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A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people ; . : - ' . : : : ! : : : : ":."::. ' .:":::.".': ':::i :': "7[ ..: " i " " . . : ~ ; . : ::2 ~" . ' : " : .... :.:k'

John R Daly and Esther M. L. Chang

John P Dab/ RN, BA, BHSc, MEd (Hons), PhD, FRCNA, Associate Professor of Nursing, University of Western Sydney, Macarthur, PO Box 555, Campbelltown, NSW 2560

Esther M L Chang RN, BAppSc, DIpEd, MEd, Admm PhD, Associate Professor of Nursing, U mverslty of Western Sydney, Hawkesbury, Rmhmond NSW 2753, Austraha

(Requests for offprints to JD) Manuscript accepted 25 November 1995

The aim of this pilot research project was to identify priority areas for clinical nursing research for renal specialist nurses practising in general critical care. Research participants in the study included Clinical Nurse Specialists (CNSs) and Clinical Nurse Consultants (CNCs), n = 12. The study sample was national with representation from a number of major metropolitan teaching hospitals in Australia. The Delphi technique was used to obtain the most reliable consensus of the specialist nurses. Research priorities emerged in four areas: I) clinical research which is of highest value to patients; 2) clinical research which is of highest value to CNSs/CNCs; 3) clinical research which would provide improved community care and 4) research that would be of value for CNSs/CNCs professional needs. In the final phase of the study nine high priorities were identified. The findings of the study suggest directions for clinical nursing research which would benefit renal specialist nurses and their patients.

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I N T R O D U C T I O N

In a recent Australian study of the clinical nursing research priorities of critical care nurses, a decision was taken to Include four subgroups:

• general critical care • cardiac critical care (coronary care and

cardiothoracic critical care) • neurosurglcal/neuromedical critical care • renal nurses involved m managing the

critically ill (Daly et al 1995).

The sample in each subgroup was national and included specialist nurses who were regarded as experts m their area of nursing

practice. The researchers were motivated to under-

take a study of clinical nursing research priorities in Austrahan critical care for a number of rea- sons. Firstly, the area lacks a substantive knowledge base which has been developed through research endeavour. Identified priorities could be foundational for a number of necessary and relevant research projects m critical care nursing. This could be regarded as a preliminary step in the generation of nursing knowledge for the area. Secondly, it has been suggested that the most prudent approach to building the knowledge base for nursing practice through research is one which is systematic (Hinshaw et al 1988). Identification of agreed priority areas for clinical nursing research would assist in the sequential investigation of practice problems to ensure the most rational, economic use of resources and attention to the most pressing problems con- fronting clinicians and thmr patients. Thirdly, the authors are of the view that problems to be addressed through clinical nursing research nmst emerge from the context of pracnce. If nursing research is to have relevance to the needs of chmcal nurses and their patients it is imperative that nurses have the opportunity to influence the determination of clinical nursing research priorities (Greenwood 1984). In particular there is a need to harness the expertise of those clinical practitioners best equipped to recognise and use research.

The component of the research study reported here sought to uncover the chnlcal nursing research priorities of renal specialist nurses involved In caring for the critically ill. An additional area of concern addressed in the study was research that would be of value with regard to the professional needs of the research participants. Renal specialist nurses are often involved in caring for critically ill people in Australia. In general, they are involved in dialyslng patients with impaired or deteriorat- ing renal function. The services they provide in this context are broad-ranging and may include actually carrying out dialysis, supervising the renal management of the critically ill by non- specialist nurses, consultancy or educational activities.

The notion and process o f generating clinical nursing research priorities are not new. The

Intenswe and Critical Care Nursing (1996) 12, 4549 © 1996 Pearson Profesmonal Ltd

46 Intensive and Critical Care Nursing

approach has been used extensively in the USA, and on a limited basis in the UK (Bond & Bond 1982). In Australia, two studies have been reported in the literature (Bartu et al 1993, Daly et al 1995). O f relevance to critical care nursing per se are several studies under- taken in the USA (Lewandowskl & Kositsky 1983, Lindquist et al 1993, Riegel et al 1993) and one in Australia (Daly et al 1995). A review of the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database uncov- ered no previous studies of the clinical nursing research priorities of renal specialist nurses.

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M E T H O D O L O G Y

Research participants

Aggregates of nursing research topics or problems were identified by a national sample of renal specialist nurses involved in managing patients in general critical care settings. The panel in this study consisted of 12 renal speciahst nurses.

