Novice research: central venous access device care infections.

NOVICE RESEARCH

Novice research: central venous access device care infections Hannah Doyle and Amanda McNaughton

I

© 2014 MA Healthcare Ltd

n England, 42.3% of bloodstream infections are related to central venous access devices (CVADs) (Department of Health (DH), 2011). In the recently published epic3 guidelines, Loveday et al (2014) reveals that bloodstream infections associated with the post-insertion care of CVADs are one of the most dangerous complications in healthcare. As the use of CVADs is bcoming increasingly common, this is an important area of concern for nurses. This literature search was undertaken by a novice researcher to review the evidence for the important area of infection prevention and control in relation to CVADs and to learn from the process. Within the broader area of infection prevention and control, this article will focus on the use of sterile or nonsterile gloves in CVAD care. As a result of chemical and heat treatment, sterile gloves are free from bacteria and other microorganisms, and this state is maintained through the use of sterile individual packaging (NHS Supply Chain, 2013). Non-sterile gloves have not been sterilised, and are used for clean non-touch technique rather than aseptic technique (World Health Organization, 2009). Sterile gloves are required for use by practitioners in the care of CVADs. However, this article focuses on the post-insertion care of CVADs rather than the insertion itself. While the authors look primarily at the use of sterile or non-sterile gloves in this article, they recognise that there are several other infection prevention and control practices used for the reduction of infections caused by CVADs including hand decontamination and the use of aprons or gowns (Loveday et al, 2014). The literature review described in this article has focused on the oncology patient population as cancer and cancer treatment can weaken the immune system (Cancer Research UK, 2013). This may make this group of patients more susceptible to infection and it is important that their immune systems are not further compromised by infection. It is imperative that best practice is carried out when caring for CVADs to reduce this risk, which can be identified using evidence-based nursing practice and other available evidence-based guidelines.

Hannah Doyle is 2nd Year BSc Student and Amanda McNaughton is Lecturer, Adult Nursing, King’s College, London Accepted for publication: April 2014

British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 8

Abstract

This article describes a literature review of published evidence on infection prevention and control in central venous access device (CVAD) care conducted by a novice researcher (lead author) under the supervision of her lecturer (second author). It includes details of the search as well as of the analysis which led to the selection and critical appraisal of a selected article identified and, importantly, discussion of the limitations and lessons learned by the novice researcher with her experimental approach. Infection control is paramount within nursing practice as a result of the number of healthcare-associated infections, which are preventable if evidence-based practice is followed and when trust protocols are informed by evidence. The question posed by the author prior to undertaking the literature search related to whether the use of sterile gloves for CVADs reduces infections in the oncology patient population compared with the use of non-sterile gloves. The question was formulated using the PICO (Population, Intervention, Comparison, Outcome) process and relevant literature was located using CINAHL and MEDLINE databases. The results of the review demonstrated no significant difference in infection rates using sterile or non-sterile gloves when handling CVADs but further research in this area is needed to validate the findings. Key words: Infection prevention and control ■ Central venous access devices ■ Sterile gloves ■ Non-sterile gloves ■ Oncology patients ■ Evidence-based practice ■ Critique Evidence-based practice (EBP) is defined as ‘practice that is supported by a clear, up-to-date rationale, taking into account the patient/client’s preferences and using your own judgement’ (Aveyard and Sharp, 2013: 4) and is underpinned by robust empirical evidence (Sackett et al, 1996). EBP uses knowledge from credible evidence, personal sources of knowledge such as professional expertise, and patient values and preferences to aid decision-making in health care and, vitally for nursing practice, to improve the quality of care received by patients (Aveyard and Sharp, 2013). The Nursing and Midwifery Council (NMC) (2008: 6) Code requires nurses to ‘deliver care based on the best available evidence or best practice’. Nurses must also understand the evidence Table 1. Application of PICO technique to formulate a focused research question P

Population

Oncology patients

I

Intervention

Sterile gloves

C

Comparison

Non-sterile gloves

O

Outcome

Reduce infections

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NOVICE RESEARCH Table 2. CINAHL database search Database

Search terms

Subject headings selected

Total no of results

CINAHL

Oncology patient*

‘Cancer patients’ (S1)

15 803

Catheter infection*

‘Catheter-Related Infections 3387 OR ‘Catheter-Related Bloodstream Infections’ (S2)

S1 AND S2

72

S1 AND S2

Limiter—publish date 2003–2013

46

S1 AND S2

Limiter — publish date 2003–2013 Narrowed by Geographic: UK and Ireland

8

to help focus the question (Aveyard and Sharp, 2013): The question formulated for the purposes of this review was: ‘Does the use of sterile gloves worn by health professionals for central venous access devices reduce infections in oncology patients compared with the use of non-sterile gloves?’ This process is demonstrated in Table 1. PICO is the most common technique used within evidence-based practice to frame and answer a clinical question (Aveyard and Sharp, 2013) and is particularly useful for questions related to therapies, with therapy as the ‘Intervention’ in PICO becoming the clear focus of the question.

