drugs, lack of commu- nication among professionals, pharmaceutical pro- cedures, work overload, professional knowledge and attitude, inadequate identification and similar names of the drugs(2-3,5).

Drugs associated with a higher risk of injuring the patient, due to failures in use, are known as po- tentially dangerous or highly surveillance drugs and include therapeutic classes, such as neuromuscular blockers, and specific drugs, such as injectable con- centrated potassium chloride(6).

Nursing professionals are an important barrier in preventing errors in the administration of poten- tially dangerous drugs, as they can act in anticipation, identification and prevention of occurrence. Despite this, errors continue to happen, and the insufficient knowledge of the nursing team on the subject has been reported as the main triggering factor(7).

Specifically, nurses have a relevant decision- -making role in the management of potentially dan- gerous medications, either by working directly with patients or in the guidance/supervision of nursing teams. Therefore, it is important to identify nurses’ knowledge about these drugs, in order to contribute to making positive and critical decisions in the stages

of error prevention. Thus, this study aimed to charac- terize the knowledge about the use of potentially dan- gerous drugs among nurses in hospital health care.

Methods

Quantitative, descriptive-exploratory research, carried out with nursing assistants from a Brazilian university hospital, with urgent and emergency servi- ces, located in the Northeast Region, in the countrysi- de of Sergipe, Brazil. The hospital had 112 operational beds, 32 of which were for adult medical clinic, 12 for pediatric clinic, 20 for surgical clinic, 10 for adult in- tensive care, 41 for emergency care (23 observation beds, 15 semi-intensive beds and three for intensive care) and two operating rooms with post-anesthetic recovery.

The nursing workforce consisted of 202 pro- fessionals, 162 (80.2%) of whom were technical and/ or auxiliary and 40 (19.8%) of higher education. This hospital was in a transition period from the state to the federal public administration, during the data col- lection of the present research, from December 2016 to February 2017. Most employees were still linked to temporary employment contracts and/or redistribu- tion plans to other hospitals.

The sample plan included the assistance nurses of the institution, who were contacted personally by the researcher, at moments considered more relaxed during the shift or when desired/planned by the pro- fessional, in a reserved place. The final sample consist- ed of 26 nurses, considering the reasons for exclusion: legal leave (n=5), did not answer the questionnaire, after three attempts to contact (n=5), and refusal to participate (n=4). Because the questionnaire was de- veloped for the exclusive measurement of knowledge about potentially dangerous drugs by nurses(8), nurs- ing technicians and assistants were not included in the sample.

This questionnaire was developed and validat- ed by the Chinese, with face, content and construct

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Knowledge about the use of potentially dangerous drugs among hospital health care nurses

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validations; internal consistency was evaluated us- ing the Kuder-Richardson formula 20 reliability co- efficient (KR-20), obtaining a satisfactory value, with α=0.74(8). For application in Brazil, the instrument was translated, culturally adapted, evaluated and val- idated, through the face and content validities of the instrument, with subsequent pre-test(9). It is a self-ad- ministered instrument, with 20 statements (17 false and 3 true), “true”, “false”, “I don’t know” answer op- tions and a final score of 100 points, divided into two domains: the first, on medication administration, ad- dresses storage, prescription, dispensing and admin- istration particularities; and the second, about clinical procedures related to administration, particularities such as routes of administration and dosages(9-10).

The data were tabulated in Microsoft Office Excel and analyzed in the Statistical Package for the Social Sciences, version 20 for Windows. Descriptive statistical analysis was performed using univariate and bivariate techniques to obtain the distribution of absolute and relative frequencies, considering the sig- nificance level of 5%. For classification of knowledge, scores ≥70% were considered as good knowledge and scores <70%, as low knowledge(10). The data are pre- sented in tables.

Ethical and legal aspects in research involv- ing human beings were respected and the proj- ect was approved by the Research Ethics Com- mittee, with Presentation Certificate for Ethical Appreciation No. 62175516.0.0000.5546 and opinion No. 1,875,657/2016.

