- Email: [email protected]
Research in the perianesthesia setting: The basics of getting started
Research in the Perianesthesia Setting: The Basics of Getting Started Gina Myers, MS, RN Michele Kosinski, MS, RN
Research can be defined as a process that systematically investigates a situation with the objective of expanding the existing knowledge of a profession. Research asks the question “Does what we do as nurses help or hinder?” The purpose of this article is to provide a brief history of nursing research and to review basic research methods. In addition, examples of potential research projects focused in the perianesthesia practice arena will be explored. Practical steps will be outlined to guide novice nurse researchers in their early endeavors. © 2005 by American Society of PeriAnesthesia Nurses. Objectives—On completion of this activity, the learner will be able to (1) differentiate between quantitative and qualitative research, (2) identify the types of quantitative and qualitative research, and (3) state the current ASPAN research initiatives. NURSING RESEARCH is slowly gathering momentum as bedside practitioners and health care leaders look to validate nursing’s impact on patient outcomes and the health care system as a whole. However, nursing research is not a new concept. Florence Nightingale was revolutionary in her observation, interpretation, and interventions regarding the human response to illness. Nightingale documented her findings in Notes on Nursing1 and was the first to monitor and record the effects of fresh air, hand washing, and adequate nutrition on patient outcomes. These first steps paved the way for nursing practice and research for centuries to come. Most nurses want to improve care and maximize outcomes for their patients, particularly the vulnerable or critically ill. In the perianesthesia arena, nurses care daily for these patients. Research provides a way to achieve better outcomes. Krenzischek,2 in addressing the vision of ASPAN and research stated, “ It is our commitment to educate perianesthesia nurses in methods of quality patient care and to promote patient care that is guided by research and research methods. Our core values are patient focused. . ..” Journal of PeriAnesthesia Nursing, Vol 20, No 1 (February), 2005: pp 35-44
Research can be defined as a process that systematically investigates a situation with the purpose of contributing to the existing knowledge of a profession.3 The goal, to expand the profession’s knowledge base, can be accomplished through either fundamental or applied research. Fundamental research extends the theory that is already present within the profession. Applied research investigates a solution to an identified problem.4 Nursing research focuses on situations that affect patients and their families. More specifically, it looks at how people respond to health and illness, how nursing interventions can be used with both the ill and the well, how we educate patients and/or nurses, and what our role is in disease management.5 Nursing research can involve any situation or phenomenon that a nurse encounters in his or her daily practice in any care arena.
Gina Myers, MS, RN, is a nurse at St. Joseph’s Hospital Health Center, Syracuse, NY; and Michele Kosinski, MS, RN, is a nurse at St. Joseph’s Hospital Health Center, Syracuse, NY. Address correspondence to Gina Myers, MS, RN, St. Joseph’s Hospital Health Center, 301 Prospect Avenue, Syracuse, NY 13203; e-mail address: [email protected]. © 2005 by American Society of PeriAnesthesia Nurses. 1089-9472/05/2001-0008$30.00/0 doi:10.1016/j.jopan.2004.11.003 35
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For many nurses, the idea of doing research can be intimidating. It seems there are many things that one must know and a certain level of education one must have to conduct research. Although increasing the level of formal education will assist in the research process, any nurse can become involved in an investigation. Some nurses may think “why would I bother with research, my questions are not that important” or “I could never do research.” The purpose of this article is to let perianesthesia nurses know that no matter the location of work, they can do research. The profession needs perianesthesia nurses to do research. Nurses who have been practicing for several years are especially valuable. Some recent timehonored practices that have been abolished through research are as follows:
● Maalox, sugar, and heat lamps to treat pressure ulcers.
● Blue dye in tube feeding to monitor for aspiration.
● Discharge of patients from the perianesthesia care unit regardless of core temperature. These customs changed because of research, which is established by using systematic evaluation of interventions and patient outcomes. Historically, there have been several approaches to patient care. One approach is to do things a certain way, “because that’s the way we’ve always done it.” Another approach to patient care is based on intuition or experience. For the experienced practitioner, this can be a valid approach; however, caution must be used to be certain our interventions are based on facts instead of tradition or comfort level. The third approach is evidence based. This is practice grounded in the routine and systematic evaluation of interventions and patient outcomes. Evidence-based research poses the question “Do specific nursing efforts help or hinder?” This leads to nursing research.
