Life@SGH Issue 17

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01 . NURSINGRESEARCH

Qualitative Nursing Research Searching from within: A personal insight

By Jordan Hwang

Qualitative Research methodology is the softer and more humanistic side of nursing research. It aims to provide insight into the meaning of human thoughts, behaviours, patterns and interactions in relation to health, illness and death.

As qualitative research has always been a ‘touch and go’ topic during my tertiary education, I never truly understood the process of this research methodology. In fact, I was faced with many difficult questions and challenges during the data analysis phase.

I find qualitative research methodology particularly meaningful in my area of nursing speciality of Haematopoietic Stem Cell Transplantation/ Haematology Nursing. And also in oncology and palliative nursing, and long-term care patients.

‘What do I do with the data?’ and ‘How do I craft my findings to answer my research question?’. I am grateful to Mr Edward Poon, Nursing Director of Dover Park Hospice, who is one of the nursing experts in qualitative research methodology. His enthusiasm motivated me and sustained my interest in qualitative research.

It gives meaning to how patients feel when subjected to prolonged hospital stay in isolation, for example, suffering from the side effects of cancer treatment or even facing death.

The understanding of human behaviour and their reaction towards health and disease have always been my interest. The interest of knowing propelled me into my first nursing research project using the qualitative method in 2006.

I was privileged to further increase my knowledge in qualitative nursing research when I was nominated to attend the Qualitative Methods in Health Research organised by Nursing Division in collaboration with Curtin University, Australia.

The five-day workshop, held from 23rd to 30th April 2008, was packed with indepth explanation and understanding of

Jordon Hwang, second from left.

the philosophies underpinning qualitative research methods.

We were introduced to the 5 different types of qualitative research methods; the complete process of qualitative research and the very interesting but tedious exercise of forming meaning from raw interview data.

Like every workshop, there were tasks and assignments to be completed.

The three assignments required us to replicate the entire qualitative research process from identifying a research topic, writing a research proposal, data collection by interviewing a participant,

SGH Nursing Research Council The Nursing Research Council is one of the nine Nursing Councils in Singapore General Hospital. It aims to provide strategic directions for nursing research and evidence-based nursing practice through a shared model.

The Council has three remits: 1) Research development, 2) Research utilisation, and 3) Research education.

Members of the Nursing Research Council comprise of nurses from SGH and National Heart Centre. The Council is well-represented with members from - clinical, specialty care, advanced practice, education and administration.

Members of the SGH NRC (term of appointment until 31 August 2011): Chairperson: • Ms Chen Xiao Rong, Nurse Educator, Training & Development Unit, SGH. Co-Chairperson: • Mr. Nidu Maran Shanmugam S/O B K, Advanced Practice Nurse, Orthopaedics, SGH Secretariat: • Mr. Sim Kiak Kong, Nurse Clinician, Nursing Division, SGH

transcribing verbatim and analysing the verbatim to formulate themes to answer the research question.

I found the assignments particularly helpful in reaffirming my understanding and interest in qualitative nursing research. The final task of the workshop was a 4000-word report write-up.

I feel that all nurses interested in research and wanting to better improve their care for their patients should give qualitative research methodology a try. The Qualitative Methods in Health Research is definitely a ‘must’ core nursing research course to attend.

By: SSN Norashikin Binte Sarip & NC Teo Lee Wah

Members: • Prof Fong Kok Yong, Chairman, Division of Medicine & Acting Chairman, Division of Research, SGH • Ms Tan Geok Eng, Administrator Bioethics, Medical Board, SGH • Ms Sharonjit Kaur D/O D Singh, Principal Enrolled Nurse, Ward 76, SGH • Ms Siah Chiew Jiat, Senior Staff Nurse, Ward 47A, SGH • Ms Tay Pei Yin, Senior Staff Nurse, Major Operating Theatre, SGH • Ms Norashikin Binte Sarip, Senior Staff Nurse, CTS ICU, NHC • Ms Fazila Bte Abu Bakar Aloweni, Senior Staff Nurse, Ward 57, SGH • Mr Jordan Hwang Chung Cheng, Nurse Clinician, Ward 72, SGH • Ms Chan Yoke Ling, Nurse Clinician, Diabetes Centre, SGH

