International Journal of Nursing Studies

Editorial Board

2010-08-01

Classic papers in nursing and midwifery research

Ian Norman — 2010-08-01

Nursing and midwifery are practice disciplines and applied fields of research enquiry. Few, if any, research methods are unique to nursing/midwifery and seminal papers which have informed research in these fields are drawn predominantly from other disciplines. In this issue of the International Journal of Nursing Studies (IJNS) we feature one such paper in the first of what we expect to be an occasional series of ‘classic’ research papers, published together with a commentary which draws out the contribution of the paper to nursing and midwifery research.

Statistical methods for assessing agreement between two methods of clinical measurement

J. Martin Bland, Douglas G. Altman — 2010-08-01

Abstract: In clinical measurement comparison of a new measurement technique with an established one is often needed to see whether they agree sufficiently for the new to replace the old. Such investigations are often analysed inappropriately, notably by using correlation coefficients. The use of correlation is misleading. An alternative approach, based on graphical techniques and simple calculations, is described, together with the relation between this analysis and the assessment of repeatability.

Reliability assessment and approaches to determining agreement between measurements: Classic methods paper

Peter Griffiths, Trevor Murrells — 2010-08-01

Abstract: This classic methods paper () considers the assessment of agreement between measures, an often overlooked aspect of assessing measurements taken for use in research and practice and (re) introduces the ubiquitous ‘Bland Altman’ procedures for assessing agreement. The importance of these procedures is high and they address issues that are not always considered in research which uses measurement scales or describes the characteristics of scales developed for use in clinical practice. Many widely used approaches for reliability assessment can fail to consider the agreement between measures at all and can give an entirely misleading impression of an instrument's suitability for use in research or practice.

Early sheath removal and ambulation in patients submitted to percutaneous coronary intervention: A randomised clinical trial

Andrea Cornelia Augustin, Alexandre Schaan de Quadros, Rogério E. Sarmento-Leite — 2010-08-01

Abstract: Introduction: Despite recent technical improvements and device developments, post-percutaneous coronary intervention care in patients submitted to this procedure performed through the femoral approach remains almost unchanged. An earlier sheath removal and ambulation could help to cut costs, save health system resources and prevent patient discomfort. However, this approach has not yet been well assessed.Objectives: The main objective of this paper was to evaluate a strategy of post-procedure immediate sheath removal and early ambulation.Methods: A randomised trial was conducted in 347 patients submitted to percutaneous coronary intervention that used a 6 French gauge arterial sheath. The intervention group (IG, n=172) had the arterial sheath removed immediately after the procedure and ambulated after 3h of bed rest. The control group (CG, n=175) had the arterial sheath removed 4h after the end of the angioplasty and rested for an additional 6h. The primary end point was the development of major vascular complications: hematoma>10cm, pseudo-aneurism and arterial bleeding after or during ambulation. Secondary end points were minor vascular complications: hematoma<10cm, vasovagal reactions after sheath removal, and assessment of patient's comfort during the peri-operative period.Results: Baseline characteristics did not differ statistically between groups, as major bleeding (IG=1.7% vs. CG=0.6%; p=0.31). Regarding other vascular complications and vasovagal reactions, there were also no significant differences. Patients of IG had less pain (26% vs. 41%, p=0.004) than CG, but the frequency of urinary retention was the same in both groups.Conclusion: This study, although underpowered, indicates that immediate arterial sheath removal with early ambulation after PCI was not significantly associated with an increase in major vascular complications and was associated with increased patient comfort. Although further studies with larger samples are necessary to confirm these results, this study suggests that immediate arterial sheath removal with early ambulation may be an alternative for selected elective patients submitted to percutaneous coronary interventions and for those with difficulties to endure prolonged bed rest.

