92440 Evidence for Nursing: Research Concepts, RCT & Case Study

This assignment solution provides answers to questions related to nursing research concepts, evidence-based practice, and a case study analysis of an article by Byrne et al. (2017) on gum chewing after bowel surgery. The solution covers topics such as the importance of using specific and short search terms in database searches, the relationship between Tanner’s Model of Clinical Judgment and Evidence-Based Practice, and the purpose of a systematic review compared to a randomized controlled trial. Furthermore, the assignment delves into the research methodology and results of the case study, addressing the benefits of using a randomized controlled trial design, identifying primary and secondary outcomes, assessing pain measurement methods, evaluating sample size adequacy, discussing potential baseline differences between intervention and control groups, analyzing the impact of patient blinding, and interpreting statistical findings such as median time to first bowel motion and confidence intervals. The analysis also includes an assessment of whether chewing gum reduced the need for morphine equivalents post-surgery based on reported p-values.

92440 EVIDENCE FOR NURSING
Assessment Item 2: Understanding research concepts Weight: 35% of overall mark
PART ONE: Contribution to Week 3 and Week 4 Discussion Forums (6 marks)
PART TWO: General content questions (7 marks)
One of the underlying concepts explored through this subject was conveying broad clinical scenarios and questions
to searchable questions and using refined search terms to extract data.
1. Why is it important to use short search terms in database search instead of long descriptive sentences?
(Max 30 words, 1 mark)
Short terms find information relevant to the search because databases are indexed. Long sentences make
the databases search for every word in the sentence which brings unexpected results.
2. Why is it important to use specific search terms in database search instead of broad search terms (Max 30
words 1 mark).
Specific search terms only literature that has the term in the search and has few specific results. Broad
search terms return many articles even including the less the relevant ones.
3. Describe the relationship between the two frameworks that underpin this subject: Tanner’s Model of
Clinical Judgement and Evidence Based Practice? (Max 150 words, 3 marks)
Tanner’s Model of Clinical judgment summarizes an approach to handling health situations. It explains how
health concerns, patients' needs problems and decision for care approach should be taken. This model
highlights the importance of simulation in the enhancement of clinical judgment skills and capabilities. It
emphasizes that clinical judgments require critical thinking creativity and decision making. This research-
based model of highlights the main components as notice, interpretation, response, and reflection.
Evidence-Based Practice (EBP) is an approach that uses current nest evidence conscientiously, explicitly and
judiciously in formulating clinical decisions. It is the integration of the clinical skills to the best possible
external evidence. EBP integrates the clinical expertise, consumers' values, and the reliable research
evidence in the decision-making process. Clinicians bring their expertise, education, then integrates it with
consumers' encounter and lived experience, preferences, unique strengths, expectations, concerns, values,
and beliefs.
4. Describe the purpose of a systematic review compared to a single randomised controlled trial? (Max 50
words, 2 marks)
A systematic review is centered towards a particular clinical topic aiming to provide a specific answer. The
authors search extensively for studies underpinning the topic, review and assess their quality summarizing
the findings in a predetermined manner as per the question. Randomized control trials are experimental,
and they involve practical studies on real patients to identify the outcome
PART THREEE: Research methodology and results (17 marks)
92440 Evidence for Nursing Assessment 2: Understanding research concepts 1

