A Research Critique
Having recently completed a placement on a surgical ward, one of the key issues was the control and relief of pain that patients experienced post operatively. Pain was generally managed by IV analgesics or intra muscular injections of pethidine, the latter were usually requested by the patient once he had begun to experience the feeling of pain; but by the time an injection of pethidine was ready to be administered, the pain could have, and usually did, become much stronger, causing distress and discomfort to the patient concerned. For this reason the student decided to find a research study regarding pain relief post operatively, and to evaluate the results of the research and decide whether it could or not it could be put into practice. The student will therefore attempt to critically evaluate this research article, published in the Nursing Standard, entitled "Patient Satisfaction with Post Operative Analgesia".
The title of the research paper is concise, self explanatory and suggests that the population of the article will be post-operative patients. The researcher is a nurse manager in the clinical oncology directorate and the student feels that the researcher is therefore suitably qualified to undertake such research given her qualifications and the position she holds.
In this article, the researchers intention was to research and provide evidence to show which method of pain relief was better for patients undergoing total knee replacements, based on the side effects of the analgesia given via epidural or IV infusion, patient satisfaction and the length of stay in hospital experienced by the patients involved.
The abstract is a brief description of the study placed at the beginning of the journal article. Because researchers know that many people will read only the abstract, they normally strive to communicate only that which is essential for readers to grasp what the study was all about (Polit & Hungler 1985). In this article the researcher has provided a concise abstract that does just this, and provides a brief overview of her research study in a few short paragraphs. It details the aims, the method, the results and the conclusion that was reached.
Before any type of research is undertaken, it is important that the researcher identify’s what research has taken place prior to his own research project. This is done by reviewing any publications relating to the research project, and is usually referred to as the literature review.
By conducting a literature review the researcher will be able to determine what has already been researched by others, how long ago the research took place, whether the information is up to date, how it was researched and the effectiveness of the research results. This will enable him to identify the merits, strengths, weaknesses and shortcomings of each. The best place to begin is with the most recent publications. These often summarize and criticize earlier work, report contemporary research, and provide bibliographies for further perusal (Seaman, C. H.C.1987). Once this has been done the researcher can then decide whether her own research project is necessary and if it will contribute towards a more effective and up to date outcome that can be put into use in its relevent setting. For these reasons, a search of the available literature in the proposed field of study is mandatory, as it is only against the background of previous research and published knowledge that a research project can be proposed and implemented (De Rave, L. 1996).
In the research article, the author has looked at a variety of background literature, dating from 1995 back to 1983, and the student assumes that this is the literature the researcher reviewed before proceeding with her project. The student feels that the information here is rather weak and misleading, as further on under the heading of discussion, she mentions previous studies carried out by various authors yet does not go into detail about the exact nature of these studies or whether these were actually older research projects. Despite this the background literature explains the effect of pain post-operatively and its possible complications, and the effects of epidural and patient controlled analgesia to relieve pain. She has also included a relatively comprehensive list of references at the end of the article.
When reading published papers it is important to consider whether the author has taken into account the up-to-date knowledge base associated with a particular research question (Crookes & Davies 1998). From the list of literature references provided, it is evident that the researcher has taken into account a variety of literature detailing the use of PCA’s, pain management, patients experiences of pain e.t.c. before embarking on her research project. As there appears to be no evidence in the background literature review to suggest previous research that illustrates or proves which methods of pain relief is best, the student feels that the researcher of the article is justified in her quest to find out which is the better method of delivering pain relief, enabling shorter hospital stays and satisfaction to patients.
Before a research project can finally get underway, it is important that ethical issues are addressed. The critical reader of research requires sufficient knowledge of ethical principles to be able to decide for him or herself whether a research project has been carried out in an ethical manner. This requires some insight into ethical theories which can inform and solve the ethical dilemmas associated with research, (Crookes & Davies1998). We cannot assume that we have a right to undertake research or to ask questions of people, without gaining their permission or informed consent, (Burnard & Morrison1994).
In this article the researcher has taken ethical considerations into account, and has obtained approval for her research to take place by receiving permission from the hospital based ethical committee, the local research ethical committee and from the patients involved in the research, by obtaining their informed consent. Once these issues have been dealt with, the researcher is then able to begin her study.
The sampling process is a crucial element of the research design. It determines from whom or from what the data are to be collected, which (in turn) influences the method of data analysis that can be used (Seaman, C.H.C.1987).