Participating in research expands the body of nursing knowledge. Moreover, when nurses are engaged in research, patients receive more effective care, and nurses have better insight into ways of practice. Nursing research validates to the whole health care community why our interventions are so important. As nurses, we are privileged to know information about patients that other disciplines may not. For example, nurses walk into a room and perceive that the patient is fearful to undergo anesthesia. Understanding this, the nurse connects with the patient and offers words of comfort in just the right way. How did the nurse instantly grasp this from the patient? How did the nurse know just the right way to offer comfort? Any experienced perianesthesia nurse can answer these questions. Our patients depend on the nurse to be the “link” and benefit from our expertise. The real question becomes whether there is research data to validate what the nurse perceived to be true. Thus, without research, nurses cannot share their unique knowledge with those outside of nursing, nor can they pass it along to novice nurses who are doing their best to quickly learn what their experienced colleagues already understand. In addition, a lack of supporting data can make it difficult to implement improvements in the way nurses perform interventions and validate nursing practice. It is often difficult to modify an age-old process without the evidence to support the rationales for change. Other reasons exist to support nursing involvement in research. Nursing research attempts to describe, explain, predict, and/or control the world around us. Description focuses on creating a picture of what is happening in a particular situation. The nurse does not seek to change anything, but rather to obtain a clear understanding of the circumstances. Explanation aims to provide possible reasons why something may be happening a certain way or why something is the way it is. Prediction allows insight into the future in an attempt to forecast the probability of an event or situation occurring or not occur-
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Table 1. Types and Examples of Quantitative Research Research Type
Descriptive Correlational Quasi-experimental Experimental
Example of Research
“A Survey of Current Perianesthesia Nursing Practice for Pain and Comfort Management”11 “Postoperative Recovery at Home After Ambulatory Gynecologic Laparoscopic Surgery”12 “Aromatherapy with Peppermint, Isopropyl Alcohol, or Placebo is Equally Effective in Relieving Postoperative Nausea”13 “Effects of Recliner-Chair Versus Traditional Hospital Bed on Postsurgical Diagnostic Laparoscopic Recovery Time”14
ring. Lastly, control gives nurses the ability to change how they do things in the pursuit of improvement. Potential areas of nursing research will fit into one or more of those categories.3
Types of Research Nursing is both a science and an art, and as such, is served by both quantitative and qualitative research techniques. To comprehend and apply findings, it is important to understand the intent and scope of each type of research. Quantitative research focuses on the traditional scientific causal relationship between variables. Information is provided numerically. Qualitative research seeks to understand and describe the human experience in illness and wellness. Both types of research have a different, yet equally important, role in the holistic approach to patient care and outcomes.5 Quantitative Research
Quantitative research seeks to show causal relationships between variables. Quantitative research is objective, based on deductive reasoning, and measures a given response to an intervention. Numbers are used to depict values and are also used in analysis. Data collection is completed via the use of a valid and reliable tool which measures a response to a specified intervention. There are four basic types of quantitative research: descriptive, correlational, quasiexperimental, and experimental. They are listed with examples in Table 1.
Descriptive research is the least rigid method of quantitative research and seeks to define the characteristics of a particular situation or group. Descriptive research is performed when little is known about how variables interact. Descriptive research determines the frequency of events, categorizes information, and organizes it in a logical fashion. One example is thermoregulation and hemodynamic stability in the perianesthesia patient. Descriptive research shows that hypothermic patients have more blood pressure instability during their first hour in the PACU.6 Correlational research investigates the relationship between or among variables or things. This relationship can be defined as either positive or negative. The goal of correlational research is to identify the strength of the relationship between variables. Using the thermoregulation example, those patients who are hypothermic are also hypotensive. Thus, the patient’s cold temperature has a negative relationship to blood pressure. Quasi-experimental research is performed to examine causality in situations where complete control is neither possible nor desired. In most health care research, a specific type of patient or situation is studied. In the study of hypothermic patients, any patient who was admitted to the PACU with a defined low core temperature (eg, ⬍96.8°F) would be included in the study. Thus, those with a defined normal temperature would be excluded. Researchers do not want to
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Table 2. Types and Examples of Qualitative Research Research Type
Example of Research
Phenomenological
“Telephone Follow-up for Day Surgery Patients: Patient Perceptions and Nurses’ Experiences”15 “Chronically Ill Children Coping with Repeated Hospitalizations: Their Perceptions and Suggested Interventions”16 “Nurses’ Advocacy in an Australian Operating Department”17 “Plato, Nightingale, and Contemporary Nursing”18
Grounded-theory Ethnographic Historical
make patients hypothermic so that blood pressure can be monitored. They use the population already in place who meets that definition. Quasi-experimental research helps explain why certain events occur in specific patient populations. The last type of quantitative research is experimental, and is the most rigid of the quantitative genre. Three requisite factors for experimental research are control, manipulation, and randomization. A controlled investigation is performed for the purpose of predicting or explaining certain events. This type of research mandates that certain patients will receive an experimental intervention or treatment, whereas others will receive usual care. All patients have an equal chance of receiving the experimental intervention. By returning to the thermoregulation example, a perianesthesia nurse researcher may want to evaluate a new patient-warming device. One group of patients would use the new device, and the other group would be warmed with traditional therapies. This study could evaluate which therapy was more effective in returning patients to a normal temperature. Many believe that quantitative investigations are the only “valid” type of research because they can be definitively measured. However, people and their responses to illness, wellness, and interventions cannot be fully captured with finite tools and numbers. For this reason, the role and significance of qualitative research are substantiated.
