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Searching from within: A personal insight

01 . NURSINGRESEARCH

A Special

Pull-Out

Qualitative Research methodology is the softer and more humanistic side of nursing research. It aims to provide insight into the meaning of human thoughts, behaviours, patterns and interactions in relation to health, illness and death.

I fi nd qualitative research methodology particularly meaningful in my area of nursing speciality of Haematopoietic Stem Cell Transplantation/ Haematology Nursing. And also in oncology and palliative nursing, and long-term care patients.

It gives meaning to how patients feel when subjected to prolonged hospital stay in isolation, for example, suffering from the side effects of cancer treatment or even facing death.

The understanding of human behaviour and their reaction towards health and disease have always been my interest. The interest of knowing propelled me into my first nursing research project using the qualitative method in 2006.

the philosophies underpinning qualitative research methods.

We were introduced to the 5 different types of qualitative research methods; the complete process of qualitative research and the very interesting but tedious exercise of forming meaning from raw interview data.

Like every workshop, there were tasksand assignments to be completed. The three assignments required us to replicate the entire qualitative research process from identifying a research topic, writing a research proposal, data collection by interviewing a participant,

By Jordan Hwang

SGH Nursing Research Council By: SSN Norashikin Binte Sarip & NC Teo Lee Wah

The Nursing Research Council is one of the nine Nursing Councils in Singapore General Hospital. It aims to provide strategic directions for nursing research and evidence-based nursing practice through a shared model.

The Council has three remits:1) Research development,2) Research utilisation, and 3) Research education.

Qualitative Nursing Research

As qualitative research has always been a ‘touch and go’ topic during my tertiary education, I never truly understood the process of this research methodology. In fact, I was faced with many diffi cult questions and challenges during the data analysis phase.

‘What do I do with the data?’ and ‘How do I craft my fi ndings to answer my research question?’. I am grateful to Mr Edward Poon, Nursing Director of Dover Park Hospice, who is one of the nursing experts in qualitative research methodology. His enthusiasm motivated me and sustained my interest in qualitative research.

I was privileged to further increase my knowledge in qualitative nursing research when I was nominated to attend the Qualitative Methods in Health Research organised by Nursing Division in collaboration with Curtin University, Australia.

The fi ve-day workshop, held from 23rd to 30th April 2008, was packed with in-depth explanation and understanding of

transcribing verbatim and analysing the verbatim to formulate themes to answer the research question.

I found the assignments particularly helpful in reaffi rming my understanding and interest in qualitative nursing research. The fi nal task of the workshop was a 4000-word report write-up.

I feel that all nurses interested in research and wanting to better improve their care for their patients should give qualitative research methodology a try. The Qualitative Methods in Health Research is defi nitely a ‘must’ core nursing research course to attend.

Members of the Nursing Research Council comprise of nurses from SGH and National Heart Centre. The Council is well-represented with members from - clinical, specialty care, advanced practice, education and administration.

Members of the SGH NRC (term of appointment until 31 August 2011):

Members: • Prof Fong Kok Yong, Chairman,

Division of Medicine & Acting Chairman,

Division of Research, SGH

• Ms Tan Geok Eng, Administrator

Bioethics, Medical Board, SGH

• Ms Sharonjit Kaur D/O D Singh,

Principal Enrolled Nurse, Ward 76, SGH

• Ms Siah Chiew Jiat, Senior Staff Nurse,

Ward 47A, SGH

• Ms Tay Pei Yin, Senior Staff Nurse,

Major Operating Theatre, SGH

• Ms Norashikin Binte Sarip,

Senior Staff Nurse, CTS ICU, NHC

• Ms Fazila Bte Abu Bakar Aloweni,

Senior Staff Nurse, Ward 57, SGH

• Mr Jordan Hwang Chung Cheng,

Nurse Clinician, Ward 72, SGH

• Ms Chan Yoke Ling, Nurse Clinician,

Diabetes Centre, SGH

• Ms Teo Lee Wah, Nurse Clinician,

Nursing Development Unit, NHC

• Ms Lim Su Fee, Advanced Practice Nurse,

Rehabilitation, SGH

• Ms Karen Perera, Assistant Director,

Nursing, Nursing Division, SGH

• Dr Tracy Carol Ayre, Deputy Director,

Nursing, Nursing Division, SGH

Chairperson: • Ms Chen Xiao Rong, Nurse Educator,

Training & Development Unit, SGH.

