SCHOOL OF HEALTH NURSING & MIDWIFERY BSc in Nursing Studies Distance Learning TRIMESTER 3

Assignment no 2 done by B00195533

Number of word: 2739 Module tutor: George Fik

APPLIED NURSING RESEARCH MODULE NURS09119

DATE OF SUBUMISSION: August, 2009

Assignment No 2 done by B00195533

ACKNOWLEDGEMENT

I thank The Almighty God who has guided and gave us the force to do this assignment. My thanks also go to the authorities of the University of the West of Scotland, School of Nursing & Midwifery for their facilitations. I gratefully acknowledge the divers authors for their works consulted while doing this assignment. Special thanks are addressed to our Tutor George Fik for his support during the whole course of this module. Finally, I thank anyone who contributed closely and by far to the realisation of this assignment.

May God bless all!

B00195533

Assignment No 2 done by B00195533

THE RELATIONSHIP BETWEEN NURSES AND DOCTORS IN CLINICAL PRACTICE A good relationship/collaboration between nurses and doctors contribute significantly to the quality improvement of clinical services. Its the basis for reducing length of stay and improves the satisfaction of health professionals (Refatti C. and Bevilacqua A, 2007). Its evident that team working improves outcomes (Anon, 2008). However; the situation of the nurse-doctor relationship remains very variable (Casteldine, 2005) Traditionally, doctors made all decisions in patient care and imposed their authority/decisions. Modern practice changed this relationship to one of complementary respect for roles (Marilyn, 2008). Different studies show a good nurses-doctors relation; Refatti C.

and Bevilacqua study, (2007) document that there is a good attitude to collaboration. Both favour interdisciplinary education. its the same situation with KROGSTAD, U et al. (2004) study but this showed that doctors were satisfied with the inter-professional co-operation more than nurses while the Ogbimis et al. (2005) study pointed out that nurses has better opinion of doctors' work than doctors has about nurses' work. A relative good relationship has been concluded by Qolohle et al. (2006) qualitative studys but also some negatives points affecting relation were doctors inconsistent clinic visits, role confusion, dominance of the doctor in the relationship, and lack of doctor-nurse forums for communication. The nurse-doctor relationship is also extent affected by what the patients think of them. (Fagin et al. 2004). My constant is that in some areas where the role and the scope of practice for nurses is not specified and regularized especially in under development countries like ours; many problems and disagreements occur between nurses and doctors especially on decision making and sometimes patients may get the consequences of this.
3

Assignment No 2 done by B00195533

How the literature search has been conducted After setting research topic; the Inclusion criteria have been set to enable to identify the literature that addresses the research question discard the literature that is not relevant to the topic; this approach is supported by Aveyard (2007). Criteria were English language; only published article and 2000 onwards. Electronic searching has been used and at the first and in most cases. As (Aveyard, (2007) recommended to use different approaches to identifying appropriate literature; the reference list searching has been tried during this literature search. Keywords has been identified about the topic and used so that the essence of the research topic for the review can be captured (Nancy et al. 2004). Keywords used were the relationship between nurses and doctors or doctors-nurse relationship. As Aveyard (2007) pointed out that while searching; you may find other alternatives new keywords and encounter alternative ways in which the research topic is represented; new search keywords has been identified while the search was progressing and have been used in different databases. Those keywords are: interaction; collaboration; communication, cooperation, conflict in the place of relationship; nursesdoctors team. The use of the AND/OR commands has been considered in searching strategy to ensures that both terms are searched for either one term or another. Many databases and sites have been used for literature search. Those are Google which has guided us to other useful sites, netlibrary, internurses, pubmed; ebscohost, CINAHL and Wiley interscience.

Assignment No 2 done by B00195533

Both qualitative and quantitative research has been found but most of them were qualitative and has been identified primary because an evaluation of relationship seems to be more qualitative than quantitative aspect. The relevant article found was copied and saved and the site has been copied as references saved in word document with a keyword used. Aveyard (2007) suggested also this strategy. The abstract was read in order to find if the article is relevant as it was sometime not possible to access in full each identified paper. When it was relevant; it has been appraised in general to verify its reliability and validity. Findings have been brought together to summarise into manageable amount. Qualitative studies have been analysed separately as some researchers argue that it is not appropriate to attempt to bring together qualitative study results (Aveyard, 2007). CRITICAL APPRAISAL This is a critical appraisal of a qualitative study on the relationship between doctors and nurses offering primary health at KwaNobuhle (Uitenhage) done by Qolohle et al, (2006).

