EVIDENCE-BASED NURSING
INTRODUCTION
The goal of research in nursing is to be able to improve practice and improve services given to patients. Evidence-based research is meant to aid nurses in providing quality care. It has been discovered in recent years that both nursing and evidence-based research are vital to nurses providing adequate, quality and effective care. This essay will critically appraise the “Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap using Girou et al., 2002. An appraisal checklist (Craig and Smyth, 2002) will be used as well as published literature. The discussion will be based on the criteria in the checklist provided which are study design, sample, measures, researcher, data, data collection and analyse and summary, and I will also discuss how the findings of the research will be use to inform practice
DESIGN
Study design is defined by Comack (2002) as the method used to address a research. This includes the plan and strategy, which guide the researcher in writing their theory. Study design is used to achieve greater control, improve the validity of the study and examine research problem. In this study a randomised-controlled trial (RCT) was used. There are different types of study design. These include descriptive dimensional design, comparative descriptive design etc. (Burns and Groove 2001). This study compares the efficacy of hand rubbing with alcohol-based solution versus conventional hand washing with antiseptic soap in two groups which were randomly allocated to perform patient activities in reducing hand contamination during routine patient care. The study used comparative descriptive and quantitative study design to compare two groups. The strength of a quantitative research relies in its reliability. Quantitative research also usually begins with a concept articulated as a hypothesis when measured, produce data, and by deduction enables a conclusion to be drawn. These criteria were met by this study where the handrubbing with alcohol based solution group was used as the intervention group, while handwashing with antiseptic soap was used as the control group. In all, 23 health care workers were randomly allocated to two groups to perform 114 patient care activities. However, the randomisation was unequal. 59 patient care activities were performed in handrubbing group and 55 in handwashing with 1 participant dropping out of the study after four samplings instead of five due to visible soiling of hands with body fluids.
An opague sealed envelope was used to assign participants into groups meaning that both the clinicians and the participants were not aware of the hand hygiene method they were going to use until they arrived at the unit. The microbiologist who examined the result was also unaware of the hand hygiene method used. Since this is the case, I will say that the study was a Double blinded study because information was concealed from all participants involved. A double blinded study was designed in order to avoid bias. A double blinded study is when both the investigator and the participant are unaware of who was receiving which treatment (Greenhalgh 2001).
SAMPLE
The characteristics of both groups were similar in terms of working condition because they are all health workers and the distribution of activities was comparable between the two groups. The characteristics of both groups were similar in terms of working condition because they are all health workers and the distribution of activities was comparable between the two groups. As the participants were randomly allocated to two groups divided as: 11 healthcare workers in handwashing and 12 in handrubbing, the method of sampling can be classified as Stratified random sampling method. Sampling is a subset of population that is selected for a study. The two methods of sampling are : probability sampling (random sampling and stratified random sampling) and purposive sampling (quota sampling). The study shows that the median duration of patient care activities were different. There were 15 patient care activities in handwashing compared to 11 patient care activities in handrubbing. This may have caused the elevation of bacterial contamination in handwashing as opposed to that observed in hand rubbing. Also, the cumulative number of participants during monitoring session was more in handrubbing (11) than in handwashing (8) and the median duration (interquartile range) of monitoring session of handrubbing (91) was higher than handwashing (75). This may have affected the outcome of the study. To further strengthen this point, 184 activities were observed in handrubbing while only 158 were observed in handwashing, causing a difference in activity of 26 which may have been significant in showing the effectiveness of one method over the other. As stated by Elwood (1988), a control group should have similar characteristics as the participant group as a difference could present a confounding factor. Also the compliance rate in hand hygiene was significantly higher in handrubbing (71%) than in handwashing. The question is, would this have affected the outcome of the study as compliance is a very important factor in a study such as the one being analysed ?. It was also noted that study did not clearly state how consent from participants was achieved. One can assume that they were consented as it is very important in a study like the one being critiqued.