Literature search by database

Table 3. MEDLINE database search Database

Search term

Subject headings selected

Subheading selected

Total number of results

MEDLINE

Oncology nurs*

‘Oncology Nursing’

‘Organisation & Administration’ (1)

998

catheter*

‘Catheterization Central Venous’

‘Adverse Effects’ (2)

7074

1 AND 2

4

1 AND 2

Specific Year Range: 2003–2013

4

1 AND 2

Specific Year Range: 2003–2013 Limit to English Language

4

base underpinning their practice as not only are health professionals accountable for the care they deliver, but they must also feel confident that their care provision is always up to date and in line with best practice.

Formulating the research question To identify a research question, the PICO (Population, Intervention, Comparison, Outcome) technique was applied

To ensure a rigorous review of the literature surrounding the formulated PICO question, a systematic search approach was undertaken.

CINAHL search To locate literature easily and efficiently and to keep the search relevant and focused, the author made use of the electronic database CINAHL (Cumulative Index to Nursing and Allied Health Literature), as it is a major resource for articles in nursing and is the most comprehensive and widely used database for locating nursing and midwifery journal literature (KCL Library, 2013). An overview of the CINAHL database search can be seen in Table 2. It must be noted that when the lead author input the search terms ‘sterile gloves’ and ‘non-sterile gloves’ from her formulated PICO into the database, no results were generated. This indicated that the literature had been categorised using different keywords and would, therefore, not be identified by one particular search strategy. Owing to the novice status of the lead author, an experimental approach was undertaken by searching different keywords in an attempt to find relevant literature, explaining why the PICO keywords were not identified. Similarly, ‘Catheter-Related Infections’ was used, a search term that may include urinary catheters. Of course this was not intended to be the focus of the search but in an effort

Author (Year)

Database

Is it a research paper (rather than review)?

If research, was Was it published it conducted in in the last 10 the UK? years?

Was it published in a reputable source?

Was it peer reviewed?

Does it answer my research question?

Arch (2007)

MEDLINE

N

N/A (review)

Y

Y

Y

N

Arora et al (2010)

CINAHL

N

N/A (review)

Y

Y

Y

N

Breen et al (2009)

MEDLINE

N

N/A (review)

Y

Y

Y

N

Chambers et al (2005)

CINAHL

Y

N

Y

Y

Y

Y

Dal Molin et al (2011)

CINAHL

Y

N

Y

Y

Y

N

Heibl et al (2010)

CINAHL

Y

N

Y

Y

Y

N

Hemsworth et al (2007)

MEDLINE

Y

Y

Y

Y

Y

Y

Kefeli et al (2009)

CINAHL

Y

N

Y

Y

Y

N

Maaskant et al (2009)

CINAHL

Y

N

Y

Y

Y

Y

Schoot et al (2013)

CINAHL

N

N/A (review)

Y

Y

Y

N

van de Wetering et al and van Woensel, 2007

CINAHL

N

N/A (review)

Y

Y

Y

N

West and Mitchell (2004)

MEDLINE

N

N/A (review)

Y

Y

Y

N

(Fineout-Overholt et al, 2010)

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Table 4. Evaluation of generated literature from CINAHL and MEDLINE



NOVICE RESEARCH Table 5. Evaluation using CASP UK Critical Appraisal Tool for a Cohort Study (A) Are the results of the study valid? 1. Did the study address a clearly focused issue?

Yes—it is clear the study tried to specifically detect a harmful event, with the focus risk factor being exogenous septicaemia. The population studied was paediatric oncology patients; clearly focused.