Restoring embodied control following surgical treatment for colorectal cancer: A longitudinal qualitative study

Claire Taylor, Alison Richardson, Sarah Cowley — 2010-08-01

Abstract: Background: This article presents the findings of a study about recovery following surgery for colorectal cancer. Most patients diagnosed with this cancer are treated with surgery. Few studies have employed a qualitative approach to examine their experiences and perceptions of recovering from this treatment.Objectives: The purpose of this study was to discover the process of recovery for individuals following curative surgery for colorectal cancer.Design: This qualitative study drew on grounded theory methods and used a prospective longitudinal design.Settings: Ethical approval was granted by three Local Research Ethics Committees enabling patients to be recruited from three different hospitals in the South of England.Participants: Purposive sampling was used to identify patients diagnosed with colorectal cancer who had had surgery with curative intent.Methods: Each participant was interviewed up to four times following their surgery: at 6 weeks then at 3, 6 and 12 months. Sixty-two interviews were conducted. Emerging concepts from the analysis defined further data collection. Relevant literature was theoretically sampled and all data analysed using constant comparison. Theoretical saturation was achieved.Results: Sixteen participants were recruited. Analysis of study data identified four conceptual stages representing the main phases individuals can experience during their recovery. They are: disembodiment, restoring embodiment, reclaiming control and managing embodied control. These occur in a stepwise progression, reflecting the emotional, physical and social processes involved in restoring perceived control over the body. They reflect the difficulty individuals can experience in understanding and self-managing their bodies. There is a desire to regain confidence and certainty over body function but this is threatened by fears about future health.Conclusions: Achieving a sense of control of one's body, after surgery for colorectal cancer, proves to be a major challenge. Greater recognition of the consequences of cancer and its treatment upon the body and individualised management is required. Addressing how individuals can regain embodied control during their recovery needs to be integral within post-treatment support.

Predictors of adjustment to nursing home life of elderly residents: A cross-sectional survey

Ga Eon Lee — 2010-08-01

Abstract: Background: Adjustment to a nursing home by elderly residents is an issue in transitional care in nursing homes. Although research on relocation adjustment has been conducted in many countries, adjustment has generally been measured with life satisfaction scales, assuming equivalence between life satisfaction and successful adjustment. Research has not been reported on adjustment to relocation using an adjustment scale.Objectives: To identify predictors of nursing home life adjustment.Design: Descriptive study with cross-sectional surveys.Participants and setting: One hundred fifty-six residents from seven nursing homes completely subsidized by the South Korea government.Methods: A structured questionnaire about resident characteristics, relocation characteristics, social support and general facility satisfaction was administered. The facility characteristics were obtained from the facility records. A scale of nursing home adjustment was also used during one-on-one interviews. Multiple regression was used to identify predictors of adjustment to the nursing home life for elderly residents.Results: The predictors of nursing home adjustment were self-efficacy, self-reported health, preconception about nursing homes, emotional support from staff and other residents, family satisfaction and general satisfaction with the facility. The total explained variance for this model was 60.6%.Conclusions: Nursing home staff should consider the following four factors in assisting the elderly achieve successful adjustment to a nursing home: residents, relocation, social support and facilities. Social support inside the facility should be fostered to improve nursing home adjustment. Further studies are needed to explore adjustment using a nursing home adjustment scale.

Gender specific variations in the description, intensity and location of Angina Pectoris: A cross-sectional study

2010-08-01

Abstract: Background: Some research suggests that men and women may experience Angina Pectoris (AP) differently. More research is needed to characterize AP symptoms by gender and to familiarize health care providers with them, to enable proper education, diagnostic evaluation and timely management.Objective: This study examines gender differences in the description, intensity and location of AP in patients with CHD.Design: A cross-sectional study was performed to compare AP patients according to gender.Settings: This study was performed on patients residing in Tehran, who were being treated in a hospital and were admitted to cardiac units.Participants: Five hundred patients with AP were selected. The participants were patients with AP who were diagnosed with CHD based on documented results from an angiography.Method: Outpatients who were admitted to the cardiac units were screened. Informed consent was obtained from all study participants, who then completed the Iranian version of the AP characteristics questionnaire.Results: Women were significantly more likely to feel pain in the left arm and hand, odds ratio 1.5 (95% CI=1.0–2.1, P=0.04), left scapula, odds ratio 2.3 (95% CI=1.6–3.5, P<0.001), and neck, odds ratio 2.8 (95% CI=1.9–4.1, P<0.0001), while controlling for demographic and clinical factors. Women were significantly more likely to choose the possible pain descriptors for describing their AP and reported significantly greater intensity than men for all the pain descriptors. Significantly higher scores for sensory, affective, total and NRS (Numeric Rating Scale) scores were observed in women (P<0.001). Multiple linear regression analyses revealed that gender remained a statistically significant predictor of pain scores and NRS, while controlling for demographic and clinical factors.Conclusion: Women and men differ with respect to description, intensity and location of AP. Educating the general public and informing health care providers about gender variation in AP may help to decrease delays in seeking medical care.

