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BIOSTATISTICS : PS1

(Health Study Designs and Managing Data)

ABSTRACT 1

Classifying nursing organization in wards in


Norwegian hospitals: self-identification versus
observation
Background
The organization of nursing services could be important to the quality
of patient care and staff satisfaction. However, there is no universally
accepted nomenclature for this organization. The objective of the current
study was to classify general hospital wards based on data describing
organizational practice reported by the ward nurse managers, and then to
compare this classification with the name used in the wards to identify the
organizational model (self-identification).

Methods
In a cross-sectional postal survey, 93 ward nurse managers in
Norwegian hospitals responded to questions about nursing organization in
their wards, and what they called their organizational models. K-means
cluster analysis was used to classify the wards according to the pattern of
activities attributed to the different nursing roles and discriminant analysis
was used to interpret the solutions. Cross-tabulation was used to validate the
solutions and to compare the classification obtained from the cluster analysis
with that obtained by self-identification. The bootstrapping technique was
used to assess the generalizability of the cluster solution.

Results
The cluster analyses produced two alternative solutions using two and
three clusters, respectively. The three-cluster solution was considered to be
the best representation of the organizational models: 32 team leader-
dominated wards, 23 primary nurse-dominated wards and 38 wards with a
hybrid or mixed organization. There was moderate correspondence between
the three-cluster solution and the models obtained by self-identification.
Cross-tabulation supported the empirical classification as being
representative for variations in nursing service organization. Ninety-four per
cent of the bootstrap replications showed the same pattern as the cluster
solution in the study sample.
Conclusions
A meaningful classification of wards was achieved through an empirical
cluster solution; this was, however, only moderately consistent with the self-
identification. This empirical classification is an objective approach to variable
construction and can be generally applied across Norwegian hospitals. The
classification procedure used in the study could be developed into a
standardized method for classifying hospital wards across health systems and
over time.

Type of Research : Experimental study


- Cross –sectional
- Nonrandomized
- Concurrent

Components of the Study


- Subjects : 93 ward nurse manager, 32 team leader – dominated
wards, 23 primary nurse dominated wards and 38 wards with a
hybrid or mixed org.
- Method Used: Postal Survey

Flowchart/Diagram

Clust I
er N S I
D
grp. T E

1 E E N
R T
V I Cross
93 L F Postal
Non- Clust E Tabular
subje I
cts randomized er N
F C Survey
T A (Observation
grp.2
I T )
Clust
O I
er O
N
grp. N
3

ABSTRACT 2

Burnout in health-care professionals during


reorganizations and downsizing. A cohort study in nurses.
Background
Burnout is a psychological reaction triggered by interaction between personal
characteristics and stress factors. Reorganizations and downsizing with
increased workload imply stress for health-care professionals. This is a study
of burnout in nurses during a period with two comprehensive reorganizations.

Methods

In this quasi-experimental retrospective cohort study, burnout was assessed


in nurses with long work experience in three surveys during a 30 months'
period with two comprehensive reorganizations and downsizing of a hospital
unit with mostly seriously ill patients with cancer. Burnout was measured with
Bergen Burnout Indicator (BBI) at each survey, and "Sense of Coherence"
(SOC) with Antonovsky's questionnaire at the last survey.

Results

One man and 45 women aged 30 to 65 years were invited to the surveys.
There was a significant increase in burnout during the study period, the mean
increase in BBI-score was 12.5 pr year (p<0.001). The proportion of satisfied
nurses at the first and last survey were 84% and 35% respectively, and the
proportions with burnout were 0% and 29% respectively (p<0.001). Except
for auxiliary nurses with experience from the medical department, all
subgroups experienced a significant increase in BBI. Burnout was associated
with low SOC (p<0.001, r square 0.33).

Conclusions

There was a significant development of burnout in a group of nurses during a


period with two reorganizations and downsizing. Burnout was associated with
low SOC. Working with seriously ill patients with cancer has probably made
the nurses exceptionally vulnerable to the stress and workload related to the
reorganizations.