Qualitative Research
Qualitative research seeks to understand human experience. Insight is gained through description and interpretation of the person’s perspective on a chosen encounter. Although there are many types of qualitative research, all share most of the same characteristics.4 Interviews and observation are the principal ways of collecting data in qualitative research. Ideally, the researcher spends time in the natural setting where the subject experiences his or her daily life. The primary tool of the researcher for data collection is words, pictures, or sometimes artwork. On the basis of interviews with people involved within the phenomenon, the researcher attempts to tap into the perspective of the person who has experienced a situation. The researcher then searches for meaning in common themes among the interviews of the people involved.7 Qualitative research is often referred to as a “soft science” with a broad and holistic focus. Because of the subjective nature, the actual experiences of people form the basis of research. The goal of qualitative research is to truly grasp what a person goes through given a particular situation. The knowledge gained is often used to develop and build nursing theory. Four types of qualitative research are briefly reviewed. These include phenomenologic, grounded-theory, ethnographic, and historical research, which are listed, with examples, in Table 2.3
RESEARCH IN THE PACU
Phenomenologic research describes the lived experiences of a group of individuals who share similar circumstances. The researcher hopes to gain a better understanding of what it is like to have the experience under investigation. The goal of grounded-theory research is theory generation or discovery. Grounded-theory research concentrates on how people interact, what they do, and how they become involved in response to the phenomenon. Ethnography is used to describe and interpret how a cultural or social group behaves, what their customs are, and what their way of life is. It involves observation of the group in which the researcher has to become immersed in the daily lives of the group members over a period of time.7 Historical research entails looking critically at past events and investigating how they occurred and under what circumstances. This type of research examines how past trends or events shaped the present.4
Research in the Perianesthesia Setting The perianesthesia setting is filled with opportunities to conduct research. Across the country, perianesthesia colleagues have investigated topics addressing hypothermia, postoperative nausea and vomiting, hypoxia, and patient education.8 Other potential topics have been suggested by ASPAN.9 Pain management, temperature regulation, hemodynamic stability, and NPO status are just a few of the identified research priorities. Table 3 provides the key topic areas identified by perianesthesia nursing experts. Promoting research in these areas will broaden the evidence base, which supports all interventions. How to Get Started
The first step for the perianesthesia nurse to get started is to write down the questions asked in every day practice. It is important that the researcher keeps paper handy to record flashes of insight as they occur; otherwise, thoughts may not seem as clear or memory may fail. Next, a decision is made to actually do the research.
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Table 3. ASPAN Research Priorities for Perianesthesia Nursing9 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Discharge criteria and scoring systems (all phases) Postoperative nausea and vomiting Patient satisfaction issues Oxygen theraphy in the PACU Validation of perianesthesia standards NPO status Impact of nursing care on quality and outcomes issues Pain management Preoperative/preadmission testing Thermoregulation Documentation issues Effects of ICU overflow
This is often easier said than done. Most nurse researchers have at least a dozen research project ideas just waiting to be started. If this is the first time doing research, the researcher may want to take a course or read references on research to aid in understanding of the basic concepts. Partnering with others who are interested in pursing a research project is critical. Research is not a solitary journey. One way to help bridge the education practice gap is through forming relationships with nurse educators who are often very skilled in conducting research. Sources of support include peers in the perianesthesia units and other practice settings. Interdisciplinary research with physicians, respiratory therapists, physical therapists, nutritionists, and so on, opens many possibilities for collaborative research. In the perianesthesia setting, the research team may include perioperative nurses, critical care nurses, clinical nurse specialists, surgical technicians, anesthesiologists, nurse anesthetists, physical therapists, or respiratory therapists. Working with others who have different abilities and perspectives will enrich the project by bringing different ideas and viewpoints together. It is this kind of partnership that our profession needs. Last, and most important, is for the nurse researcher to find a mentor who is experienced with re-
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search and who will guide the researcher through the process, helping to avoid many stumbling blocks along the way. Your mentor will serve as the one who encourages, gives constructive criticism, and helps see the project to its completion. Before closing, a word needs to be said about replication of research. Replication is a method for determining whether results from an earlier study can be repeated when a new set of subjects and/or a different setting is used. This approach strengthens our rationale for using certain methodologies or innovations in practice.5 To strengthen existing research and add to the evidence base of perianethesia nursing practice, research findings need to be validated through the replication process. With replication, the researcher seeks to take another’s study and repeat it in an attempt to find the same results. Many practices are built on the results of 1 or 2 studies. Replicated studies help to document reliability and validity of research findings. In an article by Fahs, Lake-Morgan, and Kalman,10 the benefits and barriers to replication were described. They emphasized the need to replicate research, but they clearly stated there is a lack of enthusiasm for replication due to a lack of available resources and support. However, they urge nurses to overcome those challenges and partake in this type of scholarly activity. Furthermore, replication in research is an excellent place for the new researcher to begin learning about the research process.10
Hopefully, this introduction to nursing research will spur recognition that nursing research is a valuable and necessary tool for our professional practice. Understanding and using proven methods of best practice improves patient outcomes, patient satisfaction, validates our professional practice, and improves professional satisfaction. Krenzischek2 further noted, “Patient safety is paramount and should be a main focus. . .. We must monitor the impact, value the lessons learned from what we see, hear, and experience and enhance our decisions.” The authors would like to further challenge the readers by saying that the extent to which one is committed to research indicates a commitment to practice.
Conclusion This article was written to motivate readers professionally and expand their horizons through an improved understanding of the types of research that can be performed. Hopefully, the article will stimulate perianesthesia nurses to think of ways to improve practice and the experiences of patients. This article is merely a brief overview of the types and role of nursing research. Future articles will include more in-depth research concepts such as the research process, evaluation, and use.
Acknowledgment We thank Maureen Iacono, BSN, RN, CPAN, Manager for the PACU at St. Joseph’s Hospital Health Center in Syracuse, New York, and Ronna S. Blum, RN, MS, CCRN, Clinical Nurse Specialist for Medical/ Surgical patients at Cortland Memorial Hospital in Cortland, New York, who reviewed and gave insight to the article.