Distrust, predisposition to use health services and breast cancer screening: Results from a multicultural community-based survey

Maria C. Katapodi, Penny F. Pierce, Noreen C. Facione — 2010-08-01

Abstract: Purpose: To examine whether and how distrust of the health system and predisposition to use healthcare services influence frequency of mammograms and Clinical Breast Exams (CBEs).Methods: A community-based survey recruited 184 women (age 47±12); 49% were college-educated, 77% had health insurance, and 57% were non-white. Distrust was measured with a four-item scale (Cronbach α=0.71); predisposition to use health services with an 11-item scale (Cronbach α=0.84). Ordinal regression analysis was used to test two models examining “time since last mammogram” and “time since last CBE.” The later model had a better goodness-of-fit, as indicated by a non-significant, Pearson coefficient.Findings: Distrust to the health system was significantly correlated with age (r=−0.19*), income (r=−0.16*), and predisposition to use health services (r=−0.26**). Distrust predicted time since last CBE (B: 0.37, SE: 0.19*), which in turn was significantly correlated with time since last mammogram (r=0.44**). Predisposition to use health services predicted time since last CBE (B: −0.78, SE: 0.19**) and time since last mammogram (B: −0.47, SE: 0.22**). Insurance predicted time since last CBE (B: −0.94, SE: 0.44*), while age (B: −0.21, SE: 0.03**) and income (B: −0.19, SE: 0.09*) predicted time since last mammogram.Conclusion: Distrust of the healthcare system and predisposition to use health services influence breast cancer screening directly. Distrust interferes with behavioral patterns that favor recurrent breast cancer screening.Practice implications: Trustworthiness in the healthcare system and positive attitudes for the use of, health services enhance routine breast cancer screening. *p<0.05, **p<0.001.

The inclusion of positive aspects of caring in the Caregiver Strain Index: Tests of feasibility and validity

Hareth Al-Janabi, Emma Frew, Werner Brouwer, David Rappange, Job Van Exel — 2010-08-01

Abstract: Background and objective: Positive aspects of caring are commonly cited by carers and can potentially mediate carer strain. However, in outcome assessment for carers, it is still common practice to focus on the negative aspects of caring. This study explored the feasibility and validity of including positive items in a commonly used outcome measure—the Caregiver Strain Index (CSI).Methods: Five positive items were inserted into the CSI. The resulting ‘CSI+’ questionnaire was included in a postal survey of carers in the Netherlands. Feasibility was assessed through completion rates for the CSI+ and individual items. Validity was assessed through tests of the association of the positive items and the CSI+ scores with relevant characteristics of the care (construct validity) and related scales (convergent validity). Factor analysis was carried out the CSI+ scale.Results: The addition of the positive items did not noticeably affect the feasibility of the CSI, but did appear to improve the convergent validity of the measure. The multivariable analysis and factor analysis suggests that positive aspects of care could be grouped into ‘coping’ factors and ‘attitudinal’ factors.Conclusion: These findings support the use of positive items in outcome assessment for carers and provide some support for the use of the CSI+ as an instrument for doing this.

Accuracy of body mass index to determine obesity in women with breast cancer: An observational study of Taiwanese sample

Li-Ni Liu, Christine Miaskowski, Jong-Shyan Wang, Shin-Cheh Chen, Mei-Ling Chen — 2010-08-01