Design and measures

The Delphi method (Linstone & Turoff 1975) was used as the data-generating tool in this study. The object of this methodology is to obtain the most reliable consensus o f a group of experts. It has been used extensively in busi- ness and industry and also in the health area (Butterworth & Bishop 1995, Duffield 1988, Linstone & Turoff 1975). The method has been used to uncover research priorities in nursing in a number o f studies (see for example Bond & Bond 1982, Heinrich & Bloich 1980, Lewandowski & Kosltsky 1983, Riegel et al 1993). As a research method the Delphi method or technique has a number of strengths and limitations. Group communication process is facilitated by the method. It allows structured group communication to deal with and at the same time eliminate face-to-face con- frontations as experienced on panels or committees. The technique involves repeated individual questioning of experts by use of a series of questionnaires. It is designed to produce group consensus and statistical summaries between rounds, by which panel members communicate their judgements anonymously within a group (Anderson 1986). The method also allows for:

• feedback of individual contributions of information1 and knowledge

• assessment of the group judgement or views • opportunity for individuals to review views • a degree of anonymity for individual

responses.

Limitations of the method relate to the fact that little is known about the effect of feedback to research participants, and specifically whether certain types o f feedback can lead to questionable group consensus (for example, false or inaccurate feedback). Also there is no way of measuring the authenticity of group convergence with this method (Battersby 1994). Theoretically, it is accepted that through the processes of the method, convergence and consensus related to the research questions can be achieved.

In this study the panel of specialist nurses received three rounds of questionnaires. In round one, the participants were all sent a semi-structured postal questionnaire. This con- tamed two major sections. The first section comprised demographic questions covering experience, age, and qualifications. The second section requested that study participants develop five priority research questions in the following areas:

• clinical research which is o f highest value to patients

• clinical research which is o f highest value to CNSs /CNCs

• clinical research which would provide improved community care

• research which would facilitate health promotion and disease prevention

• research that would be of value for CNSs, /CNCs, professional needs.

Following distribution of the first questionnaire (questionnaire A), a reminder to return the item was sent to initial non-respondents and a reminder telephone call was also made if necessary. In the second round, participants were sent a questionnaire which was developed using all 197 items generated in the first round. These items were edited by the researchers. This was necessary to avoid duplication, and to format problems as research questions. Each participant was asked to respond to each research question indicating whether nursing should take a leadership role in answering the question (yes or no), as well as to rate on a seven-point scale the importance o f the research question (1 (low) to 7 (high)).

In the third round, participants received the final questionnaire (questionnaire C), which contained 52 items. These items were those that attained a median rating of 6 or above in the second round (questionnaire B). The question o f whether nursing should take a leadership role was eliminated, since the majority of the panel had selected these items as appropriate for nursing research leadership in round two. Respondents were once again asked to rate each research question on a scale o f 1 (low) to 7 (high). They were asked to discriminate

A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people 47

carefully between those questions they consid-

ered to be of high priority and those of a lesser priority. In addition, they were asked to explain briefly their reason for allocating a high priority (6 or 7 on the scale of importance) to the question. There was a 60% response rate (7) for the first two rounds o f the study and a 100% response (12) in the final round. Wi th the Delphi technique no more than three rounds of questionnaires are used as additional rounds tend to show little further changes in opinion (Duffield 1988).

A n a l y s i s

It was intended that each participant's response would carry equal weight in group rating so the median score was seen as the appropriate descriptive statistic because the scores were skewed as expected. Where participants had answered 'no ' to the question of nursing research leadership their rating of that i tem was set at zero, since the focus was intended to be solely on nursing research priorities. A decision was taken to use 6 as the cut-off point for the median score in the study. Participants were asked to give a rationale where they allocated research items a score of 6 or above.

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R E S U L T S

Survey results were recorded and analysed by the researchers using the computer software package SPSS-PC. The age of the participants ranged from 31 to 48 years, with a mean age of 35.8 (SD=6.3years) . Eight females (66.7%) and four males (33.3%) participated in the study. The participants had 6.5 to 27 years experience as a registered nurse, with a mean number of 13.1 (SD = 6.9) years. The range for years in the speciality of renal nursing ranged from 5 to 26years, with a mean of 10.7 (SD = 6.2) years. The majority of participants had obtained a specialist qualification in renal

Table I Clinical research which is of highest value to patients

Median Research Questionnaire score

I. What is the most appropriate dressing for a peritoneal 7 dialysis catheter exit site?

2. How do you prevent dialysis catheter exit site infections? 7 3. What is the patients' quahty of life and satisfaction with treatment? 6.50 4. How do patient education programmes prepare a person for 6

dialysis and transplantation? 5. What is the most appropriate simplified peritoneal dialysis catheter 6

dressing technique for CAPD patients? 6.' What aseptic, sterile procedures/precautions yield the lowest 6

refection rates?

nursing (n = 10). Seven of the participants had completed a university degree m nursing.

R o u n d three of the study resulted in a final list of nine very high priority research questions with which nurses should take a leadership role. These priorities are presented m the following tables.

Clinical research that is o f highest value to patients The panel of nurse experts developed 41 items m this section. In the final round, the six research questions they designated to be of highest pnori ty are shown in Table 1.

Clinical research that would be o f value to C N C s / C N S s O f the 23 items developed in this section only one was given high priority status. This priority is shown in Table 2.

Research that would provide improved communi ty care for patients Twenty-eight items were developed In this section, only one was given high priority by the panel in the study. This priority is shown in Table 3.