References 1. Nightingale F: Notes on Nursing. Philadelphia, PA, Lippincott, 1992 2. Krenzischek DA: Guest editorial: ASPAN’s research vision. J Perianesth Nurs 16:149-150, 2001 3. Burns N, Grove, SK: The Practice of Nursing Research: Conduct, Critique, and Utilization (ed 4). Philadelphia, PA, Saunders, 2001 4. Powers BA, Knapp TR: A Dictionary of Nursing Theory and Research (ed 2). Thousand Oaks, CA, Sage, 1995 5. Polit DF, Tatano-Beck C, Hungler BP: Essential of Nursing Research: Methods, Appraisal, and Utilization (ed 5). Philadelphia, PA, Lippincott, 2001
6. Holtzclaw BJ: Thermal balance. In: Kinney MR, Dunbar, SB, Brooks-Brunn J, et al, eds. AACN’s Clinical Reference for Critical Care Nursing. St. Louis, MO, Mosby, 99-111, 1998 7. Creswell JW: Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Thousand Oaks, CA, Sage, 1998 8. Summers S: Editorial opinion: Research. J Perianesth Nurs 16:147-148, 2001 9. American Society of PeriAnesthesia Nurses. ASPAN research priorities for perianesthesia nursing. Available at http:// www.aspan.org/ResearchInfo.htm Accessed October 2003
RESEARCH IN THE PACU 10. Fahs P, Lake-Morgan L, Kalman M: A call for replication. J Nurs Scholarsh 35:67-71, 2003 11. Krenzischek DA, Windle P, Mamaril M: A survey of current perianesthesia nursing practice for pain and comfort management. J Perianesth Nurs 19:138-149, 2004 12. Horvath KJ: Postoperative recovery at home after ambulatory gynecologic laparoscopic surgery. J Perianesth Nurs 18:324-334, 2003 13. Anderson LA, Gross JB: Aromatherapy with peppermint, isopropyl alcohol, or placebo is equally effective in relieving postoperative nausea. J Perianesth Nurs 19:29-35, 2004 14. Agodoa SE, Holder MA, Fowler SM: Effects of recliner-chair
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versus traditional hospital bed on postsurgical diagnostic laparoscopic recovery time. J Perianesth Nurs 17:318-324, 2002 15. Dewar A, Scott J, Muir J: Telephone follow-up for day surgery patients: Patient perceptions and nurses’ experiences. J Perianesth Nurs 19:234-241, 2003 16. Boyd JR, Hunsberger M: Chronically ill children coping with repeated hospitalizations: Their perceptions and suggested interventions. J Pediatr Nurs 13:330-342, 1998 17. Bull R, FitzGerald M: Nurses’ advocacy in an Australian operating department. AORN J 79:1265-1274, 2004 18. LeVasseur J: Plato, Nightingale, and contemporary nursing. J Nurs Scholarsh 30:281-285, 1998
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Research in the Perianesthesia Care Unit: The Basics of Getting Started 1.4 Contact Hours Directions: The multiple-choice examination below is designed to test your understanding of Research in the Perianesthesia Care Unit: The Basics of Getting Started according to the objectives listed. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing Education Provider Program: (1) read the article; (2) complete the posttest by indicating the answers in the test grid provided; (3) tear out the page (or photocopy) and submit postmarked before February 28, 2007, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test); and return to ASPAN, 10 Melrose Ave, Suite 110, Cherry Hill, NJ 08003-3696. Notification of contact hours awarded will be sent to you in 4 to 6 weeks.
Posttest Questions 1. Which is the most rigid type of quantitative research? a. Descriptive b. Correlational c. Quasi-experimental d. Experimental 2. Ethnography is the study of a. cause and effect b. how a culture or like group of people behave c. a type of quantitative research d. an analysis of historical events 3. Holistic nursing practice incorporates both qualitative and quantitative research a. True b. False 4. When first doing research, what is one of the most important keys to a successful endeavor? a. Taking a formal research class b. Having a Bachelor’s degree c. Finding a mentor to work with d. Doing a replication study 5. Why does the profession need you to do research? a. To broaden the knowledge base of our profession b. To help an organization meet the standards required for Magnet designation c. To validate our practice d. All of the above 6. Which of the following is NOT an ASPAN research initiative? a. Postoperative nausea and vomiting b. NPO status c. Pain management d. Use of new graduates in the perianesthesia care arena 7. Which of the following is a sample of quantitative research? a. The effects of epidural pain control on hemodynamic status b. The lived experience of unbearable pain after surgery
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c. Vietnamese women and their experiences with pain after surgery d. A historical review of the evolution of pain control in the perianesthesia care unit 8. Which of the following is a sample of qualitative research? a. The effects of Zofran on postoperative nausea b. The impact on hypothermia on postoperative nausea c. The lived experience of unstoppable nausea after abdominal surgery d. Factors increasing nausea after surgery 9. In a. b. c. d.
descriptive research, the goal is to: find a cause and effect relationship apply an intervention to a group of patients gather information about a situation when little is known about how variables interact none of the above
10. To capture the lived experience in qualitative research, which medium is not used by the researcher? a. Art b. Poetry c. Words d. Questionnaire
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ANSWERS System W010207/2. Please circle the correct answer 1. a. 2. a. 3. b. b. c. c. d. d. 6. a. 7. a. 8. b. b. c. c. d. d.
Please Print Name
a. b.
4.
a. b. c. d.
9.
a. b. c. d. a. b. c. d.
5.
a. b. c. d. a. b. c. d.
10.
Nursing License No/State
Address City
State
Zip
ASPAN Member #
EVALUATION: Research in the Perianesthesia Care Unit: The Basics of Getting Started (SD, strongly disagree; D, disagree; ?, uncertain; A, agree; SA, strongly agree) 1. To what degree did the content meet the objectives? a. Objective # 1 was met. b. Objective # 2 was met. c. Objective # 3 was met. 2. The program content was pertinent, comprehensive, and useful to me. 3. The program content was relevant to my nursing practice. 4. Self-study/home study was an appropriate format for the content. 5. Identify the amount of time required to read the article and take the test. 25 min 50 min 75 min 100 min 125 min Test answers must be submitted before February 28, 2007 to receive contact hours.
