- Email: [email protected]
A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people
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A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people ;.:-'.: ::!::::
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John R Daly and Esther M. L. Chang
John P Dab/ RN, BA, BHSc, MEd (Hons), PhD, FRCNA, Associate Professor of Nursing, University of Western Sydney, Macarthur, PO Box 555, Campbelltown, NSW 2560
The aim of this pilot research project was to identify priority areas for clinical nursing research for renal specialist nurses practising in general critical care. Research participants in the study included Clinical Nurse Specialists (CNSs) and Clinical Nurse Consultants (CNCs), n = 12. The study sample was national with representation from a number of major metropolitan teaching hospitals in Australia. The Delphi technique was used to obtain the most reliable consensus of the specialist nurses. Research priorities emerged in four areas: I) clinical research which is of highest value to patients; 2) clinical research which is of highest value to CNSs/CNCs; 3) clinical research which would provide improved community care and 4) research that would be of value for CNSs/CNCs professional needs. In the final phase of the study nine high priorities were identified. The findings of the study suggest directions for clinical nursing research which would benefit renal specialist nurses and their patients.
Esther M L Chang RN, BAppSc, DIpEd, MEd, Admm PhD, Associate Professor of Nursing, U mverslty of Western Sydney, Hawkesbury, Rmhmond NSW 2753, Austraha
(Requests for offprints to JD) Manuscript accepted 25 November 1995
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INTRODUCTION In a recent Australian study o f the clinical nursing research priorities o f critical care nurses, a decision was taken to Include four subgroups:
Intenswe and Critical Care Nursing (1996) 12, 4549
© 1996PearsonProfesmonalLtd
• •
general critical care cardiac critical care (coronary care and cardiothoracic critical care) neurosurglcal/neuromedical critical care renal nurses involved m managing the critically ill (Daly et al 1995).
The sample in each subgroup was national and included specialist nurses who were regarded as experts m their area o f nursing practice. The researchers were motivated to undertake a study of clinical nursing research priorities in Austrahan critical care for a number o f reasons. Firstly, the area lacks a substantive k n o w ledge base which has been developed through research endeavour. Identified priorities could be foundational for a number o f necessary and relevant research projects m critical care nursing. This could be regarded as a preliminary step in the generation o f nursing knowledge for the area. Secondly, it has been suggested that the most prudent approach to building the k n o w ledge base for nursing practice through research is one which is systematic (Hinshaw et al 1988). Identification o f agreed priority areas for clinical nursing research would assist in the sequential investigation o f practice problems to ensure the most rational, economic use o f resources and attention to the most pressing problems confronting clinicians and thmr patients. Thirdly, the authors are o f the view that problems to be addressed through clinical nursing research nmst emerge from the context o f pracnce. If nursing research is to have relevance to the needs of chmcal nurses and their patients it is imperative that nurses have the opportunity to influence the determination of clinical nursing research priorities (Greenwood 1984). In particular there is a need to harness the expertise of those clinical practitioners best equipped to recognise and use research. The component o f the research study reported here sought to uncover the chnlcal nursing research priorities o f renal specialist nurses involved In caring for the critically ill. An additional area of concern addressed in the study was research that would be o f value with regard to the professional needs of the research participants. Renal specialist nurses are often involved in caring for critically ill people in Australia. In general, they are involved in dialyslng patients with impaired or deteriorating renal function. The services they provide in this context are broad-ranging and may include actually carrying out dialysis, supervising the renal management of the critically ill by nonspecialist nurses, consultancy or educational activities. The notion and process o f generating clinical nursing research priorities are not new. The
46
Intensiveand Critical Care Nursing approach has been used extensively in the USA, and on a limited basis in the UK (Bond & Bond 1982). In Australia, two studies have been reported in the literature (Bartu et al 1993, Daly et al 1995). O f relevance to critical care nursing per se are several studies undertaken in the USA (Lewandowskl & Kositsky 1983, Lindquist et al 1993, Riegel et al 1993) and one in Australia (Daly et al 1995). A review of the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database uncovered no previous studies of the clinical nursing research priorities of renal specialist nurses.