The title of this study is clear and accurate. As there are many qualitative research aspects; indication of the approach used for identifying the focus of the study should be good (Nancy et al. 2004) As Fawcett et al, (2009) pointed out that an abstract is concise summary of the contents of the full report; abstract is present, focused and provide a picture of the article. The introduction of the research report must include the study purpose, a brief review of the literature, a simple framework discussion, the research
5

Assignment No 2 done by B00195533

question and hypothesis (Nancy et al, 2004). This introduction points out the significance of the problem to professional but the purpose of the study in not clearly stated. The introduction could be separated into subsections (Fawcett et al. 2009). The literature review must reflect the synthesis of all points or value in relation with the research question. Gaps must be uncovered and primary data are preferred and up to date, the purpose of the research must be followed (Geri et al, 2006). The literature reviews in this report has been done and in general data used are primary and up to date, identify what is known about the topic and follow the research topic. However; no balanced view clearly, only poor relationship articles are stated; a depth literature search to enrich the literature review is important (Denise F. et al. 2007). As some phenomenologist argue that the literature review done before the data collection may influence the data analysis and interpretations and the bracketing will not be controlled so the findings will be researchers effect experience and preconceive beliefs about the topic rather to confront data in pure form (Denise F. et al. 2007). The literature review has been done before collecting data which threats the findings. The purpose must be state precisely and concisely includes the names of the main concepts, or study variables, and propositions, or hypotheses (Fawcett et al. 2009); the purpose here has not been clearly stated; only the type of the study has been state. Thus it needs to read the whole article in order to understand which the purpose was. The purpose clearly stated permit to know which type of study it is (UWS, 2009). The designs purpose is to have a situation with maximum possibilities to obtain the accurate responses to objectives; research question and hypothesis. (Nancy et al. 2004). A descriptive design has been used in this research. The methodology used is clearly stated; the approach used is appropriate to the research problem. Strengths and weakness are recognized.
6

Assignment No 2 done by B00195533

The goal of selecting simple in qualitative design is to be able to obtain maximum information that cant be found in any other sources (Fawcett et al, 2009). Its good in this report as they state how the sampling was done and the sample size: the purposeful sampling method has been used with maximum variation sampling to obtain a sample that has very diverse characteristics. A total of 10 informants were selected; their characteristics, the process and the inclusion criteria used to choose informants are well described in details (Qolohle et al. 2006). About the simple size; it may be small or large depending on many factors such as the type of research; available time and material; number of researchers. I agree with Immy H. et al. 2002) who stressed that in qualitative studies: simple size doesnt necessary determine the importance of the study or the quality of data. That why in 1994 Walcotts Textbook for transforming qualitative data said that the large sample in qualitative research doesnt enhance it indeed, it can do harm as it may lack the depth and richness of the small sample (Walcott, 1994, cited in Immy H. et al. 2002). Another concern here is the weakness of purposive sampling to find convincing reasons about those included in study and those who are not as its a self selected (Immy H. et al. 2002). Furthermore, it has a limitation of the inability to assess the representativeness of the participants in relation to the population. There may be errors of judgment in overrepresenting or underrepresenting elements included in the study; unfortunately, no way to test this. (Gillis et al. 2002 p.507) Considering this report, the total informants was 10; It important however to state the response rate and the attrition rate and explains the reasons (Fawcett et al, 2009); as in the report; 1 doctor is missing and the reason is not stated; only 4 doctors are state instead of 5 who were selected (Qolohle et al. 2006).

Assignment No 2 done by B00195533

Another big concern is about a doctor with the voluntary clinic included in the research due to an overt discontent. This makes the study questionable and the rigor of the research is threatened especially about sampling selection and findings (particularly in purposive sampling). It seems to be some different interests/issues (financial and or material) for informants which led to be included in the study not because they were useful informants (Immy H. et al. 2002). The researcher-informant relationship is clear as it is stated that the chief researchers knew the work and habits of informants and this helped in identification of informants to reduce bias of the purposive sampling with maximum variation sampling strategies and minimise the threat of mortality effects to the study rigorous (Fawcett et al. 2009 p.203). I agree with Fawcett et al. (2009 p.228) that the close relationship between research- participant in qualitative research can reduce the number of participants who withdraw from a study, but it can also create a problem when the data are analyzed. Human beings have rights that must be protected when they are involved in research (Fawcett et al. 2009 p.209). Its very important that the ethical implications are noted in this report with the approval from ethic committee and permission from authorities for collecting data. However; a description of procedure used to obtain informed consent from research participants is neither stated nor the way to protect and guaranty the privacy, confidentiality and autonomy aspect. Ethically; the person include in simple size must not be jeopardized by uncovering their ideologies and or practices. Immy H. et al. 2002). All procedures for data collection must be clearly identified and described. (Fawcett et al, 2009, p.199). Interview has been used, responses have been recorded on an audio and videotape. However; its important to state where the interview took place and how the researcher tried to control the interruptions, distractions and the time consuming.