SD
D
?
A
SA
1 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
4 4 4 4 4 4 4
5 5 5 5 5 5 5
Research can be defined as a process that systematically investigates a situation with the objective of expanding the existing knowledge of a profession. Research asks the question “Does what we do as nurses help or hinder?” The purpose of this article is to provide a brief history of nursing research and to review basic research methods. In addition, examples of potential research projects focused in the perianesthesia practice arena will be explored. Practical steps will be outlined to guide novice nurse researchers in their early endeavors. © 2005 by American Society of PeriAnesthesia Nurses. Objectives—On completion of this activity, the learner will be able to (1) differentiate between quantitative and qualitative research, (2) identify the types of quantitative and qualitative research, and (3) state the current ASPAN research initiatives. NURSING RESEARCH is slowly gathering momentum as bedside practitioners and health care leaders look to validate nursing’s impact on patient outcomes and the health care system as a whole. However, nursing research is not a new concept. Florence Nightingale was revolutionary in her observation, interpretation, and interventions regarding the human response to illness. Nightingale documented her findings in Notes on Nursing1 and was the first to monitor and record the effects of fresh air, hand washing, and adequate nutrition on patient outcomes. These first steps paved the way for nursing practice and research for centuries to come. Most nurses want to improve care and maximize outcomes for their patients, particularly the vulnerable or critically ill. In the perianesthesia arena, nurses care daily for these patients. Research provides a way to achieve better outcomes. Krenzischek,2 in addressing the vision of ASPAN and research stated, “ It is our commitment to educate perianesthesia nurses in methods of quality patient care and to promote patient care that is guided by research and research methods. Our core values are patient focused. . ..” Journal of PeriAnesthesia Nursing, Vol 20, No 1 (February), 2005: pp 35-44
Research can be defined as a process that systematically investigates a situation with the purpose of contributing to the existing knowledge of a profession.3 The goal, to expand the profession’s knowledge base, can be accomplished through either fundamental or applied research. Fundamental research extends the theory that is already present within the profession. Applied research investigates a solution to an identified problem.4 Nursing research focuses on situations that affect patients and their families. More specifically, it looks at how people respond to health and illness, how nursing interventions can be used with both the ill and the well, how we educate patients and/or nurses, and what our role is in disease management.5 Nursing research can involve any situation or phenomenon that a nurse encounters in his or her daily practice in any care arena.
Gina Myers, MS, RN, is a nurse at St. Joseph’s Hospital Health Center, Syracuse, NY; and Michele Kosinski, MS, RN, is a nurse at St. Joseph’s Hospital Health Center, Syracuse, NY. Address correspondence to Gina Myers, MS, RN, St. Joseph’s Hospital Health Center, 301 Prospect Avenue, Syracuse, NY 13203; e-mail address: [email protected]. © 2005 by American Society of PeriAnesthesia Nurses. 1089-9472/05/2001-0008$30.00/0 doi:10.1016/j.jopan.2004.11.003 35
MYERS AND KOSINSKI
36
For many nurses, the idea of doing research can be intimidating. It seems there are many things that one must know and a certain level of education one must have to conduct research. Although increasing the level of formal education will assist in the research process, any nurse can become involved in an investigation. Some nurses may think “why would I bother with research, my questions are not that important” or “I could never do research.” The purpose of this article is to let perianesthesia nurses know that no matter the location of work, they can do research. The profession needs perianesthesia nurses to do research. Nurses who have been practicing for several years are especially valuable. Some recent timehonored practices that have been abolished through research are as follows:
● Maalox, sugar, and heat lamps to treat pressure ulcers.
● Blue dye in tube feeding to monitor for aspiration.
● Discharge of patients from the perianesthesia care unit regardless of core temperature. These customs changed because of research, which is established by using systematic evaluation of interventions and patient outcomes. Historically, there have been several approaches to patient care. One approach is to do things a certain way, “because that’s the way we’ve always done it.” Another approach to patient care is based on intuition or experience. For the experienced practitioner, this can be a valid approach; however, caution must be used to be certain our interventions are based on facts instead of tradition or comfort level. The third approach is evidence based. This is practice grounded in the routine and systematic evaluation of interventions and patient outcomes. Evidence-based research poses the question “Do specific nursing efforts help or hinder?” This leads to nursing research.