Answer:
Type of Research: Quasi-experimental Retrospective Cohort Study
Length/Duration of Study: 30 months’ period
Method Used:
- Bergen Burnout Indicator (BBI)
- “Sense of Coherence” (SOC) with Antonovsky’s Questionnaire

Components of Study:
- Subject: One man and 45 women ages 30-65 y/o
Flowchart/Diagram

Population:
One man, 45
women
(Aged 30-65 y/o)

Experimental: Control:
Burnout Nurses Satisfied Nurses

First data First data


collected: collected:
0% 84%

Period of
Manipulation: No Manipulation
30 months

Last data
Last data collected:
collected:
35%
29%

Difference (%)
during study:
Burnout = 29%
Satisfied = 19%
ABSTRACT 3

Emotional reaction to diagnosis of infertility in Kuwait and


successful clients' perception of nurses' role during
treatmen
Background

The unfulfilled desire of millions of infertile couples worldwide to have their own
biological children results in emotional distress. This study evaluated the emotional
reactions of couples attending a combined infertility clinic in Kuwait and successful
clients' perception of nurses.

Methods

Quantitative and qualitative methods were used. The first phase was by structured
interview using two standardized psychological scales: the 25-item Hopkins
Symptom Checklist and Modified Fertility Adjustment Scale. Data were collected
from 268 couples attending the combined infertility clinic, between October 2002
and September 2007. The second phase was a semi-structured interview of 10
clients who got pregnant following treatment. The interview explored their feelings
and perception of the nurses' role. Interviews were transcribed verbatim and
analyzed.

Results

The average duration of infertility was 4 years; 65.7% of the women and 76.1% of
men suffered from primary infertility. Emotional reactions experienced were:
anxiety in women (12.7%) and men (6%), depression in women (5.2%) and men
(14.9%) and reduced libido in women (6.7%) and men (29.9%). Also in men, 14.9%
experienced premature ejaculation, 5.2% weak ejaculation and 7.9% had impotence
although 4.9% were transient. In the semi-structured interviews, the emotions
expressed were similar and in addition to anger, feelings of devastation,
powerlessness, sense of failure and frustration. In the survey, 12.7% of the men
were found to show more anxiety than women (6%). Although all the 10 women
interviewed confirmed they were anxious; only 4 of their partners were reported to
be sad or anxious. Successful clients' perception of nurses' roles included nurses
carrying out basic nursing procedures, communicating, educating about
investigative and treatment procedures, providing emotional support by listening,
encouraging, reassuring and being empathetic.

Conclusions

This study illuminates the emotional reactions of infertile clients. Fertility nurses in
Kuwait can provide emotional support through communication. The need for
additional and continuous training for nurses employed in fertility settings in Kuwait
is paramount.
Type of Research: Experimental study
- Historical Cohort
Components of the study
- Subjects: 268 couples attending the combined infertility clinic
- Method used :
a. 25 item Hopkins Symptom Checklist and Modified Fertility
Adjustment Scale
b. Semi- structured Interview
Duration of the study: October 2002 – September 2007
Flowchart/Diagram
With
25 item Hopkins Outcome
(couples
268 Symptom Checklist and
who got
couple Modified Fertility pregnant)
s Adjustment Scale
Without
Outcome
With Outcome
10 Semi- structured
couple Interview
s
Without
Result from Outcome
previous(historical)
study

Onset Intervention in subjects only Time

ABSTRACT 4

Monitoring the newly qualified nurses in Sweden: the


Longitudinal Analysis of Nursing Education (LANE)
study
Background

The Longitudinal Analysis of Nursing Education (LANE) study was initiated in 2002,
with the aim of longitudinally examining a wide variety of individual and work-
related variables related to psychological and physical health, as well as rates of
employee and occupational turnover, and professional development among nursing
students in the process of becoming registered nurses and entering working life.
The aim of this paper is to present the LANE study, to estimate representativeness
and analyse response rates over time, and also to describe common career
pathways and life transitions during the first years of working life.

Methods

Three Swedish national cohorts of nursing students on university degree


programmes were recruited to constitute the cohorts. Of 6138 students who were
eligible for participation, a total of 4316 consented to participate and responded at
baseline (response rate 70%). The cohorts will be followed prospectively for at least
three years of their working life.

Results

Sociodemographic data in the cohorts were found to be close to population data, as


point estimates only differed by 0-3% from population values. Response rates were
found to decline somewhat across time, and this decrease was present in all
analysed subgroups. During the first year after graduation, nearly all participants
had qualified as nurses and had later also held nursing positions. The most common
reason for not working was due to maternity leave. About 10% of the cohorts who
graduated in 2002 and 2004 intended to leave the profession one year after
graduating, and among those who graduated in 2006 the figure was almost twice as
high. Intention to leave the profession was more common among young nurses. In
the cohort who graduated in 2002, nearly every fifth registered nurse continued to
further higher educational training within the health professions. Moreover, in this
cohort, about 2% of the participants had left the nursing profession five years after
graduating.