Abstract: Background: Obesity is common in women with breast cancer. The risk of obesity-induced metabolic syndrome is higher in Asians than in Caucasians. Excessive body fat accumulation has been associated with a worse prognosis. However, the most popular clinical indicator of obesity is not fat itself, but body mass index (BMI).Objectives: The purposes of this study were to determine the consistency of BMI and body fat percentage (BF%) in determining obesity and to identify the best BMI cutoffs for identifying obesity in Taiwanese women with breast cancer.Methods: Body fat and fat-free mass were measured by bioelectrical impedance 1 day before breast surgery for 200 women with breast cancer. BMI was calculated as weight (in kilograms) divided by height (in meters) squared.Results: BMI and BF% were highly correlated (r=0.91; p<0.001). However, BMI exhibited poor sensitivity for identifying obesity (47%). The sensitivity of BMI to detect obesity was better in women over age 60. The best BMI cutoff for obesity was 22.3kg/m2 with a sensitivity and specificity of 89% (95% CI=83–94%) and 87% (95% CI=77–93%) respectively, and the total accuracy rate improved from 65% to 89%.Conclusions: Using BMI to identify obesity in Taiwanese women with breast cancer requires careful attention to the diagnostic criterion chosen. The World Health Organization criterion tends to underestimate the prevalence of obesity, especially for younger women with breast cancer (under age 40).

Magnet Hospital attributes in European hospitals: A multilevel model of job satisfaction

Yao-Mei Chen, Mary E. Johantgen — 2010-08-01

Abstract: Background: The Magnet Recognition Program in the USA has been based on 14 hospital characteristics that were common in hospitals that were “magnets” for professional nurses. While the program has expanded to other countries, no research has explored how the concept translates to other cultures and healthcare systems, nor have multilevel approaches been used.Objective: The primary aim of this study was to explore the presence of Magnet Hospital attributes in hospitals in two European countries. In addition, the relationship between Magnet Hospital attributes and nurses’ job satisfaction was examined at both the nurse and the hospital level.Design: A secondary data analysis with cross-sectional design was conducted. A multilevel approach was taken to account for the hospital effect due to the nested nature of the data.Settings: Nurses practicing in acute care hospitals in Germany (16) and Belgium (15) were examined. Hospitals that had less than five respondents were excluded.Participants: Survey responses from 2303 registered nurses (RNs) from Belgium and 2646 RNs from Germany were included. Non-RN providers, RNs with administrative positions, and those working in non-inpatient areas were excluded. The final sample was 3182 staff nurses working in acute care hospitals.Methods: Magnet Hospital attributes that might be represented in NEXT survey items were reviewed by an expert panel before psychometric testing. Only six Magnet Forces could be measured. Latent constructs of these forces and job satisfaction were established. The measurement models and structural regression models were estimated using multilevel modeling in Mplus 4.21.Results: Six Magnet Forces were validated by two-level confirmatory factor analyses, with good fit to the data as demonstrated by the fit indices. All six Magnet Forces significantly predicted job satisfaction at the nurse level, with personnel policies having the strongest effect (b=0.96). At the hospital level, management style had the strongest effect (b=0.84) in predicting job satisfaction, followed by professional development, interdisciplinary relationship, and autonomy.Conclusions: Magnet Hospital attributes are evident in hospitals in two European countries and were found to be associated with job satisfaction. Further multilevel research should explore these attributes particularly at the nursing unit-level where work environment is experienced.

Incidence of burnout in Spanish nursing professionals: A longitudinal study

2010-08-01

Abstract: Background: Burnout is a psychological response to chronic work-related stress of an interpersonal and emotional nature that appears in professionals in service organizations who work in direct contact with the clients or end-users of the organization.Objective: The purpose of this study was to examine the incidence of burnout in a sample of staff nurses.Design: The study was longitudinal, and not randomized. The gap between time 1 (T1) and time 2 (T2) was 1 year.Settings: The data were gathered using an anonymous and self-applied questionnaire in different units of 13 Spanish hospitals.Participants: The sample consisted of 316 staff nurses, 53 males (16.8%) and 262 females (83.2%). The percentage of the response obtained was 31.37% of all the questionnaires distributed in T1, and 83.77% of all the questionnaires handed out in T2. The characteristics of the sample were stable over time.Methods: Burnout was evaluated by the Maslach Burnout Inventory (MBI-HSS). Descriptive statistics, percentages, and t-test analyses were conducted.Results: The prevalence of burnout was different according to the approach used: (a) following the cut-off points from the American manual, the prevalence was 2.84% in T1 and 1.89% in T2; and considering the clinically derived cut-off points obtained in Holland, the percentage was 1.26% in T1 and .94% in T2.Conclusions: The results only confirmed the hypothesis formulated applying the American cut-off points in T1. There was a significant increase in the levels of emotional exhaustion from T1 to T2, but there were no significant changes in the levels of personal accomplishment or depersonalization from T1 to T2. When the scores on the three dimensions of the MBI were considered together, a decrease in the incidence of burnout was obtained from T1 to T2. The prevalence of burnout in staff nurses can be modified over time, depending on the criteria used to estimate the prevalence.

