Utilizing_Evidence_for_Nursing_Practice

The purpose of this essay is to explore the effect a cancer diagnosis has on patients and their spouses. It will look into the effects cancer has upon a patient’s sexuality and their issues with intimacy, it will also look into the support patient’s feel would be useful throughout such an experience, and how this would be best put into practice and how as a student nurse I can develop my skills in this area for future practice . The essay will clearly state my question, structure and rationale also details of the structured search. It will go on to summarise the papers and critically analyse them, considering the findings and their relevance to practice, concluding by discussing the potential benefits of applying them to practice. Cancer in past years used to be seen in essence as a diagnosis of death, it is now recognised patients will not necessarily deteriorate so rapidly resulting in many invasive surgeries and treatments. Procedures such as Hickman lines, porta-caths or amputation can result in disfigurement and possibly reconstructive surgery having a varied effect on the patient, most of which known to be negative, including the loss of self-esteem, confidence and self-worth (Salter (1997) pg.133). Patients adapt differently to their individual circumstances therefore it is important to deal with the situation professionally and in as sensitive manner as possible in order to alleviate the anxieties patient’s experience (Newall (2000) pg.9). Whilst it is apparent that society has opened up in regards to sexuality than some 20 years ago, intimacy and sexual relations can still be dealt with in an “anti-therapeutic” manner. Healthcare professional’s may feel uncomfortable broaching such subjects with the patient, therefore rushing or avoiding these topics altogether leaving the patient unable to voice their concerns, ask questions, or feeling that they may not return to discussing the topic at a later date (Newall (2000) pg.9,10). Weston (1993) states that everyone has a right to enjoy a state of sexual health and this right is unaffected by age, illness and disability. It must be seen as an integral part of delivering holistic care. (Weston 1993, cited in Salter (1997) pg.31). In order to provide this care nurses are expected to offer adequate and useful information tactfully and diplomatically. It can be argued that many nurses expected to deliver this in depth knowledge are still young and unconfident about their own sexuality, thus causing potential barriers (Salter (1997) pg.32), consequently nurses need to be provided with sufficient information and training (Salter (1997) pg.30). Such issues during a patients experience are delicate albeit important topics of discussion. As a nurse researcher I feel this a good area to consider and by discussing the areas in depth allowing me to improve my understanding within the experience of cancer and effective ways of providing support. “Evidence based medicine (EBM) is the integration of best research evidence with clinical expertise and patient values” (Sackett et al (2000), cited in Crookes et al (2006) pg.163). Evidence based practice (EBP) is seen as a structured systematic approach of improving clinical practice. Clinical research is a combination of clinicians experience, patient’s preferences and values and scientific evidence that provides professionals with a quality of knowledge in specific area’s or topic’s. Evidence hopefully supports practice enabling a positive effect within clinical practice, thus potentially achieve the best possible outcomes for the patients (Newall et al (2006) pg.201). Initial steps in order to dissect and evaluate a research study are to identify and understand the steps taken by the researcher in order to answer their focused question (Parahoo (2006) pg.105). Five basic steps constitutes the EBP process and are as follows; 1. Asking a clear and answerable question, 2. Searching for the best available evidence, 3. Critically appraising the evidence, 4. Applying the results in clinical practice, 5. Evaluating practice and the performance of EBP (Crookes et al (1988) pg.163-164). It was important to clarify what information was required for the aspect/area of nursing care that was being looked at, and to convert that information into a specific and well developed question. The careful formation of a question aid’s the following steps of the process, enabling the researcher to access relevant and high quality evidence to support the required answer (Newall et al (2006) pg.26). Development of my clinical question was based mainly on personal interest. Oncology and reconstructive surgery are an area that interests me and wanted to gain a knowledge basis within the experience and its effects. A useful method of making a question more focused is by using the PICO framework formulated by Sackett et al (1997) as cited in (Newall et al (2006) pg.32) . A PICO question is broken down into 4 parts; population, intervention, comparison and outcome. A PICO question is not always the most effective framework to use and can be adapted to suit a specific question. Where there is no comparison, the question becomes a 3 part PICO question. When perspectives opposed to evidence of interventions are to be collected a PIO question is formed, the structure of a PIO question being; population, issue and outcome (Newall et al (2006) pg.32). As I wanted the perspectives of the patients and their spouses a PIO structured question was formed. The components of my question are as follows, population=patients and their spouses suffering from a cancer diagnosis, issue=intimacy and sexuality issues, and the outcome=patient and spouses perceptions of the impact cancer has on intimacy and sexuality. Therefore my clinically focused question is; How patients