Results

The study data showed a predominance of fe- males (65.4%) among the 26 participating nurses, with an average age of 35.5 years, a minimum age of 26 and a maximum age of 50 years. Most professio- nals had a time of training and experience ≤ 10 years (73.0%), with an average of 8.6 years of training, a mi- nimum of four and a maximum of 20 years. The avera- ge length of professional experience was eight years,

with a minimum of three and a maximum of 20 years. Among the participants, 23 (88.5%) of the nurses had postgraduate degrees, with a predominance of specia- lization, 22 (95.6%). Regarding the sector of activity in the university hospital, 12 (46.2%) worked in the emergency room, followed by the sectors of medical clinic, 4 (15.4%); intensive care unit; 4 (15.4%); surgi- cal clinic, 3 (11.5%); pediatrics, 2 (7.7%); and surgical center, 1 (3.8%).

Information about nurses’ employment rela- tionships showed that 14 (53.8%) of the participants had two or more bonds, compared to 12 (46.2%) who worked only in the investigated hospital. It should be noted that, among the professionals who had two or more bonds, seven worked in the emergency room and one in the intensive care unit. Data on the appli- cation of the questionnaire on potentially dangerous drugs with hospital assisting nurses, with a percenta- ge of correct answers and errors in the responses of the participants to the first (medication administra- tion) and the second (clinical procedures) domains of the questionnaire, with ranking of correct answers, are described in Tables 1 and 2, respectively.

In the first domain of the questionnaire, the average percentage of correct answers was 64.6%. Data on medication administration by professionals showed that the highest error rate (80.8%) was found in item 1.4, referring to multiple concentrations for the same medication. Item 1.10, on the differentiation in labels for medicines with similar names, was the one with the highest rate of correct answers (96.2%). Item 1.3, on the storage of insulin and heparin, ob- tained 92.3% of correct answers; in turn, item 1.6, about the correct storage of potassium chloride (KCl 19.1%), represented the second item with the highest error rate (46.2%). The highest percentage of “don’t know” responses was 27.0%, being found in item 1.8, which dealt with the transdermal patch of fentanyl as a medication for controlled use. The storage of neuro- muscular blockers, such as atracurium, also acquired a 15.4% “don’t know” response, in addition to an error rate of 30.8% among nurses.

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Table 1 – Description of the participants’ responses to the first domain, Drug Administration, of the Question- naire on Potentially Dangerous Drugs. Sergipe, SE, Brazil, 2017

Item/ Domain 1

Issue focus *Answer

Pattern (T∕F) Hits (%)

Error (%)

Does not know (%)

Ranking

1.1 Use “ampoule” or “vial” to express the dose instead of “mg” or “g” F 76.9 19.2 3.9 4º

1.2 Use “U” instead of “unit” for dose expression F 61.5 38.5 0 6º

1.3 For convenience, heparin and insulin should be stored together F 92.3 7.7 0 2º

1.4 Medicines must have multiple concentrations to allow choice F 0 80.8 19.2 10º

1.5 Oral administration of potassium is preferable to intravenous adminis- tration

T 57.7 34.6 7.7 7º

1.6 Potassium chloride 19.1% is in frequent use, so it should have easy access F 50 46.2 3.8 9º

1.7 Use “tablespoons” for pediatric dose expression F 88.5 11.5 0 3º

1.8 Treat the fentanyl transdermal patch as a controlled drug T 69.2 3.8 27 5º

1.9 Neuromuscular blockers, such as atracurium, should be stored in an easily accessible place

F 53.8 30.8 15.4 8º

1.10 Medicines with similar names must be differentiated on the label T 96.2 3.8 0 1º

Average 64.6 27.7 7.7 *T:True; F: False

Table 2 – Description of the participants’ responses to the second domain, Clinical procedures, of the question- naire on Potentially Dangerous Drugs. Sergipe, SE, Brazil, 2017

Item/ Domain 2 Issue focus

*Standard Response (T∕F)

Hits (%)

Error (%)

Does not know (%) Ranking

2.1 In mild allergic reactions with erythema, rapidly administer an ampoule of epinephrine 1: 1000 via IV

F 76.9 7.7 15.4 2º

2.2 In emergency cases, administer quickly (1 to 2 minutes) 10 ml of 10% Calcium Gluconate

F 30.8 30.8 38.4 9º

2.3 10% Calcium Gluconate and 10% Calcium Chloride are the same medicine and can be substituted for each other

F 73.1 7.7 19.2 3º

2.4 “Cc” or “mL” are used to express the dose of insulin F 88.5 7.7 3.8 1º

2.5 In calculating the dose of chemotherapy, weight is used for adults and body surface for children

F 46.2 7.7 46.1 8º

2.6 In emergencies such as ventricular fibrillation, administer 19.1% KCl IV bolus

F 61.5 26.9 11.6 5º

2.7 If the patient’s situation requires it, add 10 ml of 19.1% KCl to the ringer’s pouch and administer with rapid drip speed