The association between shift duty and abnormal eating behavior among nurses working in a major hospital: A cross-sectional study

Hidy Wong, Martin C.S. Wong, Samuel Y.S. Wong, Albert Lee — 2010-08-01

Abstract: Background: Shift work induces stress, disturbs family life and interrupts regular meal schedules. Few studies have addressed the association between shift duties and abnormal eating behavior among hospital nurses.Objectives and design: We tested the hypothesis that shift duties were independent predictors of abnormal eating. Self-administered surveys consisting of socio-demographic data, working pattern, Perceived Organizational Support (POS) questionnaire and the patterns of eating style identified by the Dutch Eating Behavior Questionnaires (DEBQ) were used.Settings: One major acute hospital in one Territory of Hong Kong.Participants: All 662 nurses who worked on a full-time basis in this hospital were invited to join the study and among them, 378 completed surveys were collected with a response rate of 57.1%. The average age was 37.2 years, and 91.5% were female. 67.3 were registered nurses, 17.9% enrolled nurses; and 14.5% were ranked nursing officers or above. 39.1% worked in acute settings (medical wards, intensive care units and emergency departments), and 62.1% of respondents had at least 11 years of clinical experience and 76.2% of respondents had shift duties with 81.9% having at least four shift duties per month. Only 66.7% of respondents had normal body mass index (BMI 18.5–22.9kg/m2).Methods: Three binary logistic regression analyses were conducted with abnormal emotional, external and restraint DEBQ as outcome variables, respectively. We controlled for age, gender, marital status, work setting (acute vs. non-acute), years of clinical experience, the frequency of shift duties, body mass index, perception of body weight changes in the past 6 months, self-perception of recent overeating and POS.Results: The proportions of participants having abnormal emotional, external and restraint DEBQ scores were 66.4%, 61.4% and 64.0%, respectively. From multiple regression analysis, nurses having 4 or more shift duties per month were more likely to present with abnormal emotional (adjusted odds ratio aOR 2.91, 95% C.I. 1.57–5.42, p=0.001) and restraint (aOR 3.35, 95% C.I. 1.76–6.38, p<0.001) DEBS scores.Conclusions: Shift duties were positively associated with abnormal eating behavior among nurses working in hospitals. More health promotional initiatives should be targeted towards hospital nurses whose duties require frequent night shifts to enhance healthy eating.

Associations between contractual status, part-time work, and intent to leave among professional caregivers for older people: Results of a national cross-sectional survey in Japan

Yuko Kachi, Kazuo Inoue, Satoshi Toyokawa — 2010-08-01

Abstract: Background: Despite a growing number of studies on leaving the organization or long-term care among professional caregivers for older people, little is known about the impact of types of employment on leaving.Objectives: To examine the association between the type of employment and intent to leave among Japanese professional caregivers.Design and settings: Secondary analysis of data from the 2006 Working Conditions Survey in Long-term Care, a nationally representative cross-sectional survey done in Japan.Participants: 10,107 professional caregivers aged 18 years and older.Methods: Predictor of intent to leave was type of employment (full-time permanent, full-time precarious, and part-time precarious). Precarious work was defined as employment that failed to meet the standard of full-time permanent employment, including fixed-term, temporary agency, and part-time work. Covariates included demographics, home or facility care, tenure in the profession, national qualification for caregivers, having other jobs, overtime work, and night shift work. We used multinomial logit models to estimate the strength of the association between the type of employment and intent to leave and to explore the possible mechanisms explaining this association.Results: In the unadjusted model, when compared to part-time precarious workers, full-time permanent workers (OR=2.37; 95% CI=2.06, 2.72) and full-time precarious workers (OR=2.41; 95% CI=2.01, 2.88) were more likely to report intent to leave. After adjustment for covariates, these odds ratios were attenuated, but nevertheless remained significant. Overtime work greatly attenuated these odds ratios in both full-time precarious and full-time permanent workers, and having national qualification for caregivers only did in the case of full-time permanent workers.Conclusions: In contrast to people in other professions, full-time caregivers are more likely to have intent to leave than part-time caregivers. This study highlights the importance of policy strategies for retaining full-time workers by reducing their overtime work and rewarding caregivers who have national qualifications.