and their spouses who have experienced a cancer diagnosis perceive the impact of the illness upon intimacy and sexuality' Once a clear and concise question has been established, by working through a logical process, evidence can be collected from primary and secondary sources in numerous ways such as websites, organisations, journals and texts, aiming to obtain the best available evidence (Dawes et al (1999) pg.16). Computer databases are a very reliable way of gaining secondary resources providing bibliographic information and material from resources such as original studies, reviews and guidelines that have been extracted from primary sources. Databases are becoming the most important and useful way of gaining primary information as they are providing more original material (Dawes et al (1999) pg.24). I chose to use the Cumulative Index of Nursing and Allied Health Literature (CINAHL) computer database to collect my data. Each element of the question was broken down into key words to be used in the search. Keywords used for population were cancer of which 82756 results were found, breast cancer received 15922 and carcinoma of breast received 419. To find citations containing either of the specified keywords the 3 keywords were combined with ‘or’ giving a total of 82915 citations, thus narrowing the search. Keywords used for issue were body image which found 3835 results, sexual relationships found 300, sexual intercourse received 1024 and intimacy received 1011, once again to narrow the search all 4 keywords were combined with ‘or’ which gave a total of 6066 collective results. Keywords used for the outcome were experiences found 35037 citations, perceptions received 20366 and views received 10895, after combining all 3 with ‘or’ the total was 61000. To narrow the citations specifically to my question, the 3 combined searches were searched with ‘and’ finding citations containing all of the specified keywords giving an end result of 99. Once the search strategy was complete and all keywords had been combined and entered into the database I applied English Language as a limit in the search duly for the fact that I am British therefore narrowing the search and saving time looking through foreign papers that could not be used. My initial question was to be specifically on breast cancer, upon reviewing my search it became apparent the information gained didn’t match up to the question being asked, as a result I reformulated my question. Once my question had been changed to generalise the cancer diagnosis the results were looked through again a decision was made as to which 3 papers would be used, this was on the basis that the papers were all qualitative papers, that they covered the topic of my question and provided me with some interesting conclusions where a pattern emerged. My search was effective in that it provided with me with a lot of useful information, just not in regards to my initial question. Once the question was reformulated and the information more relevant, I found there to be a lot of information to search through most of which not full text. Therefore for any future searches I would be sure to put full-text in my limits. Upon reading the literature the papers were summarised providing the reader with an overview of each paper. Paper 1 is a qualitative research study exploring the spouse’s perceptions of body image and sexuality in relation to breast cancer and the implications they hold for the relationship, aiming to understand the needs of the spouse during the breast cancer experience. A literature review was carried out searching the Medline computer database identifying relevant articles to the key themes of the study of which the findings were summarized in a table. The study recruited participants through advertisement in a cancer support organisation, the Cancer Council, newsletter and, support groups promotion. Purposive sampling took place to include a heterosexual couple with whom the woman received diagnosis 30 years ago followed by a mastectomy, a woman involved in the prevention, promotion and education programmes relation to sexual health and well being, providing information to those with poor sexual health, and finally a community support person for a cancer council. An interview line of question was developed and in-depth semi-structured interviews were carried out of which the questions enabled consistent exploration of themes with the participants, these were taped recorded with consent. It is not stated in the report where the actual interviews took place. Thematic analysis was carried out identifying classified themes which were catalogued into related patterns and subthemes and presented in the discussion. The conclusion drawn from the study was that breast cancer has major implications on both the woman and her partner in regards to body image, sexuality and their relationship, suggesting strategies to improve the breast cancer experience would be internet support groups, the increase of services relating to the exploration of body image and sexuality during this time, and for breast care nurses to be more aware of the impact in these areas and to be comfortable discussing them (Sheppard et al (2008). Paper 2 is a qualitative study aiming to gain the perceptions of both men and women experiencing a diagnosis of cancer, exploring how patients feel their diagnosis has impacted upon their sexuality and intimacy, and how they feel they should have been supported by healthcare professionals. The study was carried out in Australia in a multi campus teaching hospital where purposeful sampling took place across 5 sites of the campus including 2 oncology wards, a day oncology centre, a palliative care unit, a radiation oncology centre and outpatient departments. A 3-stage reflexive inquiry was carried out drawing on previous data from a larger study. Research fliers were placed in patient waiting rooms and hospital admission packs which explained the nature and purpose of the research and contained the researchers contact details. The study conducted 50 semi-structured interviews which were organised at a time and place convenient to the patient and were face-to-face, confidential and lasted approx 45 minutes the patients also consented to them being tape-recorded. 