Critical Appraisal in Nursing Essay 2022

Critical Appraisal in Nursing
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Introduction:
Hospital setting is the place where patients become more susceptible to different infections.
Most importantly, nurses and patients are the prominent sources of infection to each other.
Healthcare associated infections (HAI) are the major causes of morbidity and mortality
among the hospital admitted patients. Hence, HAI are responsible for financial burden to both
patients and healthcare system. HAI can be effectively reduced through the implementation
of the hand hygiene compliance (HHC) among health-care workers specifically nurses
(Sharma, Sharma, and Koushal, 2012). HHC should be implemented in nurses because nurses
are the health-care workers with whom patients remain in contact for most of the time during
their hospital stay. Previous studies related to HHC demonstrated mixed results which
demonstrated varying rates of HHC (Luangasanatip et al., 2015; Radhakrishna et al., 2015).
These differences in outcome might be due to different study designs and participants with
different characteristics. Varying cultural norms among the healthcare workers are also
responsible for the varied outcome of HHC studies (Sharma et al., 2012). Hence, evidence of
HHC implementation can be more useful in planning HHC studies. Evidence of previous
studies can be effectively compiled in the form of systematic review. Systemic reviews are
useful in identifying literature related to explicit methods, reproducible results and up-to-date
summary of healthcare intervention. In this essay, systematic review on HHC is being
critically appraised to illustrate focused question, appraise quality of identified studies,
summarise the findings and present the significant findings. It indicates critical appraisal of
systematic review provide more transparent information of the intervention. Appraisal of this
systematic review will be more objective appraisal, beneficial in understanding inconsistency
among different studies and enhance generalisability of the outcomes (Delgado-Rodríguez
and Sillero-Arenas, 2018; Richards, 2010).
Population: This systematic review is clearly focused on the question considering population,
intervention and outcome. In this review, selected population for the different studies are
nurses. This population can be considered as the relevant population for the review because
nurses are the most suitable population through which answer related to HHC can be
obtained. Authors reported details about the nurses merely in terms of professional
designation such as registered nurses, licenced nurses etc. However, details related to total
experience and department with which nurses are associated are not provided in the
participants section of the review. This information would have been more beneficial in
assessing effectiveness of HCC based on varied categories of nurses.
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Intervention: Authors recognised importance of intervention. Interventions used in the
research articles are clearly mentioned in this review. Selected interventions for HHC
compliance can be considered as the most suitable interventions because diverse
interventions were selected which would be helpful in expanding knowledge of HHC
compliance. Moreover, authors mentioned about excluded studies which indicate precision in
selecting interventions for incorporation in the review.
Outcomes: Authors reported outcomes in the detailed manner. Authors mentioned different
outcome measurement systems such as direct observation, electronic monitoring etc.
Moreover, authors also mentioned rankings of outcome measurements systems which would
be beneficial in selection of most useful outcome measurement system for the future studies.
Moreover, authors also mentioned exclusion criteria for the outcome measurement systems
which would be helpful in improving validity of the results.
Literature search:
To answer the question in review, authors selected research articles considering inclusion and
exclusion criteria. Inclusion criteria for the review comprise of type of study design.
Randomized controlled trials (RCTs), controlled before and after studies (CBAs), and
interrupted times series (ITS) were incorporated in this study because these study designs are
more appropriate to answer the question related to HHC in nurses. Randomised controlled
studies can be considered as the best available evidence because measurements used can limit
bias. Hence, randomised controlled studies produce valid evidence for the intervention in the
question (Whitehead, Sully, and Campbell, 2014). CBAs and ITS also provide relevant
information related to the question. These types of studies can provide the relationship
between the intervention and outcome. Hence, selection of the research articles comprising
these research designs can provide author with the best conclusion. Hence, studies
incorporated in this review can be considered as the best studies for answering the review
question. Considering the two search strategies which are mentioned in the review, it can be
concluded that systematic review identified all the relevant studies. Search strategy
mentioned in the review was based on the relevant search terms in all the relevant databases
such as Cochrane central register of controlled trials, Medline, Embase, and the Cumulative
Index to Nursing and Allied Health Literature (CINAHL). Authors incorporated studies
which were published before February; however, it was not clear whether authors considered
unpublished studies before making concluding remarks about the review question. This
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review limits studies in English language; hence, there are chances of missing important
studies from the research articles of other languages.
Quality of review:
Authors considered inclusion criteria for selecting, retrieving and screening the title and
abstracts for each study which considered relevant for incorporation in the review article.
Studies selected based on the inclusion criteria were assessed and appraised by three
reviewers. Quality of the study designs matching inclusion criteria were assessed based on
the recommendations and tools from Cochrane Effective Practice and Organization of Care
Group (EPOC). EPOC can be considered as the best tool for making difficult decisions best
informed because it provide rigorous evidence. Since, EPOC has worldwide acceptability, its
applicability in the selection of study design can be considered as the selection of quality
articles with rigour for the incorporation in the systematic review (Jones, Lees, Martin, and
Dixon-Woods, 2014). Main objective of establishing inclusion and exclusion criteria are to
reduce ambiguity in population selection, intervention, timeframe, setting, study design,
study characteristics, study selection process and outcomes. Greater ambiguity in the
inclusion and exclusion criteria can result in the poor outcome and reproducibility (Swift and
Wampold, 2018). However, in this study authors considered multiple aspects for inclusion
and exclusion criteria; hence, quality and rigour were maintained through minimising
ambiguity.
Data synthesis:
Data synthesis is important aspect in the systematic review because studies with heterogenous
study design and outcomes are being included in the systematic reviews. Data synthesis
implements statistical tool for pooling data from the different clinical studies to answer the
review question. Data synthesis is useful in providing quantitative estimate of the complete
effect of specific intervention on a defined outcome (Pollock and Berge, 2018). However, in
this review, there is no mention of statistical tool applied for the determining and combining
outcome of different studies.
