Maintaining study validity in a changing clinical environment

BACKGROUND

Nurse scientists who conduct intervention research in a variety of clinical settings find themselves facing numerous challenges posed by today's changing and sometimes complex health care environment. Maintaining study validity thus becomes a major focus of interventional research, but existing literature does not fully address challenges to study validity nor offer potential solutions.

OBJECTIVES

The purposes of this paper are to 1) discuss methodologic challenges to maintaining study validity of intervention research that is conducted in a changing clinical environment, and 2) share strategies for maximizing study validity.

METHODS

A recently completed intervention study is used as an example to discuss two specific areas that affected study validity, provide examples of selected threats to validity, and outline strategies used to minimize these threats.

RESULTS

Careful definition of goals, thoughtful decision making, and implementation of specific strategies to maintain study validity helped increased the rigor of the research.

CONCLUSIONS

Investigators conducting intervention research in changing clinical settings can reduce threats to study validity and increase design rigor by considering clinical realities (e.g., clinician-researcher role conflict) when making methodologic decisions, becoming familiar with the setting, and involving clinicians in the research.

Implementation of an oral care standard for leukemia and transplantation patients

The purpose of this project was to develop an oral care standard on two nursing units in a university hospital where care was given to patients undergoing bone marrow or stem cell transplantation (BMSCT) and other treatments for leukemia. Strategies used in this interdisciplinary effort included collaboration, consultation, education, and evaluation. In the collaboration phase, a core group of nurses talked with staff about current practices, reviewed literature and published standards, examined protocols from other institutions, decided on goals, and developed the standard. Consultation with a dentist, pharmacist, and physician occurred before completion of the standard. The education phase included in-service sessions for nurses and technicians. The evaluation phase, which occurred in two phases, focused on checking to see if the goals had been met, including tolerability and adherence. The first phase allowed identification of problem areas and subsequent revisions, whereas the second phase evaluated adherence at a later time point. Overall, most of the patients adhered to the standard. Future implications include specific recommendations such as an emphasis on oral care, documentation, and patient and staff education. This project is an example of how nurses addressed the challenge of implementing an acceptable oral care standard to decrease patients' oral complications and distress.

Acute oral pain and mucositis in bone marrow transplant and leukemia patients: data from a pilot study

The purposes of this prospective, repeated-measures descriptive pilot study were to describe patterns of acute oral pain and mucositis in patients receiving a bone marrow transplant or high-dose chemotherapy for leukemia, and to test procedures and instruments before initiating a larger intervention study. A nonprobability, purposive selection process was used to enroll 18 patients admitted to two acute care inpatient hospital units for bone marrow transplantation or leukemia therapy at a university health sciences center in the southeastern United States. Data were collected at baseline, then daily through patient interviews, oral examination, and chart review for at least 3 weeks or until discharge. Research variables were pain intensity, intolerable pain, verbal descriptors of pain, pain relief, and use of pain relief strategies (Pain Assessment Form), mucositis (erythema and ulceration) in eight anatomic locations of the oral cavity (Oral Mucositis Index), voice/talking (Oral Assessment Guide), and mood states (11-item Brief Profile of Mood States). Mild to moderate pain occurred in nearly 70% of patients and was described as "tender," "irritating," and "sore." Patients used pain medicines, mouth care, and mental and physical activities to relieve pain, and reported partial overall relief of pain. Mucositis was mild, with the tongue and buccal and labial mucosa most commonly affected with erythema and the buccal mucosa with ulceration. Voice/talking were only mildly impaired, and mood disturbance was mild. Patterns of pain, mucositis, and mood disturbance were consistent with each other and followed the trajectory described in previous research. Results suggest that nurses should continue to assess these symptoms vigorously and assist patients in selecting multiple management strategies. Research using repeated-measures designs in this acutely ill inpatient population is challenging and needs careful attention by researchers. The results have been used to improve the ongoing larger intervention study.

Patients' perspectives of fatigue while undergoing chemotherapy

PURPOSE/OBJECTIVES

To explore the experience of fatigue from the perspective of patients undergoing chemotherapy.

DESIGN

Qualitative research and secondary analysis of data from a larger study.

SETTING

Participants were recruited from 18 sites, including large outpatient chemotherapy clinics and private medical oncologists' offices.

SAMPLE

127 adult patients who were beginning their first protocol of chemotherapy.

METHODS

Data were collected through individual and open-ended interviews and a qualitative, thematic analysis of the participants' responses using grounded theory techniques.

MAIN RESEARCH VARIABLE

The experience of fatigue as perceived by patients undergoing chemotherapy.

