A Critique of Nursing Research by Smith, Pope, Goodwin and Mort

Statement of the Phenomenon of Interest

The research conducted by Smith, Pope, Goodwin and Mort (2008) is titled “Interprofessional handover and patient safety in anaesthesia: Observational study of handovers in the recovery room”. The researchers begin the article by describing the handover phenomenon in hospitals. They argue that patients in hospitals are cared for by many different healthcare professionals. Handovers, therefore, play a significant part in the care of patients. Smith et al. (2008) further state that many research studies have been carried out to examine handovers between nurses and handovers between doctors. However, handovers between different professionals have received little attention. It is based on this literature gap that the researchers embarked on their study. The focus of the study is on anesthesia which the researchers argue is among the leading departments in ensuring patient safety. The anesthesia department is therefore a viable area of study into the practice of inter-professional handover. This phenomenon of interest has been identified by the researchers. It has been achieved by stating what has already been done and what remains to be done in the area of interest. As a result, readers can understand why the study has been done in the first place (Beyea & Slattery 2006).

It is important to note that the study begins with a minimum review of literature. Specifically, Smith et al. (2008) reviewed six studies conducted by Arova and Johnson (2006), Manias and Street (2000), Sherlock (1995), Solet, Norvell, Rutan, and Frankel (2005), Horn and Bell (2004) and Gaba (2000). All these studies are relatively recent and therefore provide up-to-date information about handover practices in hospitals. The review of minimal literature is consistent with the grounded theory research studies. In such studies, the literature review is not detailed. Instead, it is kept to a minimum because its purpose is to introduce the topic in question and inform the readers of what studies have already been conducted. Unlike in other studies, the literature review in grounded theory research does not aid in the data collection or development of theory. Instead, it only explains, gives support, and develops the theory that is to be generated from the study (Grove 2003).

Purpose of the Study

The main purpose of the study by Smith et al. is “to describe the handover practice between anaesthetists and nurses in the operating theatre recovery room,” (2008, p. 332). The purpose has been made explicit by the researchers through the provision of background information of the study. Nevertheless, the researchers fail to describe the anticipated significance of the work to nursing. The readers are left to fill this gap for themselves which becomes a matter of guesswork. The study would have been strengthened if the researchers had described in advance the expected benefits of the research to nursing practice (Grove 2005).

Method

Study design and data collection methods

The method used to conduct the study is a qualitative approach using the grounded theory design. This design was used to enable the researchers to develop a theory of handover practice in anesthesia in the operating theatre recovery room. Data collection was done using two methods namely: non-participant observation and interview. The study site chosen for the study was “the main theatre complex of a district hospital located in the northern United Kingdom,” (Smith et al. 2008, p. 333). The non-participant observation was conducted by one researcher. However, some of the sessions were carried out through collaboration between two researchers. This collaboration helped to enhance the internal validity of the study as well as facilitate comparison of what was being observed (LoBiondo-Wood & Haber 2006). The data collection instrument used during the observation was note-taking. Detailed notes were taken during the sessions. The notes were then transcribed immediately at the end of the observation sessions. This prompt transcription was useful in the analysis of the data because the memories of the researchers as regards what was observed were still fresh immediately after the session. Possibilities of forgetting or confusion of the notes were thus minimized significantly.

Like in other studies, the use of non-participant observation can bring about observer-induced bias. This means that participants being observed by a stranger are likely to behave in a manner that is out of the ordinary and which is likely to influence the results of the study. In order to minimize this bias, the researchers conducted the observation over a long period of time (one year) and through the use of the presence of a former anaesthetic nurse who used to work in that department. Because the participants of the study were familiar with the nurse, they were likely to act in a normal and ordinary manner. Apart from the observation method, data were also collected through interviews. The interviews were carried out with anaesthetics and anaesthetic nurses. The interviews focused on inter-professional working relationships. The use of personal interviews enhanced the study by providing more details that could not be collected through mere observation (Munhall 2007).

Compatibility of the data collection methods with the purpose of the study

The data collection methods used in the study – observation and interviews – are compatible with the purpose of the study. Because the researchers wanted to understand inter-professional handover practices in the operating theatre recovery room, they could only do so by observing what goes on in the room or by interviewing the professionals. The methods used indeed provided the researchers with adequate information about the phenomenon under investigation. The methods used were also adequate to address the study’s purpose. What could not be observed during the observation sessions was addressed during the interview sessions (Munhall 2007).

Focus of the study on human experience

The study focused on the experiences of human beings specifically patients, anaesthetists, anaesthetic nurses, and recovery nurses. Any study that makes use of human subjects needs to ensure the utmost protection of the subjects. In this study, Smith et al. (2008) addressed the issue of protection mainly through obtaining informed consent from the participants. This entailed explaining to the participants the aim of the study, the significance of the study to nursing practice, and expected risks and benefits of participating in the study. Consent was then given after providing the potential participants with the information. Unfortunately, other methods of protecting the participants were not addressed. These include: privacy and confidentiality of personal information as well as anonymity. These measures would have enhanced the protection of the participants from any harm that could have arisen from participating in the study (Polit & Beck 2008).

