Running head: QUALITATIVE ARTICLE CRITIQUE1

Qualitative Article Critique

KeunYim IRN # 9038288566 July 6, 2011

Qualitative Research Article Critique For NUR/518 Analysis of Research Reports Elizabeth Esterl University of Phoenix

Running head: QUALITATIVE ARTICLE CRITIQUE2 Preventing Ventilator-Associated Pneumonia in the United States: A Multicenter

Mixed-Methods Study Problem Ventilator-associated pneumonia (VAP), one of the most common nosocomial infections, is associated with high morbidity and mortality. According to (Ganz et al., 2009), eight to twenty eight percent of patients receiving mechanical ventilation will have complications due to VAP. In addition, VAP causes a high mortality rate of 24% to 50%. VAP not only lengthens the hospital stay, but also increases health care costs. Medicare recently started refusing to reimburse hospitals for a health care costs if patients developed VAP. Patients receiving mechanical ventilation have decreased salivary secretion, and oral cavity hygiene worsens, resulting in bacterial overgrowth. Oral care can improve oral health

status and modulate bacterial overgrowth could reduce the development of noscomial VAP. Recent progress in identification of oral microorganisms has shown that the oropharynx can be a site of origin for dissemination of pathogenic organisms to distant body sites, such as the lungs. Clinical studies have shown that comprehensive oral care decreased the rates of VAP. It

is recommended that hospitals develop standardized and written protocols related to oral hygiene and introduce it to all levels of nursing so that they can utilize the most current evidence-based practice (EBP).

Title The topic of interest, preventing ventilator-associated pneumonia in the United States is directly addressed in the study. The method of the study, a mixed-method, is also addressed, and the population of interest is inferred by the ventilator-associated portion of the title.

Running head: QUALITATIVE ARTICLE CRITIQUE3 Abstract The results of the abstract were useful and included overviews of the objective, design, methods, results, and conclusions of the study.

Purpose The purpose of the study is clearly stated and is significant to nursing or health care. purpose of the study was to determine what practices US hospitals use for the prevention of VAP and to understand why hospitals are using some practices but not others (Damschroder, 2008, p. 933).This study is being conducted qualitatively to determine the reasons behind agency-to-agency variation in ventilator-associated pneumonia prevention strategies. The central concept of the study is that VAP is a multidimensional nosocomial issue for intensive care patients and nurses alike which results in longer hospital stays, time intubated, and vastly increased healthcare costs and that preventative practices and associated research has varied widely in recent years. Of thirty-five cited resources, twenty-one are dated within the last five years. The remaining fourteen citations, while outdated by current research standards, appear to lend credible and valuable information to the study. Expert citations and data included those from infection control professionals, hospital epidemiologists, critical care physicians, intensive care nurse managers, chief executive officers and others. Research Question The research question is why some hospitals use EBP oral-care to prevent ventilatorassociated pneumonia and not others? The

Running head: QUALITATIVE ARTICLE CRITIQUE4 Methods Design The study design is consistent with its qualitative approach. This study has a mixed-

method, sequential explanatory study. The research question, written in statement form, for this study is why are hospitals using some VAP prevention practices, but not others? The research design is appropriate to answer the research question. Sample The subjects are obtained using a method consistent with the qualitative methodology. Eighty-six healthcare workers were interviewed in the course of this study. Positions of the sample participants were also listed as fifteen infection control professionals, five hospital epidemiologists or chiefs of infectious disease, five ICU nurse managers, two critical care physicians, two vice-chairs or chairs of medicine, two IV nurses, three nurse practitioners, one quality manager or medical director and three CEOs or directors. No other information specific to sample was provided. Inclusions and exclusions other than those directly inferred by the sample were not addressed. These selections appear to fit with the concept being studied. Recruitment occurred via snowball sampling following initial contact with each hospitals lead infection control professional. Setting Fourteen hospitals throughout the United States defined the sample setting to include VA hospitals and non-VA hospitals with a greater than fifty patient capacity and an ICU. Of those, twelve had academic affiliation and five participated in a collaborative.

Running head: QUALITATIVE ARTICLE CRITIQUE5 Data Collection Thirty-eight of the interviews were conducted via telephone with audio recording and transcription. Forty-eight additional in-person interviews were conducted in six of the fourteen hospitals. Interviews ranged in length from 29-92 minutes. The researchers presented themselves as the interviewers but did not specifically address roles. Human Rights Protection The rights of human subjects were protected in this study. The study authors note that

IRB approval was obtained from all hospitals that were visited. Informed consent for the interviews was not mentioned. Each participant was able to take part as indicated by use of the term interview. The study was not actually or potentially harmful to anyone as it lacked manipulation of any kind. Other than informed consent, no possibilities for ethical missteps are apparent. Data Saturation Data saturation was not addressed in this article but the study used a snowball technique whereby interviewees were asked to recommend other potential subjects. Data Analysis Data analysis procedures were appropriate for the type of data collected and the qualitative method. This studys data was analyzed via establishment of a codebook that provided a

summary of the studies conceptual model. Each transcript was then coded by two separate persons individually and then revised in collaboration with the other. NVivo7, a computer program designed for qualitative analysis was then used to assess the coded transcripts for patterns beyond those which had been personally identified. Data was analyzed inductively for