Participating in research expands the body of nursing knowledge. Moreover, when nurses are engaged in research, patients receive more effective care, and nurses have better insight into ways of practice. Nursing research validates to the whole health care community why our interventions are so important. As nurses, we are privileged to know information about patients that other disciplines may not. For example, nurses walk into a room and perceive that the patient is fearful to undergo anesthesia. Understanding this, the nurse connects with the patient and offers words of comfort in just the right way. How did the nurse instantly grasp this from the patient? How did the nurse know just the right way to offer comfort? Any experienced perianesthesia nurse can answer these questions. Our patients depend on the nurse to be the “link” and benefit from our expertise. The real question becomes whether there is research data to validate what the nurse perceived to be true. Thus, without research, nurses cannot share their unique knowledge with those outside of nursing, nor can they pass it along to novice nurses who are doing their best to quickly learn what their experienced colleagues already understand. In addition, a lack of supporting data can make it difficult to implement improvements in the way nurses perform interventions and validate nursing practice. It is often difficult to modify an age-old process without the evidence to support the rationales for change. Other reasons exist to support nursing involvement in research. Nursing research attempts to describe, explain, predict, and/or control the world around us. Description focuses on creating a picture of what is happening in a particular situation. The nurse does not seek to change anything, but rather to obtain a clear understanding of the circumstances. Explanation aims to provide possible reasons why something may be happening a certain way or why something is the way it is. Prediction allows insight into the future in an attempt to forecast the probability of an event or situation occurring or not occur-
RESEARCH IN THE PACU
37
Table 1. Types and Examples of Quantitative Research Research Type
Descriptive Correlational Quasi-experimental Experimental
Example of Research
“A Survey of Current Perianesthesia Nursing Practice for Pain and Comfort Management”11 “Postoperative Recovery at Home After Ambulatory Gynecologic Laparoscopic Surgery”12 “Aromatherapy with Peppermint, Isopropyl Alcohol, or Placebo is Equally Effective in Relieving Postoperative Nausea”13 “Effects of Recliner-Chair Versus Traditional Hospital Bed on Postsurgical Diagnostic Laparoscopic Recovery Time”14
ring. Lastly, control gives nurses the ability to change how they do things in the pursuit of improvement. Potential areas of nursing research will fit into one or more of those categories.3
Types of Research Nursing is both a science and an art, and as such, is served by both quantitative and qualitative research techniques. To comprehend and apply findings, it is important to understand the intent and scope of each type of research. Quantitative research focuses on the traditional scientific causal relationship between variables. Information is provided numerically. Qualitative research seeks to understand and describe the human experience in illness and wellness. Both types of research have a different, yet equally important, role in the holistic approach to patient care and outcomes.5 Quantitative Research
Quantitative research seeks to show causal relationships between variables. Quantitative research is objective, based on deductive reasoning, and measures a given response to an intervention. Numbers are used to depict values and are also used in analysis. Data collection is completed via the use of a valid and reliable tool which measures a response to a specified intervention. There are four basic types of quantitative research: descriptive, correlational, quasiexperimental, and experimental. They are listed with examples in Table 1.
Descriptive research is the least rigid method of quantitative research and seeks to define the characteristics of a particular situation or group. Descriptive research is performed when little is known about how variables interact. Descriptive research determines the frequency of events, categorizes information, and organizes it in a logical fashion. One example is thermoregulation and hemodynamic stability in the perianesthesia patient. Descriptive research shows that hypothermic patients have more blood pressure instability during their first hour in the PACU.6 Correlational research investigates the relationship between or among variables or things. This relationship can be defined as either positive or negative. The goal of correlational research is to identify the strength of the relationship between variables. Using the thermoregulation example, those patients who are hypothermic are also hypotensive. Thus, the patient’s cold temperature has a negative relationship to blood pressure. Quasi-experimental research is performed to examine causality in situations where complete control is neither possible nor desired. In most health care research, a specific type of patient or situation is studied. In the study of hypothermic patients, any patient who was admitted to the PACU with a defined low core temperature (eg, ⬍96.8°F) would be included in the study. Thus, those with a defined normal temperature would be excluded. Researchers do not want to
MYERS AND KOSINSKI
38
Table 2. Types and Examples of Qualitative Research Research Type
Example of Research
Phenomenological
“Telephone Follow-up for Day Surgery Patients: Patient Perceptions and Nurses’ Experiences”15 “Chronically Ill Children Coping with Repeated Hospitalizations: Their Perceptions and Suggested Interventions”16 “Nurses’ Advocacy in an Australian Operating Department”17 “Plato, Nightingale, and Contemporary Nursing”18
Grounded-theory Ethnographic Historical
make patients hypothermic so that blood pressure can be monitored. They use the population already in place who meets that definition. Quasi-experimental research helps explain why certain events occur in specific patient populations. The last type of quantitative research is experimental, and is the most rigid of the quantitative genre. Three requisite factors for experimental research are control, manipulation, and randomization. A controlled investigation is performed for the purpose of predicting or explaining certain events. This type of research mandates that certain patients will receive an experimental intervention or treatment, whereas others will receive usual care. All patients have an equal chance of receiving the experimental intervention. By returning to the thermoregulation example, a perianesthesia nurse researcher may want to evaluate a new patient-warming device. One group of patients would use the new device, and the other group would be warmed with traditional therapies. This study could evaluate which therapy was more effective in returning patients to a normal temperature. Many believe that quantitative investigations are the only “valid” type of research because they can be definitively measured. However, people and their responses to illness, wellness, and interventions cannot be fully captured with finite tools and numbers. For this reason, the role and significance of qualitative research are substantiated.