,":.:.:":,::.-".-..,...'::".-". " ~..~:`.::`...:..:....:..:~:......:`:.....:~.........:~...:..~;......~.;:?~.:...~.....i:.?..:;?.... ..,.'.;:<:7
METHODOLOGY Research participants Aggregates of nursing research topics or problems were identified by a national sample of renal specialist nurses involved in managing patients in general critical care settings. The panel in this study consisted of 12 renal speciahst nurses.
Design and measures The Delphi method (Linstone & Turoff 1975) was used as the data-generating tool in this study. The object of this methodology is to obtain the most reliable consensus o f a group o f experts. It has been used extensively in business and industry and also in the health area (Butterworth & Bishop 1995, Duffield 1988, Linstone & Turoff 1975). The method has been used to uncover research priorities in nursing in a number o f studies (see for example Bond & Bond 1982, Heinrich & Bloich 1980, Lewandowski & Kosltsky 1983, Riegel et al 1993). As a research method the Delphi method or technique has a number of strengths and limitations. Group communication process is facilitated by the method. It allows structured group communication to deal with and at the same time eliminate face-to-face confrontations as experienced on panels or committees. The technique involves repeated individual questioning of experts by use of a series of questionnaires. It is designed to produce group consensus and statistical summaries between rounds, by which panel members communicate their judgements anonymously within a group (Anderson 1986). The method also allows for: • feedback o f individual contributions of information1 and knowledge • assessment of the group judgement or views • opportunity for individuals to review views • a degree of anonymity for individual responses.
Limitations of the method relate to the fact that little is known about the effect of feedback to research participants, and specifically whether certain types o f feedback can lead to questionable group consensus (for example, false or inaccurate feedback). Also there is no way of measuring the authenticity of group convergence with this method (Battersby 1994). Theoretically, it is accepted that through the processes of the method, convergence and consensus related to the research questions can be achieved. In this study the panel of specialist nurses received three rounds of questionnaires. In round one, the participants were all sent a semi-structured postal questionnaire. This contamed two major sections. The first section comprised demographic questions covering experience, age, and qualifications. The second section requested that study participants develop five priority research questions in the following areas: • clinical research which is o f highest value to patients • clinical research which is o f highest value to CNSs/CNCs • clinical research which would provide improved community care • research which would facilitate health promotion and disease prevention • research that would be of value for CNSs,/CNCs, professional needs. Following distribution of the first questionnaire (questionnaire A), a reminder to return the item was sent to initial non-respondents and a reminder telephone call was also made if necessary. In the second round, participants were sent a questionnaire which was developed using all 197 items generated in the first round. These items were edited by the researchers. This was necessary to avoid duplication, and to format problems as research questions. Each participant was asked to respond to each research question indicating whether nursing should take a leadership role in answering the question (yes or no), as well as to rate on a seven-point scale the importance o f the research question (1 (low) to 7 (high)). In the third round, participants received the final questionnaire (questionnaire C), which contained 52 items. These items were those that attained a median rating of 6 or above in the second round (questionnaire B). The question o f whether nursing should take a leadership role was eliminated, since the majority of the panel had selected these items as appropriate for nursing research leadership in round two. Respondents were once again asked to rate each research question on a scale o f 1 (low) to 7 (high). They were asked to discriminate
A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people
carefully between those questions they considered to be o f high priority and those o f a lesser priority. In addition, they were asked to explain briefly their reason for allocating a high priority (6 or 7 on the scale o f importance) to the question. There was a 60% response rate (7) for the first two rounds o f the study and a 100% response (12) in the final round. W i t h the Delphi technique no more than three rounds o f questionnaires are used as additional rounds tend to show little further changes in opinion (Duffield 1988).
Analysis
It was intended that each participant's response would carry equal weight in group rating so the median score was seen as the appropriate descriptive statistic because the scores were skewed as expected. Where participants had answered 'no' to the question o f nursing research leadership their rating o f that item was set at zero, since the focus was intended to be solely on nursing research priorities. A decision was taken to use 6 as the cut-off point for the median score in the study. Participants were asked to give a rationale where they allocated research items a score o f 6 or above.