Assignment No 2 done by B00195533

Furthermore, state if the researcher himself collected data as the use of others can include bias (Fawcett et al. 2009, p.194, 202). Threats may affect the study rigorous. Some can be considered here like selection bias effects as a doctor has been included in the study by an overt discontent. Maturation effects can be considered also if the period between the request of the participation in the study and the interview is long; some recent factors/situations may influences the responses of informants such as the recent conflict between nurses and doctors (Fawcett et al. 2009 p.202). Another factor to consider is the researcher presence during data collection like when the participants want to look good in the subject, researchers presence may influence their responses. The researcher should put much effort to control this and state it in the report (Denise F. et al. 2007). The consistence of the research instrument and data must be discussed in the report; their dependability and credibility, which are aspects of trustworthiness. If the data are not dependable, they cannot be credible (Fawcett et al. 2009). In this report; the activities used by researchers to estimate dependability such as inquiry audit and replication also referred as stepwise replication are not stated in the report. However credibility has been established by member checks when the researcher took the results after analysis to respondents for their comments (Fawcett et al. 2009). It good that the names; functions and contacts of researchers are stated on this report because researchers credibility must also be established by stating the researchers credentials, such as training and experience with qualitative research design used, as well as any personal experience with the subject studied because researchers are sometimes considered as the research instrument in qualitative research designs. The extent to
9

Assignment No 2 done by B00195533

which readers consider the researcher as credible influences confidence in the analysis and interpretation of the data (Fawcett et al. 2009). Without an analysis, the researcher would be able to present only meaningless words or numbers (Fawcett et al. 2009, p.226). Data analysis techniques have to be clearly identified and described in the research report and how the data were analyzed and interpreted (Fawcett et al. 2009 p.233). Content analysis has been used and a coding word data. Involvement of bracketing should be discussed on how the researcher withheld, suspended, or controlled personal biases, prejudices, and opinions in analyzing (Fawcett et al. 2009 p.228). Confirmability of the interpreted data is a crucial issue for trustworthiness of the research; the use like of an audit trail and inquiry audit should be discussed in the report if it has been done so that the fitness of the findings with the reality can be confirmed on this study (Fawcett et al. 2009 p.235). The results of this reports are presented as quotations from research participants, Fawcett et al, (2009, p.243) support this. The use of measures of frequency for the number and percent of research participants whose responses reflected each and the same concept would help to understand whether every participant or only some participants provided data that reflect each concept or dimension. This information helps to determine the extent of transferability of the findings to people from the same population. This is why in 1990 Weber Textbook for Basic content analysis declared that The best content-analytic studies use both qualitative and quantitative operations on texts (Weber, 1990 cited in Fawcett et al. 2009). The discussion is balanced and findings are compared with other previous research and linked with existing research findings. Studys limitations and weakness are acknowledged in discussion. The clinical implications were discussed. However its very difficult to interpret figures drown in
10

Assignment No 2 done by B00195533

the report; a report should be presented in simplified and understandable manner to facilitate the reader (Nancy et al. 2004). Conclusion and recommendation are not clearly stared; the emphasis of the teamwork has been discussed. Other further research areas have been suggested about the team building and elements to sustain the doctor-nurse-patient team. References are up to date in general and are stated from different sources and disciplines drown on a wide variety. The findings of this study are meaningful about the relationship between nurses and doctors as the researcher verified the credibility of the findings and tried to follow the design with ethical considerations. However the need of the study replication in different area for findings comparison, the control of different threats discussed above and conformability verification are important so that the finding transferability can be established; even the researchers himself stated that different methodology and the environment where the study was conducted may differ from others which could lead to the variant findings (Qolohle et al. 2006). Evaluation Its true that The disciplines of nursing and medicine are expected to work in unusually close proximity to one another, not just practicing side by side but interacting with one another to achieve a common good: the health and well-being of patients Waxibaro, (2008) Studies found about this topic were not many due to limitations that qualitative designs are not commonly undertaken by nurses and the use of abstract and use of inclusion/exclusion criteria to evaluate the relevant of the article could have eliminate some relevant articles to the topic. Also few such studies are carried out in under development countries. As many factors may influence the change in the doctornurse relationship like the workplace context, multidisciplinary relationships, the status and experience of doctor and nurse, patients expectations,
11