F 50.1 15.4 34.5 6º

2.8 The insulin syringe can be replaced by the 1 ml syringe and the tuberculin syringe

F 26.9 65.4 7.7 10º

2.9 Administer 500 ml of 20% NaCl with rapid drip to patients with low sodium levels

F 50 23.1 26.9 7º

2.10 Chemotherapy access can be used for blood collection and medication administration in general

F 69.2 15.4 15.4 4º

Average 57.3 20.8 21.9

*T:True; F: False

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The average of correct answers in the second domain of the questionnaire was 57.3%. According to the answers, the item with the highest percentage of correct answers (88.5%) was 2.4, which addressed the unit of insulin dose in ml or cc; in turn, the item with the highest error rate (65.4%) was 2.8, which discussed the replacement of the insulin syringe, with a rate of 26.9%, in correct answers among professionals. The approach on the use of 10.0% calcium Gluconate in emergency presented a percentage of correct answers and errors in 30.8%, representing the second item with the highest percentage of errors by the participants. The response rate “does not know” with a higher percentage (46.1%) was found in item 2.5, which dealt with the dosage of chemotherapy for adults and children, presenting a rate of 46.2% in correct answers and constituting the third question with less hits. No statistically significant relationships were found between the participants’ sociodemographic data and knowledge about potentially dangerous drugs.

Discussion

The main difficulties encountered in conduc- ting the study were related to the application of the questionnaire, as the professionals were afraid to res- pond to an instrument that could assess their know- ledge as erroneous. Thus, the researcher reinforced the ethics and benefits of research, and even in the face of some refusals, he was accessible and available to wait patiently during the professional’s shift, since he could not be taken home.

The study limitation was related to the develo- pment in a single hospital, with a relatively small sam- ple of nurses and a descriptive approach to the data. Therefore, it points out the need to conduct multicen- tric research, with comparative analyzes, and evalua- tions of the type before and after training on the sub- ject, even with control groups.

The strength of the study was to reveal a profile that can serve as a comparison to other Brazilian stu- dies, as well as to similar hospitals. Despite being a lo-

cal context, the data highlighted the need to reinforce nurses’ knowledge, which may reflect on safer nursing practice and better guidance of work teams. Nursing teaching institutions can pay attention to the areas of greatest knowledge deficiency, presented in the stu- dy, and thus develop specific teaching programs. For health institutions, the need to adopt permanent edu- cation strategies with professionals is reinforced to contribute to patient safety.

The length of experience and the continuous encouragement of the institution can represent im- portant factors for the involvement of professionals in health care and in continuing education activities for the necessary improvement of the profession, directly influencing patient safety(11).

In Brazil, there is a greater performance of nur- sing professionals between 26 and 50 years old, with a tendency for a decrease in the workforce of nurses up to 60 years old. In addition, the average salary of nurses, which is in the range of R$ 2,000, which can influence the performance in other bonds, without observing, in most cases, the increase in substan- tial income; furthermore, the exhaustive routine can compromise the professional’s biopsychosocial heal- th and, consequently, influence the assistance provi- ded(12).

Continuing education strategies are essential for improving nurses’ knowledge and practice(13). With regard to knowledge about potentially dange- rous drugs, the average number of correct answers found, in the present study, on important aspects in their administration (64.6%), was close to the finding in a study carried out with nurses in Palestine, in whi- ch an average of correct answers in 58.9%, which may be related to the greater number of nurses participa- ting in the study (n=301)(10).

In medication administration, the highest num- ber of concentrations and multiple dosages can re- present a risk factor for the occurrence of errors(10). Thus, data that revealed the belief in the existence of multiple concentrations of potentially dangerous dru- gs among the nurses in the study evidenced the lack

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of knowledge about important aspects that may favor medication errors in patient care, reinforcing the im- portance of the immediate adoption of measures that prevent this occurrence.

Methods to avoid medication errors, accor- ding to safe practices in the use of high-risk drugs, include reducing the number of pharmaceutical pre- sentations; standardization of presentations; use, whenever possible, of the lowest concentration pre- sentation/formulation; limitation of the number of presentations and concentrations available, as well as the elaboration of educational materials easily acces- sible to professionals(4,14).