2. Was the cohort recruited in an acceptable way?

Yes—there is no selection bias as patients were not selected; all patients admitted on the ward were part of the study, thus the generalisability of the findings was not compromised. Generalisability depends on the size of the sample too. The representation of the defined population is limited as only one hospital was studied, introducing potential institutional bias.Other hospitals, primary healthcare settings and areas of the UK must be studied for a true representation of the population

3. Was the exposure accurately measured to minimise bias?

No—subjective measurement was used; nurses’ routine practice was suspended and nurses told to use non-sterile gloves. How this was monitored or checked is not specified, so it is unclear whether this measurement was carried out and unknown whether all the subjects used the same procedure. There is no evidence to suggest sterile gloves prevent infections more so than non-sterile gloves. However, the accuracy of adherence to the new ‘exposure’, which in this case, was not wearing sterile gloves for all participants in the study, is unclear

4. Was the outcome accurately measured to minimise bias?

Yes—Objective measurement was used; swabs for bacterial culture. Validity of measurement is limited as this is not common practice for measuring infections in NHS (throat and rectal swabs). Reliable and consistent system established for detecting all the cases. Same measurement system for different groups. Subjects and outcome assessor were not blinded to exposure, though this would not influence results

5. (a) Have the authors identified all important confounding factors? 5. (b) Have they taken account of the confounding factors in the design and/ or analysis?

(a) No—the confounding factor that was not identified was that the research was only carried out in one hospital. Further, it cannot truly be determined whether there was any underlying motive for the study to be undertaken; the study concluded that not wearing sterile gloves would save the NHS money, however, the few children who reached septicaemia did not seem to receive a lot of focus Nursing infection prevention and control practice, such as non-touch technique, differs among nurses; this needed to be monitored to ensure consistency. Control group was historical, so different staff and/or methods could have been used for the different groups. One group may have had more immunocompromised patients than the other, causing variance in rates of infections. Patients were only tested if presented with symptoms such as increased temperature and localised heat, swelling and pain; patients could have been asymptomatic of infection (b) No—a randomised control trial (RCT) would have reduced selection bias and confounding variables, as the effects of potential confounding variables would have been divided fairly evenly across different groups. However, this could not be used as it would compromise requirements for consistent care for patients, and the number of staff involved in caring for central lines (Hemsworth et al, 2007)

6. (a) Was the follow up of subjects complete enough? 6. (b) Was the follow up of subjects long enough?

(a) No—study was only carried out on inpatients; those discharged home or to primary healthcare settings with their CVADs may have left prior to being symptomatic. Patients should have been monitored for a long enough period following discharge for infections to be identified. The patients that were lost to follow-up may have had different outcomes than those available for assessment. (b) Yes—3 years is a long enough time to accumulate suitable data for the findings to be considered reliable, however, it must be noted that this would not have necessarily been undertaken with the same patients) (Aveyard and Sharp, 2013)

7. What are the results of this study?

There does not appear to be a statistically significant difference in the incidence of exogenous septicaemia comparing the use of sterile gloves and non-sterile gloves in CVADs for paediatric oncology patients from this study. However, it is not completely clear from the study whether non-sterile gloves are actually worn except in some cases to protect the practitioner; this needs to be clarified in order to confirm the conclusions The reported comparative rate between the sterile gloves/non-sterile gloves is chi-square=3.14; p =0.08. As the p (probability) value is over the standard 0.05, it is more likely that the occurrence is a result of chance, and thus increases the probability of a Type I error in the study (Aveyard and Sharp, 2013). The absolute risk reduction (ARR) was not presented in the article.

8. How precise are the results?

Using a 95% confidence interval, the confidence intervals for sterile gloves are 0.569-1.030, and for nonsterile gloves 0.619–1.21. As the confidence intervals overlap, there is no significant difference, and as the intervals for both groups were small, it is more likely the results reflect what would be found in the larger population (Aveyard and Sharp, 2013). As the sample size appeared to be big enough for the results to be generalised, there was a high effect of intervention, thus decreasing the chance of a Type II error in the study (Aveyard and Sharp, 2013). However, the lead author is making this assumption based on the of 177 children with infections over the study period, which was considered low—the total number making up the sample size was not given. This information should be specified to give a clearer picture of the results


(B) What are the results?


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NOVICE RESEARCH Table 5. Continued 9. Do you believe the results?

Yes—the article concurs with the national epic3 guidelines thus increasing credibility. As the study was observational and not a RCT there is potential selection bias. The p value indicates that the results were likely owing to chance. A significant confounding factor was identified (study took place within one hospital) As nursing infection prevention and control was not observed and monitored for consistency, and the control group was historical, it could be argued that the design and methods of this study are sufficiently flawed, making the results unreliable (C) Will the results help locally?