Co-Chairperson: • Mr. Nidu Maran Shanmugam S/O B K,

Advanced Practice Nurse, Orthopaedics, SGH

Secretariat: • Mr. Sim Kiak Kong, Nurse Clinician,

Nursing Division, SGH

The Council meets monthly to discuss

nursing research related issues,

incorporate evidence-based fi ndings

into nursing practice and organise

training programmes to develop nurses’

knowledge and skills in research. The

Council is also responsible for the

review and approval of nursing research

proposals before submission to the

centralised Institutional Review Board.

Jordon Hwang, second from left.

02 . NURSINGRESEARCH

Comprehensive System Review Training

By NE Chen Xiao Rong & APN Lim Su-Fee

A group of 12 nurses, from various hospitals and polyclinics across SingHealth, attended the Joanna Briggs Institute (JBI) Comprehensive Systematic Review (CSR) workshop in Adelaide, Australia, from 5 to 9 May, 2008.

The JBI CSR Training Program is designed to prepare members of Collaborating Centers,

researchers and clinicians to develop, conduct and report systematic reviews of evidence. The

participants completed four modules of the JBI CSR training programme. With the aid of the

JBI systematic review software, we were able to critically appraise all forms of research literature

and synthesise relevant information from a variety of sources. We also gained insight into using

JBI ConNECT (Clinical Online Network of Evidence for Care and Therapeutics). This is the online

gateway to the collection of evidence-based resources and tools designed to assist in the clinical

decision making process and to support best practice. Participants who successfully completed

the modules are certifi ed by JBI as competent in the systematic review process.

The participants had a wonderful time gaining knowledge on evidence-based practice,

building up network and enjoying the fellowship.

Helpful websites for research and EBN information:

http://www.cochrane.org/

http://www.joannabriggs.edu.au/about/home.php

http://www.shef.ac.uk/scharr/ir/netting

About JBIThe JBI was established in 1996 to integrate resource into nursing practice through

evaluation of evidence, so as to improve the effectiveness of nursing practice and health

care outcomes.

JBI Library of Systematic Reviews JBI Library of Evaluation Reports

Please contact Dr Tracy Ayre at tracy.carol.ayre@sgh.com.sg or Ms Karen Perera at Karen.

perera@sgh.com.sg for the logon ID and password.

Pictured from left to right:Back row: Lem Wen Sze; Chen Xiao Rong; Ng Wai May; S Indra; Li Jie; Juhana Binte Mohamed Tahir; Lian Siew Bee.Front row: Lee Yean; Lim Su-Fee; Lucylynn Lizarondo (JBI Trainer); Tan Ai Meng; Fazila Binte Abu Bakar Aloweni; Samantha Lim Xinyi.

Pictured from left to right:Back row: Juhana Binte Mohamed; S Indra; Lee Yean; Li Jie.Front row: Samantha Lim Xinyi; Ng Wai May; Fazila Binte Abu Bakar Aloweni; Lian Siew Bee;Lim Su-Fee; Tan Ai Meng; Lucylynn Lizarondo (JBI Trainer); Lem Wen Sze.

Nursing Division subscribes to the Joanna Briggs Institute

for our nurses to access the following:

Did You Know?

The Research RecipeQuestions to think about in writing your proposal

1. What is the question? What are you measuring?2. What are the current gaps in the literature? 3. Who will be your research team? 4. What are the variables of interest? 5. What type of data should you collect? What instruments should you use?6. Decide on design, population, sample size, analysis7. How will you recruit participants?8. How will you obtain consent from participants? 9. How will data be collected? Who will collect? Who will manage the data?10. How will data be analyzed?

The Process of Nursing Research

RESEARCHINFOCUS . 03

Aims: To test the effi cacy of green

tea with that of conventional topical

metronidazole powder by comparing the

rate of malodour score reduction using

the verbal numeric scale (VNS).

Methods: This was a prospective

randomised experimental study comparing

two types of odour control agents used for

treating malodourous fungating malignant

wounds in a tertiary hospital in Singapore.

