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Abstract |
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 Top Abstract Research MethodsResultsDiscussionReferences |
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• Objectives To replicate the original study and estimate instrument reliability.
• Methods A cross-sectional design was used, and survey data from nursing personnel and bedside observational data from 9 intensive care units were collected.
• Results A total of 181 surveys (47%) were returned, and data were collected from 436 bedsides. Reported frequencies of oral care and use of oral care products differed between nonintubated and intubated patients (P<.001). The mean documented frequency of oral care for nonintubated patients was 1.8 (SD 1.5); self-reported frequency was 3 (SD 2.4). The mean documented frequency of oral care for intubated patients was 3.3 (SD 1.8); self-reported frequency was 4.2 (SD 2.1). Documented oral care frequency differed by unit (P = .006) and intubation status (P < .001). Mean observed head-of-bed position was 38° (SD 24°) for nonintubated patients and 23° (SD 12°) for intubated patients (P < .001). Intubation status, but not unit, affected observed head-of-bed position (P < .001). Three survey items had adequate reliability evidence (r=0.70). Interrater reliability for bedside data collection was 96% or greater.
• Conclusions Despite inadequate estimates of survey reliability, findings generally were comparable to results of the original study; nurses report more frequent oral care than is documented. Intensive care nurses elevate the head of patients’ beds in accordance with self-reports.
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Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
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| Aspiration of oral and gastric contents is a major contributor to hospital-acquired pneumonia.
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Grap et al6 surveyed 77 nursing personnel in 3 adult ICUs to determine nurses’ self-reports of oral care products used, methods used, and frequency of oral care provided; the priority given to oral care; and the frequency of oral care documentation in the medical records. At 5 randomly selected times in 1 month, data on the frequency of oral care and the types of products used in the preceding 24 hours were extracted from the medical records of 170 ICU patients. Grap et al reported that oral care was documented less often (mean 1.2 times per 24 hours) than reported in the survey (2.5 times per 24 hours for nonintubated patients and >5 times per 24 hours for intubated patients); the numbers of intubated and nonintubated patients and head-of-bed positioning practices were not reported.
To help determine the generalizability of the findings of Grap et al,6 the members of the Cardiovascular Recovery Room (CVRR) Research Committee and Journal Club at St. Luke’s Episcopal Hospital in Houston, Tex, replicated the original study. Replication, defined as deliberate subsequent investigation in which researchers use study procedures the same as those in the original research to determine repeatability of earlier results,7 is essential for evidence-based practice. Small-scale studies conducted in only one type of clinical setting limit the generalizability of findings and thus pose the risk that erroneous findings will be put into practice. The objectives of this replication study were to
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Research Methods |
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The university and hospital institutional review boards approved the study. Voluntary completion of the survey served as informed consent for the nursing staff to participate in the study, and patients’ consent was waived.
Setting and Sample
Survey data were collected from registered nurses and patient care assistants in 9 adult ICUs (Table 1
) in a 946-bed, nonprofit, university-affiliated hospital. Surveys were distributed to 384 members of the nursing staff employed in the ICUs in June 2004: 302 nurses and 82 patient care assistants.
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Oral Care Survey
After pretesting with 10 members of the CVRR Research Committee and Journal Club, the survey used in the original study6 was modified only to reflect the names of the study site ICUs and to clarify the time frames in questions 3 and 4 (eg, every 12 hours instead of twice a day). (Please see the original study6 for a description of the survey.) A visual analog scale is used as the response format for several items, and we printed out each survey page to maintain a consistent 100-mm scale. A copy of the survey with a cover sheet was placed in the unit mailbox of each ICU staff member. Large boxes were placed in each unit for return of the survey, and an investigator picked up surveys twice a week. Two weeks later, a second identical survey printed on a different color of paper was distributed to all ICU nursing staff. The cover sheet invited completion of the survey a second time for psychometric testing via the test-retest method.8
A research assistant entered all data, measuring the visual analog scale responses with a millimeter ruler. The retest survey data were removed from the spreadsheet for all analyses except test-retest reliability. Frequencies were tabulated for all variables. The general linear model procedure in SPSS (version 11.5 for Windows, SPSS Inc, Chicago, Ill), 1-way analysis of variance, was used to examine differences by unit in survey variables. Because error variances were unequal across groups for some of the variables, the Dunnett test was used. A paired t test was used to compare differences between practices reported for nonintubated and intubated patients. An 
of .05, corrected for multiple comparisons as appropriate, was used for all analyses.