10. Can the results be applied to the local population?

Yes—An observational study was the appropriate method to answer this question owing to the requirement for consistency of supportive patient care, and also the number of staff involved in CVAD care. The subjects of this study were children. These findings could be applied to paediatric patients but are not generaliseable to the general adult population. Though it is unlikely that settings will differ greatly across the country, further research across different age groups in hospitals around the UK is needed for the results to be generalised

11. Do the results of this study fit with other available evidence?

Yes—Slota et al (2001), a randomised study in a paediatric intensive care unit (ICU) comparing hand-washing and non-touch technique with sterile gloves found no statistically significant difference in infection rates between the two groups. This fits with evidence for the paediatric population but not for oncology patients

12. What are the implications of this study for practice?

Observational studies, for certain questions, are the only source of evidence possible. However, one observational study rarely provides sufficient evidence to recommend changes to clinical practice or policies. Observational study recommendations are always stronger when supported by other evidence; therefore more research is needed before the results are considered for any change to practice

(CASP UK, 2013)

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MEDLINE search The second database used was MEDLINE (Medical Literature Analysis and Retrieval System Online), as it is the most renowned database for literature in health and biomedicine (Kings College London (KCL) Library, 2013). An overview of the systematic search undertaken in MEDLINE can be seen in Table 3. The search approach for MEDLINE was similar to that undertaken in CINAHL and described in the previous section. ‘Map Term to Subject Heading’ was selected for the first two searches to allow the key word to be matched against the database thesaurus to produce a wider range of literature. The limitations applied to the search were the publication date, by selecting all literature published ‘2003–2013’ in the ‘Specific Year Range Filter’, and the language, by specifying literature published in English only (as opposed to geographical location, which is what is requested by CINAHL). These filters were set for practical reasons of the time and resources available together with the financial implications of hiring a translator. Again, ‘sterile gloves’ and ‘non-sterile gloves’ were not used as a result of the lack of generated results when attempting a search with these terms.

Strengths of the literature search Aveyard and Sharp (2013) discuss the strengths and limitations of the search strategy they recommend. The strengths of the search strategy used within the author’s search are that it ensured all key literature and research for the topic was identified from the databases selected, and the systematic approach guaranteed a thorough search by locating the best available information rather than information that is readily available (Aveyard et al, 2011).

Limitations of the literature search However, many limitations have been identified with the experimental approach of the literature search as a result of the


to increase the results generated, the novice researcher removed ‘vascular’ from the search terms. Aveyard and Sharp (2013) give thorough and clear advice for how to undertake the most effective systematic search. The search process undertaken by the author is based on their recommendations. For searches S1 and S2, ‘Suggest Subject Terms’ was selected to broaden the search to any relevant literature, and wild card ‘*facility’ was applied to identify alternative spellings and plurals (* is a search abbreviation that prompts different variations of a word; e.g. facilities, facilitate, etc). The Boolean operator ‘OR’ was used in the S2 search to improve the chances of finding relevant information as this approach allows identification of all of the articles in which either term appears. The two searches were then combined using ‘AND’ to locate only the articles in which both terms appear. Inclusion criteria were refined by date, and limited to all literature post 2003, as although literature published post 2008 is considered up-to-date and current (Aveyard and Sharp, 2013), this restriction could result in a loss of highly relevant literature published prior to this date. Therefore, literature published within the last 10 years rather than the last 5 years was included within the search. The search was then further narrowed by geographical location; only UK and Ireland were included (UK and Ireland are grouped together by the system) as healthcare systems vary greatly across the world and the author felt that a global search may have limited its transferability to the UK. While there may be little significant difference in the principles of infection prevention and control across the developed world, there may be variation in compliance and implementation across different healthcare systems. However, Gold (2011) asserts that Medicare, the Australian government-run universal healthcare system, is similar to the NHS. Given this, Australian healthcare research may have been used in retrospect.



NOVICE RESEARCH novice status of the lead author culminating in the creation of this article which the lead author hopes will encourage other novices to undertake research and learn lessons from limitations identified. One limitation was that relevant literature may have been categorised using different keywords to the ones selected by the author and may therefore have been missed by the chosen search strategy. Furthermore, the relevant topic may have been mentioned within the literature but not to a large enough extent for it to have been indexed when entered into the database. As the search described within this article was an independent project, it would be unlikely to harness the same skills and resources available to an entire team working together, and a novice is more likely to miss sources than an experienced researcher. While the novice status of the researcher makes for useful learning as mentioned, it has also been identified as a limitation. An experimental approach was taken to the searches, meaning the necessary search terms were not identified or standardised across databases. This questions the relevance of the PICO tool and the chosen research question in terms of applying them to database searches. A more experienced researcher or team may be able to provide a more consistent, thorough database search and ensure correct incorporation of the PICO tool. Furthermore, searches undertaken in additional databases would have likely resulted in more literature addressing the chosen question upon which the lead author could have drawn during the critical appraisal. No definitive conclusions can be drawn from a single study. Also, it is possible that the reason the lead author was not able to generate results to address the chosen question is that practitioners are in fact using sterile gloves in practice without the need for alternatives, in which case, there may not be demand for further research in this area.