MEASUREMENT
Measurement is the process of conveying numbers to objects, events or situations in concurrence with some rule (Hinchliff 2003). The measurement used in this study was an ordinal measurement because the study categorises data in a ranked manner (Burn and Grove 2001). An ordinal measure uses mean, median and percentage, frequency and inter quartile range which was used by the researcher in this study. In the study, there was variability in the measurement of data which could have affected the outcome of the result. The median was used to measure time spent on handrubbing and hand washing before and after patient care. The time spent on hand hygiene in the handwashing group was relatively lower in 65% of cases with handwashing lasting less than the required 30secs for bactericidal activity compared to handrubbing group. In a study such as this, the time spent on hand hygiene is very important. The variability in timing may have affected the effectiveness of hand hygiene in the handwashing group. In terms of bactericidal action, handrubbing will be expected to be more effective than handwashing as it is possible that not all the bacterial would have been gotten rid of in 65% of cases in the handwashing group due to the shortage in timing. This may have caused the huge variation in the median of the handwashing group shown in Figure 2 of the paper. The mean is the average of all scores and this was used to calculate the average percentage reduction in both groups for example each of the result was evaluated using percentage (e.g. the percentage reduction in contamination at the first evaluated hand rubbing was 88% (74-97%). It is clearly shown in the study that handrubbing with alcohol based solution caused a significantly higher reduction in bacterial contamination than the reduction seen in the handwashing group (83% reduction compared to 58%). This difference in reduction is even more significant if the error bars are to be put into consideration. The error bar in the handwashing group was very high suggesting a huge variation in the data collected. This variation may have been caused by the variation in timing during data collection as discussed above. If this is so, this may have had a significant effect on the percentage median reduction in contamination observed. Another area to critique is the method of measurement of data. The design of the study did not allow the use of glove juice technique to determine bacterial contamination. As a result, bacterial contamination was measured by taking agar fingerprint of participants’ hands. Glove juice technique would have been more effective in recovering the actual bacterial burden as was clearly acknowledged by the study. The study also acknowledged that the degree of hand contamination in handwashing may have been underestimated since the same technique was not used for comparison of the hand hygiene procedures tested for culture plates. Thus questioning the validity of the true score obtained. This shows that the measurement which should actually be properly controlled as expressed by Burns and Grove (2001) was not properly controlled.
RESEARCHER
The researchers conducted the study in accordance with quantitative methods of research. They drew a hypothesis and designed an experiment which attempted to test the hypothesis. Sufficient data analysis was carried out and statistical analysis done. The researchers based the results on the number of participants involved in the study, the hand hygiene carried out and the bacterial contamination observed in the different hand hygiene methods. Since both the researchers and clinicians were not aware of which groups the participants belonged to, the study can be said to follow a double-blind study design. As stated in Burns and Grove (2001), researchers are investigators who investigate studies and interpret them on the basis of the result of statistical analysis. After all the data had been collected, they were passed to the assessor in an alleged unbiased format (ordered in a way that it did not reflect groups). The assessor then analysed the progress of each participant and the effectiveness of each location and intervention before drawing a conclusion.
DATA
Data is a piece of information gather obtained in the course of a study (Denise et al 1995). This study started with 23 healthcare workers designed to perform 114 patient care activities in five sessions. All participants were adequately accounted for at the end of the study. Out of the 23 participants (100%) 22 participants (95%) completed data at baseline and one group experienced dropout i.e. the intervention group, which show a loss of 5%. In order to obtain an average percentage reduction for each participant, the mean was calculated over the five sessions per participant. Then Mann-Whitney test was used to compare the percentage reduction between two groups as shown in table 2. The reduction in bacterial contamination achieved by handrubbing (86%) was found to be higher than that achieved in handwashing (73%). The figures used to plot the graphs shown in figure 2 are not the same as those stated above. The huge variability in the mean bacterial count observed before hand hygiene (huge standard deviation) displayed in the table was not mentioned (Refer to table 2).