Accuracy of biochemical markers for predicting nasogastric tube placement in adults—A systematic review of diagnostic studies

2010-08-01

Abstract: Objective: The objective of this study was to investigate the diagnostic performance of biochemical tests used to determine placement of nasogastric (NG) tubes after insertion in adults.Design: A systematic review of diagnostic studies was undertaken.Data sources: A literature search of the bibliographic databases and the World Wide Web was performed to locate original diagnostic studies in English or Chinese on biochemical markers for detecting NG tube location.Review methods: Studies in which one or more different tests were evaluated with a reference standard, and diagnostic values were reported or could be calculated were included. Two reviewers independently checked all abstracts and full text studies for inclusion criteria. Included studies were assessed for their quality using the QUADAS tool. Study features and diagnostic values were extracted from the included studies.Results: Of the 10 studies included in this review, seven investigated the diagnostic accuracy of pH, one investigated the diagnostic accuracy of pH and bilirubin respectively, two a combination of pH and bilirubin and one a combination of pH, pepsin and trypsin levels in identifying NG tube location. All studies used X-rays as the reference standard for comparison. Pooled results demonstrated that a pH of ≤4.0 had the ability to predict only 63% of the tubes located in the stomach. However, a pH value of ≤5.5 to determine gastric placement demonstrated a sensitivity of 0.89 (95% CI 0.82–0.94) and a specificity of 0.87 (95% CI 0.81–0.93). Bilirubin coupled with pH had a high specificity (0.99) which demonstrated the ability of the test to identify misplaced tubes in intestine. However, the ability of the test to correctly identify gastric placement of feeding tubes was relatively low (sensitivity <0.90).Conclusions: Due to the heterogeneity of the studies and small sample sizes, conclusions about the diagnostic performance of the different tests cannot be drawn. Better designed studies exploring the accuracy of diagnostic tests are needed to improve the diagnostic policy. Until stronger evidence becomes available practice related to the diagnostic tests used within the clinical setting will continue to be dictated by local preferences and cost factors.

The impact of common mental disorders on the work functioning of nurses and allied health professionals: A systematic review

Fania R. Gärtner, Karen Nieuwenhuijsen, Frank J.H. van Dijk, Judith K. Sluiter — 2010-08-01

Abstract: Objective: This study aims to inventory aspects of work functioning of nurses and allied health professionals that are affected by common mental disorders.Design: A systematic review of psychological and occupational health literature was performed.Data sources: A sensitive systematic literature search based on index terms and text words was conducted in four electronic databases: PubMed, PsycINFO, Embase, and Cinahl. The literature search was limited to journal articles published between 1998 and 2008, written in English, German, or Dutch.Review methods: For inclusion, studies had to examine a relationship between common mental disorders and a measure of work functioning in nurses or allied health professionals. No restrictions on study design were handled. Methodological quality was assessed for each study. The data were categorized into themes, for which the strength of evidence was assessed using six levels of evidence.Results: Sixteen of 2792 studies met the inclusion criteria, of which 13 had a cross-sectional design, 1 was a vignette study, and 2 were narrative reviews. In all studies, the subjects were nurses. The retrieved aspects of sub-optimal work functioning due to common mental disorders were merged into 15 themes. Strong evidence was found for five themes: general errors, medication errors, near misses, patient safety, and patient satisfaction. Moderate evidence was found that common mental disorders are associated with complex motor skills and with general performance; while evidence for an association between common mental disorders and needle stick injuries was inconclusive. Seven themes had only narrative evidence: interpersonal behaviour, energy, focus on goals and responsibility, work speed, avoiding work while on the job, coping with emotions, and motivation.Conclusion: Common mental disorders were found to be associated with various impairments in work functioning in nurses, these include task-related, intrapersonal and interpersonal aspects of work. In particular, strong evidence was found for an association between common mental disorders and general errors, medication errors, near errors, patient safety, and patient satisfaction. These results provide input for preventive actions to improve both health and work functioning in health care workers.