The sample population is the group of individuals in which the researcher is interested (Polgar & Thomas 1995). The article gives details of the age and type of group to be included in the research, being patients presenting for total knee replacement, but gives no indication of the ethnic origin or cultural background of these people. The majority of the sample group were women.
It mentions, briefly, the exclusion criteria, the number of patients who refused to be included in the research and the amount of patients who withdrew for other reasons, although it did not give details why the patients refused to take part nor did it give reasons explaining why two patients withdrew from the study. It did, however, give reasons to explain why six patients were withdrawn from the study, as the researcher felt these patients showed signs of being in an acute confusional state post-operatively. Using an assignment procedure, the participants are allocated into groups (Polgar & Thomas 1995). The researcher gave details of how the remaining 61 patients, all of whom were patients at the same hospital and whose average age was 72, were selected to have either the epidural or the IV analgesics, which was by random selection using the last digit of their hospital number to determine which treatment they received.
The student feels that none of the sample population were particularly vulnerable to manipulation by the researcher, as the report states that some patients were excluded from the research due to acute confusional states post-operatively, two patients were free to opt out of the study and two patients were also permitted to withdraw from the study. This indicates that none of the patients were "forced" to take part in the research and that by giving their informed consent they participated of their own will. In addition to this, it is assumed, that of the remaining 61 participants, the sample population was appropriate for understanding and answering the research question.
A pilot study is often defined as a smaller version of a proposed study that is conducted to refine the methodology (Burns & Grove 1995). The student notes that a pilot study was undertaken by the researcher to help in the revision of forms and clarity of meaning, yet it gives no details about the sample group used for this study. It does mention that the same group of surgeons performed all of the operations but does not give any outcomes or any other information relating to this.
The methods section of a research report describes how the study was conducted. It describes the study design, sample, setting, methods of measurement, and data collection process (Burns & Grove. 1995). A well documented methods section is a necessary condition for understanding, evaluating and perhaps replicating a research project (Polgar & Thomas, 1995).
The student would suggest that the researcher used an experimental approach to this research project as the subjects were put into groups by a random process, the reasons for doing so are clearly explained and the student feels that this is an appropriate way of conducting this particular study.
The researcher focuses on methods such as observing, questioning, and measuring or upon the various instruments used, (Seaman, C.H.C. 1987). The researcher posed questions by means of a questionaire upon the patients discharge from hospital or after seven days, in order to establish patient satisfaction and length of stay in hospital. She used a quantative approach to test the hypothesis that epidural analgesia permits minimal side effects, more mobility, greater satisfaction and shorter hospital confinement.
Data was collected using the questionaires, self assessment forms and analogue scales, which the student feels was a relatively simple process that the patients would be able to understand, and which provided written evidence from which the researcher could draw a conclusion.
Quantitative research usually attempts to answer research questions associated with frequency or occurrences to make reliable and valid measures of a concept in order to produce results that can be generalised (McSherry & McSherry 2001) A quantative design is one concerned with measurement, measuring the magnitude, size, or extent of a phenomenon. The quantative design counts, measures and analyzes data statistically (Seaman,1987).
The student would suggest that this research also takes a qualititative, phenomenological approach to capture the "lived experience" (Burns & Grove 1995) in so much as the study was carried out in the hospital setting, where the patients were participating, they were given pain tools with which to assess their pain levels and which would enable the researcher to determine the meaning and indications of the outcome. In addition, the sample population was a relatively small one (Burnard & Morrison 1990) and confined to one hospital.
Qualititative research is a more subjective approach using life experiences, personal accounts, diaries or observational practices of a given phenomena or event in order to understand the meanings behind the occurrence (McSherry R & McSherry. W 2001). One of the benefits of qualititative research is that it can help to identify constraints within clinical practice (Marrow. C 1996).
Quantitative and qualitative research compliment each other because they generate different kinds of knowledge that are useful in nursing practice (Burns & Groves 1995).
