Research question
Evidence based practice (EBP) is the integration of clinical expertise, best research evidence and patient values to provide the best available care to patient. Implementing EBP is vital in daily practice to cover gaps in patient care and find best approach to achieve optimal outcome for patients (Schmidt & Brown, 2014). Critical thinking and evaluation of credibility of research papers helps to understand the significance of the evidence for application in nursing practice. The main purpose of this paper is to look into the issue of oncology nurse’s risk for occupational exposure to hazards because of administration of chemotherapy for patients and critically evaluate research paper by Colvin, Karius and Albert (2016) to evaluate whether oncology nurses adhere to safe-handling practices or not. The review of the quality and credibility of the work will have implications on implementing strategies that reduces oncology nurse’s exposure to occupational hazards.
The aim of the study by Colvin, Karius and Albert (2016) was to examine objective versus subjective ambulatory oncology nurse adherence to chemotherapy safe-handling guideline for preventing chemotherapy exposure. The review of the background information of the research paper reveals that the study seeks to address the issue of oncology nurse’s exposure to hazard during chemotherapy. The research aim related to the research question whether direct observation or self-assessment show nurses adherence to safe handling guidelines or not. The researcher justified the need for research in this area by giving evidence regarding the various adverse health effects for workers who administer chemotherapy. As hazardous drugs used during chemotherapy have carcinogenic and teratogenic properties, the author also suggested the need to use personal protective equipment and adhere to guideline for administration of chemotherapy to promote safety. However, another issue highlighted by the author was that there is sporadic adherence to guidelines across different practical setting. Polovich and Clark (2012, May) argues that one of the unique challenge during administration of chemotherapy drug is that there is no established limits for health worker exposure. In this scenario, taking safety strategies like use of PPE, hazard identification and training and education for staffs became necessary. However, this paper also supported the fact nurses experience many barriers to adherence to PPE use. Hence, presence of these issues made the research in the area important.
The main sample population for the study by was ambulatory oncology nurse. As the study had two methodologies- the observational component and the self-assessment survey component, different sample size were taken for the two steps. The sample size taken for the study included 12 nurses. Inclusion criteria was set only for participants who took part in observation part and this mainly included inclusion of RNs with two or more years of experience. Other criterion was that all oncology nurse must have delivered chemotherapy agents to patients in outpatient setting. Based on the method used to recruit sample, it can be said that Colvin, Karius and Albert (2016) employed purposive sampling strategy to recruit research participant. It is a type of selective sampling technique where the judgment for sample size and research participants relies on the researcher. Sound judgment and critical thinking is used to select a representative sample (Orcher, 2016). However, the main limitation of this approach is that it can contribute to biases that may affect the credibility of the work.
Sample
Based on the review of sample size, it can be said that the sample size is too small for both the observation part and the self-assessment questionnaire part. As it was a single centre study and the author included only 12 nurses, this may have an impact on the reliability of the research evidence. The findings of the research cannot be generalized for other setting because of small sample size. Although Colvin, Karius and Albert (2016) made estimation of the desired sample size, however this was not appropriate as per the purpose of investigation (Chow et al., 2017). Instead of 12, there was a need for evaluation of at least more than 30 nurses. Furthermore, no step was taken to include wide range of sample group such as those with different work experience and qualification. Considering this factor would have helped to enhance the application of the research findings in other practical setting. However, taking only 12 nurses affected the ability to understand impact of work experience, demographic factors and clinical skills on adherence.
The study used a prospective and comparative mixed method research by first conducting observation of nurses who are involved in the administration and disposal of chemotherapy and then completing a questionnaire of adherence to PPE recommendation with nurse. Considering the research aim and objective, the use of mixed method approach was suitable because comparison of observation and self-assessment data required different approach. Observation was related to analysis of objective behaviour of nurses related to safe handling. In addition, self-assessment questionnaire related to analysis of subjective behaviour of nurses to adherence to safe handling technique during chemotherapy. Mixed method study is an approach to collect and integrate quantitative and qualitative data related to research findings (Morse, 2016). The main advantage of using mixed method approach in this study is that it gave the opportunity to learn about the best practices and barriers to adherence to guideline. Observation method would help to collect data related to objective factors affecting adherence to safety guidelines and self-assessment questionnaire would help to collect qualitative data related to experience of nurse in adhering to safety guidelines. As Colvin, Karius and Albert (2016) aimed to compare two types of findings related to objective and subjective data related to adherence to chemotherapy safe handling, the use of mixed method helped to compare qualitative and quantitative data. Side by side comparison can favour analysis of both personal experience as well as elements that affects quality of care (Wisdom & Creswell, 2013).
Another important feature of the research design was that it was a prospective study. A prospective study is one which examines outcome related to any disease and relates this to risk of protective factors (Bryman, 2016). In accordance with this approach, the examination of observation and self-assessment response was done to evaluate the adherence to chemotherapy safety protocol and risk of occupational exposure for research participants. This approach helped to analyse the outcome for two NIOSH recommendation related to PPE and work practice controls. Another advantage of prospective research design is that there is low chance of bias or confounding factors in prospective studies.
Design of study
Data collection is the most vital step of research methodology and quality data collection depended on consideration of relevance, completeness, reliability and understandability of research data. Reliability and preciseness is obtained by the use of standards tools or by framing a checklist that considers all important elements of the research question. Colvin, Karius and Albert (2016) collected data in two phases. For the observation phase, three observers were recruited who had knowledge about oncology nursing care and PPE recommendations. They were also trained in observing behaviours. Furthermore, common nursing skill checklist was provided to each of the three observers which acted as a framework for assessment of handling, administering and disposing skills of participants. The rigor in data collection is also understood from the fact that quality of data collection was assessed by the principal investigator every day. This approach helped to minimize any bias or error during data collection. Another important aspect of the first phase of data collection was that data was collected confidentially which helped to observe nurses several times without any interruptions. By making the nurse unaware of the fact that they were being observed helped to get real insight related to adherence to chemotherapy protocol without any risk of bias. However, this may lead to ethical risk because of non-compliance to confidentiality and privacy requirement of research participants (Petrova, Dewing & Camilleri, 2016).