Assignment No 2 done by B00195533

training and education, institutional norms, professional norms, risk management and defensive practice (Fagin et al. 2004); further research could be done such as replication and studies on the situation of doctorsnurses relationship in under development countries in comparison with developed countries; the Importance of forums for communication between nurses and doctors; and the importance of nursing regularization and nursing counsel in improving health professionals teamwork.

12

Assignment No 2 done by B00195533

REFERENCES BOOKS Aveyard, (2007). Doing a Literature Review in Health and Social Care: a Practical Guide [Online]. Maidenhead, New York McGraw-Hill International (UK) Limited, 2007. Available: Netlibrary [29 July 2009].

Denise F. et al, (2007) Nursing research, Generating and assessing evidence for nursing practice. Edition: 8[Online]. Lippincott Williams & Wilkins, Available: google books [09 August 2009]. Fawcett et al (2009) Evaluating Research for Evidence-based Nursing Practice [Online]. Philadelphia F.A. Davis Company, Available: Netlibrary [09 August 2009].

Geri et al, (2006) Nursing research, method and critical appraisal for evidence based practice, Edition 6 [Online]. Elsevier health sciences; Available: google books [09 August 2009]. Gillis et al (2002) Research for Nurses: Methods and Interpretation[Online]. Philadelphia, PA F.A. Davis Company. Available: Netlibrary [10 August 2009].

Immy H. et al. (2002) Qualitative research in nursing. Edition 2, [Online] illustrated, revised, Wiley-Blackwell, 2002 Available: google books [09 August 2009]. Marilyn, (2008), The Informed Practice Nurse, 2nd Edition [Online]. Wiley series in Nursing Available: google books [09 August 2009]. Nancy et al, (2004), The practice of nursing research, conduct, critique and utilisation Edition5, illustrated [Online]. Available: Elsevier Health
Sciences, 2004, Available: google books [09 August 2009].

13

Assignment No 2 done by B00195533

Nancy et al, (2004), The practice of nursing research, conduct, critique and utilisation Edition 5, illustrated [Online] Elsevier Health Sciences, 2004, Available: google books [09 August 2009]. University of the West of Scotland (2009) Appraising nursing research, support material, Scotland, UK INTERNET REFERENCES Anon. (2008) Interprofessional working: the doctornurse relationship and collaborative practice [Online]. Available: http://www.learningmatters.co.uk/sampleChapters/pdfs/97818444516164.pdf [27 July 2009]. Casteldine (2005) The relationship between nurses and doctors [Online]. Available: http://www.internurse.com/cgi-bin/go.pl/library/article.cgi? uid=18208;article=BJN_14_11_625 [25 July 2009]. Fagin et al (2004) The doctornurse relationship, [Online]. Available: http://apt.rcpsych.org/cgi/reprint/10/4/277.pdf [29 Jul 2009]. KROGSTAD, U et al (2004), Doctor and nurse perception of interprofessional co-operation in hospitals [Online]. Available: http://intqhc.oxfordjournals.org/cgi/reprint/16/6/491 [27 July 2009]. Ogbimi et al (2005) Questionnaire survey of working relationships between nurses and doctors in University Teaching Hospitals in Southern Nigeria [Online]. Available: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1471789 [25 July 2009]. Qolohle et al (2006) A qualitative study on the relationship between doctors and nurses offering primary health at KwaNobuhle (Uitenhage) [Online]. Available:

14

Assignment No 2 done by B00195533

http://www.safpj.co.za/index.php/safpj/article/viewFile/454/430 [26 July 2009].

Refatti C. and Bevilacqua A, (2007) The integration between doctors and nurses in medical wards: the results of a survey [Online]. Available: http://web.ebscohost.com/ehost/detail?vid=1&hid=7&sid=25ab2942-cf324cd3-81ae3f9068841117%40sessionmgr11&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d %3d#db=rzh&AN=2009579604 [27 July 2009]. Waxibaro, (2008) The nurse-doctor relationship, [Online]. Available: http://somalidoc.com/smf/nursing-education-center/the-nurse-doctorrelationship!/ [25 Jul 2009]

15