Patients were randomised to either control

Young Investigator’s Award (Nursing) 2009Comparing the effectiveness of green tea versus topical metronidazole powder in malodour control of fungating malignant wounds in a controlled randomised longitudinal study.Lian SB, Xu Y, Aw FC, Goh SL, Wong ZWNursing Division, Singapore General Hospital, Singapore

wounds. All patients in both arms shown

improvement in malodour control by Day

7. Treatment group was as effective as

control group and there was no statistical

signifi cance (p>0.05) to demonstrate which

treatment is more superior.

Conclusion: Green tea dressing is as effective

as conventional topical metronidazole powder

in controlling the malodour. Green tea is

cheap, easily available and has no risk of drug

resistance for long term use. Alternatively,

Best Oral Paper (Nursing) 2009 A randomised, double-blind trial to assess the effectiveness of intrarectal diclofenac suppository administration compared to intravenous pethidine in relieving pain during extracorporeal shockwave lithotripsy.

Aims: To compare the clinical effi cacy of intra-

rectal diclofenac suppository with intravenous

pethidine for pain relief during outpatient

extracorporeal shockwave lithotripsy (ESWL).

Methods: This randomised double-blind

study was conducted at the Urology Centre

in Singapore General Hospital. 60 eligible

patients who had urinary calculi were included

in the study. Patients were randomised into

two groups (30 in each group). Patients in the

study group received intra-rectal diclofenac

Yatim J1, Ng LG2, Shen L3

1Division of Nursing, Singapore General Hospital, Singapore; 2Department of Urology, Singapore General Hospital, Singapore; 3Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

analysis. The median VAS score was higher in

the study group compared to the control group

throughout the ESWL procedure (p = 0.027).

The median VAS score was 4.5 (range 1–10) in

the study group while it was 2 (range 0–3) in

the control. Furthermore, 4 (50%) patients in

the study group required rescue analgesic for

pain control, while none in the control group

required rescue analgesic. No side-effects were

seen in any patient who received diclofenac

suppository but one patient given pethidine had

giddiness that subsided later.

(metronidazole power) or treatment (green tea)

group and follow-up with daily dressing for a

week with a designated nurse. Both subject

and the designated nurse would rate the

malodour score daily on a VNS of 0 (no odour)

to 10 (worst odour that one can imagine).

Results: Thirty cancer patients with malodour

fungating wounds were randomised into

either treatment (n=15) or control arm

(n=15). There were 20 breast wounds, 8

abdominal wounds and 2 head and neck

it can also be used interchangeably with

metronidazole powder to reduce the risk of

drug resistance.

suppository 100-mg 30 minutes before

treatment and equal volume of intravenous

saline (placebo) before treatment started, while

those in the control group were given glycerin

suppository as placebo intra-rectally 30 minutes

before procedure and single dose of 1ml/ kg

body weight intravenous pethidine before

the start of the procedure. Pain intensity was

identifi ed with a Visual Analogue Scale (VAS).

Results: 16 patients with urolithiasis who

underwent ESWL were recruited for this interim

Conclusion: The preliminary data demonstrated

that intra-rectal diclofenac suppository was not

effective in providing pain relief during ESWL.

Best Systematic Review (Nursing) 2009 Patency of arterial catheters with heparinised solutions versus non-heparinised solutions: a systematic review and meta-analysis of randomised controlled trials.

Aim: To evaluate the effect of heparin on duration of patency of arterial catheters.

Methods: The methodological quality of the included randomised controlled trials was assessed using criteria for masking of randomisation, masking of intervention, masking of outcome measurement and completeness of follow-up. The main outcome measure was patency of arterial catheter. Data on relevant outcomes were extracted and the effect size was

Chen LJ1, Ng GH1, Ong S2, Lee P2

1Surgical Intensive Care Unit, Singapore General Hospital, Singapore2Department of Anaesthesia, Singapore General Hospital, Singapore

estimated by calculating Relative Risk (RR), Risk Difference (RD) and associated 95% Confi dence Intervals (CI).

Results: Four trials met the eligibility criteria. Owing to inconsistency in the outcomes reported, only three trials could be included in the meta-analysis. These studies included 5145 adults. Heparin signifi cantly prolonged duration of patency of arterial catheters and decreased the risk of clot formation (RR 0.47, CI 0.41 to 0.52).