%....:...-.-..:..i::-.:'..::-...,.:-.--":::'..-..-.,.-.:i..,.:,..; ::..:,...-:::... ~.:.. -"..-"i..~.C'.: :.." ::. RESULTS
Survey results were recorded and analysed by the researchers using the computer software package SPSS-PC. The age o f the participants ranged from 31 to 48 years, with a mean age of 35.8 (SD=6.3years). Eight females (66.7%) and four males (33.3%) participated in the study. The participants had 6.5 to 27 years experience as a registered nurse, with a mean number o f 13.1 (SD = 6.9) years. The range for years in the speciality o f renal nursing ranged from 5 to 26years, with a mean o f 10.7 (SD = 6.2) years. The majority o f participants had obtained a specialist qualification in renal
47
nursing (n = 10). Seven o f the participants had completed a university degree m nursing. R o u n d three o f the study resulted in a final list of nine very high priority research questions with which nurses should take a leadership role. These priorities are presented m the following tables.
Clinical research that is o f highest value to patients The panel o f nurse experts developed 41 items m this section. In the final round, the six research questions they designated to be o f highest pnority are shown in Table 1. Clinical research that w o u l d be o f value to CNCs/CNSs O f the 23 items developed in this section only one was given high priority status. This priority is shown in Table 2. Research that w o u l d provide i m p r o v e d c o m m u n i t y care for patients Twenty-eight items were developed In this section, only one was given high priority by the panel in the study. This priority is shown in Table 3. Research that w o u l d facilitate health p r o m o t i o n and disease prevention This area was concerned with research which would be of value to C N S s / C N C s in facilitating health promotion and disease prevention. Twenty-three items were developed in this section; however, no priorities emerged as very high. N o items scored a median value o f 6 following round three. Research that w o u l d be o f value for C N S s ' / C N C s ' professional needs The expert panel in this study developed 72 items in this section. The item shown to be o f highest priority is shown in Table 4.
:- .., :-.....~i!..:;:..:L--''..:";,..:-::-.......:::i.; ::.::.{;:".&!'.:':" ',:: .. ;!::'"..:.'u i~:...:-. DISCUSSION
Table I Clinical research which is of highest value to patients Research Questionnaire I. Whatis the mostappropriatedressingfor a peritoneal 2. 3. 4. 5. 6.'
dialysis catheter exit site? How do you prevent dialysis catheter exit site infections? What is the patients' quahty of life and satisfaction with treatment? How do patient education programmes prepare a person for dialysis and transplantation? What is the most appropriate simplified peritoneal dialysis catheter dressing technique for CAPD patients? What aseptic, sterile procedures/precautions yield the lowest refection rates?
Median score
7 7 6.50 6 6 6
This study has shown that the Delphi method is a useful tool for assisting nurses to identify priority areas for clinical research, a finding consistent with a number o f previous studies. The findings o f the study need to be interpreted within the context o f assumptions, lirmtations and generalisability o f results, Clearly, the sample size in the study places limitations on the degree to which one can generalise from its results. It is interesting to note that in the final analysis the participants generated high priority research questions in only four o f the five areas
48
Intensive and Critical Care Nursing
Table 2 Clinical research which is of highest value to CNSs/CNCs
Research Questionnaire I. What are the most effective methods for training patients for home dialysis?
Median score 7
Table 3 Clinical research which would provide improved community care
Research Questionnaire I. What is the impact of home dlalys~s on family relationships?
Median score 6
developed by the researchers. N o high priorities emerged in the section 'research that would facilitate health promotion and disease prevention'. This was also the case with the general critical care nurses in the study overall (Daly et al 1995). This raises questions about how the nurse participants conceptuahse their practice. In the section 'research that would be of highest value to patients' the major concerns of the research participants were catheter dressing procedures and infection control in peritoneal dialysis. In addition, the participants saw patient education programmes for dialysis and transplant patients, and quahty ofhfe and satisfaction with treatment, as high priority areas for research. It is surprising that other clinical priorities did not emerge in this section. The participants were asked to focus on their practice in critical care, an area where vascular access is a c o m m o n requirement for haemodialysis procedures. In the second round quesnonnalre used m the study a number of research priorines were concerned with venous access and its management, and haemodlalysis and its potential complications. In this section, the participants were concerned with minimising patient discomfort assocmted with peritoneal infection and maintaining the life of peritoneal dialysis catheters. It was suggested that clinical research could assist in reducing catheter infection rates and improve patient safety and clinical outcomes. Patient education is a neglected area from the perspective of the research participants. They suggest that educanon and its evaluation are important to achieve patient compliance, maximum service and benefits to patients. In the rationales for inclusion of quality o f life and patient satisfaction with treatment the nurses in the study were o f the view that the patients are rarely consulted regarding these matters. Quality of life was suggested as a variable which should be considered
in determining continuation of treatment. In the area of research which would be of value to C N S s / C N C s in the speciality area, only one high priority emerged (Table 2). Again this seems incongruous m the context o f critical care, an area from which patients are never directly discharged home on dialysis. Rationales for this priority included education to ensure compliance, relieving demand on acute hospital beds and achievement o f the best possible outcomes for individual patients. The research priority which was generated in the section 'research which would provide improved community care' also related to home dialysis. Issues related to this included concerns with placing undue burdens on families of patients discharged home on dialysis. Also, there was the perception that families are often neglected and not prepared to cope with a sick member who is dialysis dependent. The final section in the research questionnaire was concerned with research that would be of value for C N S s ' / C N C s ' professional needs. The one priority which emerged here was jusnfied by perceptions that on-going education is essential to maintenance o f a quality service. Also participants acknowledged that this facilitated improvement in professional/ clinical knowledge base o f nurses. Participants were concerned with how this could be best facilitated and assured.