Description of the data collection strategies

One of the limitations of Smith et al.’s (2008) study is the lack of detailed description of the data collection methods and process. The researchers only stated briefly that they used observation and interviews to collect data. However, readers do not know how the observation sessions were: how long they lasted, how the participants were observed, if they were observed individually or in groups, if the professionals were observed working together or working independently, and what the observers were doing during the observation. Likewise, Smith et al. (2008) failed to describe the interview sessions. Readers therefore do not know how the interviews were carried out, what the setting for the interviews was, if the interviews were done using individual professionals or if they were more of focus group discussions, how long the interviews lasted, and who was in charge of the interviews. The lack of such crucial information makes the study difficult for other interested researchers to replicate it (Speziale & Carpenter 2007).

Sampling

Study site

Smith et al. (2008) clearly state that they conducted their study in a theatre complex of a district hospital in the northern United Kingdom. Unfortunately, such a description is wanting. The researchers could have stated the exact name of the hospital as well as the exact name of the location of the hospital. The researchers also failed to give reasons as to why this particular hospital was chosen for the study. What special features does the hospital have that made it suitable for the study? Why was this particular hospital and not any other selected for the study? Was there any criterion used in the selection of the hospital? If yes, what was the criterion? Such details could have been described in-depth by the researchers to make the readers understand better the significance of the choice of the hospital. The details would also make it easier for other researchers interested in conducting a similar study to select either a similar hospital or a different one and compare the results (Speziale & Carpenter 2007).

Participants

Smith et al. (2008) state that in total forty-five handovers were observed and nineteen interviews were conducted during the study. The participants of the study included seventeen anaesthetists and fifteen recovery nurses. However, the researchers failed to explain how the participants were selected. What was the sampling technique used? Did the study include all the anaesthetists, anaesthetic nurses and recovery nurses operating in the recovery room? Were only a few of the professionals selected? If so, what was the criterion used to select these participants? What was the sampling size used for the study? These questions have not been addressed by the researchers. Additional detail is needed to inform the readers of the entire sampling process used in the study. The importance of providing such information lies in the fact that the sample used has a significant impact on the results of the study (Grove 2003).

Appropriateness of the participants to the study

Despite the lack of information about the sampling technique used, the participants chosen for the study were appropriate for the study. The researchers were interested in understanding the inter-professional handover practices in the operating theatre recovery room. The main professionals who operate in the operating theatre recovery room are anaesthetists, anaesthetic nurses and recovery nurses. All these professionals were included in the study and therefore the information gathered from them was appropriate in addressing the purpose of the study. The researchers were thus able to describe how handovers practices are carried out between different professionals (Smith et al. 2008).

Data Analysis

Data analysis procedure

Analysis of the collected data was done in three stages. First, the transcripts from the observation and interview sessions were read individually and then summarized. Second, after the summarization, the researchers then embarked on a discussion of the readings. Comparisons and contrasts of the information were then made by the researchers. From this analysis, the extent and boundaries of the three outstanding themes were identified. It is important to note that the researchers did not have any hypothesis or research question prior to conducting the study. As a result, the decision to evaluate inter-professional handover was made after the researchers collected the data and began to analyze them. From the process, it was clear that inter-professional handover was an area worth assessing. It is unfortunate to note that besides the brief mentioning of the data analysis process, the process was not described in detail. This makes it difficult for readers to understand how the researchers analyzed the data and how they came up with their findings. Despite this limitation, the researchers remained true to the data collected. Objectivity in the analysis of data was ensured through group discussion of the transcripts (Munhall 2007). All the researchers read each of the transcripts and then discussed and compared what they had understood from the readings together as a group (Smith et al. 2008).

Credibility, auditability and fittingness of the data

The credibility of the study was ensured by the recognition by the participants of the experiences as their own. In order to ensure that the participants behaved in an ordinary manner and that their behaviour was not influenced by the presence of the observer, the researchers included a former colleague of the participants in the observation sessions. The familiar face made the participants to relax and carry on with their duties normally. The auditability of the study is negatively affected because the researchers fail to adequately record the data analysis process. As a result, readers may find it difficult to follow the thinking of the researchers and instead to take what has been written on its face value. The fittingness of the study refers to the applicability of the findings to other settings outside the study site as well as the meaningfulness of the findings to persons who did not take part in the study. The study if fitting because it can be applicable to other operating theatre recovery rooms located in other hospitals and regions. The study describes the handover process among different professionals in the operating theatre recovery room and therefore similar situations may occur in such settings. Second, the study is fitting because the findings are useful to other hospital units that are operated by different professionals, for instance, critical care units and home care units. Such facilities may use the study’s findings to understand the handover process.