Selecting the appropriate article for critique To summarise the literature found and to identify an appropriate article for critique, the critical approach tool was adapted from the evaluation table by Fineout-Overholt et al (2010) (Table 4) to enable a quick and efficient appraisal of the literature using a consistent approach. The article selected following this process was Does the number of exogenous infections increase in paediatric oncology patients when sterile surgical gloves are not worn for accessing Central Venous Access Devices? (Hemsworth et al, 2007). This was the only article that met all selection criteria set out by the author. While it looks at the paediatric population rather than the adult oncology population that the lead author was seeking to gather literature about, the novice researcher was aware of how specific the question was and thought it unlikely that she would find an article to the criteria’s exact specifications if she also included adult patients as an inclusion criterion. It was published in the European Journal of Oncology Nursing which is a peer-reviewed journal, making it more credible (Aveyard and Sharp, 2013); it was carried out within the last 10 years and it appeared to answer the formulated question. The other articles were discarded as the abstracts did not answer the question and the healthcare systems were not thought to be transferable to the UK.


Critical appraisal of the study The selected article was then critically appraised to determine its strengths and weaknesses, and its relevance to the literature review research question. The critical appraisal tool used was the CASP UK (2013) tool for cohort studies. Although Aveyard et al (2011) suggest an appraisal tool for novices and Crowe and Sheppard (2011) have developed a general tool for a variety of research types, CASP is design-specific and provides a more appropriate in-depth and focused structure for the purposes of this review (Aveyard and Sharp, 2013). The critical appraisal using the CASP tool for cohort studies can be seen in Table 5.

Discussion of the findings In evaluating and judging the quality and usefulness of the article selected as evidence, several strengths and weaknesses are identified.

Strengths of the study selected for critique The study has strong credibility in terms of both the peerreviewed publication in which it was published and the article’s content in relation to national guidelines. For example, the article is concurrent with the national epic3 guidelines stating that sterile and non-sterile gloves should be used by nurses in the post-insertion care of CVADs (Loveday et al, 2014), both increasing its credibility and addressing the needs of health professionals in providing guidance for day-to-day practice. The research study selected was a prospective design, using statistical analysis to present findings. Results were obtained from a statistically significant number of people (177 children of the total number had infections over the 6-year study period) allowing the study’s results to be generalisable and applied to other contexts. While there was a small increase in infections when use of sterile gloves was abandoned, this was not statistically significant (99 episodes vs 78 episodes in the historical population). The methodology of the study was outlined clearly and systematically.Therefore, the reproducibility of the study is strong and the research can be repeated by others in different settings to strengthen the findings. Furthermore, the research accurately measures and reports what it set out to in the first instance, confirming its validity.

Limitations of the study selected for critique However, the research held several limitations. For example, less bias could have been achieved, as although cohort studies are used to find causes or impacts of diseases, randomised controlled trials (RCTs) are less biased in attributing results to the exposure compared with cohort studies and are able to more reliably control confounding factors, variables, etc. As the research population is focused on paediatric oncology patients, it is not transferrable or relevant to all patients and contexts and thus cannot be applied to adults. The lack of confounding variables identified within the study and, importantly, the lack of discussion surrounding ethical approval calls the rigour of the research into question and makes it difficult to determine how robust the evidence is. Therefore, the author feels that clarification from the authors of the selected study is needed around these issues in order for the research to reclaim reliability. As sequential accumulations

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NOVICE RESEARCH

n 42.3% of bloodstream infections are associated with CVADs, and this is one of the most dangerous complications in health care n Nurses should ensure that their infection prevention and control practice is evidence-based and reflects recent guidance to improve the quality of care received by patients n Although the results of the study demonstrate no apparent significant difference in the use of sterile or non-sterile gloves, further research is needed before any conclusions can be drawn n As a novice approach was taken in the literature review and in the selection and critical appraisal of the article, an experienced team of researchers using a broader range of databases and search terms would ensure a more robust and consistent literature review n Novices can learn valuable lessons from engaging in research through critical analysing their strategies and identifying limitations which can then be applied to future literature reviews and research

begin with observational research (Aveyard and Sharp, 2013), a national multicentre RCT would provide further evidence. This research is communicated to clinical staff through the reputable peer-reviewed journal, European Journal of Oncology Nursing, and its recommendations for the use of ‘sterile or non-sterile gloves’ are in line with epic3, a national evidencebased guideline (Loveday et al, 2014: 25), which remains the most comprehensive guidance on the prevention of infections associated with CVADs (DH, 2011). However, this research is not well used, as Scales (2009) reported, IV care is often performed with little regard for asepsis. To encourage evidencebased practice in the hospital setting, wards and departments should audit practice regularly against policies and procedures, and take appropriate measures to resolve identified issues (DH, 2011; Loveday et al, 2014).