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CONCLUSION The participants perceived research as being the vehicle which could provide them with answers to the questions generated in this study. It could be argued that not all of the questions generated in this study have direct relevance to the renal management of the critically ill. The researchers were hopeful that the clinical priorities generated by the renal specialist nurses would relate significantly to the critically ill across all sections of the study. Nonetheless the study findings provide baseline data which could be foundational to renal nursing research projects in critical care and
Table 4 Research that would be of value for CNSs'/CNCs' professional needs
Research Questionnaire I. The need for self-development and on-going education in the specialty area of renal nursing. How can this be done regularly?
Median score
A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people
elsewhere. Also, they allow insight into the c o n c e r n s and priorities o f the c o h o r t w h o partlcipated in this study w i t h regard to their practice in critical care and their specialty area. T h e study findings r e p o r t e d here c o u l d assist in p r o v i d m g d i r e c n o n for renal nursing research in Australia and elsewhere. It is t h r o u g h sigmficant and substantive research e n d e a v o u r that a s o u n d basis for nursing p r a c n c e will e m e r g e . Identification o f clinical priorities for nursing research can be r e g a r d e d as a first step m this process.
REFERENCES Anderson P 1986 The Delphi technique in practice Austrahan Journal of Advanced Nursing 3 (1) 22-32 Bartu A, McGowan S, Nelson M, R.obertson J 1993 A Western Australian Delphi survey of staff development research pnorlnes AustrahanJournal of Advanced Nursing 9 (3): 141-147 Battersby D 1994 The generic skills, attributes and values expected of graduates from the Faculty of Health Studies at Charles Stuart University Charles Stuart Umverslty, Bathurst Bond S, Bond J 1982 A Delphi study of clinical research priorities. Journal of Advanced Nursing 7 (6): 563-575
49
Butterworth T, Bishop V 1995 ldenufymg the charactensncs ofopumum practice: fin&ngsfrom a sm'veyofpracnce experts in nursing, rmdwlferyand health vlsmng Journal of Advanced Nursing 22 (1) 24-32 Daly J, Chang E M L, Bell P F 1995 Clinical nursing research priorities m crmcal care: a pilot study Australian Critical Care 8 (1): 34-35. Dut~ield C 1988 The Delphi techmque. The Australian Journal of Advanced Nursing 6 (2) 41-45 GreenwoodJ 1984 Nursing research, a posmon paper Journal of Advanced Nursing. 9' 77-82 HemrlchJ, Bloch D 1980 Survey of knowledge for practice conference group discussion Nursing Research 28 218 Hmshaw A S, Hemnch J. Block D 1988 Evolving clinical nursing research priorities: a national endeavour. Journal of Professional Nursing 4 (6): 398,458-459 Lewandowska L A, Kosltsky A M 1983 Research pnormes in critical care nursing: a study by the American Association of Crmcal Care Nurses. Heart & Lung 12 (1): 35 44 Lmdqmst 1<, BanaslkJ, BarnsteinerJ et al 1993 Deterrmmng AACNs research prmrmes for the 90s American Journa] of Cntical Care 2 (2): 110-117 Llnstone H A, TuroffM 1975 The Delphi technique: techniques and applications. Ad&son-Wesley, Massachusetts Rlegel B, BanaslkJ, BarnstelnerJet al 1993 Reviews and summanes of research related to AACN 1980 research pnormes: climcal topzcs. American Journal of Cntzcal Care 2 (5): 413-425
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A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people ;.:-'.: ::!::::
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John R Daly and Esther M. L. Chang
John P Dab/ RN, BA, BHSc, MEd (Hons), PhD, FRCNA, Associate Professor of Nursing, University of Western Sydney, Macarthur, PO Box 555, Campbelltown, NSW 2560
The aim of this pilot research project was to identify priority areas for clinical nursing research for renal specialist nurses practising in general critical care. Research participants in the study included Clinical Nurse Specialists (CNSs) and Clinical Nurse Consultants (CNCs), n = 12. The study sample was national with representation from a number of major metropolitan teaching hospitals in Australia. The Delphi technique was used to obtain the most reliable consensus of the specialist nurses. Research priorities emerged in four areas: I) clinical research which is of highest value to patients; 2) clinical research which is of highest value to CNSs/CNCs; 3) clinical research which would provide improved community care and 4) research that would be of value for CNSs/CNCs professional needs. In the final phase of the study nine high priorities were identified. The findings of the study suggest directions for clinical nursing research which would benefit renal specialist nurses and their patients.