Also, the confluency of the bacterial growth in the agar plate may have caused some discrepancy in the total bacteria count and this discrepancy will be more if there was more soiling of participants hands. The huge variability in the mean bacterial count before hand hygiene would be reflected in the ease of counting of bacterial colonies as it will be expected that the more soiling, the more bacterial present on agar plate and the more occurrence of confluent growth.
DATA COLLECTION AND ANALYSIS
Data analysis organises and gives meaning to the data (Denise et al 1995). Participants results were analysed in the different groups they were assigned to. The experiment was initially designed to detect a 30% difference in the reduction of hand contamination with the two techniques. The significance levels used was 5% with a power of 95%. However, only 25% difference in percentage reduction of hand contamination was achieved (83% reduction for handrubbing and 58% reduction for handwashing. There are a number of reasons why handrubbing may have looked more effective than handwashing. Firstly, the compliance rate for handwashing was lower than that for handrubbing as already discussed above. Also, the analysis shows that the number of percentage activities for participants who wore glove was 51% for handrubbing and 46% for handwashing. This gave more data to be analysed for handrubbing compared to handwashing. All these may have affected the outcome of the study.
CONCLUSION
There was a lot of variation in the data for the handwashing study. The error bar for this study was huge whereas that for the handrubbing study was small making the reduction in bacterial contamination more obvious and more conclusive. With this in mind and based on this study, it cannot be absolutely concluded that handrubbing is more effective than handwashing until a more stringent research is carried out. Care has therefore got to be taken when drawing conclusions from a study sure as this.
ADDITION: If this essay is what I think it is, then she should conclude that in light of the discussion above, care has to be taken before implementing the results of this study for informed practice as the reduction in bacteria contamination during handwashing may not have been fully shown.
If it is what I think it is, then she needs a page worth of information at the end on implementation: changes to practice, encouragement to staff and evaluating changes to practice.
I wish her good luck. Tell her she needs to look for more references in the relevant sections. I have bolded them as (ref) so it is obvious.
References
Burns N, Grove S K (2001). The practice of Nursing research; Conduct Critique and utilization. 4th Edition. London: W.B. Saunders Company.
Comack, D. (Ed) (2002) The Research Process in Nursing (4th Ed). Oxford: Blackwell Science.
Craig J V and Smyth R L (2002). The Evidence-Based Practice Manual for Nurses. (Eds) London: Churchill Livingston.
Denise, F et al (1995) Nursing Research Principle and Method. Philadelphia: J.B Lippincott Company.
Elwood (1988). Causal Relationships in Medicine. Oxford University Press. Cited in Watkins M (1994) Reading Research Critically. II. An Introduction to appraisal: assessing evidence. Journal of Clinical Nursing Vol 3 No. 5.
Girou E, Loyeau S , Legrand P, Oppein F, Brun-Buisson C (2002). The Efficacy of Handrubbing with Alcohol based solution versus Standard Handwashing with Antiseptic Soap:randomised clinical trial. France: BMJ Vol 325:362
Greenhalgh T (2001). How to Read a Paper: The Basics of Evidence Based Medicine. 2nd Edition. London. BMJ Publishing.
Hinchliff S, Norman S, Schober J (2003). Nursing Practice and Health Care. 4th Edition. London. Arnold.
Total word count excluding references = 2030 approximately.
Finally, here is an email I received from the writer:
If the essay is what I think it is (Critically appraise Girou et al., Efficacy of ….), she will do just fine. Tell her to send you a criteria and checklist next time.
Have a good weekend. She can ignore the extra reference I specified on her work. I already sorted that out. Tell her to check the format of the references and do it according to the College’s specification. There are two formats there. That was deliberate. Denise… and Comac.. are different formats. She should use which one suits the college’s specification best and make it uniform. Also, if the essay is what I think it is, then she has to add a page on implementation and say if she intends to implement this study or note