Qualitative Research
Qualitative research seeks to understand human experience. Insight is gained through description and interpretation of the person’s perspective on a chosen encounter. Although there are many types of qualitative research, all share most of the same characteristics.4 Interviews and observation are the principal ways of collecting data in qualitative research. Ideally, the researcher spends time in the natural setting where the subject experiences his or her daily life. The primary tool of the researcher for data collection is words, pictures, or sometimes artwork. On the basis of interviews with people involved within the phenomenon, the researcher attempts to tap into the perspective of the person who has experienced a situation. The researcher then searches for meaning in common themes among the interviews of the people involved.7 Qualitative research is often referred to as a “soft science” with a broad and holistic focus. Because of the subjective nature, the actual experiences of people form the basis of research. The goal of qualitative research is to truly grasp what a person goes through given a particular situation. The knowledge gained is often used to develop and build nursing theory. Four types of qualitative research are briefly reviewed. These include phenomenologic, grounded-theory, ethnographic, and historical research, which are listed, with examples, in Table 2.3
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Phenomenologic research describes the lived experiences of a group of individuals who share similar circumstances. The researcher hopes to gain a better understanding of what it is like to have the experience under investigation. The goal of grounded-theory research is theory generation or discovery. Grounded-theory research concentrates on how people interact, what they do, and how they become involved in response to the phenomenon. Ethnography is used to describe and interpret how a cultural or social group behaves, what their customs are, and what their way of life is. It involves observation of the group in which the researcher has to become immersed in the daily lives of the group members over a period of time.7 Historical research entails looking critically at past events and investigating how they occurred and under what circumstances. This type of research examines how past trends or events shaped the present.4
Research in the Perianesthesia Setting The perianesthesia setting is filled with opportunities to conduct research. Across the country, perianesthesia colleagues have investigated topics addressing hypothermia, postoperative nausea and vomiting, hypoxia, and patient education.8 Other potential topics have been suggested by ASPAN.9 Pain management, temperature regulation, hemodynamic stability, and NPO status are just a few of the identified research priorities. Table 3 provides the key topic areas identified by perianesthesia nursing experts. Promoting research in these areas will broaden the evidence base, which supports all interventions. How to Get Started
The first step for the perianesthesia nurse to get started is to write down the questions asked in every day practice. It is important that the researcher keeps paper handy to record flashes of insight as they occur; otherwise, thoughts may not seem as clear or memory may fail. Next, a decision is made to actually do the research.
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Table 3. ASPAN Research Priorities for Perianesthesia Nursing9 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Discharge criteria and scoring systems (all phases) Postoperative nausea and vomiting Patient satisfaction issues Oxygen theraphy in the PACU Validation of perianesthesia standards NPO status Impact of nursing care on quality and outcomes issues Pain management Preoperative/preadmission testing Thermoregulation Documentation issues Effects of ICU overflow
This is often easier said than done. Most nurse researchers have at least a dozen research project ideas just waiting to be started. If this is the first time doing research, the researcher may want to take a course or read references on research to aid in understanding of the basic concepts. Partnering with others who are interested in pursing a research project is critical. Research is not a solitary journey. One way to help bridge the education practice gap is through forming relationships with nurse educators who are often very skilled in conducting research. Sources of support include peers in the perianesthesia units and other practice settings. Interdisciplinary research with physicians, respiratory therapists, physical therapists, nutritionists, and so on, opens many possibilities for collaborative research. In the perianesthesia setting, the research team may include perioperative nurses, critical care nurses, clinical nurse specialists, surgical technicians, anesthesiologists, nurse anesthetists, physical therapists, or respiratory therapists. Working with others who have different abilities and perspectives will enrich the project by bringing different ideas and viewpoints together. It is this kind of partnership that our profession needs. Last, and most important, is for the nurse researcher to find a mentor who is experienced with re-
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search and who will guide the researcher through the process, helping to avoid many stumbling blocks along the way. Your mentor will serve as the one who encourages, gives constructive criticism, and helps see the project to its completion. Before closing, a word needs to be said about replication of research. Replication is a method for determining whether results from an earlier study can be repeated when a new set of subjects and/or a different setting is used. This approach strengthens our rationale for using certain methodologies or innovations in practice.5 To strengthen existing research and add to the evidence base of perianethesia nursing practice, research findings need to be validated through the replication process. With replication, the researcher seeks to take another’s study and repeat it in an attempt to find the same results. Many practices are built on the results of 1 or 2 studies. Replicated studies help to document reliability and validity of research findings. In an article by Fahs, Lake-Morgan, and Kalman,10 the benefits and barriers to replication were described. They emphasized the need to replicate research, but they clearly stated there is a lack of enthusiasm for replication due to a lack of available resources and support. However, they urge nurses to overcome those challenges and partake in this type of scholarly activity. Furthermore, replication in research is an excellent place for the new researcher to begin learning about the research process.10
Hopefully, this introduction to nursing research will spur recognition that nursing research is a valuable and necessary tool for our professional practice. Understanding and using proven methods of best practice improves patient outcomes, patient satisfaction, validates our professional practice, and improves professional satisfaction. Krenzischek2 further noted, “Patient safety is paramount and should be a main focus. . .. We must monitor the impact, value the lessons learned from what we see, hear, and experience and enhance our decisions.” The authors would like to further challenge the readers by saying that the extent to which one is committed to research indicates a commitment to practice.
Conclusion This article was written to motivate readers professionally and expand their horizons through an improved understanding of the types of research that can be performed. Hopefully, the article will stimulate perianesthesia nurses to think of ways to improve practice and the experiences of patients. This article is merely a brief overview of the types and role of nursing research. Future articles will include more in-depth research concepts such as the research process, evaluation, and use.
Acknowledgment We thank Maureen Iacono, BSN, RN, CPAN, Manager for the PACU at St. Joseph’s Hospital Health Center in Syracuse, New York, and Ronna S. Blum, RN, MS, CCRN, Clinical Nurse Specialist for Medical/ Surgical patients at Cortland Memorial Hospital in Cortland, New York, who reviewed and gave insight to the article.