Esther M L Chang RN, BAppSc, DIpEd, MEd, Admm PhD, Associate Professor of Nursing, U mverslty of Western Sydney, Hawkesbury, Rmhmond NSW 2753, Austraha
(Requests for offprints to JD) Manuscript accepted 25 November 1995
:
.-:..,..:.:,,..::,
.-::.:,.:::
.,-.,
.
. ";,..-:"
:-
.:.:
.....
.:::.,..::.,
INTRODUCTION In a recent Australian study o f the clinical nursing research priorities o f critical care nurses, a decision was taken to Include four subgroups:
Intenswe and Critical Care Nursing (1996) 12, 4549
© 1996PearsonProfesmonalLtd
• •
general critical care cardiac critical care (coronary care and cardiothoracic critical care) neurosurglcal/neuromedical critical care renal nurses involved m managing the critically ill (Daly et al 1995).
The sample in each subgroup was national and included specialist nurses who were regarded as experts m their area o f nursing practice. The researchers were motivated to undertake a study of clinical nursing research priorities in Austrahan critical care for a number o f reasons. Firstly, the area lacks a substantive k n o w ledge base which has been developed through research endeavour. Identified priorities could be foundational for a number o f necessary and relevant research projects m critical care nursing. This could be regarded as a preliminary step in the generation o f nursing knowledge for the area. Secondly, it has been suggested that the most prudent approach to building the k n o w ledge base for nursing practice through research is one which is systematic (Hinshaw et al 1988). Identification o f agreed priority areas for clinical nursing research would assist in the sequential investigation o f practice problems to ensure the most rational, economic use o f resources and attention to the most pressing problems confronting clinicians and thmr patients. Thirdly, the authors are o f the view that problems to be addressed through clinical nursing research nmst emerge from the context o f pracnce. If nursing research is to have relevance to the needs of chmcal nurses and their patients it is imperative that nurses have the opportunity to influence the determination of clinical nursing research priorities (Greenwood 1984). In particular there is a need to harness the expertise of those clinical practitioners best equipped to recognise and use research. The component o f the research study reported here sought to uncover the chnlcal nursing research priorities o f renal specialist nurses involved In caring for the critically ill. An additional area of concern addressed in the study was research that would be o f value with regard to the professional needs of the research participants. Renal specialist nurses are often involved in caring for critically ill people in Australia. In general, they are involved in dialyslng patients with impaired or deteriorating renal function. The services they provide in this context are broad-ranging and may include actually carrying out dialysis, supervising the renal management of the critically ill by nonspecialist nurses, consultancy or educational activities. The notion and process o f generating clinical nursing research priorities are not new. The
46
Intensiveand Critical Care Nursing approach has been used extensively in the USA, and on a limited basis in the UK (Bond & Bond 1982). In Australia, two studies have been reported in the literature (Bartu et al 1993, Daly et al 1995). O f relevance to critical care nursing per se are several studies undertaken in the USA (Lewandowskl & Kositsky 1983, Lindquist et al 1993, Riegel et al 1993) and one in Australia (Daly et al 1995). A review of the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database uncovered no previous studies of the clinical nursing research priorities of renal specialist nurses.