Conclusion After formulating the research question using PICO, the author conducted a literature search within databases CINAHL and MEDLINE to identify appropriate literature to answer the research question. However, in future searches this could be expanded to include other databases such as OVID, British Nursing Index, Cochrane Library and PubMed (Aveyard and Sharp, 2013) to gather more published evidence that meet the search criteria. This would improve the search process, as one article alone cannot determine that there is no difference wearing sterile or non-sterile gloves. Only one article was discussed as it was the only piece of literature found in both databases that answered the research question. Besides using more databases, an experienced team of researchers could ensure an exhaustive and systematic search, as the appropriate search terms from the research question were not used in the database searches as a result of the experimental method undertaken by the novice lead author. Also, the research question and PICO search terms should be less specific to allow more relevant literature to be accessed for discussion. The CINAHL database search included the search term catheter without specifying the word ‘vascular’. Therefore, literature may have been generated associated with urinary catheters

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that was thus not relevant. However, this was done to ensure all relevant literature was identified some literature could have been categorised in the databases under the broad term of catheter rather than specifically under vascular catheter, thus encompassing a broader range of literature for analysis. The literature regarding urinary catheterisation and other catheters were removed from consideration in Table 4. After critically appraising the results of the literature search and selecting the most appropriate article, the selected article was then subjected to further critical appraisal using the CASP tool for cohort studies. The author discovered through this process that despite some strengths, the research was generally limited in its quality and ability to answer the research question, as it focused on paediatric patients rather than adults and there were questions around its reliability. An RCT across the UK for both children and adults is needed to demonstrate more rigour and to confirm the results of the study. From this single article, it could be surmised that there was no significant difference between rates of infection using sterile and non-sterile gloves. However, it is too risky to hold this conclusion based on a single article from a search with so many limitations. It may therefore be useful to review other infection prevention and control procedures associated with CVADs such as hand decontamination and the use of aprons or gowns to reduce infection rates. Although the findings are interesting, care should be taken with applying them and any change to practice must be made in conjunction with the comprehensive epic3 guidelines (Loveday et al, 2014). However, the use of research surrounding infection prevention and control could be better and is improving as the body of evidence emerges. Nurses should ensure their practice is evidence-based and reflects recent guidance in this area (Scales, 2009). Nurses are responsible for post-insertion CVAD care and as associated bloodstream infections are one of the most dangerous complications in health care (Loveday et al, 2014), nurses can play a significant role in addressing this concern. The lead author hopes that the detail of her review process and the transparency used in critiquing her experimental method and identifying limitations can be used as a learning tool to BJN encourage research among novices. Conflict of interest: none Arch P (2007) Port navigation: let the journey begin. Clin J Oncol Nurs 11(4): 485-8 Arora RS, Roberts R, Eden TO, Pizer B (2010) Interventions other than anticoagulants and systemic antibiotics for prevention of central venous catheter-related infections in children with cancer. Cochrane Database Syst Rev (12): CD007785. doi: 10.1002/14651858.CD007785.pub2 Aveyard H, Sharp P, Woolliams M (2011) A Beginner’s Guide to Critical Thinking and Writing in Health and Social Care. Open University Press, Maidenhead Aveyard H, Sharp P (2013) A Beginner’s Guide to Evidence Based Practice in Health and Social Care, 2nd edn. Open University Press, Berkshire Barras C (2012) Evolution could explain the placebo effect. New Scientist (2881): 17-18. http://tinyurl.com/kcuw7e9 (accessed 9 April 2014) Breen M, Coombes L, Bradbourne C (2009) Supportive care for children and young people during cancer treatment. Community Pract 82(9): 28-31 Cancer Research UK (2013) The immune system. http://tinyurl.com/p6dnr5p (accessed 9 April 2014) Chambers ST, Sanders J, Patton WN et al (2005) Reduction of exit-site infections of tunnelled intravascular catheters among neutropenic patients by sustained-release chlorhexidine dressings: results from a prospective randomized controlled trial. J Hosp Infect 61(1): 53-61 Critical Appraisal Skills Programme (2013) 12 questions to help you make sense of cohort study. http://tinyurl.com/p9w2ac2 (accessed 9 April 2014) Crowe M, Sheppard L (2011) A review of critical appraisal tools show they lack