The reduction of medication errors is associa- ted with the adoption of educational strategies, such as the production of educational materials; organiza- tional, such as the elaboration of institutional proto- cols; and technological, such as the implementation of computerized systems(14). Thus, the importance of care with medicines with similar names and common- ly used in the institution is highlighted, and the parts of the names that differentiate them should be highli- ghted, and preferably stored in separate locations(4).

Ways of storing neuromuscular blockers and using and storing potassium chloride also showed high error rates among nurses. Neuromuscular blo- ckers present particularities in use and storage, and must be stored separately and labeled with an alert identification for the risk of inappropriate use, mainly due to the erroneous administration being associated with significant damage or the death of the patient; si- milar packaging and labeling, lack of knowledge about improper use and storage are among the main reasons for lethal adverse events involving these drugs(15).

In the administration of medications, intrave- nous infusions can occur continuously or intermitten- tly, quickly between 3 and 5 minutes, in 30 minutes, or in periods of 1 to 3 hours, considering factors such as patient conditions and possible complications(16). The concentration of the substance is an important factor to be considered. Knowledge about potassium chlori- de, for example, is fundamental in therapy, since po-

tassium imbalances can bring serious consequences to patients’ lives and require immediate action in he- alth, which can cause arrhythmias, paralysis and we- akness; in intravenous administration, the potassium concentration should not exceed 20 mEq/h (100–150 mEq/day)(17).

The data on clinical procedures with poten- tially dangerous drugs investigated in the present stu- dy showed a correct rate (57.3%), close to that found in a study carried out in Palestine, in which a 60.9% correct rate was identified(10). The main deficiency found among participating nurses regarding clinical procedures was related to the replacement of the in- sulin syringe with the 1 ml or the tuberculin.

Insulin is a drug that requires precision in the dosage administered, errors related to its use can cause serious damage, such as prolonged exposure to hypoglycemia and consequent confusion, fainting or convulsion, period of exacerbated hyperglycemia or even death of the patient; these events are mainly associated with preparation and infusion(18). Thus, the replacement of the unit syringe with the one for mL or tuberculin can contribute to the error in the pre- paration and administration of insulin, resulting in hypoglycemia and hyperglycemia that will bring con- sequences to the patient.

Aspects about the speed of administration of 10% calcium gluconate should also be addressed by health institutions with professionals, due to the limi- ted knowledge shown in the study. The speed of in- fusion of calcium gluconate should be slow, since the rapid infusion is associated with bradycardia or asys- tole; in symptomatic cases of hypocalcemia, the admi- nistration of 1 to 2 g of calcium gluconate is allowed in 10 to 20 minutes(17).

The lack of knowledge about chemotherapy calculations, evidenced among the study participants, demonstrated that nurses may not be used to using chemotherapy drugs, which is probably due to the lack of chemotherapy treatment in the institution where the collection was performed. However, as most nur- sing professionals can work in more than one health

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Knowledge about the use of potentially dangerous drugs among hospital health care nurses

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institution, knowledge of this information is essential to avoid the occurrence of errors associated with the administration of chemotherapy drugs(11).

In addition, the gradual increase in the role of nurses in palliative care assistance to patients with cancer and other chronic diseases, mainly related to aging, has demonstrated the importance of knowled- ge and practice of procedures, such as hypodermo- clysis for medication administration, due to subcuta- neous route is being well supported by these patients. However, the use of this action can be associated with complications that, although they are mostly easily re- versible and with low potential to cause damage, rein- force the relevance of care with the administration of medications by professionals(19).

Data found in this study pointed to an urgent need for permanent education with health care pro- fessionals. Nursing and health institutions are co- -responsible for the permanent education of profes- sionals, as a way to guarantee safe and risk-free health care, due to the importance of patient safety(11,13).

Conclusion

Insufficient knowledge about the administra- tion and clinical procedures of potentially dangerous drugs was identified among hospital assisting nurses, mainly related to the use of electrolytes, chemothera- py and insulin. Therefore, it is essential to adopt pro- fessional, institutional and educational actions, with a priority focus on these drugs, to improve safety in the use of medicines.

Collaborations

Santos GO and Farre AGMC contributed to the conception, design, analysis and interpretation of data, writing, relevant critical review of the intellectual con- tent and final approval of the version to be published. Santana ITS, Rocha HMN, Carvalho AA, Santos GKBB and Matos ALP collaborated with a relevant critical re- view of the intellectual content, writing of the article and final approval of the version to be published.