,":.:.:":,::.-".-..,...'::".-". " ~..~:`.::`...:..:....:..:~:......:`:.....:~.........:~...:..~;......~.;:?~.:...~.....i:.?..:;?.... ..,.'.;:<:7
METHODOLOGY Research participants Aggregates of nursing research topics or problems were identified by a national sample of renal specialist nurses involved in managing patients in general critical care settings. The panel in this study consisted of 12 renal speciahst nurses.
Design and measures The Delphi method (Linstone & Turoff 1975) was used as the data-generating tool in this study. The object of this methodology is to obtain the most reliable consensus o f a group o f experts. It has been used extensively in business and industry and also in the health area (Butterworth & Bishop 1995, Duffield 1988, Linstone & Turoff 1975). The method has been used to uncover research priorities in nursing in a number o f studies (see for example Bond & Bond 1982, Heinrich & Bloich 1980, Lewandowski & Kosltsky 1983, Riegel et al 1993). As a research method the Delphi method or technique has a number of strengths and limitations. Group communication process is facilitated by the method. It allows structured group communication to deal with and at the same time eliminate face-to-face confrontations as experienced on panels or committees. The technique involves repeated individual questioning of experts by use of a series of questionnaires. It is designed to produce group consensus and statistical summaries between rounds, by which panel members communicate their judgements anonymously within a group (Anderson 1986). The method also allows for: • feedback o f individual contributions of information1 and knowledge • assessment of the group judgement or views • opportunity for individuals to review views • a degree of anonymity for individual responses.
Limitations of the method relate to the fact that little is known about the effect of feedback to research participants, and specifically whether certain types o f feedback can lead to questionable group consensus (for example, false or inaccurate feedback). Also there is no way of measuring the authenticity of group convergence with this method (Battersby 1994). Theoretically, it is accepted that through the processes of the method, convergence and consensus related to the research questions can be achieved. In this study the panel of specialist nurses received three rounds of questionnaires. In round one, the participants were all sent a semi-structured postal questionnaire. This contamed two major sections. The first section comprised demographic questions covering experience, age, and qualifications. The second section requested that study participants develop five priority research questions in the following areas: • clinical research which is o f highest value to patients • clinical research which is o f highest value to CNSs/CNCs • clinical research which would provide improved community care • research which would facilitate health promotion and disease prevention • research that would be of value for CNSs,/CNCs, professional needs. Following distribution of the first questionnaire (questionnaire A), a reminder to return the item was sent to initial non-respondents and a reminder telephone call was also made if necessary. In the second round, participants were sent a questionnaire which was developed using all 197 items generated in the first round. These items were edited by the researchers. This was necessary to avoid duplication, and to format problems as research questions. Each participant was asked to respond to each research question indicating whether nursing should take a leadership role in answering the question (yes or no), as well as to rate on a seven-point scale the importance o f the research question (1 (low) to 7 (high)). In the third round, participants received the final questionnaire (questionnaire C), which contained 52 items. These items were those that attained a median rating of 6 or above in the second round (questionnaire B). The question o f whether nursing should take a leadership role was eliminated, since the majority of the panel had selected these items as appropriate for nursing research leadership in round two. Respondents were once again asked to rate each research question on a scale o f 1 (low) to 7 (high). They were asked to discriminate
A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people
carefully between those questions they considered to be o f high priority and those o f a lesser priority. In addition, they were asked to explain briefly their reason for allocating a high priority (6 or 7 on the scale o f importance) to the question. There was a 60% response rate (7) for the first two rounds o f the study and a 100% response (12) in the final round. W i t h the Delphi technique no more than three rounds o f questionnaires are used as additional rounds tend to show little further changes in opinion (Duffield 1988).
Analysis
It was intended that each participant's response would carry equal weight in group rating so the median score was seen as the appropriate descriptive statistic because the scores were skewed as expected. Where participants had answered 'no' to the question o f nursing research leadership their rating o f that item was set at zero, since the focus was intended to be solely on nursing research priorities. A decision was taken to use 6 as the cut-off point for the median score in the study. Participants were asked to give a rationale where they allocated research items a score o f 6 or above.