We used the retest method to test for evidence of instrument stability. The testing interval was 2 to 4 weeks, and staff members’ hospital badge numbers were used to separate the data. Responses to individual items by the same respondent were correlated for the 2 test periods using the Pearson product-moment correlation procedure. The criterion for adequate evidence of stability was r = 0.70.8
Bedside Observation Procedures
Thirteen members of the CVRR Research Committee and Journal Club were trained in bedside data collection in April 2004. Evidence for interrater reliability was tested with 54 patients randomly selected from the study units (6 patients per ICU). For 13 different raters, our approach to evaluation of interrater reliability consisted of percentage agreement from cross-tabulations of rater by variable. Of 13 raters, 9 (69%) had acceptable interrater agreement (=95%) and were certified to collect bedside data in the study. Interrater reliability was tested again in August 2004 before collection of bedside data commenced and intermittently thereafter and was 96% or greater.
After data collectors were certified, 7 days were randomly selected prospectively from all days in August and September 2004 for bedside data collection. Frequency of oral care and type of products used were recorded from the ICU flow sheet of the medical record for the previous 24 hours for all ICU patients. Elevation of the head of the bed at the time of bedside data collection was estimated by visualization of the protractor angle reading on each bed and was recorded to the nearest 5° (eg, a reading of ~23° was recorded as 25°); the protractor bubble marks were in 10° to 15° intervals. The position of the head of the bed in patients sitting out of bed was recorded as 90°. Patients’ age, sex, ethnicity, and intubation status during the previous 24 hours also were noted.
A research assistant entered data from the bedside observations onto a spreadsheet. Frequencies were tabulated for all variables. A Student t test was used to compare differences in documented frequency of oral care and observed position of the head of the bed for nonintubated and intubated patients. To compare observed position of the head of the bed with survey-reported positioning practices, we recoded the interval-level data for the observed position of the head of the bed to correspond to the survey’s ordinal-level data. The general linear model procedure was used with a 2-way analysis of variance to examine differences in oral care frequency and position of the head of the bed by unit and intubation status.
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Results |
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Survey Findings
A total of 198 surveys were returned; 139 (70%) were returned from the first distribution and 59 (30%) from the second. Seventeen of the surveys returned from the second distribution were retest surveys. Thus, the survey sample size was 181 for a 47% response rate. Most surveys were from nurses (148, 82%); 31 (17%) were from patient care assistants, and 2 (1%) of the surveys did not specify the job title of the respondent. The response rates for each unit are shown in Table 1
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The demographic characteristics of survey respondents were as follows: mean years of nursing experience, 13.5 (SD 8.3); mean years of ICU experience, 10 (SD 7.9); and mean years worked in study unit, 6.2 (SD 5.9). Most respondents (116, 64%) had a baccalaureate degree or higher. The demographic data predominantly characterize the nurse respondents because most of the missing data (
13% for each item) were from the surveys returned by patient care assistants.
Objective 1: Describe Oral Care and Practices for Positioning the Head of the Bed Self-Reported By Nursing Personnel in the Adult ICUs
Mean frequency of oral care reported for nonintubated patients was 3 (SD 2.4), which corresponded to oral care being provided every 8 hours. Mean frequency of oral care for intubated patients was 4.2 (SD 2.1), which corresponded to oral care being provided every 6 hours. The difference between frequencies of oral care reported for nonintubated and intubated patients was significant (t = –6.2, df = 174, P < .001), but no significant difference was found in reported frequency by unit for nonintubated and intubated patients.
Reported use of oral care products differed significantly between nonintubated and intubated patients (P < .001). The reported use of mouthwash, toothbrush, and toothpaste was higher in nonintubated patients, and the reported use of sodium chloride, peroxide mixture, chlorhexidine, and toothette swabs was higher in intubated patients.
| Reported use of oral care products differed between intubated (sodium chloride, peroxide mixture, chlorhexidine) and nonintubated (mouthwash, toothbrush, toothpaste) patients.
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Reported use of mouthwash, sodium chloride, peroxide mixture, and chlorhexidine for intubated patients differed significantly by unit (Table 2). Staff in the cardiovascular recovery unit reported the lowest use of mouthwash (30, SD 34) and staff in the neuroscience ICU reported the highest use (69, SD 34). Survey respondents in the cardiovascular recovery unit reported lower use of sodium chloride (12, SD 21) than did respondents from the surgical ICU (45, SD 42), lower use of peroxide solution (28, SD 38) compared with respondents from the coronary care unit (60, SD 33) and the surgical ICU (75, SD 33), and higher use of chlorhexidine (85, SD 29) than did respondents from the coronary care (47, SD 34) and surgical ICU (44, SD 37).