Conclusion

Both high response rates and professional retention imply a potential for a thorough
analysis of professional practice and occupational health.

Type of Research : Cohort / Multiple Cohort design


Components of the study : 6138 students eligible for participation,
4316 consented to participate
Timeline : 3years

10% intended to have a profession


Professio
one year after graduating
nal
retention

43
16
Maternity
Cessati leave
on to
work More common to young
nurses

Onset of study 3 years

ABSTRACT 5

Musculoskeletal complaints among Italian X-ray


technology students: a cross-sectional questionnaire
survey
Background

There is a high prevalence of musculoskeletal disorders among healthcare


professional students. Although recent studies show musculoskeletal disorders are a
common problem among X-ray technologists, there are no data on these disorders
among students of this healthcare profession. We have therefore estimated the
prevalence of musculoskeletal complaints among a group of X-ray technology
students.

Methods

The students (n = 109) currently attending the 3-year X-ray technologist school at a
large University in the Apulia region of Southern Italy were recruited for the study,
with a 100% participation rate. A questionnaire collected data concerning personal
characteristics, physical exposure during training activities, and the presence of
musculoskeletal symptoms in the neck, shoulders, low back, hand/wrist and legs.

Results

The prevalence of complaints in any body site over the previous 12 months was
37%. Low back pain was the most frequently reported symptom (27%), followed by
neck (16%), shoulder (11%), leg (8%) and hand/wrist (5%) pain. Poor physical
activity was associated with the complaints.

Conclusions
Our study showed prevalence rates of musculoskeletal complaints among X-ray
technology students to be somewhat high, representing about half of those found in
Italian technologists. The most common musculoskeletal problem was low back
pain, which had also been found in research conducted among nursing students.
Our research also showed a significant association between poor physical activity
and the presence of musculoskeletal disorders in young university students.

Type of Research: Experimental study


- Cross-sectional
Components of the study
A. Subjects: 109 students currently attending the 3-year X-ray
technologist school
B. Method used :
c. questionnaire

Flowchart/Diagram

With outcome:
prevalence of
musculoskeletal
109 students
disorders is high
currently
among Xray
attending the
technology 3-yr x-ray students
technologist
school

Without outcome

duration

ABSTRACT 6

An exploration of knowledge, attitudes and advice given


by health professionals to parents in Ireland about the
introduction of solid foods. A pilot study
Background

For the purposes of this paper "weaning is defined as the introduction of the first
solid foods to infants". Global recommendations by the World Health Organisation
(WHO) recommend that all infants be exclusively breast-fed for the first six months
of life. No global recommendations have been made for formula fed infants. In
Europe it is recommended that weaning foods should be introduced between 18
weeks and 26 weeks regardless of whether infants are breast or formula fed. In the
United Kingdom it is recommended that solids be introduced at around six-months
for both breast and formula fed infants. In Ireland official guidelines recommend
that breast fed infants should be introduced solids at 6 months of age while for
formula fed infants the recommendation is for 4 months. The disparity between
these global, European, UK and local recommendations may be a source of
confusion for parents and health care professional based in Ireland. Emerging
evidence suggests that babies in Ireland are given solid foods before the
recommended age but there has been little investigation of the weaning advice
provided by health professionals. Since community health professionals have
routine parent interactions in the pre-weaning and early-weaning period and hence
are in a unique position to positively influence parental weaning decisions, this
study aimed to explore their knowledge, attitudes and advice practices about
weaning.

Methods

A mixed-methods approach was used for the research, commencing with a multi-
disciplinary focus group to guide and develop a questionnaire. Questionnaires were
then distributed in a postal survey to General Practitioners (GPs) (n 179), Practice
Nurses (PNs) (n 121), Public Health Nurses (PHNs) (n 107) and Community
Dieticians (CDs) (n 8).

Results

The results indicate varying levels of knowledge of official weaning


recommendations and a variety of advice practices. CDs and PHNs acknowledged a
clear role in providing weaning advice while demonstrating high confidence levels in
providing this advice. However, 19% of PNs and 7% of GP respondents did not
acknowledge that they have a role in providing weaning advice to parents; even
though Health Service Executive (HSE) written literature given to parents states
that they should seek information from PNs and GPs.

Conclusion

Small pockets of misinformation about the introduction of solid foods persist


amongst health professionals which may lead to inconsistent advice for parents.
Further research is needed.