%....:...-.-..:..i::-.:'..::-...,.:-.--":::'..-..-.,.-.:i..,.:,..; ::..:,...-:::... ~.:.. -"..-"i..~.C'.: :.." ::. RESULTS
Survey results were recorded and analysed by the researchers using the computer software package SPSS-PC. The age o f the participants ranged from 31 to 48 years, with a mean age of 35.8 (SD=6.3years). Eight females (66.7%) and four males (33.3%) participated in the study. The participants had 6.5 to 27 years experience as a registered nurse, with a mean number o f 13.1 (SD = 6.9) years. The range for years in the speciality o f renal nursing ranged from 5 to 26years, with a mean o f 10.7 (SD = 6.2) years. The majority o f participants had obtained a specialist qualification in renal
47
nursing (n = 10). Seven o f the participants had completed a university degree m nursing. R o u n d three o f the study resulted in a final list of nine very high priority research questions with which nurses should take a leadership role. These priorities are presented m the following tables.
Clinical research that is o f highest value to patients The panel o f nurse experts developed 41 items m this section. In the final round, the six research questions they designated to be o f highest pnority are shown in Table 1. Clinical research that w o u l d be o f value to CNCs/CNSs O f the 23 items developed in this section only one was given high priority status. This priority is shown in Table 2. Research that w o u l d provide i m p r o v e d c o m m u n i t y care for patients Twenty-eight items were developed In this section, only one was given high priority by the panel in the study. This priority is shown in Table 3. Research that w o u l d facilitate health p r o m o t i o n and disease prevention This area was concerned with research which would be of value to C N S s / C N C s in facilitating health promotion and disease prevention. Twenty-three items were developed in this section; however, no priorities emerged as very high. N o items scored a median value o f 6 following round three. Research that w o u l d be o f value for C N S s ' / C N C s ' professional needs The expert panel in this study developed 72 items in this section. The item shown to be o f highest priority is shown in Table 4.
:- .., :-.....~i!..:;:..:L--''..:";,..:-::-.......:::i.; ::.::.{;:".&!'.:':" ',:: .. ;!::'"..:.'u i~:...:-. DISCUSSION
Table I Clinical research which is of highest value to patients Research Questionnaire I. Whatis the mostappropriatedressingfor a peritoneal 2. 3. 4. 5. 6.'
dialysis catheter exit site? How do you prevent dialysis catheter exit site infections? What is the patients' quahty of life and satisfaction with treatment? How do patient education programmes prepare a person for dialysis and transplantation? What is the most appropriate simplified peritoneal dialysis catheter dressing technique for CAPD patients? What aseptic, sterile procedures/precautions yield the lowest refection rates?
Median score
7 7 6.50 6 6 6
This study has shown that the Delphi method is a useful tool for assisting nurses to identify priority areas for clinical research, a finding consistent with a number o f previous studies. The findings o f the study need to be interpreted within the context o f assumptions, lirmtations and generalisability o f results, Clearly, the sample size in the study places limitations on the degree to which one can generalise from its results. It is interesting to note that in the final analysis the participants generated high priority research questions in only four o f the five areas
48
Intensive and Critical Care Nursing
Table 2 Clinical research which is of highest value to CNSs/CNCs
Research Questionnaire I. What are the most effective methods for training patients for home dialysis?
Median score 7
Table 3 Clinical research which would provide improved community care
Research Questionnaire I. What is the impact of home dlalys~s on family relationships?