• Ms Teo Lee Wah, Nurse Clinician, Nursing Development Unit, NHC • Ms Lim Su Fee, Advanced Practice Nurse, Rehabilitation, SGH • Ms Karen Perera, Assistant Director, Nursing, Nursing Division, SGH • Dr Tracy Carol Ayre, Deputy Director, Nursing, Nursing Division, SGH

The Council meets monthly to discuss nursing research related issues, incorporate evidence-based findings into nursing practice and organise training programmes to develop nurses’ knowledge and skills in research. The Council is also responsible for the review and approval of nursing research proposals before submission to the centralised Institutional Review Board.

02 . NURSINGRESEARCH

Comprehensive System Review Training A group of 12 nurses, from various hospitals and polyclinics across SingHealth, attended the Joanna Briggs Institute (JBI) Comprehensive Systematic Review (CSR) workshop in Adelaide, Australia, from 5 to 9 May, 2008.

By NE Chen Xiao Rong & APN Lim Su-Fee

The JBI CSR Training Program is designed to prepare members of Collaborating Centers, researchers and clinicians to develop, conduct and report systematic reviews of evidence. The participants completed four modules of the JBI CSR training programme. With the aid of the JBI systematic review software, we were able to critically appraise all forms of research literature and synthesise relevant information from a variety of sources. We also gained insight into using JBI ConNECT (Clinical Online Network of Evidence for Care and Therapeutics). This is the online gateway to the collection of evidence-based resources and tools designed to assist in the clinical decision making process and to support best practice. Participants who successfully completed the modules are certified by JBI as competent in the systematic review process.

The participants had a wonderful time gaining knowledge on evidence-based practice, building up network and enjoying the fellowship.

Helpful websites for research and EBN information: http://www.cochrane.org/ http://www.joannabriggs.edu.au/about/home.php http://www.shef.ac.uk/scharr/ir/netting

Nursing Division subscribes to the Joanna Briggs Institute

Did Yo Know u ?

for our nurses to access the following:

Pictured from left to right: Back row: Lem Wen Sze; Chen Xiao Rong; Ng Wai May; S Indra; Li Jie; Juhana Binte Mohamed Tahir; Lian Siew Bee. Front row: Lee Yean; Lim Su-Fee; Lucylynn Lizarondo (JBI Trainer); Tan Ai Meng; Fazila Binte Abu Bakar Aloweni; Samantha Lim Xinyi.

Pictured from left to right: Back row: Juhana Binte Mohamed; S Indra; Lee Yean; Li Jie. Front row: Samantha Lim Xinyi; Ng Wai May; Fazila Binte Abu Bakar Aloweni; Lian Siew Bee; Lim Su-Fee; Tan Ai Meng; Lucylynn Lizarondo (JBI Trainer); Lem Wen Sze.

About JBI The JBI was established in 1996 to integrate resource into nursing practice through evaluation of evidence, so as to improve the effectiveness of nursing practice and health care outcomes.

JBI Library of Systematic Reviews

JBI Library of Evaluation Reports

Please contact Dr Tracy Ayre at tracy.carol.ayre@sgh.com.sg or Ms Karen Perera at Karen. perera@sgh.com.sg for the logon ID and password.

The Research Recipe The Process of Nursing Research

Questions to think about in writing your proposal 1.

2.

3.

4.

5.

What is the question? What are you measuring?

What are the current gaps in the literature?

Who will be your research team?

What are the variables of interest?

What type of data should you collect?

What instruments should you use?

6. Decide on design, population, sample size, analysis 7. How will you recruit participants?

8. How will you obtain consent from participants?

9. How will data be collected?

Who will collect?

Who will manage the data?

10. How will data be analyzed?

RESEARCHINFOCUS . 03 Young Investigator’s Award (Nursing) 2009 Comparing the effectiveness of green tea versus topical metronidazole powder in malodour control of fungating malignant wounds in a controlled randomised longitudinal study.

Lian SB, Xu Y, Aw FC, Goh SL, Wong ZW Nursing Division, Singapore General Hospital, Singapore

Aims: To test the efficacy of green tea with that of conventional topical metronidazole powder by comparing the rate of malodour score reduction using the verbal numeric scale (VNS).