References

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Ethical Considerations

Evaluate the article and identify potential ethical considerations that may have occurred when sampling, collecting data, analyzing

data, or publishing results. Summarize your findings below in 250-500 words. Provide rationale and support for your evaluation.

Application of Analysis

Chapter5

Essential Questions

• What are the essential elements in evaluating prior research?

• How does the analysis of quantitative versus qualitative studies differ?

• How are results communicated from data collection and analysis?

Introduction

The use of statistics and statistical analysis is part of the clinical practitioner’s role. This may appear in different

ways from reviewing existing clinical research to participating in a study. There are some critical questions

when understanding statistics and the role of clinician in health care:

• Why is it important to keep up-to-date on clinical research?

• Why is it important for health care facilities to conduct ongoing studies?

• What type of studies are important?

Previous chapters focused on understanding the elements of statistics and research, including how to select and

conduct hypothesis testing based upon the type of data collected. This chapter focuses on the application of prior

information to understand information written in prior research studies and set up statistical tests and interpret

results both statistically and clinically.

Academic Research Study Extraction

In the evaluation of research articles, it is important that key areas can be identified for interpretation and

understanding. In the review of both qualitative and quantitative research, it can be daunting to extract the relevant

information to determine the primary goals and outcomes of the study. For clinical studies, this also means

addressing the epidemiology.

The simplest way to extract relevant information is to first start with those key areas.

1. Topic: What is the broad topic research area/title? 2. Problem statement: What is the problem that the research is attempting to address? In many studies, authors identify

a lack of research in a specific area or population.

3. Purpose statement: Why did the author complete the study? In some studies, this often appears in a sentence containing the phrase, “the focus of this study … ”

4. Research questions: What specific questions does the author need to address? In many articles, this is not explicitly written but can be derived.

5. Hypothesis, variables, or phenomena: What are the variables the author has identified to address the research goal (quantitative)? How is the phenomena described that the author seeks to better understand (qualitative)?

6. Sample and location: What was the sample used, and where did the study take place? 7. Methodology: Was the research quantitative or qualitative? Did the author provide any more details, such as

quantitative correlational or qualitative case study?

8. Data collection: How did the author approach data collection? For example, did the author use surveys, interviews, or clinical studies?

9. Data analysis: What approach did the author use to analyze the data? Did the author mention statistical tests? What type of statistical data was provided? What type of information is provided with qualitative studies?

10. Results: What were the results of the study? Did the author find anything significant? Did the study address epidemiology?

These 10 questions for article evaluation are useful to perform a quick review of the study’s key elements; however,

it is important to start the process by first reading the full article. The format in which information is displayed in

Table 5.1 can be used as a template to organize information found for each of these article elements. In some

studies, information can be easily located in the abstract and in clearly organized sections; however, this is not

always the case.

Table 5.1

Quantitative Article Evaluation

Article Citation Aljohani, A. H., Alrubyyi, M. A., Alharbi, A. B., Alomair, A. M., Alomair, A. A., Aldossari, N. A.,

& ... Tallab, O. M. (2018). The relation between diabetes type II and anemia. The Egyptian Journal

of Hospital Medicine, 70(4), 526. doi:10.12816/0043795

Point Description

Broad Topic

Area/Title

The Relation Between Diabetes Type II and Anemia

Problem

Statement

“There is consequently a need for more studies on the incidence and prevalence of anemia among

patients with diabetes mainly those with renal malfunction” (p. 527).

Purpose

Statement

“This study consequently purposed to determine the pervasiveness of anemia due to renal

insufficiency among patients with type 2 diabetes” (p. 526, 527).

Research

Questions

Is there a relationship between patients with anemia and patients with type II diabetes?

Define Variables/

Hypotheses

Categorical variable: Gender

Continuous variables: Age, Hb, Ferritin, MCV, TIBC, FBG, Erythroietin, eGFR, Urea, Na, K, CA,

and HbA1c

(found on pages 528 and 529)

Sample 50 participants

Case group: 25 participants with diabetes (8 male/17 female)

Control group: 25 participants without diabetes (7 male/18 female (p. 528)

Methodology Quantitative, case-control study (p. 527)

How was Data

Collected?

Medical records for the patients were examined from physical examinations (p. 528)

How was Data

Analyzed?