FINDINGS

The analysis resulted in eight major thematic categories: (a) experiencing fatigue, (b) effects on well-being, (c) attribution of origin, (d) awareness and expectations, (e) emotional reactions, (f) activity, (g) the "biggest" concern, and (h) strategies and plans.

CONCLUSIONS

This study demonstrates the variation, extent, duration, and temporality of fatigue among patients receiving chemotherapy and the dynamic, changing aspects of the experience.

IMPLICATIONS FOR NURSING PRACTICE

Fatigue must be considered within the context of patients' daily lives and environments, disease processes, and treatment modalities. Nurses must listen carefully to patients' own descriptions of being tired. Further research examining patients' perspectives of and experiences related to fatigue is necessary to increase the theoretical understanding of fatigue and to improve therapeutic nursing interventions.

Differences in pain knowledge in cancer patients with and without pain

PURPOSE

The authors determined: 1) whether there were differences in knowledge about pain between oncology outpatients with and without cancer-related pain and 2) whether there were relationships between selected patient characteristics (age, gender, education, Karnofsky performance status, pain intensity, and pain duration) and the knowledge about pain of oncology outpatients with cancer-related pain.

DESCRIPTION OF STUDY

Three hundred sixty-nine oncology outpatients completed several self-report questionnaires including a demographic questionnaire, a pain experience scale that measured knowledge about pain and pain management, the Karnofsky performance scale, and descriptive numeric rating scales that measured pain intensity and pain duration.

RESULTS

Patients with cancer-related pain knew significantly more about pain and its management than pain-free patients (P < 0.004). However, in both groups, mean knowledge scores were below 60%. Older patients with cancer-related pain had less knowledge about pain than younger patients (P < 0.0001). In addition, patients with cancer pain who had more education and those with higher reported pain intensity scores had more knowledge about pain and pain management. Finally, women with cancer pain had more knowledge than men about pain and pain management.

CLINICAL IMPLICATIONS

Results of this study suggest that oncology patients with and without pain need more education about pain and effective pain management strategies.

Differences in pain knowledge and perception of the pain experience between outpatients with cancer and their family caregivers

PURPOSE/OBJECTIVES

To determine if knowledge about pain and the perception of the pain experience differ when comparing outpatients experiencing cancer-related pain with their family caregivers.

DESIGN

Quantitative, descriptive.

SETTING

Sixteen oncology outpatient settings that are part of the Oncology Nursing Research Network.

SAMPLE

Eighty-six outpatients with cancer-related pain and their family caregivers.

METHODS

Patients and their family caregivers were recruited in the outpatient setting and asked to complete a demographic questionnaire and the Pain Experience Scale. The patients also were asked to complete the Karnofsky Performance Scale.

MAIN RESEARCH VARIABLES

Patients' and their family caregivers' knowledge about pain and their perception of the pain experience.

FINDINGS

No significant differences in knowledge scores were found between the patients and their family caregivers. A significant difference in the perception of the pain experience was found, with the family caregivers viewing the experience more negatively than the patients did. Family caregivers reported that (a) patients had significantly higher levels of pain compared to patient reports, (b) patients experienced significantly greater distress from their pain than the patients reported for themselves, and (c) family caregivers experienced significantly greater distress from the patients' pain than the patients reported for their caregiver.

CONCLUSIONS

Outpatients with cancer and their family caregivers possess limited knowledge about pain and pain management and perceive the pain experience differently.

IMPLICATIONS FOR NURSING PRACTICE

Outpatients and their family caregivers need to be better educated about how to manage cancer-related pain. In addition, to reduce patient and caregiver distress, oncology nurses need to facilitate communication between patients and family caregivers about the pain experience.

Advances in understanding the mechanisms and management of acute myelogenous leukemia

PURPOSE/OBJECTIVES

To review current knowledge about the causes, pathophysiology, treatment, and nursing care of patients with acute myelogenous leukemia (AML).

DATA SOURCES

Articles, books, and proceedings of national meetings.

DATA SYNTHESIS

AML, an an often fatal disease, is characterized by signs of anemia, thrombocytopenia, neutropenia, and leukemic cell infiltration throughout the body. Possible etiologies include genetic predisposition and exposure to radiation, chemicals, and viruses. Various types of chemotherapy and bone marrow transplantation are treatments of choice. Both result in significant side effects and complication rates.

CONCLUSIONS

Throughout every stage, nursing care is of the utmost importance. Research continues to increase understanding of the disease process and the survival of patients.

IMPLICATIONS FOR NURSING PRACTICE

Goals of care are directed at prevention of bleeding, infection, fluid and electrolyte imbalance, and chemotherapy-related side effects; assisting patients and families to cope with diagnoses, therapy, and prognoses; and helping the patient to achieve an acceptable quality of life regardless of the eventual outcome.