Critical Appraisal
Rebecca Nappi
Nursing Research
NUR 4222
Christine Turner
July 7, 2018
CRITICAL APPRAISAL 2
Critical Appraisal
Introduction
The purpose of this paper is to critically critique and appraise the study, “A simulation
Study of the Factors Influencing the Risk of Intraoperative Slipping”. This study was written by
the following authors; J. Nakayama, G. Gerling, K. Horst, V. Fitz, L. Cantrell and S. Modesitt.
One of the authors, John Nakayaa is a gynecology medical doctor (Nakayama et al., 2015, p. 24).
Two authors are members of the systems and information engineering department of the
University of Virginia. This combined medical and technology background is important to the
method of this study since mannequins were used as test subjects in place of humans so a strong
understanding of physics and technology to mimic real life situation is important. This
quantitative study aimed to measure the amount of slippage that could occur during steep
Trendelenburg positioning of patients undergoing gynecological surgery and how this slippage
could be manipulated by using different materials under the mannequins. The title should include
for gynecological surgery because it is misleading that it is evaluating all types of positions that
could result in slippage. The abstract was clear and made it easy to understand the authors goals
and their methods for achieving their goals. The study’s findings were very condensed and
compactly written in the abstract. The report is easy to follow and understand. The language is
appropriate for medical personnel. The authors report that this topic has not been well studied in
Problem Statement
The report presents causation for the study in their introduction. The explanation for the
need of Trendelenburg positioning is well written and very detailed even presenting the needed
degrees. The study is limited to gynecological surgery and the position this type of surgery
CRITICAL APPRAISAL 3
requires. This study would not accurately represent results that could be used for reverse
Trendelenburg or non-lithotomy Trendelenburg positioning which are both frequently used in the
operating room. The authors are very transparent about their studies limitations right from the
beginning explaining that obesity is not well addressed in the study. Obesity is a major factor
researching best practice on preventing operating room slippage. The theoretical framework for
this study was based on lived experiences of operating room staff observing patients slipping or
moving on the operating table. This is a very common observation and the known danger and
patient movement is well understood and of major concern. This study attempts to answer the
theoretical question of whether different materials under the patient could eliminate this danger.
Research Methodology
The method of this study was severely compromised by using mannequins as “human
surrogates” (Nakayama et al., 2015, p. 25). They did not have an exact height of the mannequin
but simply said, “average female height” which is disappointing. The exact material of the
mannequin was not obtained but rather just generalization of rubberized silicone and
polyvinylchloride. Baby powder was used on the mannequin to, “better approximate human
skin” two studies were referenced to back their decision to add baby powder which was an
excellent citation. However, the accuracy of this approximation is subjective due to the lack of
human skin and texture. Humans could have been used with no ethical dilemma, no risk of injury
or increased cost to the researchers however the decision to use mannequins was still used. The
weight ranges tested were from 100lbs to 250lbs by 50lbs increments. The use of higher weights
would have increased external validity as it would better reflect the current American body
weight. The researchers did not test any of the surfaces without a sheet under them which
CRITICAL APPRAISAL 4
limiting for others to extrapolate their findings and reproduce since using a sheet is typically
never used due to the slickness of sheets. Linear regression models were an excellent choice to
accurately display the variables and the degree of slippage with P values. The same evaluator
was used to measure the angles recorded for each test thus eliminating variability produced by
human error. The evaluator also reproduced the results three times before recording their
findings which increased the accuracy of the findings and gave the study further confidence.
Showing values for both supine Trendelenburg and lithotomy Trendelenburg was an interesting
The results were well organized and easy to read from both the written description and
the data tables presented within the report. The author gave opinion several times in the results
which was an interesting decision. The reader could tell when the findings were a surprise to the
author. There was no explanation given as to why the operating room tables made an impact on
the findings. It was stated but never addressed. Addressing that this issue is multi-factorial and
no one variable altered the outcome independently was informative. Understanding each variable
and addressing each one individually but then combined with the others was an excellent
observation by the researcher and documented well. Comparing supine to lithotomy slippage
resulted in an interesting finding and opens the door to more potential research.
Gel pads are widely used within operating rooms across America and the findings in this
report show it was an inferior product when compared to the other materials, even just the
bedsheet. Although additional research is needed to assess prolonged Trendelenburg and higher
patient weights this report showed some clear understanding of weight implications on slippage
CRITICAL APPRAISAL 5
and material. An incidental finding of different operating room tables making an impact on the
Conclusion
The study was one of the first of its kind showing the degree of Trendelenburg a patient
could tolerate before they would slip as represented by the mannequin. The study tried to mimic
human skin and weight distribution to best of their capabilities within this design and
methodology. The findings were as expected for lived experience with the outlier of the gel pad
being one of the least appropriate materials. The weight of the mannequin and amount of
slippage was directly inversed when comparing supine and Trendelenburg which led the
every day in operating rooms everywhere and as found in this study slippage occurs. Movement
can lead to serious injuries and should be taken seriously by those working in this field. Patient
safety is every nurses, doctors and organizations top priorities and studies like this help us
References
Nakayama, J., Gerling, G., Horst, K., Fitz, V., Cantrell, L., & Modesitt, S. (2015). A Simulation
Study of the Factors Influencing the Risk of Intraoperative Slipping. Clinical Ovarian
https://doi.org/https://doi.org/10.1016/j.cogc.2014.12.001