Conclusions: Infusion of low-dose heparin through an arterial catheter prolonged the duration of patency. The use of heparin for arterial catheters enables haemodynamic monitoring continuously as intended therapy by reducing occlusion. Evidence from this systematic review supports the use of heparin in fl ush solutions to maintain the patency of arterial lines. None of these studies was powered to evaluate the incidence of adverse events. Caution is reinforced and monitoring of side-effects of

heparin is recommended if this therapy is to be adopted as a routine practice.

04 . RESEARCHINFOCUS

Best Poster (Nursing) 2009 Maintain oxygen saturation of premature infants within optimal target level.

Introduction: Advances in technology

have resulted in increasing survival rates

of premature infants. Oxygen therapy is

the commonly used therapy in neonatal

as part of the respiratory support. The

number of premature babies surviving with

consequences of severe Retinopathy of

Prematurity (ROP) has prompted a review

of oxygen therapy as a contributing factor.

Prolonged exposure to high concentrations of

oxygen may cause irreversible damage to Very

Low Birth Weight (VLBW) preterm infants’

eyes and is a potential cause of blindness.

Aim: To reduce the incidences of premature

infants with severe ROP (stages > 3) requiring

laser surgery to zero.

Methods: We brainstormed the underlying

causes leading to hyperoxia in premature

Results: After phase 1 implementation,

the percentage of time oxygen saturation

(SpO2) readings > 95% was reduced to

between 15 and 50%. However, fi ndings

of phase 1 study raised the concern of

fl uctuation of SpO2 readings due to

inconsistency in titration of FiO2, which can

also result in deviation from the optimal

target range. This has prompted the

development of an algorithm for gradually

titrating fraction of inspired oxygen (FiO2)

to manage high and low SpO2 with the

aim of maintaining SpO2 within the

optimal target range. Following the phase

2 implementation, the percentage of SpO2

readings above 95% was markedly reduced

to between 0 and 15%. The incidence of

neonates with severe ROP stage 3 requiring

laser surgery has decreased from 4 (in 2007)

to 1(in 2008).

Lau YY , Tay Y Y, Chang P, and Loh K TDepartment of Neonatal and Developmental Medicine, Singapore General Hospital

Nursing Research Resources

The Nursing Intranet also has links to the British National Formulary and ePharmacopoeia for drug-related information, other specialty organisations (e.g. National Cancer Institute), and research and evidence-based guidelines from organisations such as Joanna Briggs Institute.

The SGH Education Resource Center houses books, current journal titles, and maintains online databases with links to full text articles and books. The collection of books and journal titles held at ERC and in other local libraries can be searched via the Online Public Access Catalogue. The librarian also assists staff to perform literature search services.

Every nurse principal investigator is assigned a research facilitator to support and guide him/her in the research project. Nurses who need access to workstations or SPSS to perform their research work can contact Mr Sim, Nursing Research Council, Secretariat, at Tel: 6326 6080.

infants and the root causes were identifi ed.

We conducted a study on 37 infants born at

gestational age of less than 32 weeks with

birth weights less than 1500gms receiving

supplemental oxygen, admitted to Neonatal

Intensive Care Unit from April to September

2008. The infants were administered oxygen

via either ventilator support, nasal CPAP or

I/N oxygen and titration of oxygen is based

on oxygen saturation (SpO2) measured

using Hewlett Packard monitor Model

66S. We monitored the SpO2 trend, SpO2

alarm limit and percentage of time alarm

limit set incorrectly. In April 2008 (Phase

1), we implemented a change in clinical

practice by adopting an oxygen saturation

targeting protocol. In June 2008, (Phase

2 implementation), we further develop an

algorithm for gradually titrating fraction of

inspired oxygen (FiO2).

Conclusions: The implementation of a

change in clinical practice aimed at avoiding

high SpO2 was associated with a signifi cant

decrease in the incidence of both severe

ROP and the need for laser surgery. This

reduced hospital cost and length of stay for

premature infants.

Vast resources are available to nursing staff to support participation in nursing research and evidence-

based nursing activities. Such support include, access to librarians, nursing-specifi c and other health

science journals, electronic databases for online retrieval of

research literature, workspaces designated for nurses and

research advice and support.

Nurses have access to the online library accessible via

SingHealth Intranet,including access to OVIDSP MEDLINE,

Journals@OVID, MD Consult, EmBase and CINAHL. Nurses can

also access the OVID database from their homes using a logon

ID and password.