KEY POINTS



NOVICE RESEARCH rigor: Alternative tool structure is proposed. J Clin Epidemiol 64(1): 79-89. doi: 10.1016/j.jclinepi.2010.02.008. Epub 2010 Dal Molin A, Rasero L, Guerretta L, Perfetti E, Clerico M (2011) The late complications of totally implantable central venous access ports: the results from an Italian multicenter prospective observation study. Eur J Oncol Nurs 15(5): 377-81 Department of Health (2011) High Impact Intervention. Central venous catheter care bundle. DH, London. http://tinyurl.com/d64s9cv (accessed 9 April 2014) Fineout-Overholt E, Melnyk BM, Stillwell SB,Williamson KM (2010) Evidencebased practice step by step: Critical appraisal of the evidence: part I. Am J Nurs 110(7): 47-52 Gold S (2011) Four healthcare systems divided by the English language. http:// tinyurl.com/pk2fa6e (accessed 9 April 2014) Heibl C,Trommet V, Burgstaller S et al (2010) Complications associated with the use of Port-a-Caths in patients with malignant or haematological disease: a single-centre prospective analysis. Eur J Cancer Care (Engl) 19(5): 676-81. doi: 10.1111/j.1365-2354.2009.01115.x. Epub 2009 Hemsworth S, Selwood K, van Saene R, Pizer B (2007) Does the number of exogenous infections increase in paediatric oncology patients when sterile surgical gloves are not worn for accessing central venous access devices? Eur J Oncol Nurs 11(5): 442-7 Kefeli U, Dane F, Yumuk PF et al (2009) Prolonged interval in prophylactic heparin flushing for maintenance of subcutaneous implanted port care in patients with cancer. Eur J Cancer Care (Engl) 18(2): 191-4. doi: 10.1111/j.1365-2354.2008.00973.x King’s College London Library (2013) Key databases for Nursing, Midwifery and Physiotherapy. KCL Library Services, London. http://tinyurl.com/q9ugbww (accessed 9 April 2014) Loveday HP, Wilson JA2, Pratt RJ et al (2014) epic3: national evidence-based

guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 86(S1): S1-70. doi: 10.1016/S0195-6701(13)60012-2 Maaskant JM, De Boer JP, Dalesio O, Holtkamp MJ, Lucas C (2009) The effectiveness of chlorhexidine-silver sulfadiazine impregnated central venous catheters in patients receiving high-dose chemotherapy followed by peripheral stem cell transplantation. Eur J Cancer Care (Engl) 18(5): 477-82. doi: 10.1111/j.1365-2354.2008.00964.x Nursing and Midwifery Council (2008) The code: Standards of conduct, performance and ethics for nurses and midwives. NMC, London. http:// tinyurl.com/35om3cs (accessed 9 April 2014) Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312(7023): 71-2 Scales K (2009) Correct use of chlorhexidine in intravenous practice. Nurs Stand 24(8): 41-6 Schoot RA, van Dalen EC, van Ommen CH, van de Wetering MD (2013) Antibiotic and other lock treatments for tunnelled central venous catheterrelated infections in children with cancer. Cochrane Database Syst Rev 6: CD008975. doi: 10.1002/14651858.CD008975.pub2 Slota M, Green M, Farley A, Janosky J, Carcillo J (2001) The role of gown and glove isolation and strict handwashing in the reduction of nosocomial infection in children with solid organ transplantation. Crit Care Med 29(2); 405–12 van de Wetering MD, van Woensel JB (2007) Prophylactic antibiotics for preventing early central venous catheter Gram positive infections in oncology patients. Cochrane Database Syst Rev (1):CD003295 West F, Mitchell SA (2004) Evidence-based guidelines for the management of neutropenia following outpatient hematopoietic stem cell transplantation. Clin J Oncol Nurs 8(6): 601-13 World Health Organization (2009) Glove Use Information Leaflet. WHO, Geneva. http://tinyurl.com/lx7vbxz (accessed 9 April 2014)

Critiquing Nursing Research 2nd edition About the book

The fundamentals of the book, however, remain the same. It focuses specifically on critiquing nursing research and the increasing requirement for nurses to become conversant with

and understand its link with the use of evidence to underpin practice.  This second edition retains allresearch the successful Having read this book, nurses should be more familiar with the approaches and techniques involved in critiquing nursing research and be able to utilise some of these skills and techniques in their own efforts to critique. Accordingly, they will be better placed to make informed judgements regarding the quality of the research paper and the value of the evidence reported.

features of the first, plus additional material on psychiatric research and critiquing nursing research when writing a dissertation. As nurse education around the world increasingly moves towards an all-graduate discipline, it is vital for nurses to have the ability to critique research in order to benefit practice. This book is the perfect tool for those seeking to gain or develop precisely that skill and is a must-have for all student nurses, teachers and academics.