CASE STUDY 1: Read the article carried out by Byrne et al. (2017). A copy of this article is in Assessment 2 folder.
5. What is the benefit of using randomised control trail study design in this study? (1 mark)
Some of the advantages of using randomization method in this study was to eliminate any changes of bias. The
blinding during the data collection minimised the performance bias. The allocation concealment minimised the bias
that could have occurred as assessment or performance bias. The prospective design helped to minimize recall
errors and bias in the selection. Randomization also helped in eliminating confounding factors that could have been
caused by unequal distribution of predictive factors, and it made comparison easier.
6. What are the study’s primary and secondary outcomes? (2 marks)
The first primary outcome was the discharge time which was not significant with or without adjustment of the
surgery. The scores between the groups were (5.8 days) for the chewing group and (6.1 days) for non-chewing
group. Another outcome was the first flatus time. Again, there was no significant different between the two groups
where both scored (P = 0.076): 42.0 (2.9) for chewing group and 58.0 (8.2) non-chewing group. The score was still
not significant after adjusting the surgery type. The last primary outcome was first bowel motion (TBM).
The TBM of the chewing group was 50.0 hours (2.4) and that of non-chewing group 80.0 hours (6.5) which was
significantly lower. There was also a significant decrease in TBM after surgery type adjustment.
Secondary outcomes were complication rates, pain and total morphine equivalent (TMEq) medication for seven days
after the procedure.
One of the secondary outcomes were complication rates. Intraoperative complication from the CG was 7 (9%) and 7
(9%) from the NCG. Early postoperative complication was 36 (44%) for CG and 42 (55%) for NCG. The NCG has 13
patients (17%) with recurrent ileus compared to eight (10%) CG. Reoperation was 3 (4%) patients for NCG and (0) for
CG. Another outcome was in medication where there was no variance in total morphine equivalent for 24 hours.
However, CG had significant reduction of morphine equivalents between day 2-7 post procedure. Another outcome
was pain scores which were higher in patients who had no bowel event in NCG than CG.
7. How did the researchers assess pain? (1 mark)
Pain was first recorded though a paper-based case report form (CRF). The patients reported pain scores were only
recorded until the patient’s TBM. Pain was assessed through a scale of 0-10 with 0 being no pain and 10 the most
extreme pain.
8. Has the study used an adequate sample size? (Justify your answer, 1.5 marks)
The study adequately used the sample size. For instance, the prospective design allowed the researchers to watch
the outcome as the patient’s recovery progress. This design also helped the researchers to the profess with other
factors. With this design, they were able to sufficiently select, allocate and administer the chewing gums to the
treatment group and monitor the development by comparing with the control group. The study was also able to
eliminate bias, succeeded in the blinding, and the observations were consistent.
9. What important baseline differences between intervention and control group participants exist that may affect
the study results? (2 mark)
The important difference that in the baseline that could have affected the study was the considerable difference
while allocating groups from the randomisation. The study had 43% patients in the CG group who had ileostomy
closures while the NCG had 25% patients of ileostomy. An ileostomy closure is a minor surgery for closing the
ileostomy temporary. This resection is less painful, needs less amount of analgesia and the patient gets quick gut
recovery than other surgeries colectomy. Since there was variance in such procedures, this could have also affected
the pain and recovery assessments.
10: how is the patients’ lack of blindness to their group allocation likely to affect the study results (1.5 marks)?
The purpose of blinding is to reduce and where possible eliminate both the ascertainment and performance that
may occur after randomization. The failure to blind patients can have great effects on the trial since they will have
the knowledge of different group assignments. This awareness affects greatly affect the patient’s behaviour during
92440 Evidence for Nursing Assessment 2: Understanding research concepts 2

the trial and their reactions can cause subjective outcomes. For example, if one patient knows that he or she is not
receiving a treatment that could have improved the conditions, he/she may drop the trial reject to comply with the
trial procedures. Besides, such a patient can sneak to find alternative treatment somewhere else outside the study
protocols. Such a patient can also leave the study and her/his data would not be recorded.
11. Was chewing gum effective in reducing length of hospital stay in this study? (Justify your answer, 1.5 marks)
Yes, but there was no significant efficacy. The difference between the two groups was LOS was 0.9 days. The LOS in
chewing group was (5.8 days) while that of the non-chewing group was 6.1 days. This was a difference of only 0.9
days. There was still little merging of the difference even after adjusting the type of surgery.
12. Authors report that the median time to first bowel motion (TBM) was 50 hours in the chewing gum group?
What does this mean to you? (1 mark)
In relation to data interpretation, median refers to the middle number after arranging all the numbers in a sequence
in a ranked order. Therefore, the median sits between the lower half and the higher half. If line separating the higher
half and the lower half is recording a by stating that the median time to TBM was 50 hours in CG, the authors imply
that after arranging the TBM of the 82 patients in CG, they then took the TBM of the patient number 41 and 42. They
then found the mean of their TBM which was 50 hours. Therefore, if the median was 50 hours, then more than a half
of the patients’ TBM was counting less or equal to 50 hours.
13. Authors found that the median time to first bowel motion (TBM) was 50 hours in the chewing gum group with
95% CI 45.2-54.8. What does this confidence interval tell to you? (See figure 4, justify your answer, mark 2)
If the authors found the median was 50 hours in CG 95% 45.2-54.8. first of all, the sample median of 50 hours should
be taken as a point of estimate of the entire population of patients who had bowel surgery. This point of estimation
cannot be taken to provide much relevant information since it is not true that if every patient chewed a gum would
have taken 50 ours TBM. There is no good estimation of how far or lower the mean would have gone if data for all
the patient would have been taken. For example, the authors could not be confident that all the patient’s median
TBM was within the 5 hours of 50 hours TBM. However, with a confidence interval of 95% CI 45.2-54.8, there is more
information. The authors mean that the median TBM of the patients who can chew the gum would lie between the
two margins of 45.22 and 54.8 because 95% of the calculated time CI would have the 50 hours TBM. If the authors
decided to take repeated samples and then compute a 95% confidence interval on each sample, they will end up
have 95% of the intervals containing the medians, and 5% of the intervals would not contain the population median.
14. Looking at Table 3, did chewing gum reduce the need for morphine equivalents for the total 7 days post-
surgery in the intervention group? (Hint: compare the mean required morphine for the chewing gum group with
the mean required morphine for the non-chewing gum group, see the reported p value). (Justify your answer,
mark 1.5)
The starting point is a null hypothesis where we assume that the chewing the gum did not affect the morphine need
for morphine equivalents. The null is 1, meaning no effects. The closer the value of morphine equivalent to 1, then
the higher the level of the validity of the null hypothesis.
24 hours the P was 0.589 which was closer to 1, this means that the chewing gum did not work
Day 2, the P was 0.019, which was far from 1, this means the chewing gum works
Day 3, the P was 0.002, which was far from 1, this means the chewing gum worked, and improved from day 2
Day 4, the P was 0.025, which was far from 1, this means the chewing gum worked but for some reasons, there was
a fall from the previous trend.
Day 5, the P was 0.033, which was far from 1, this means the chewing gum worked but for some reasons, it was
rising towards one.
Day 6, the P was 0.013, which was far from 1, this means the chewing gum went back to the previous working trend,
and indication that maybe there was an external factor that was causing the variation.
Day 7, the P was 0.002, which was far from 1, this the chewing gum worked, and the trend went back to day two,
which also means the external factor that was causing the variation was controlled.
92440 Evidence for Nursing Assessment 2: Understanding research concepts 3