1. Observational Study

-Cross sectional
2. Components:

A. Subject: 415 respondents which are professionals comprised of 179 (GP),


121 (PN), 107(PHN) & 8 (CD)

B. Tools: Questionnaires to assess their knowledge about child weaning

3. Flow chart/ Diagram

CDs and PHNs


acknowledged a clear role
in providing weaning advice
while demonstrating high
confidence levels in
providing this advice.

415 health
professional
s
19% of PNs and
7% of GP
respondents did
not acknowledge
ABSTRACT 7 that they have a
role in providing
Effects of earplugs and eye masksweaning
on nocturnal
advice sleep,
melatonin and cortisol in a simulated intensive care
to parents.
unit environment
Introduction

Environmental stimulus, especially noise and light, is thought to disrupt sleep in


patients in the intensive care unit (ICU). This study aimed to determine the
physiological and psychological effects of ICU noise and light, and of earplugs and
eye masks, used in these conditions in healthy subjects.

Methods

Fourteen subjects underwent polysomnography under four conditions: adaptation,


baseline, exposure to recorded ICU noise and light (NL), and NL plus use of earplugs
and eye masks (NLEE). Urine was analyzed for melatonin and cortisol levels.
Subjects rated their perceived sleep quality, anxiety levels and perception of
environmental stimuli.

Results
Subjects had poorer perceived sleep quality, more light sleep, longer rapid eye
movement (REM) latency, less REM sleep when exposed to simulated ICU noise and
light (P < 0.05). Nocturnal melatonin (P = 0.007) and cortisol secretion levels (P =
0.004) differed significantly by condition but anxiety levels did not (P = 0.06). Use
of earplugs and eye masks resulted in more REM time, shorter REM latency, less
arousal (P < 0.05) and elevated melatonin levels (P = 0.002).

Conclusions

Earplugs and eye masks promote sleep and hormone balance in healthy subjects
exposed to simulated ICU noise and light, making their promotion in ICU patients
reasonable.

Experimental

- Randomized controlled Trial

-Crossover Study

Components:

A. Subject: 14 Healthy volunteers, composed of 8 female & 6 male with ages


21-70 y/o

B. Experimental treatment: Ear plugs & Eye masks to help manage frequent
sleep arousal from ICU NL

C. Control: ICU Noise & Light (NL) as sleep disruptor

Flow chart/ Diagram

ICU NL with ear ICU NL without ear


plugs & eye masks plugs & eye masks
7
subject
s
Adaptation

Baseline

14
subject Randomizatio
ICU NL without ear ICU NL with ear
s n
plugs & eye masks plugs & eye masks
7
subject
s
AB

ABSTRACT 8

Inter-rater reliability of the Full Outline of


UnResponsiveness score and the Glasgow Coma
Scale in critically ill patients: a prospective
observational study
Introduction

The Glasgow Coma Scale (GCS) is the most widely used scoring system for
comatose patients in intensive care. Limitations of the GCS include the impossibility
to assess the verbal score in intubated or aphasic patients, and an inconsistent
inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new
coma scale not reliant on verbal response, was recently proposed. The aim of the
present study was to compare the inter-rater reliability of the GCS and the FOUR
score among unselected patients in general critical care. A further aim was to
compare the inter-rater reliability of neurologists with that of intensive care unit
(ICU) staff.

Methods

In this prospective observational study, scoring of GCS and FOUR score was
performed by neurologists and ICU staff on 267 consecutive patients admitted to
intensive care.

Results

In a total of 437 pair wise ratings the exact inter-rater agreement for the GCS was
71%, and for the FOUR score 82% (P = 0.0016); the inter-rater agreement within a
range of ± 1 score point for the GCS was 90%, and for the FOUR score 92% (P =
ns.). The exact inter-rater agreement among neurologists was superior to that
among ICU staff for the FOUR score (87% vs. 79%, P = 0.04) but not for the GCS
(73% vs. 73%). Neurologists and ICU staff did not significantly differ in the inter-
rater agreement within a range of ± 1 score point for both GCS (88% vs. 93%) and
the FOUR score (91% vs. 88%).
Conclusions

The FOUR score performed better than the GCS for exact inter-rater agreement, but
not for the clinically more relevant agreement within the range of ± 1 score point.
Though neurologists outperformed ICU staff with regard to exact inter-rater
agreement, the inter-rater agreement of ICU staff within the clinically more relevant
range of ± 1 score point equalled that of the neurologists. The small advantage in
inter-rater reliability of the FOUR score is most likely insufficient to replace the GCS,
a score with a long tradition in intensive care.