SPSS; descriptive statistics for categorical; summary statistics, independent t-test; and ANOVA

test; Pearson correlation for Hb and HG for both male and female (p. 528)

What Were the

Results?

The study indicated the following were statistically significant (low p-values) between the case

group and control group.

Hb Male and Hb Female

Ferritin Male and Ferritin Female

MCV

TIBC

Of the biochemical parameters, the following were significant:

FBG, Erthropoietin, eGFR, Urea, K, C1, Ca, HbA1c

Creatinine was not significant

In the correlation test, HB and HG (female) was significant, but

HB and HG (male) was not significant.

(pp. 528-529)

Clinical implications:

The study did find a higher occurrence of anemia in patients with diabetes (87.5% males, 82.3%

female). The study also concluded that the presence of anemia may increase the likelihood of

poorly controlled diabetes (p. 529).

Check for Understanding

1. Would there be any additional evaluation of the article? 2. Did the researchers appear to follow ethical guidelines? 3. What were the assumptions and limitations of the study?

Table 5.2

Qualitative Article Evaluation

Article

Citation

Jangland, E., Nyberg, B., & Yngman-Uhlin, P. (2017). It's a matter of patient safety: Understanding

challenges in everyday clinical practice for achieving good care on the surgical ward - a qualitative

study. Scandinavian Journal of Caring Sciences, 31(2), 323-331. doi:10.1111/scs.12350

Point Description

Broad Topic

Area/Title

Identify the challenges and barriers linked to quality care and patient safety in the surgical ward.

Problem

Statement

“Identify the challenges and barriers linked to quality of care and patient safety in the surgical

ward” (p. 324). Study addresses gap where there were only a few studies that looked at both the

nurses’ and leaders’ perspective.

Purpose

Statement

“The aim of this study was to explore, from the perspectives of care leaders, the situations and

processes that support or hinder good and safe care on the surgical ward” (p. 324).

Research

Questions

What are the perspectives of leaders on the processes that support good quality care in the surgical

ward?

What are the perspectives of leaders on processes that hinder good quality care in the surgical

ward?

How do leaders’ experiences inform improvement in clinical practice?

Describe

Phenomena

Categorical variable: Gender

Continuous variables: Age, Hb, Ferritin, MCV, TIBC, FBG, Erythroietin, eGFR, Urea, Na, K, CA,

and HbA1c

(found on pages 528 and 529)

Sample “10 leaders in surgery departments (four department leaders and six nursing managers) from 1

university hospital and 2 county hospitals in different regions in Sweden” (pp. 324-325).

Methodology Qualitative-descriptive design

How was

Data

Collected?

Repeated reflective interviews using semistructured interviews

How was

Data

Analyzed?

Systematic text condensation

What Were

the Results?

Study identified four major themes (pp. 326-328):

1. Constant demands for increased efficiency and production 2. Continual nursing turnover and loss of competence 3. A traditional hierarchical culture 4. Vague goals and responsibilities in the development of nursing care

Clinical implications:

Based upon the study, which has limitations as it was performed in one country (Sweden),

organizational changes are required to ensure higher levels of competence of staff and resources

available to surgical ward nurses to ensure higher quality care (p. 330).

The two evaluations above provide a roadmap for reviewing prior research. Much of the research completed in the

clinical setting may not be as comprehensive; however, it is important to understand the process. In a clinical

setting, there may be opportunities to reduce cycle time, increase quality, or participate in studies that influence

health outcomes. Understanding the process, knowing how to evaluate the data, and communicating the results

enables contribution to the organization.

Application of Statistics to Scenario

A medical office has noticed an increase in patient dissatisfaction and as well as an increase in usage of urgent care

facility services rather than seeing their primary care physicians (PCPs). To increase understanding of the patient

perception, the office surveyed the patients and received 81 responses. The survey includes a total of eight

questions. The first five questions capture satisfaction and urgent care utilization responses, and the last three

questions capture data on education, gender, and age group.

• Q1: You meet with your Primary Care Physician greater than one time per year. Responses Strongly Disagree to

Strongly Agree.

• Q2: You spend more than 10 minutes with your Primary Care Physician discussing health concerns. Responses

Strongly Disagree to Strongly Agree.

• Q3: You are more likely to go to urgent care versus your Primary Care Physician. Responses Strongly Disagree to

Strongly Agree.

• Q4: What is the number of times you went to urgent care in the past 12 months? Numerical response requested.