In general, a low P value is an indication that the sample was providing adequate evidence for rejecting the null
hypothesis and accepting that the chewing gum was working for all the patients.
15. Would you consider using chewing gum for your patients post bowel surgery? (Justify your answer taking into
consideration the results of statistics, clinical significance, and cost) (2 marks)
Yes, I would consider using them because the analysis of Byrne et al. (2017) and other studies have shown that
chewing gum has various advantages. The study of Byrne et al (2017) had demonstrated with enough evidence that
using chewing gum can lower the length of stay and it can decrease the time taken for the first bowel movement.
The study has also shown that chewing the sugar-free gum had outcomes such as causing quick recovery and
bringing back the functioning of the bowel. Also, it has shown that chewing gum can decrease the need for
analgesics. Further, if the study has shown that chewing gum caused no harm to the patient, then it is worth using it
because if it works, the customer would benefit, if it does not due to other factors uncounted, the patient would not
be harmed.
PART THREE: Implementation of EBP (5 marks)
Thinking broadly about the way you engage with evidence in your clinical practice, please answer the following
questions:
16. What are some of the barriers to implementing new research findings into clinical practice? (2 marks for 4
identified barriers)
There are various barriers to the implementation of research findings in clinical practice. These barriers can be
classified as those that result from patients, those that result from health professionals, and those that result from
health organizations and government. The barriers from patients are much more individualized. Recognizing that
each patient is different from the other, the patient’s beliefs about health care systems, their culture or other
individualized factors can affect the implementation of the finding. Considering that patients should be involved in a
shared decision-making process, some patients’ opinions might conflict with those of healthcare professionals. In
such a situation, health officials must honour the decision of the patients as there is the belief that ‘patients are
experts of their problems.’ In addition, financial capacity of the patient can affect a research implementation. Where
patients are supposed to purchase or adhere to a particular health life style, lack of finances might hinder the
patients from facilitating the implementation of the findings. Another factor is patient education, if patients are not
well-informed of the purpose of the new approach, they would be unlikely to take it. Health care providers can also
be barriers to clinical finding implementations. These barriers come through information constraints which is lack of
relevant information for the implementation of the approach at the right time. Other clinicians’ barriers include lack
of support tools, limited guidelines, the providers altitude etc. Organization barriers include lack of financial support
for the implementation of the finding, poor implementation policies, lack of government support, lack of insurance
support, and few number of personnel.
17. Reflecting on your learning experience in this subject, how the subject help prepare you for your role as a
junior clinician? (Max 150 words, 3 marks).
This subject has enriched my skills in evidence-based practice. The subject has equipped me with more knowledge in
making clinical decision that can help in supporting patients in their recovery. For instance, learning how to interpret
clinical findings is an essential skill in nursing career. Apart from interpreting the results, the subject has also taught
me how I can do my own research. One of the important knowledge from this subject is the development of a search
strategy in databases. Considering that researching is one important area whereby nurses have to gather evidence to
support their work, I will be having an easier time in my research by using short terms to get specific results. Also, by
assessing different studies from that have been conducted by other researchers, I will be able to filter out what is
relevant for my clinical question and what is irrelevant.
92440 Evidence for Nursing Assessment 2: Understanding research concepts 4