For the second phase of data collection, self-assessment questionnaire was delivered to all outpatient oncology nurses and all the nurses had to return the anonymous questionnaire. This step helped to maintain privacy and confidentiality consideration during research and analyse data without using private and personal details of research participants (Petrova, Dewing & Camilleri, 2016). However, one important aspect that was missing in the data collection process was that no details were provided regarding the evidence basis for the skill checklist and the safe handling adherence checklist. This limits the quality of the data collection process.
The research finding is considered appropriate if it is able to answer the research question or meet all the objectives of research. In response to the research aim of assessing observed and self-assessed adherence to PPE and safe-handling policies, the findings of the study by Colvin, Karius and Albert (2016) revealed that nurse completed the process of disposal, discarding and attaching of secondary tube 100% of the time and there were also items that were not completed by nurse 100% of the time. In case of self-assessment of adherence, the adherence level was 100% only for disposal of contaminated equipments. Overall, gaps in PPE and safe handling practice was identifies by observation and self-assessment of questionnaire. Many nurses were found not adhering to the use of gowns and gloves during chemotherapy thus suggesting that nurse gave more priority to treatment rather than protecting themselves from the hazard. Boiano, Steege and Sweeney (2014) justified that poor attitude towards risk is the main exposure for not wearing gloves and gown. The study revealed that the common reason cited for not wearing glove is the perception that skin exposure is minimal. Hence, the findings by () confirms inconsistent work practices related to safe handling.
Data collection
Exposure to occupational risk for oncology nurse was the main research issue in the study by Colvin, Karius and Albert (2016) and based on difference in adherence rate observed by the observation and self-assessment data, the research findings helped to understand the strategies needed for reduce exposure to hazards. For example, the study suggested the need for assessment of level of exposure as this is a major gaps found in the clinical setting. In addition, adherence to guideline was highly dependent on organization support activities like implementation of appropriate policies, resource and education to reduce occupation risk for nurses.
Despite the strength of the study in highlighting differences in adherence to safety guidelines as per the observation and self-assessment questionnaire data, there are certain limitations that reduces the credibility of the research findings and presents the need for conducting future study with improved research methodology. Firstly, conducting study in single center with small sample size affected the reliability and transferability of the work. In addition, limitations in recruitment process was also informed as the Colvin, Karius and Albert (2016) did not considered the speciality or years of experience in oncology unit while assessing adherence rate. Hence, there is a need to overcome these limitations in future research by taking larger sample size and duration of work in oncology nursing.
The article by Colvin, Karius and Albert (2016) focused on the issue of many occupational risks for chemotherapy nurse because of exposure to teratogenic and carcinogenic agent during the administration of chemotherapy agent. The study discussed about lack of adherence to safe handling practices in clinical setting. The main purpose of the study was to collect and evaluate adherence to safety guidelines using observation and self-assessment as a data collection method. Prospective mixed method study design was used to assess subjective and objective information related to adherence. By the use of skill checklist and self-assessment questionnaire, the study revealed difference in rate of adherence. This gap in adherence also revealed poor attitude towards risk and lack of organizational support for implementing safety guideline policies. However, the evidence does not give any evidence that can be directly applied to clinical setting. To achieve reliable quality improvement data, there is a need to conduct multi-center study with large small sample size. However, the significance of the research is that it gives idea regarding the strategies that would favour increasing adherence to safety guideline.
To conclude, high quality and credible evidence is needed for application in clinical practice. However, as the study had many methodological limitations, the study findings cannot be applied for practice change now.
References:
Boiano, J. M., Steege, A. L., & Sweeney, M. H. (2014). Adherence to Safe Handling Guidelines by Health Care Workers Who Administer Antineoplastic Drugs. Journal of Occupational and Environmental Hygiene, 11(11), 728–740. https://doi.org/10.1080/15459624.2014.916809
Bryman, A. (2016). Social research methods. Oxford university press.
Chow, S. C., Shao, J., Wang, H., & Lokhnygina, Y. (2017). Sample size calculations in clinical research. Chapman and Hall/CRC.
Colvin, C. M., Karius, D., & Albert, N. M. (2016). Nurse Adherence to Safe-Handling Practices: Observation Versus Self-Assessment. Clinical journal of oncology nursing, 20(6).
Morse, J. M. (2016). Mixed method design: Principles and procedures. Routledge.
Orcher, L. T. (2016). Conducting research: Social and behavioral science methods. Routledge.
Petrova, E., Dewing, J., & Camilleri, M. (2016). Confidentiality in participatory research: Challenges from one study. Nursing Ethics, 23(4), 442-454.
Polovich, M., & Clark, P. C. (2012, May). Factors influencing oncology nurses’ use of hazardous drug safe-handling precautions. In Oncology nursing forum (Vol. 39, No. 3).
Schmidt, N. A., & Brown, J. M. (2014). Evidence-based practice for nurses. Jones & Bartlett Publishers.
Wisdom, J., & Creswell, J. W. (2013). Mixed methods: integrating quantitative and qualitative data collection and analysis while studying patient-centered medical home models. Rockville: Agency for Healthcare Research and Quality
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