References 1. Nightingale F: Notes on Nursing. Philadelphia, PA, Lippincott, 1992 2. Krenzischek DA: Guest editorial: ASPAN’s research vision. J Perianesth Nurs 16:149-150, 2001 3. Burns N, Grove, SK: The Practice of Nursing Research: Conduct, Critique, and Utilization (ed 4). Philadelphia, PA, Saunders, 2001 4. Powers BA, Knapp TR: A Dictionary of Nursing Theory and Research (ed 2). Thousand Oaks, CA, Sage, 1995 5. Polit DF, Tatano-Beck C, Hungler BP: Essential of Nursing Research: Methods, Appraisal, and Utilization (ed 5). Philadelphia, PA, Lippincott, 2001
6. Holtzclaw BJ: Thermal balance. In: Kinney MR, Dunbar, SB, Brooks-Brunn J, et al, eds. AACN’s Clinical Reference for Critical Care Nursing. St. Louis, MO, Mosby, 99-111, 1998 7. Creswell JW: Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Thousand Oaks, CA, Sage, 1998 8. Summers S: Editorial opinion: Research. J Perianesth Nurs 16:147-148, 2001 9. American Society of PeriAnesthesia Nurses. ASPAN research priorities for perianesthesia nursing. Available at http:// www.aspan.org/ResearchInfo.htm Accessed October 2003
RESEARCH IN THE PACU 10. Fahs P, Lake-Morgan L, Kalman M: A call for replication. J Nurs Scholarsh 35:67-71, 2003 11. Krenzischek DA, Windle P, Mamaril M: A survey of current perianesthesia nursing practice for pain and comfort management. J Perianesth Nurs 19:138-149, 2004 12. Horvath KJ: Postoperative recovery at home after ambulatory gynecologic laparoscopic surgery. J Perianesth Nurs 18:324-334, 2003 13. Anderson LA, Gross JB: Aromatherapy with peppermint, isopropyl alcohol, or placebo is equally effective in relieving postoperative nausea. J Perianesth Nurs 19:29-35, 2004 14. Agodoa SE, Holder MA, Fowler SM: Effects of recliner-chair
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versus traditional hospital bed on postsurgical diagnostic laparoscopic recovery time. J Perianesth Nurs 17:318-324, 2002 15. Dewar A, Scott J, Muir J: Telephone follow-up for day surgery patients: Patient perceptions and nurses’ experiences. J Perianesth Nurs 19:234-241, 2003 16. Boyd JR, Hunsberger M: Chronically ill children coping with repeated hospitalizations: Their perceptions and suggested interventions. J Pediatr Nurs 13:330-342, 1998 17. Bull R, FitzGerald M: Nurses’ advocacy in an Australian operating department. AORN J 79:1265-1274, 2004 18. LeVasseur J: Plato, Nightingale, and contemporary nursing. J Nurs Scholarsh 30:281-285, 1998
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Research in the Perianesthesia Care Unit: The Basics of Getting Started 1.4 Contact Hours Directions: The multiple-choice examination below is designed to test your understanding of Research in the Perianesthesia Care Unit: The Basics of Getting Started according to the objectives listed. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing Education Provider Program: (1) read the article; (2) complete the posttest by indicating the answers in the test grid provided; (3) tear out the page (or photocopy) and submit postmarked before February 28, 2007, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test); and return to ASPAN, 10 Melrose Ave, Suite 110, Cherry Hill, NJ 08003-3696. Notification of contact hours awarded will be sent to you in 4 to 6 weeks.
Posttest Questions 1. Which is the most rigid type of quantitative research? a. Descriptive b. Correlational c. Quasi-experimental d. Experimental 2. Ethnography is the study of a. cause and effect b. how a culture or like group of people behave c. a type of quantitative research d. an analysis of historical events 3. Holistic nursing practice incorporates both qualitative and quantitative research a. True b. False 4. When first doing research, what is one of the most important keys to a successful endeavor? a. Taking a formal research class b. Having a Bachelor’s degree c. Finding a mentor to work with d. Doing a replication study 5. Why does the profession need you to do research? a. To broaden the knowledge base of our profession b. To help an organization meet the standards required for Magnet designation c. To validate our practice d. All of the above 6. Which of the following is NOT an ASPAN research initiative? a. Postoperative nausea and vomiting b. NPO status c. Pain management d. Use of new graduates in the perianesthesia care arena 7. Which of the following is a sample of quantitative research? a. The effects of epidural pain control on hemodynamic status b. The lived experience of unbearable pain after surgery
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c. Vietnamese women and their experiences with pain after surgery d. A historical review of the evolution of pain control in the perianesthesia care unit 8. Which of the following is a sample of qualitative research? a. The effects of Zofran on postoperative nausea b. The impact on hypothermia on postoperative nausea c. The lived experience of unstoppable nausea after abdominal surgery d. Factors increasing nausea after surgery 9. In a. b. c. d.
descriptive research, the goal is to: find a cause and effect relationship apply an intervention to a group of patients gather information about a situation when little is known about how variables interact none of the above
10. To capture the lived experience in qualitative research, which medium is not used by the researcher? a. Art b. Poetry c. Words d. Questionnaire
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ANSWERS System W010207/2. Please circle the correct answer 1. a. 2. a. 3. b. b. c. c. d. d. 6. a. 7. a. 8. b. b. c. c. d. d.
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EVALUATION: Research in the Perianesthesia Care Unit: The Basics of Getting Started (SD, strongly disagree; D, disagree; ?, uncertain; A, agree; SA, strongly agree) 1. To what degree did the content meet the objectives? a. Objective # 1 was met. b. Objective # 2 was met. c. Objective # 3 was met. 2. The program content was pertinent, comprehensive, and useful to me. 3. The program content was relevant to my nursing practice. 4. Self-study/home study was an appropriate format for the content. 5. Identify the amount of time required to read the article and take the test. 25 min 50 min 75 min 100 min 125 min Test answers must be submitted before February 28, 2007 to receive contact hours.
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