• Q5: Rate your overall satisfaction with the medical office. Responses Strongly Disagree to Strongly Agree.

• Q6: What is the highest level of education you completed?

• Q7: What is your gender?

• Q8: What is your age?

To review the responses from the data collected in the scenario, click on the button below.

Scenario Data

Table 5.3

Patient Dissatisfaction Application Scenario

Point Description

Broad Topic Area/Title Understand the relationship between patient satisfaction and usage of

services at urgent care facilities.

Problem Statement Recent indicator identified lower patient satisfaction and higher incidence

of using services at urgent care facilities. There is a need to understand the

perception of patient satisfaction for the XYZ medical office and decrease

usage of urgent care.

Research Questions What is the patient perception of satisfaction with the medical office?

Do patients use urgent care as an alternative to the primary care physician

(PCP)?

Is there a relationship between patient satisfaction and usage of urgent

care facilities?

Hypothesis H10: There is no relationship between the perception for number of visits

and perception of time spent with PCP.

H1A: There is a relationship between the perception for number of visits

and perception of time spent with PCP.

H20: There is no relationship between the perception for number of visits

and the likelihood to go to urgent care.

H2A: There is a relationship between the perception for number of visits

and the likelihood to go to urgent care.

H30: There is no relationship between the perception for number of visits

and the overall satisfaction.

H3A: There is a relationship between the perception for number of visits

and the overall satisfaction.

H40: There is no relationship between the perception time spent with PCP

and likelihood to go to urgent care.

H4A: There is a relationship between the perception of time spent with

PCP and likelihood to go to urgent care.

H50: There is no relationship between the perception of time spent with

PCP and overall satisfaction.

H5A: There is a relationship between the perception of time spent with

PCP and overall satisfaction.

H50: There is no relationship between the number of visits to urgent care

in past 12 months and overall satisfaction.

H5A: There is no relationship between the number of times went to urgent

care in past 12 months and overall satisfaction.

Describe Phenomena

(qualitative) or Define Variables/

Hypotheses (quantitative)

Nominal: education, gender, age group

Ordinal: Survey Questions 1-3 and 5

Continuous: Survey Question 4: Number of visits to urgent care in last 12

months

Sample 80 patients from XYZ medical office

How is Data Being Collected? Sent electronic survey to 300 patients, and received 80 responses.

How Will Data be Analyzed Descriptive statistics

Correlation analysis

What Were the Results? Statistical relationships were identified. The null hypothesis would be

rejected and the alternative hypothesis would be accepted in all cases.

From a practical perspective, while the results indicated higher scores for

the likelihood to go to urgent care versus the PCP, the actual descriptive

statistics for urgent care visits do not support this.

Communicating Results

The data can be sorted for communication based upon summary and descriptive statistics for some of the variables

prior to the hypothesis tests. As an example, to describe the sample respondents by age group and gender, the data

can be converted in Excel to percentages (see Table 5.4). These percentages can be written out or included in a

table.

Table 5.4

Converting Frequency to Percentage Example

Age Group Female Percent Female Male Percent Male Total Percent Total

by Age Group

< 20 9 18.0% 2 6.7% 11 13.8%

20-25 7 14.0% 4 13.3% 11 13.8%

23-31 10 20.0% 5 16.7% 15 18.8%

32-37 8 16.0% 4 13.3% 12 15.0%

38-43 6 12.0% 4 13.3% 10 12.5%

> 44 10 20.0% 11 36.7% 21 26.3%

Total 50 30 80

Even though the responses to the survey questions were ordinal as they were translated from Strongly Disagree (1)

to Strongly Agree (5), with larger samples, responses can be treated as continuous. Frequently, the three most

common forms of descriptive statistics are displayed in a chart. These include the mean, median, and standard

deviation (see Table 5.5).

Table 5.5

Example of Descriptive Statistics

Question n M Mdn SD

Q1 80 1.93 2.00 1.11

Q2 80 2.15 2.00 1.29

Q3 80 3.31 4.00 1.41

Q4 80 1.41 1.00 1.37

Q5 80 3.13 3.00 1.31

Beyond addressing some information on descriptive statistics, the hypothesis tests need to be addressed. Prior to

conducting statistical testing, the data needs to be assessed for normality. When assessing for normality, a

statistical program, such as SPSS, determines if the data meets the conditions of a normal distribution. Often, when

data is derived from survey data responses with ranges from strongly disagree to strongly agree, the data is not

normally distributed unless the samples are very large. In this case, the sample received was only 80. Table 5.6

displays the normality tests for the variables that will be tested. Because the sample size is lower, the Shapiro-Wilk

results should be used. The Kolmogorov-Smirnov test is most applicable for samples of more than 2,000 data

points. Based upon a 0.05 level of significance, a researcher would reject the null hypothesis, which stated that the

data was normally distributed.