Median score 6
developed by the researchers. N o high priorities emerged in the section 'research that would facilitate health promotion and disease prevention'. This was also the case with the general critical care nurses in the study overall (Daly et al 1995). This raises questions about how the nurse participants conceptuahse their practice. In the section 'research that would be of highest value to patients' the major concerns of the research participants were catheter dressing procedures and infection control in peritoneal dialysis. In addition, the participants saw patient education programmes for dialysis and transplant patients, and quahty ofhfe and satisfaction with treatment, as high priority areas for research. It is surprising that other clinical priorities did not emerge in this section. The participants were asked to focus on their practice in critical care, an area where vascular access is a c o m m o n requirement for haemodialysis procedures. In the second round quesnonnalre used m the study a number of research priorines were concerned with venous access and its management, and haemodlalysis and its potential complications. In this section, the participants were concerned with minimising patient discomfort assocmted with peritoneal infection and maintaining the life of peritoneal dialysis catheters. It was suggested that clinical research could assist in reducing catheter infection rates and improve patient safety and clinical outcomes. Patient education is a neglected area from the perspective of the research participants. They suggest that educanon and its evaluation are important to achieve patient compliance, maximum service and benefits to patients. In the rationales for inclusion of quality o f life and patient satisfaction with treatment the nurses in the study were o f the view that the patients are rarely consulted regarding these matters. Quality of life was suggested as a variable which should be considered
in determining continuation of treatment. In the area of research which would be of value to C N S s / C N C s in the speciality area, only one high priority emerged (Table 2). Again this seems incongruous m the context o f critical care, an area from which patients are never directly discharged home on dialysis. Rationales for this priority included education to ensure compliance, relieving demand on acute hospital beds and achievement o f the best possible outcomes for individual patients. The research priority which was generated in the section 'research which would provide improved community care' also related to home dialysis. Issues related to this included concerns with placing undue burdens on families of patients discharged home on dialysis. Also, there was the perception that families are often neglected and not prepared to cope with a sick member who is dialysis dependent. The final section in the research questionnaire was concerned with research that would be of value for C N S s ' / C N C s ' professional needs. The one priority which emerged here was jusnfied by perceptions that on-going education is essential to maintenance o f a quality service. Also participants acknowledged that this facilitated improvement in professional/ clinical knowledge base o f nurses. Participants were concerned with how this could be best facilitated and assured.
'V !'::::':
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:'-i.'"':'= : ' '~ v'.': ' " ' : " . . : .
.:.,7:!.,
:..
CONCLUSION The participants perceived research as being the vehicle which could provide them with answers to the questions generated in this study. It could be argued that not all of the questions generated in this study have direct relevance to the renal management of the critically ill. The researchers were hopeful that the clinical priorities generated by the renal specialist nurses would relate significantly to the critically ill across all sections of the study. Nonetheless the study findings provide baseline data which could be foundational to renal nursing research projects in critical care and
Table 4 Research that would be of value for CNSs'/CNCs' professional needs
Research Questionnaire I. The need for self-development and on-going education in the specialty area of renal nursing. How can this be done regularly?
Median score
A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people
elsewhere. Also, they allow insight into the c o n c e r n s and priorities o f the c o h o r t w h o partlcipated in this study w i t h regard to their practice in critical care and their specialty area. T h e study findings r e p o r t e d here c o u l d assist in p r o v i d m g d i r e c n o n for renal nursing research in Australia and elsewhere. It is t h r o u g h sigmficant and substantive research e n d e a v o u r that a s o u n d basis for nursing p r a c n c e will e m e r g e . Identification o f clinical priorities for nursing research can be r e g a r d e d as a first step m this process.
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Butterworth T, Bishop V 1995 ldenufymg the charactensncs ofopumum practice: fin&ngsfrom a sm'veyofpracnce experts in nursing, rmdwlferyand health vlsmng Journal of Advanced Nursing 22 (1) 24-32 Daly J, Chang E M L, Bell P F 1995 Clinical nursing research priorities m crmcal care: a pilot study Australian Critical Care 8 (1): 34-35. Dut~ield C 1988 The Delphi techmque. The Australian Journal of Advanced Nursing 6 (2) 41-45 GreenwoodJ 1984 Nursing research, a posmon paper Journal of Advanced Nursing. 9' 77-82 HemrlchJ, Bloch D 1980 Survey of knowledge for practice conference group discussion Nursing Research 28 218 Hmshaw A S, Hemnch J. Block D 1988 Evolving clinical nursing research priorities: a national endeavour. Journal of Professional Nursing 4 (6): 398,458-459 Lewandowska L A, Kosltsky A M 1983 Research pnormes in critical care nursing: a study by the American Association of Crmcal Care Nurses. Heart & Lung 12 (1): 35 44 Lmdqmst 1<, BanaslkJ, BarnsteinerJ et al 1993 Deterrmmng AACNs research prmrmes for the 90s American Journa] of Cntical Care 2 (2): 110-117 Llnstone H A, TuroffM 1975 The Delphi technique: techniques and applications. Ad&son-Wesley, Massachusetts Rlegel B, BanaslkJ, BarnstelnerJet al 1993 Reviews and summanes of research related to AACN 1980 research pnormes: climcal topzcs. American Journal of Cntzcal Care 2 (5): 413-425