Methods: This was a prospective randomised experimental study comparing two types of odour control agents used for treating malodourous fungating malignant wounds in a tertiary hospital in Singapore.

Patients were randomised to either control

(metronidazole power) or treatment (green tea) group and follow-up with daily dressing for a week with a designated nurse. Both subject and the designated nurse would rate the malodour score daily on a VNS of 0 (no odour) to 10 (worst odour that one can imagine).

wounds. All patients in both arms shown improvement in malodour control by Day 7. Treatment group was as effective as control group and there was no statistical significance (p>0.05) to demonstrate which treatment is more superior.

Results: Thirty cancer patients with malodour fungating wounds were randomised into either treatment (n=15) or control arm (n=15). There were 20 breast wounds, 8 abdominal wounds and 2 head and neck

Conclusion: Green tea dressing is as effective as conventional topical metronidazole powder in controlling the malodour. Green tea is cheap, easily available and has no risk of drug resistance for long term use. Alternatively,

it can also be used interchangeably with metronidazole powder to reduce the risk of drug resistance.

Best Oral Paper (Nursing) 2009 A randomised, double-blind trial to assess the effectiveness of intrarectal diclofenac suppository administration compared to intravenous pethidine in relieving pain during extracorporeal shockwave lithotripsy.

Yatim J1, Ng LG2, Shen L3 1 Division of Nursing, Singapore General Hospital, Singapore; 2Department of Urology, Singapore General Hospital, Singapore; 3Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Aims: To compare the clinical efficacy of intrarectal diclofenac suppository with intravenous pethidine for pain relief during outpatient extracorporeal shockwave lithotripsy (ESWL).

Methods: This randomised double-blind study was conducted at the Urology Centre in Singapore General Hospital. 60 eligible patients who had urinary calculi were included in the study. Patients were randomised into two groups (30 in each group). Patients in the study group received intra-rectal diclofenac

suppository 100-mg 30 minutes before treatment and equal volume of intravenous saline (placebo) before treatment started, while those in the control group were given glycerin suppository as placebo intra-rectally 30 minutes before procedure and single dose of 1ml/ kg body weight intravenous pethidine before the start of the procedure. Pain intensity was identified with a Visual Analogue Scale (VAS).

Results: 16 patients with urolithiasis who underwent ESWL were recruited for this interim

analysis. The median VAS score was higher in the study group compared to the control group throughout the ESWL procedure (p = 0.027).

The median VAS score was 4.5 (range 1–10) in the study group while it was 2 (range 0–3) in the control. Furthermore, 4 (50%) patients in the study group required rescue analgesic for pain control, while none in the control group required rescue analgesic. No side-effects were seen in any patient who received diclofenac suppository but one patient given pethidine had giddiness that subsided later.

Conclusion: The preliminary data demonstrated that intra-rectal diclofenac suppository was not effective in providing pain relief during ESWL.

Best Systematic Review (Nursing) 2009 Patency of arterial catheters with heparinised solutions versus non-heparinised solutions: a systematic review and meta-analysis of randomised controlled trials.

Chen LJ1, Ng GH1, Ong S2, Lee P2 Surgical Intensive Care Unit, Singapore General Hospital, Singapore 2 Department of Anaesthesia, Singapore General Hospital, Singapore

1

Aim: To evaluate the effect of heparin on duration of patency of arterial catheters.

Methods: The methodological quality of the included randomised controlled trials was assessed using criteria for masking of randomisation, masking of intervention, masking of outcome measurement and completeness of follow-up. The main outcome measure was patency of arterial catheter. Data on relevant outcomes were extracted and the effect size was

estimated by calculating Relative Risk (RR), Risk Difference (RD) and associated 95% Confidence Intervals (CI).

Results: Four trials met the eligibility criteria.

Owing to inconsistency in the outcomes reported, only three trials could be included in the meta-analysis. These studies included 5145 adults. Heparin significantly prolonged duration of patency of arterial catheters and decreased the risk of clot formation (RR 0.47, CI 0.41 to 0.52).