50 men and women ranging from ages 22-85 participated in the study with a range of cancer diagnosis and who had experienced some form of cancer treatment since diagnosis. Study limitations were applied to English speaking patients and patient population demographics were presented in a table. Purposeful sampling allowed the researchers to narrow the sample size to include adequate inclusion of the most widespread cancers in Australia; breast, prostate, bowel and lung. This sampling resulted in 62% of the participants having experienced one of the 4 cancer types. To ensure a systematic and transparent approach to the management of data and analysis, results of the interviews were transcribed and entered into a qualitative software tool called NVivo, open coding resulted in 147 codes being identified which showed 5 clusters of responses to the diagnosis. Results revealed in the study were that irrespective of a patient’s age, gender, culture or sexuality that the cancer experience can dramatically alter the sexual and intimate aspects of a person’s life and that it is of high importance that these patients have access to a competent and knowledgeable nurse who is able to assist in these areas (Horden et al (2007). Paper 3 is a qualitative study designed to collect the perceptions of couples whom are survivors of prostate cancer and treatment and to find out what most concerned them during their experience. It does not state in the study where the focus group was carried out. 23 couples who were already enrolled in other prostate cancer studies were invited to participate over the phone, they were offered a light lunch and $15 for a travel reimbursement, 10 invited couples attended the focus group. The average age of the men was 63 years with a range of 45-81 years, all of which had experienced varied treatments, and time since treatment ranged from 1.5-8 years. The average age of the women was 62 years with a range of 38-75. The focus group consisted of three 30minute sections where couples had the chance to discuss their experiences as 1.Couples, 2.Individual men and women in 2 separate groups and 3. Regarding their current intimacy and relationship needs. The discussions were led by the male and female investigators accompanied by male and female associates. Findings showed women felt their roles in the relationship had changed finding this hard to deal with, also that their sexual relationship had become to clinical and feeling a frustration at the lack of sexual information available. Men felt that there was a miscommunication between them and their partners and that their sexual relationship had become difficult and unromantic due to the lack of spontaneity. The couples findings showed both men and women felt they needed more information about surviving prostate cancer, agreeing that hearing from other couples with similar experiences would be useful. Women suggested support groups as a source of information, where as men suggested a guidebook of what to expect, or a book of other men’s experiences (Sanders et al (2006). The Oxford Dictionary (2003) states a critic as ‘involving or exercising careful judgement or observation’ as cited in (Crookes et al (2006) pg.35). The aim of carrying out nursing research is to influence nursing practice, to achieve this, information collected must be critically evaluated to establish if it of high enough quality (Dempsey et al (2000) pg.49). Successful critical analysis is important to reach a balanced view on the work in question, this means breaking down the literature and examining all aspects in detail considering strengths and weaknesses and coming to a decision about its value within the research process (Crookes et al (2006) 1998 pg.35). In quantitative studies ‘reliability’ and ‘validity’ are the terms used referring to the analysis and tools of data collection used. Data collection tools used in qualitative studies are not as structured and may not be as easy to determine, making it difficult to test for validity and reliability (Parahoo (2006) pg.410). To evaluate the trustworthiness of a qualitative study the following terms apply instead ‘credibility’, ‘dependability’, ‘transferability’, and ‘confirmability’(Larrabee (2009) pg.97). Using the Critical Appraisal Skills Programme (CASP) as a guide these terms are applied to my papers comparing and contrasting strengths and weaknesses (www.phru.nhs.uk). Lincoln and Guba (1985) state credibility is the accurate interpretation of the participant’s views and experiences surrounding the phenomena being studied as cited in (Craig et al (2007) pg.164). Negative case analysis is a technique where the researcher purposefully searches for cases that conflict with the existing analysis thus refining their search and increasing credibility (Craig et al (2007) pg.165), this technique was not carried out in any of the 3 papers decreasing confidence in the credibility of the results. Massey (1995) states “Triangulation is a strategy in which multiple methods are used in the research design to study the phenomenon and converge on the truth”. It is considered to be one of the strongest methods of contributing to a balanced approach of evidence in qualitative research (Massey (1995) pg.49). Denzin (1989) as cited in (Hammel et al (2004) pg.117) identified 4 types of triangulation a combination of these being used in all 3 