Compatibility of the analysis strategy to the purpose of the study

The data analysis procedure used in the study – identification of emergent themes – is compatible not only with the purpose of the study but also with the study design used. As earlier stated, the purpose of the researchers in conducting this study was to describe the handover practice between anaesthetists and nurses in the operating theatre recovery room. The description of the handover practice could only be possible through the identification of the emergent themes. In addition, the study design used is grounded theory which results in the development of theories from the collected and analyzed data. It is only through the analysis strategy used in the study that the researchers could be able to come up with theories of inter-professional handover practices in the operating theatre recovery room. The analysis strategy used is therefore compatible with the study.

Discussion of Findings

From the data analysis, Smith et al. (2008) found that handover had three main objectives:

It provided an opportunity to communicate the knowledge of the anaesthetist concerning the patient’s perioperative care to the nurse so as to aid the patient’s continuous care; it represented the changeover of responsibility from one healthcare professional to another; and it offered an ‘audit point’ in care to assess what has already been done and plan for future management (Smith et al. 2008, p. 336).

Hence, the findings of the study have been presented in a thematic context, with each arising theme explained in depth and separately from the rest. One of the greatest strengths of the article is the inclusion of the observation notes by the researchers as part of the results. A total of three observational transcripts have been included in the article. The transcripts further enhance the results of the study by informing the reader of what exactly was observed in the sessions. The transcripts also enable the readers to further understand the researchers’ findings by comparing the documented findings with the transcripts.

The researchers’ conceptualizations are also consistent with the data collected. For instance, in the ‘handover in context’ theme, the researchers argue that they observed the receiving nurse seeking additional information that was not voluntarily provided by the patient. This statement is supported by one of the transcripts included in the article (figure 1) in which the recovery nurse enquired about the name of the patient who had been wheeled into the recovery room. Reading the findings as well as the transcripts enables readers to understand the real meaning of the experiences from the report (Polit & Beck 2008).

The findings of the study have been discussed in the context of what other researchers have found in the same area. Smith et al. (2008) made reference to other studies that were conducted before and which either found similar or different results. For instance, while Smith et al. (2008) found that handovers are characterized by informal and locally negotiations, other scholars such as Patterson, Roth, Woods, Chow and Gomes (2004) found that the handover procedure is closely specified and formalized. The presentation of both supporting and contrasting evidence enables the readers to understand the phenomenon under investigation better and to question why some studies had dissimilar results from the results of the current study. Future investigation of the phenomenon under different settings is thus encouraged.

Conclusion, Implications, and Recommendations

Smith et al. (2008) concluded their article by stating that informal practices exist in safety-sensitive units such as anaesthesia. They argued that safety gains could be made if the practices were standardized and followed stringent protocol. However, such formal procedures could be made more effective by acknowledging the informal aspects found by the researchers. This conclusion provides readers with a framework in which to utilize the results. The conclusion also reflects the findings of the study by making references to them. The study carried out by Smith et al. (2008) definitely has significant implications for nursing practice. Unfortunately, the researchers failed to state explicitly the implications of the study. This is left to the imagination of readers. Nevertheless, the readers stated the need for future studies. They recommended the conduction of further studies in order to clarify the relationship between the formal and informal elements of inter-professional handover practices in the operating theatre recovery room. This recommendation therefore lays the platform for future studies to be carried out to address the issue of inter-professional handovers in hospitals.

Conclusion

The research article by Smith et al. (2008) is informative. The study is also significant because it aims at narrowing the literature gap in the area of inter-professional handover practices. The findings and their discussion are detailed thereby enabling the readers to understand the phenomenon deeper. Nevertheless, the researcher article has inherent limitations that negatively affect its credibility. These limitations include: lack of detailed description of the data collection and analysis procedure, lack of description of the sampling technique used, and lack of explanation of the significance of the study to nursing practice. These limitations make it difficult for others to replicate the study in different settings. However, the purpose of the study was addressed in that the researchers were able to describe inter-professional handover practices in the operating theatre recovery room. The credibility of this study can be enhanced by addressing the inherent limitations.

References

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Smith, A, Pope, C, Goodwin, D & Mort, M 2008, ‘Interprofessional handover and patient safety in anaesthesia: Observational study of handovers in the recovery room’, British Journal of Anaesthesia, vol. 101, pp. 332-7.

Solet, D, Norvell, J, Rutan, G & Frankel, R 2005, ‘Lost in translation: challenges and opportunities in physician-to-physician communication in patient handoffs’, Academy of Medicine, vol. 80, pp. 1094-9.

Speziale, H & Carpenter, D 2007, Qualitative research in nursing: advancing the humanistic imperative, Lippincott Williams & Wilkins, Philadelphia, PA.