Conclusions: Infusion of low-dose heparin through an arterial catheter prolonged the duration of patency. The use of heparin for arterial catheters enables haemodynamic monitoring continuously as intended therapy by reducing occlusion. Evidence from this systematic review supports the use of heparin in flush solutions to maintain the patency of arterial lines. None of these studies was powered to evaluate the incidence of adverse events. Caution is reinforced and monitoring of side-effects of

heparin is recommended if this therapy is to be adopted as a routine practice.

04 . RESEARCHINFOCUS Best Poster (Nursing) 2009 Maintain oxygen saturation of premature infants within optimal target level.

Lau YY , Tay Y Y, Chang P, and Loh K T Department of Neonatal and Developmental Medicine, Singapore General Hospital

Introduction: Advances in technology have resulted in increasing survival rates of premature infants. Oxygen therapy is the commonly used therapy in neonatal as part of the respiratory support. The number of premature babies surviving with consequences of severe Retinopathy of Prematurity (ROP) has prompted a review of oxygen therapy as a contributing factor.

Prolonged exposure to high concentrations of oxygen may cause irreversible damage to Very Low Birth Weight (VLBW) preterm infants’ eyes and is a potential cause of blindness.

Aim: To reduce the incidences of premature infants with severe ROP (stages > 3) requiring laser surgery to zero.

Methods: We brainstormed the underlying causes leading to hyperoxia in premature

infants and the root causes were identified.

We conducted a study on 37 infants born at gestational age of less than 32 weeks with birth weights less than 1500gms receiving supplemental oxygen, admitted to Neonatal Intensive Care Unit from April to September 2008. The infants were administered oxygen via either ventilator support, nasal CPAP or I/N oxygen and titration of oxygen is based on oxygen saturation (SpO2) measured using Hewlett Packard monitor Model 66S. We monitored the SpO2 trend, SpO2 alarm limit and percentage of time alarm limit set incorrectly. In April 2008 (Phase 1), we implemented a change in clinical practice by adopting an oxygen saturation targeting protocol. In June 2008, (Phase 2 implementation), we further develop an algorithm for gradually titrating fraction of inspired oxygen (FiO2).

Results: After phase 1 implementation, the percentage of time oxygen saturation (SpO2) readings > 95% was reduced to between 15 and 50%. However, findings of phase 1 study raised the concern of fluctuation of SpO2 readings due to inconsistency in titration of FiO2, which can also result in deviation from the optimal target range. This has prompted the development of an algorithm for gradually titrating fraction of inspired oxygen (FiO2) to manage high and low SpO2 with the aim of maintaining SpO2 within the optimal target range. Following the phase 2 implementation, the percentage of SpO2 readings above 95% was markedly reduced to between 0 and 15%. The incidence of neonates with severe ROP stage 3 requiring laser surgery has decreased from 4 (in 2007) to 1(in 2008).

Conclusions: The implementation of a change in clinical practice aimed at avoiding high SpO2 was associated with a significant decrease in the incidence of both severe ROP and the need for laser surgery. This reduced hospital cost and length of stay for premature infants.

Nursing Research Resources Vast resources are available to nursing staff to support participation in nursing research and evidencebased nursing activities. Such support include, access to librarians, nursing-specific and other health science journals, electronic databases for online retrieval of research literature, workspaces designated for nurses and research advice and support.

Nurses have access to the online library accessible via SingHealth Intranet,including access to OVIDSP MEDLINE, Journals@OVID, MD Consult, EmBase and CINAHL. Nurses can also access the OVID database from their homes using a logon ID and password.

The SGH Education Resource Center houses books, current journal titles, and maintains online databases with links to full text articles and books. The collection of books and journal titles held at ERC and in other local libraries can be searched via the Online Public Access Catalogue.

The librarian also assists staff to perform literature search services.

The Nursing Intranet also has links to the British National Formulary and ePharmacopoeia for drug-related information, other specialty organisations (e.g. National Cancer Institute), and research and evidence-based guidelines from organisations such as Joanna Briggs Institute.

Every nurse principal investigator is assigned a research facilitator to support and guide him/her in the research project. Nurses who need access to workstations or SPSS to perform their research work can contact Mr Sim, Nursing Research Council, Secretariat, at Tel: 6326 6080.