papers albeit it some stronger and more detailed than others (Hammell et al (2004) pg.117). Paper 1 clearly stated the data collection use of semi structured interviews, showing the use of data triangulation and method triangulation as the researcher used different participants from various recruited areas to support findings. Data triangulation was used in Paper 2 using 5 areas in which to gather the data. Method triangulation was also used in Paper 2 as various ways in which to gain interest from participants was used, also investigator triangulation was present as data analysis was presented at patient and health professional forums for validation. The credibility of data can be supported by the presence of member checking, providing the researcher with feedback on the findings giving them a chance to correct parts of the study if necessary also making sure that researcher bias isn’t present (Lodico (2006) pg.276), this method was only carried out in paper 2. Paper 3 states a focus group was used in the collection of data and participant’s were invited to attend via a phone-call. The researcher shows the use of method triangulation by breaking down the focus group into segments to gain the views of both patient and spouses (Hammell et al (2004) pg.118). Also the application of investigator triangulation which strengthens credibility as the potential for bias is decreased by pleural investigator participation offering their knowledge and expertise (Grove (2005) pg.225). Paper’s 1 and 2 were both approved by an ethics committee and given informed consent by participants, although the procedure of how this was gained is not recorded in Paper 1. Paper 3 only implies consent was given, due to the fact participants were invited along to the focus group, it does not state if this was documented, or if the study had been ethically approved. This dramatically impacts on the credibility of Paper 3 as many ethical issues arise during the process of a study, the Research Ethics Committee ensures the protection of both participants and researchers, and anyone undertaking research has to apply to them for ethical approval (Newall et al (2006) pg.41). Transferability refers to the setting in which the study took place and whether or not the findings would be similar if taken part elsewhere, the researcher should provide as much detail as possible in order for the reader to be able to make an informed choice about the research (Lodico (2006) pg.275). A thick description provides the researcher with explicit details of how the study was conducted and is vitally important to the transferability of a paper (Polit et al pg.493). Paper 3 does not provide a very detailed account of their actions, the site chosen is not stated, nor is how the data was recorded or analysed. The only information offered is how the participants were recruited, and a brief protocol of the focus group including the questions asked and length time sessions held for, this lack of detail reducing transferability (Craig et al (2007) pg.170. A thick description is given in paper 1 although not very thorough. The paper provides a brief description of thematic analysis use although not clearly stating how themes were drawn from the data. Whilst details of the participants, how they were accessed and areas they were recruited from are provided, details such as the site/location and where the interviews took place are not, nor a specific geographical area (Craig et al (2007) pg.166). This absence of detail does not make the details of the study very transparent or easy to replicate as a result making the description weak and depleting confidence in transferability (Craig et al (2007) pg.170). Paper 2 provides an in-depth thick description substantially increasing transferability it documents the site selected and sampling strategy, how the researcher accessed participant’s, how the data was collected and recorded and provides a detailed account of the analysis process, also giving an in-depth description of the open coding process and how the themes were derived from the data (Craig et al (2007) pg.167). The researcher states that during analysis it became apparent the study needed to be expanded, in order to effectively explore the aspects under study and documents the actions taken to adapt the research design, showing flexibility and as a result increasing confirmability and dependability (Craig et al (2007) pg.169). Purposeful sampling is a technique used in order to select participants who are relevant to the subject or research question (Dempsey et al (2000) pg.110). This form of sampling has been used in all 3 papers by recruiting in relevant areas and in the representation of the participants chosen, thus credibility is increased as the chance of judgement is reduced in the findings, as the sample chosen is knowledgeable in the field (Wengraf (2004) pg.103) . A rationale for using this sampling technique is not documented in paper 3 whereas paper 2 and 3 both explained their aim was to gain data from a representative sample, therefore strengthening its credibility and reducing potential bias (Craig et al (2007) pg.165). The concept of confirmability is that two or more researchers would generate the same findings regardless of participants or surroundings, and that findings are not influenced by researcher bias (Stommell et al (2004) pg.288). Paper 2 documents research rigour was applied throughout data collection and analysis controlling potential bias, stating researcher reflexivity was recorded in a journal and a systematic diary log. Such actions account for the researchers influence on the research process and can also be referred to as an ‘audit trail’ (Macnee et al (2008) pg.171), making the process transparent and increasing the transferability, dependability and confirmability of the