Inter-rater reliability of the Full Outline of UnResponsiveness score


and the Glasgow Coma Scale in critically ill patients

1.) Type of Research: Observational Study

- Cohort Study

- The study took place between May 2006 – April 2007

2.) Components of the Study:

A.) Subjects: 328 critically ill patients who were admitted in the two subunits
of the ICU in University Hospital of Basel, Switzerland

B.) Materials: Glasgow Coma Scale and Full Outline of UnResponsiveness


Score

C.) Conductors/Evaluators: Neurologist and ICU staff

3.) Flowchart:

ABSTRACT 9

Effect of negative air ions on the potential for bacterial


contamination of plastic medical equipment
Background

In recent years there has been renewed interest in the use of air ionizers to control
the spread of infection in hospitals and a number of researchers have investigated
the biocidal action of ions in both air and nitrogen. By comparison, the physical
action of air ions on bacterial dissemination and deposition has largely been
ignored. However, there is clinical evidence that air ions might play an important
role in preventing the transmission of Acinetobacter infection. Although the reasons
for this are unclear, it is hypothesized that a physical effect may be responsible: the
production of air ions may negatively charge items of plastic medical equipment so
that they repel, rather than attract, airborne bacteria. By negatively charging both
particles in the air and items of plastic equipment, the ionizers minimize
electrostatic deposition on these items. In so doing they may help to interrupt the
transmission of Acinetobacter infection in certain healthcare settings such as
intensive care units.

Methods

A study was undertaken in a mechanically ventilated room under ambient


conditions to accurately measure changes in surface potential exhibited by items of
plastic medical equipment in the presence of negative air ions. Plastic items were
suspended on nylon threads, either in free space or in contact with a table surface,
and exposed to negative ions produced by an air ionizer. The charge build-up on the
specimens was measured using an electric field mill while the ion concentration in
the room air was recorded using a portable ion counter.

Results

The results of the study demonstrated that common items of equipment such as
ventilator tubes rapidly developed a large negative charge (i.e. generally >-100V) in
the presence of a negative air ionizer. While most items of equipment tested
behaved in a similar manner to this, one item, a box from a urological collection and
monitoring system (the only item made from styrene acrylonitrile), did however
develop a positive charge in the presence of the ionizer.

Conclusion

The findings of the study suggest that the action of negative air ionizers
significantly alters the electrostatic landscape of the clinical environment, and that
this has the potential to cause any Acinetobacter-bearing particles in the air to be
strongly repelled from some plastic surfaces and attracted to others. In so doing,
this may prevent critical items of equipment from becoming contaminated with the
bacterium.
DIAGRAM
ABSTRACT 10

Computer-assisted resilience training to prepare


healthcare workers for pandemic influenza: a
randomized trial of the optimal dose of training
Background

Working in a hospital during an extraordinary infectious disease outbreak can cause


significant stress and contribute to healthcare workers choosing to reduce patient
contact. Psychological training of healthcare workers prior to an influenza pandemic
may reduce stress-related absenteeism, however, established training methods that
change behavior and attitudes are too resource-intensive for widespread use. This
study tests the feasibility and effectiveness of a less expensive alternative - an
interactive, computer-assisted training course designed to build resilience to the
stresses of working during a pandemic.

Methods

A "dose-finding" study compared pre-post changes in three different durations of


training. We measured variables that are likely to mediate stress-responses in a
pandemic before and after training: confidence in support and training, pandemic-
related self-efficacy, coping style and interpersonal problems.

Results

158 hospital workers took the course and were randomly assigned to the short (7
sessions, median cumulative duration 111 minutes), medium (12 sessions, 158
minutes) or long (17 sessions, 223 minutes) version. Using an intention-to-treat
analysis, the course was associated with significant improvements in confidence in
support and training, pandemic self-efficacy and interpersonal problems.
Participants who under-utilized coping via problem-solving or seeking support or
over-utilized escape-avoidance experienced improved coping. Comparison of doses
showed improved interpersonal problems in the medium and long course but not in
the short course. There was a trend towards higher drop-out rates with longer
duration of training.

Conclusions

Computer-assisted resilience training in healthcare workers appears to be of


significant benefit and merits further study under pandemic conditions. Comparing
three "doses" of the course suggested that the medium course was optimal.

1.) Type of Research: Experimental Study

- Randomized Uncontrolled Trial

2.) Components of the Study:


A.) Subjects: 158 healthcare workers with consent to participate from Mount
Sinai Hospital in Toronto, Canada

B.) Materials/Instruments: Three computer assisted courses that will help


healthcare workers to prepare for influenza pandemic.

3.) Flow Chart