Running head: QUALITATIVE ARTICLE CRITIQUE6 possible results, results contradictory to expectation and to ensure rigor. Critical examination of researcher roles, assumptions and preconceptions was not apparent. Results and Discussion The main finding of the study is that while a great amount of US hospitals appear to accept semi recumbentpatient positioning as a VAP prevention measure many do not appear to utilize other portions of ventilator bundles such as specialty beds and secretion suctioning regardless of the recommendations of the Centers for Disease Control and Prevention. Additionally, it was found that collaborative hospitals were more likely to implement semi recumbent positioning but not the other portions of the bundle. It was found that nurse involvement in any particular intervention was directly influenced by perception of efficacy and that staffing, peer promotion, and altered performance self-perception all affected rates of compliance with bundle practices, specifically recumbent positioning. Subglottic secretion drainage was found to have questionable affect on VAP incidence. Further research into the relationship of evidence and decision-making regarding implementation of VAP bundles was recommended. Information presented in tables and figures included setting and sample characteristics, these graphics were easy to understand. I agree with the interpretation of results, however according to the authors not enough similar data exists to determine whether or not findings of the study agree with past research. The authors interpretation makes sense from a theoretical standpoint and offers several ideas that I could use. Overall Impressions This article is significant for the practice of healthcare; the findings resonate with me and my practice as I frequently see post-intubation patients suffering the effects of ventilatorassociated pneumonia as well as the more rapid improvement and discharge of those patients which do not contract VAP.Major limitations of the study include the fact that self-reporting was

Running head: QUALITATIVE ARTICLE CRITIQUE7 relied on from ICPs at the various hospitals with no method of verification, and by a possible threat to rigor from unforeseen differences in included and excluded facilities that would affect generalizability. Major strengths of the study include provision of valuable information, potential for encouragement of increased nurse involvement in VAP prevention, and the possibility for increased awareness of the efficacy of various components of VAP bundles. I do not believe the results can be considered transferable based on the relatively small sample size and the potential threats to the rigor of study findings that remain unresolved. Using Research Results Participants of reviewed studies were patients in healthcare workers employed in a hospital, mostly on a managerial level or above. I am not a nurse manager or an infectious disease specialist but I do frequently see patients who have been recently extubated, some of which suffer from VAP. This study will help with understanding efficacy of procedures and interventions. I suppose by extension it could be said to help with future quality improvement programs and education. However I do not believe it will not help with assessment, understanding patients perspectives, interpersonal relationships, or work life and environment. The findings will may some new policies, procedures and standards. Patient safety can be easily maintained, and improved, based on the recommendations. I believe the findings will be acceptable to patients, administrators, colleagues and other professionals who are open to EBP. Appropriate equipment, staff, time, money, knowledge, and skills will be necessary to implement the results. However investments of time and money will be overshadowed by savings on the other end of new interventions which, combined with improved patient outcomes and staff competency, makes the benefit of changing practice well worth it. An attitude change will be necessary for those opposed to EBP or change in general. The study recommends the future

Running head: QUALITATIVE ARTICLE CRITIQUE8 research for items that were not fully understood. Also, the study suggests that we need better understanding how evidence related to prevention practices is identified, interpreted, and used to ensure that research findings are reliably translated into clinical practice (Damschroder, 2008, p. 938).

Running head: QUALITATIVE ARTICLE CRITIQUE9 References

Babcock, H.M., Fraser, V.J., Garrison, T., Jones, M., Kollef, M.H., Travillion, E., & Zack, J.E. (2004). An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: A comparison of effects. CHEST Journal, 125, 2224-2231. Cutler, C.J., & Davis, N. (2005).Improving oral care in patients receiving mechanical ventilation.American Journal of Critical Care, 14, 389-394. Damschroder, L., Forman, J., Kaufman, S. R., Kowalski, C. P., Krein,S. L., & Saint, S. (2008). Preventing ventilator-associated pneumonia in the United States: A multicenter mixed-methods study.Infection Control and Hospital Epidemiology, 29(10),933-940. Ganz, F., Fink, N., Raanan, O., Asher, M., Bruttin, M., Nun, M., &Benbinishty, J. (2009). ICU nurses oral-care practices and the current best evidence.Journal of Nursing Scholarship, 41(2), 132-138. Kollef, M., Afessa, B., Anzueto, A., Veremakis, C., Kerr, K., Margolis, B., &Schinner, R.

(2008). Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: The NASCENT randomized trial. Journal of the American Medical Association, 300(7), 805-813. Krein, S., Kowalski, C., Damschroder, L., Forman, J., Kaufman, S., & Saint, S. (2008). Preventing ventilator-associated pneumonia in the United States: A multicenter mixedmethods study. Infection Control & Hospital Epidemiology, 29(10), 933-940