paper and also the credibility of the findings (Craig et al (2007) pg.171). As discussed previously, Paper 2 allowed member checking to take place, the feedback of which was put into NVivo a computer-assisted analysis package. This organized the data providing a deeper understanding of the findings (Craig et al (2007) pg.174). The use of this package also ensured that the researcher’s actions towards the study remained consistent and aided in producing an audit trail (Macnee et al (2008) pg.171), maintaining a transparent approach to the management of the data therefore increasing credibility (Craig et al (2007) pg.174). Neither paper 1 or 3 have documented any form of reflexive account or audit trial, this lack of detail largely decreases confirmability due to potential bias (Grove (2005) pg.628), participant checking is not present either, this lack of data validation also increases the chance of bias thus affecting the credibility of the results (Parahoo (2006) pg.327). Dependability is the term used to ensure rigour is present in qualitative studies, given via thorough descriptions of data collection and analysis tools used (Lodico et al (2006) pg.276). Paper 1 and 2 both conducted interviews of which the data was collected using an audio recording device which was then transcribed, the presence of which increasing both credibility and dependability (Craig et al (2007) pg.170). Paper 3 did not document how they recorded data which reduces dependability as focus groups can produce a lot of verbal data of which can be very hard to document by hand (Dempsey et al (2000) pg.180).The absence of audio equipment can be argued to be a weakness in the study as tape-recording provides the researcher with an accurate version of what has been said and is material that can be recalled at a later date if needed (Parahoo (2006) pg.397). The next steps in the EBP process are to apply the findings to practice and evaluate their performance (Crookes et al (2006) pg.163-164), as a student nurse researcher the final stages of the EBP process are unable to be carried out in this essay, although the relevance of the findings in clinical practice are discussed. It is evident when looking at current frameworks such as The Royal College of Nursing (RCN) A framework for adult nursing cancer, that the findings concur with modern practice. The RCN states “Good communication between professional carer’s and their patients, and between professionals, is an essential part of good patient care” and that “Communication and counselling skills training are widely available...” (www.rcn.org.uk pg.16). The findings in all 3 studies clearly demonstrated the importance the role a cancer nurse plays throughout the cancer experience. Patients in paper 2 stated irrespective of their cancer site, treatment, age or relationship status they had wanted individualized patient communication at a time relevant to what they were feeling. Communication was the key concept outlined in all 3 papers between patients and their spouse and also the healthcare professionals involved. The NHS Cancer Plan (2000) acknowledged good communication skills, sensitivity and approachability were among the attributes needed for an effective relationship between patient and professionals, recognising the need to incorporate such skills into training and qualification requirements (www.doh.gov.uk pg.63). Horden et al (2007) states “health professionals suggested lack of specialized knowledge, education or training, experience and collegial support as reasons for this structured avoidance within the communication process. These findings are not surprising, as much of the literature, ongoing education and clinical practice guidelines emphasize medicalised and functional aspects of patient sexuality”. All 3 papers confirmed the need for cancer nurses to have well-developed skills in communication in order to raise their awareness of the impact a cancer diagnosis has on sexuality and intimacy, and to increase their knowledge, confidence and competency in discussing such sensitive topics, thus implying that these targets set out ten years ago are not fully being achieved, and that these skills would be more beneficial to current practice if they were specific to the patients individual needs (www.doh.gov.uk pg.63). It is important to remember that that as a student researcher new to the EBP process it is easy to pull out mostly bad points of a paper and deem it not good enough, it takes experience and practice in order to develop the appropriate skills to recognise if a paper is of a high quality. Therefore some of the aspects that have been documented as weak or absent from the 3 papers may not be a completely true account (Craig et al (2007) pg.121). The fact that all 3 papers concluded with the same findings and that similar strategies were suggested by the participants, suggests that although Paper’s 1 and 3 were weaker is certain areas of their research strategies in comparison to Paper 2, that it cannot be inferred that the undocumented evidence did not take place, as in many cases such evidence is in the form of feildnotes available upon request (Craig et al (2007) pg.168). To conclude; the aim of this essay was to explore the effect a cancer diagnosis has on patients and their spouses in regards to intimacy and sexuality. On a personal level I aimed for the essay to enable the development of knowledge in this area. Findings have shone light on the support and strategies patient’s feel would be beneficial to the cancer experience and hope that I may put these into practice in the future. As a student nurse I feel that these findings will not alter my practice, but that they reinforce the need for good communication skills hopefully enabling me to make a positive difference towards a patient’s journey in the future.