About the authors

Dr John R. Cutcliffe holds the as ‘David G.students Braithwaite’ Professor ofhave  Very suitable toChairundertake Nursing Endowed at the University of Texas (Tyler); he is also an Adjunct Professor of Psychiatric Nursing at Stenberg College International School of Nursing, Vancouver, Canada and a Visiting Professor at the University of Ulster, United Kingdom. He is an Associate Editor for the Journal of Psychiatric and Mental Health Nursing and an Assistant Editor for the International Journal of Nursing Studies. John’s clinical background is in psychiatric and general nursing, having worked as a clinician and then as an educator in the United Kingdom. He is an international scholar having worked in universities in four different countries: England, Northern Ireland, Canada and the United States. Martin Ward is an Independent Mental Health Nursing Consultant; he is also Co-ordinator of Mental Health Nursing Studies at the University of Malta and Chair of the Expert Panel of Horatio - European Psychiatric Nurses, based in the Netherlands. From 1995 to 2000 he held the post of Director of Mental Health for the Royal College of Nursing. Martin has been a Trustee of the English Health Advisory Service (HAS) and a member of the HAS Inspectorate and has also been involved with work with the World Health Organisation. In 1997, both authors were instrumental in designing and launching the NPNR National Journal Club.

Critiquing Nursing Research

John Cutcliffe and Martin Ward

This second edition of Critiquing Nursing Research retains the features which made the original book a best-seller while incorporating new material in order to expand its applicability. In addition to reviewing and updating the material of the original text, the authors have added two further chapters: the first focuses on how to critique research as part of the work of preparing a dissertation; and the second on mental health research agendas throughout Europe.

Critiquing Nursing Research 2nd edition

a dissertation where they critique three pieces of nursing research.

ISBN-13: 978-1-85642-316-8; 234 x 156 mm; paperback; 244 pages; publication November 2006; £25.99


Order your copies by visiting

www.quaybooks.co.uk or call our Hotline www.quaybooks.co.uk

+44(0)1722 716 935

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781856 423168

Foreword by Professor Kevin Gournay


ISBN 978-1-85642-316-8


The new and updated edition of the best-selling book

CritiquingNRes3.indd 1 25/03/2011 09:41


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Paediatric ICU nurses: preventing central venous device infections.

Central venous access in children.

Central Venous Access Device-Related Bacillus Cereus Endocarditis: A Case Report and Review of the Literature.

Fracture and atypical migration of an implantable central venous access device.

Spontaneous migration of an implanted central venous access device into the ipsilateral jugular vein.

Ultrasound-guided central venous access: what's new?

Pyoderma gangrenosum: an exceptional complication of venous access device.

Percutaneous endovascular salvage techniques for implanted venous access device dysfunction.

Intensive care ultrasound: II. Central vascular access and venous diagnostic ultrasound.

A single center's experience with Candida parapsilosis related long-term central venous access device infections: the port removal decision and its outcomes.

Infections related to totally implantable venous-access ports.

Infections related to totally implantable venous-access ports.

An ultrasound method for safe and rapid central venous access.

Insertion of totally implantable central venous access devices by surgeons.

Spontaneous intrajugular migration of long-term central venous access catheters.

Case report of a central venous access device-associated thrombosis with aortic embolism in a preterm infant.

Outpatient percutaneous central venous access in cancer patients.

Competence is central to vascular access care.

Central venous Access device SeCurement And Dressing Effectiveness (CASCADE) in paediatrics: protocol for pilot randomised controlled trials.

Complications associated with central venous access device in children with haemophilia: a nationwide multicentre study in Finland.

Central Venous Pressure Monitoring; Introduction of a New Device.

A new case of bacterial endocarditis in a child with severe Haemophilia A carrying a central venous access device.

A newly designed total implantable venous access device in rats for research with high efficiency and low cost.

Long-term follow-up of children with haemophilia - low incidence of infections with central venous access devices.