A valid instrument measures what it purports to measure (Seaman. C.H.C. 1987). If a technique is not reliable, it is certainly not valid; but that does not mean that just because it is reliable, it acquires validity (Reid. N. !993). In view of the nature of the research being done, the student feels that the methods of collecting data are suitable and consistent with the aims of the study as they are simple enough for the patient to comprehend and effective enough to show the researcher if and when the patient is in pain. However, whilst the student is of the opinion that using analogue scales is a valid way of measuring a patients pain, it may not always be reliable as some patients, for instance, may prefer to put up with pain rather than bother the busy nurse for some pain relief. So no instrument is completely valid. Thus, one determines the degree of validity of a measure rather than whether validity exists. Validity will vary from one sample to another and from one situation to another; therefore validity testing actually validates the use of an instrument for a specific group or purpose, rather than being directed toward the instrument itself (Burns N & Groves. 1995).
The significance of a study is associated with its importance to the nursing body of knowledge (Burns & Groves). The researcher has presented the article reasonably well, providing written evidence, graphs and charts to illustrate her findings and relating her findings back to the observations of others before her. The student feels that this is one of the strengths of the research project as the researchers results show that there is no drastically clear method of pain relief that is better than the other, but that they are both similar in effect.
By using the graphs and charts, it is easy to see and understand her findings, which would perhaps be useful in persuading nursing professionals to adopt her methods of obtaining information from the patients and acting on the information they receive i.e. by using a pain assessment tool to evaluate the pain levels of the patient, and the effectiveness of the pain relieving method prescribed and whether an alternative method should be considered. The researchers findings would also suggest that patients could be able to choose which method of pain relief they would prefer, in the knowledge that the amount of pain relief they would receive would be identical to the other.Effective pain relief ensures the patient is pain free, therefore feels no anxiety or stress which in turn is beneficial to the patient.
Because there was no evidence to support the claims that epidural analgesia was a more effective method than IV analgesia, the hypothesis stated in the article was not validated.
In concluding the study, the researcher appears to be somewhat misleading as she states that patient preference is difficult to quantify yet none of the patients were given a preference of which treatment they received as treatment was selected randomly. She does explain that no significant differences could be found between the IV analgesia and epidural and points out the importance of good pain management on the part of the nursing staff. The student agrees that patients should be empowered with as much knowledge as possible regarding pain relief and that they should be involved in managing their own pain if they are able and so desire. This research article shows that there is very little difference between IV analgesia and epidural analgesia, and that the patient should be given a choice of the method of pain relief that is more preferable to him.
Generalisation is the ability to apply the conclusion reached from studying the elements in a sample to the population from which the study was drawn (Seaman C.H.C). For example, if the study was conducted on diabetic patients, it may be possible to generalize the findings to persons with other illnesses or to well individuals (Burns & Grove). The researcher does not relate her study to any other group of patients other than orthopaedic patients, particularly the elderly. The student suggests that the results of this study could be applied to any patients who require pain relief, as the findings indicate the similarities between IV analgesia and epidural analgesia thus giving the patient a choice of equally effective pain relief.
Research is a means of understanding, assessing and evaluating what we do as nurses (Burnard and Morrison 1994). Progress in nursing education is reflected in stimulating a spirit of enquiry and discussion of alternatives (Macleod Clark & Hockey1992).There is a strong argument that all professional practice should be research based and research validated because our patients and clients deserve care which has been demonstrated, through research, to be the best that can be given (Reid N. 1993). With this in mind, the student has attempted to critique a research article in which she has looked at the title of the piece and how it reflects the contents of the article.
The aim of the research was discussed defining the question that was being asked by the researcher.
The student briefly discussed the abstract, explaining the reason why abstracts are generally placed at the beginning of a research report.
The literature review was then discussed, in which the student pointed out the importance of reviewing publications in relation to the research project.
Ethics was another important aspect to consider when undertaking a research project, and the student briefly explained why this was so.
She discussed the sampling process, and looked at the sample chosen by the researcher giving a brief outline of their age, medical problem and where the sample population were taken from.
When discussing methodology the student looked at quantitative and qualitative methods of research and explained how they applied to the students selected research article.
To determine the validity and reliability of the research article the student discussed the data collection methods and how they could or could not be reliable or valuable to the nursing profession.
The researchers analysis and presentation of findings was discussed and the student made comments on the presentation, the use of graphs and charts and the results demonstrated by the researcher and the benefits of such information to nursing professionals.
The student also explored the researchers conclusion and looked at the generalisability of the research and how it might be beneficial to a wide variety of other patients post-operatively.
Whilst the researchers results indicate very little difference between the two methods of pain relief the student feels that the study was worth while as it indicates that both methods are as good as each other, and it allows the patient some choice, which the student feels is important to patient care.