Research that would facilitate health promot ion and disease prevention This area was concerned with research which would be of value to C N S s / C N C s in facilitat- ing health promotion and disease prevention. Twenty-three items were developed in this section; however, no priorities emerged as very high. N o items scored a median value o f 6 following round three.

Research that would be o f value for CNSs ' /CNCs' professional needs The expert panel in this study developed 72 items in this section. The item shown to be of highest priority is shown in Table 4.

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D I S C U S S I O N

This study has shown that the Delphi method is a useful tool for assisting nurses to identify priority areas for clinical research, a finding consis- tent with a number of previous studies. The findings of the study need to be interpreted within the context of assumptions, lirmtations and generalisability of results, Clearly, the sample size in the study places limitations on the degree to which one can generalise from its results.

It is interesting to note that in the final anal- ysis the participants generated high priority research questions in only four of the five areas

48 Intensive and Critical Care Nursing

Table 2 Clinical research which is of highest value to CNSs/CNCs


I. What are the most effective methods 7 for training patients for home dialysis?

Table 3 Clinical research which would provide improved community care


I. What is the impact of home dlalys~s 6 on family relationships?

developed by the researchers. No high priorities emerged in the section 'research that would facilitate health promotion and disease prevention'. This was also the case with the general critical care nurses in the study overall (Daly et al 1995). This raises questions about how the nurse participants conceptuahse their practice.

In the section 'research that would be of highest value to patients' the major concerns of the research participants were catheter dressing procedures and infection control in peritoneal dialysis. In addition, the participants saw patient education programmes for dialysis and trans- plant patients, and quahty ofhfe and satisfaction with treatment, as high priority areas for research. It is surprising that other clinical priorities did not emerge in this section. The participants were asked to focus on their practice in critical care, an area where vascular access is a common requirement for haemo- dialysis procedures. In the second round ques- nonnalre used m the study a number of research priorines were concerned with venous access and its management, and haemodlalysis and its potential complications. In this section, the participants were concerned with minimis- ing patient discomfort assocmted with peritoneal infection and maintaining the life of peritoneal dialysis catheters. It was suggested that clinical research could assist in reducing catheter infection rates and improve patient safety and clinical outcomes. Patient education is a neglected area from the perspective of the research participants. They suggest that educa- non and its evaluation are important to achieve patient compliance, maximum service and ben- efits to patients. In the rationales for inclusion of quality o f life and patient satisfaction with treatment the nurses in the study were o f the view that the patients are rarely consulted regarding these matters. Quality of life was suggested as a variable which should be considered

in determining continuation of treatment. In the area of research which would be of

value to CNSs /CNCs in the speciality area, only one high priority emerged (Table 2). Again this seems incongruous m the context o f critical care, an area from which patients are never directly discharged home on dialysis. Rationales for this priority included education to ensure compliance, relieving demand on acute hospital beds and achievement o f the best possible outcomes for individual patients. The research priority which was generated in the section 'research which would provide improved community care' also related to home dialysis. Issues related to this included concerns with placing undue burdens on families of patients discharged home on dialysis. Also, there was the perception that families are often neglected and not prepared to cope with a sick member who is dialysis dependent.

The final section in the research questionnaire was concerned with research that would be of value for CNSs ' /CNCs ' professional needs. The one priority which emerged here was jusnfied by perceptions that on-going education is essential to maintenance o f a quality service. Also participants acknowledged that this facilitated improvement in professional/ clinical knowledge base o f nurses. Participants were concerned with how this could be best facilitated and assured.

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CONCLUSION

The participants perceived research as being the vehicle which could provide them with answers to the questions generated in this study. It could be argued that not all of the questions generated in this study have direct relevance to the renal management of the critically ill. The researchers were hopeful that the clinical priorities generated by the renal specialist nurses would relate significantly to the critically ill across all sections of the study. Nonetheless the study findings provide baseline data which could be foundational to renal nursing research projects in critical care and

Table 4 Research that would be of value for CNSs'/CNCs' professional needs


I. The need for self-development and on-going education in the specialty area of renal nursing. How can this be done regularly?

A study of clinical nursing research priorities of renal specialist nurses caring for critically ill people 49

elsewhere. Also, they allow insight into the

concerns and priorities o f the cohor t w h o par-

t lcipated in this study wi th regard to their prac-

tice in critical care and their specialty area. T h e

study findings repor ted here could assist in p ro-

v idmg d i recnon for renal nursing research in

Australia and elsewhere. It is th rough sigmfi-

cant and substantive research endeavour that a

sound basis for nursing pracnce will emerge.

Identif icat ion o f clinical priorities for nursing

research can be regarded as a first step m this

process.

REFERENCES

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Bartu A, McGowan S, Nelson M, R.obertson J 1993 A Western Australian Delphi survey of staff development research pnorlnes AustrahanJournal of Advanced Nursing 9 (3): 141-147

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