Table 5.6

Test for Normality

Tests of Normality

Kolmogoroz-Smirnov a Shapiro-Wilk

Statistic df Sig. Statistic df Sig.

Q1 .247 80 .000 .771 80 .000

Q2 .250 80 .000 .810 80 .000

Q3 .237 80 .000 .866 80 .000

Q4 .256 80 .000 .801 80 .000

Q5 .211 80 .000 .895 80 .000

a. Lilliefors Significance Correction

Because the test results identified that the data was not normally distributed, a nonparametric test would be used

to conduct the hypothesis testing for correlation. The correlation test to use in this scenario is the Spearman Rho

test. If the data was normally distributed, the commonly used Pearson Product Moment test would be used.

Table 5.7 demonstrates the SPSS output for the Spearman Rho correlation test between survey Questions 1 and

2. Correlation coefficients are reviewed on a scale of -1 to +1. The relationship is stronger if the calculated

coefficient is closer to either -1 or +1. In this case, there is a strong relationship between meeting with the PCP

more than one time per year and spending more than 10 minutes with the PCP discussing health concerns.

Another statistic to review in the output is the p value. If the p-value is less than the level of significance

identified in the study, the null hypothesis would be rejected and the alternative hypothesis would be accepted.

Table 5.7

Test for Correlation Q1&Q2

Spearman’s rho Q1 Correlation Coefficient 1.000 .777**

Sig. (2-tailed) . .000

N 80 80

Q2 Correlation Coefficient .777** 1.000

Sig. (2-tailed) .000 .

N 80 80

Correlation coefficients are reviewed on a scale of -1 to +1. The relationship is stronger if the calculated

coefficient is closer to either -1 or +1. If the correlation coefficient is positive, then the two variables are moved

upward in the same direction. If the statistic is negative, then one variable increases as the other variable results

decrease (Levine, Krehbiel, Berenson, 2013). In this case, there is a strong relationship between meeting with PCP

more than one time per year and spending more than 10 minutes with the PCP discussing health concerns. Another

statistic to review in the output is the p-value. If the p-value is less than the level of significance identified in the

study, the null hypothesis would be rejected and the alternative hypothesis would be accepted. Table 5.8 displays

the remaining correlation coefficients depicted in the table as r and the corresponding p-values for the test.

Table 5.8

Correlation tests from Example

Variable n r’s p-value

Q1&Q2 80 .777 .000*

Q1&Q3 80 .566 .000*

Q1&Q5 80 -.313 .005*

Q2&Q3 80 .419 .000*

Q2&Q5 80 -.348 .002*

Q4&Q5 80 -.212 .060*

Table 5.8 demonstrates that there is a statistical correlation between all variables tested at a 0.05 level significance

except Q4 (number of times visited urgent care in the last 12 months) and Q5 (overall satisfaction with the medical

office). The data output requires analysis to the original hypothesis questions in the study.

Reflective Summary

This chapter reviewed the application of statistics to research, how to identify data, select the appropriate tests, and

apply this to data sets. The chapter also explored how to review articles or studies for the key elements for

understanding. This understanding was further applied to a practical scenario including analysis of data collected.

The statistical and practical analysis of results for communication are essential in the roles of a clinician and the

tools learned in this course provided the framework for increased understanding.

Key Terms

Hypothesis: A testable statement of a relationship; an epidemiologic hypothesis is the relationship is between the

exposure (person, time, and/or place) and the occurrence of a disease or condition.

M: Table notation for statistical mean of data array.

Mdn: Table notation for statistical median of data array.

N: Table notation representing the sample size.

P values: The probability that there is enough evidence to make conclusions resulting from the data collected in the

study.

r: Table notation representing the coefficient of correlation.

SD: Table notation representing the standard deviation of the data array.

Variable: A data item such as characteristics, numbers, properties, or quantities that can be measured or counted.

The value of the data item can vary or be manipulated from one entity to another. There are three different types of

variables—dependent, independent, and extraneous.