Combining results of different studies is another aspect of data synthesis. Data synthesis also
comprise of descriptive comparisons of different aspects of study such as study design,
intervention, population and outcome of the study. Comparative data of different studies can
be effectively presented in the tabular form. This form of presentation can be helpful in the
comparative assessment of the different study designs and its respective study outcomes.
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Presentation of the results in the combined tabular format can be helpful in ranking different
studies based on their usefulness as evidence for review question (Pollock and Berge, 2018).
However, in this review information related to quality of evidence such as GRADE was not
provided. In this review, combined results are presented in the form of table comprising of
information about different aspects of study such as author name, study design, intervention,
measurement period, comparisons, main outcome (hand hygiene) and notes. This information
is useful in displaying overall picture of the study. Moreover, results in the table are provided
in the form of numerical values such as percentage improvement in the hand hygiene
compliance. Moreover, statistical significance of the results is also mentioned. However, in
the tabular format number of participants in each study were not mentioned. Obtained results
in each study with respect to number of participants in each study would have been beneficial
in assuring validity of outcome of each study.
In addition to the combined results in the tabular format, results of each study are also
mentioned separately. Presentation of results separately for different studies is beneficial in
reporting results in more elaborative manner with additional discussion about the results.
Results of each study are mentioned separately under the heading of its respective study
design. Hence, this systematic review can be considered with high quality score because it
allows rigorous way to assess the quality of individual studies which have been kept together
under its respective study design (Pollock and Berge, 2018).
In this systematic review, similarities among individual studies are not included.
Consideration of similarities among different studies, would have been helpful in more
effective comparison of outcome of each study.
Similar results from the different studies are also not considered for comparison among
different studies. Comparison of similar results from different studies would have been
helpful in ranking studies with respect to GRADE of its evidence.
Results:
The main result of the review is the overall outcome of the review. Results of the review are
presented in both numerical and descriptive form. Results are presented in the form of
influence of different strategies on improvement in HHC, duration of sustainability of HHC,
and time duration for the decline of HHC post intervention. If the results demonstrated in
systematic review are going to be accepted as the evidence; then it should be ensured that
these results are not by chance. Hence, results should be represented in the form of statistical
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significance. Statistical results can be presented in the form of p-value and confidence
interval (Kwak and Kima, 2017). Overall results of this systematic review are not represented
in the form of statistical significance; however, results of the selected individual studies are
presented in the form of statistical significance. Statistical results representation of the
systematic review can be considered as statistical interference. Statistical inference can be
useful in the generalisation of obtained data of HHC to large population of nurses with
diverse characteristics. However, authors did not report statistical inference for the combined
results of different research articles which are selected for the review. Statistical inference is
possible in case of review article with a greater number of research articles (Kwak and Kima,
2017). However, a smaller number of research articles were selected for this review article.
The number of primary studies reviewed would be helpful in detecting if statistical power can
detect effect of intervention. Inclusion of higher number of studies in the systematic review
would be helpful in improving statistical power. Improvement in the statistical power would
be helpful in making healthcare decisions. Hence, such systematic reviews with inclusion of a
greater number of primary studies can be considered as the high-quality decision. This type
of judgement is specifically important in cases where evidence need to be implemented at
different healthcare settings. HHC as evidence should be implemented at different healthcare
settings. However, in this systematic review a smaller number of primary studies were
incorporated (Fleming, Koletsi, Ioannidis and Pandis, 2016; Harder, Remschmidt, Haller,
Eckmanns and Wichmann, 2016).
Discussion and result analysis:
Results can be considered more useful, if these results can be implemented to the local
population. Evidence obtained through results can be implemented to the local population;
after local population is defined. It is necessary to understand the nurse population in the
primary studies included in the review for decision making about applicability of outcome to
the local population. However, characteristics of nurse population in the in the primary
studies were not clearly mentioned in the systematic review. This hindrance can be avoided
in this review because HHC can be similar to nurses with the different characteristics. Hence,
evidence of HHC gathered in this review can be applicable worldwide. Evidence gathered
through this systematic review can be applicable to local and global nurse population because
it provides answers to specific questions such as type of HHC intervention and timing and
duration of HHC intervention. However, studies mentioned in the review reported different
interventions and different duration of intervention. Hence, it is difficult implement similar
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intervention and duration of intervention for the local nurse population. In such scenario, it is
necessary to modify type of intervention and duration of intervention according to local needs
(Manchikanti, Benyamin, Helm, and Hirsch, 2009).
From the provided results in the review, it is evident that all the important outcomes are not
considered. In the review article, it has been mentioned that education is the main
intervention provided for the HCC. However, it is not clear, the qualification and expertise of
person who provided education for HCC. Education can either be provided by experts in the
filed or senior member of the team who has enough experience in the relevant filed.
Information about the person providing education could have been more beneficial in
assessing quality of evidence. HHC can be achieved through different hand decontamination
techniques. However, hand sanitiser is the only hand decontamination technique mentioned
in this review. Process of hand decontamination can be different for different types of
patients such normal patient, patients with bleeding and patients with urinary tract infection
(Harder et al., 2016). However, in this review hand decontamination was not categorised
based on different types of patients.
Advantages and disadvantage:
Data presented in the review would be beneficial in implementing HHC evidence to the local
population with few modifications. Moreover, information provided in this review can be
helpful in planning future studies.
Conclusion:
Critical appraisal of systematic review performed in three stages such design, process or
conduct of review an outcome of the review. Final outcome of the systematic review usually
measured based on the level of evidence. Level of evidence should be more trustworthy and
should inform the practice.
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