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). Reported use of the various positions for the head of the bed did not differ significantly among units.
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Objective 2: Estimate Reliability of the Survey Instrument
The 17 surveys received for estimation of test-retest reliability were combined with the 10 test-retest surveys from the pilot study, yielding a sample size of 27 sets of surveys for reliability testing. Pairwise exclusion from the analysis with missing data resulted in sample sizes that varied from 22 to 27 for each correlation. Correlation coefficients varied from –0.18 to 0.80. When the criterion that correlation was 0.70 or higher was used, only 3 items showed evidence of stability between survey administrations: use of mouthwash (r = 0.71), toothpaste (r = 0.77), and toothbrush (r = 0.80) for intubated patients.
Bedside Observation Findings
Eight members of the CVRR Research Committee and Journal Club who were certified for data collection collected data from 436 bedsides in August and September 2004. The number and percentage of observations by unit are shown in Table 1 in relation to the total response rates on the survey.
The demographic characteristics of the patients occupying the bedsides during the observations were as follows; however, in an unknown number of instances, the same patient’s bedside was observed on more than a single occasion. Please note that percentages do not total 100% because of missing data (3%) for each variable. During the periods when bedside data were collected, more ICU patients were men (263, 62%) than were women (159, 38%). The number of nonintubated patients (276, 64%) exceeded the number of intubated patients (154, 36%); intubation status was missing for 6 (1%) of the observations. Ethnic distribution, collected from the medical record, was as follows: 280 white (64%), 84 African American (19%), 51 Hispanic (12%), and 9 other (2%). Mean age was 63 (SD 15) years; the youngest patient was 18 years old, and the oldest patient was 95 years old.
Objective 3: Compare the Frequency With Which Oral Care Is Documented in the Medical Record With Self-Reported Frequencies
Mean frequency of oral care documented for the previous 24 hours was 2.3 (SD 1.7). The difference between frequency of oral care for nonintubated and intubated patients was statistically significant (t = –8.8, df = 275, P < .001). The mean documented frequency of oral care for nonintubated patients was 1.8 (SD 1.5); the self-reported frequency was 3 (SD 2.4). The mean documented frequency of oral care for intubated patients was 3.3 (SD 1.8); the self-reported frequency was 4.2 (SD 2.1).
Unit (F8,377 = 2.8, P = .006) and intubation status (F1,377 = 44, P < .001) had a significant effect on documented frequency of oral care. The interaction of unit and intubation status was not significant. Post hoc testing showed that documentation of oral care by staff from the coronary care and medical-surgical ICUs was significantly less frequent than documentation of such care by staff in the pulmonary ICU, regardless of a patient’s intubation status. In every unit, intubated patients were observed to have oral care documented more frequently than nonintubated patients did.
| In every unit, oral care was documented more frequently in intubated patients than in nonintubated patients.
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Objective 4: Compare Direct Observations of Positioning of the Head of the Bed With Self-Reported Practices
Mean position of the head of the bed observed at the time of bedside data collection was 33° (SD 22°). The mean observed position was 38° (SD 24°) for nonintubated patients and 23° (SD 12°) for intubated patients; the difference was statistically significant (t = 8.6, df = 401, P < .001). As with the self-reported practices in the survey, the observed use of the flat position and elevation less than 30° for nonintubated and intubated patients were not different, but the 30° to 45° and greater than 45° positions were observed more frequently in nonintubated patients (Table 3). Intubation status, but not unit, had a significant effect on observed position of the head of the bed (F1,377 = 18, P < .001). In every unit, nonintubated patients were observed to be positioned at a higher level than intubated patients were.
| The level of backrest elevation differed significantly between intubated (23°) and nonintubated (38°) patients.
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Discussion |
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Replication of research is a time-honored strategy for extending generalizability of study findings. Replication requires duplication of methods and procedures used in the original study to allow meaningful comparison. In our study, we used the methods reported by Grap et al6 for data collection, but we performed more extensive analyses of the data and tested evidence for reliability of the measures.
Survey responses of the Houston sample (this study) and the Richmond sample (original study) are compared in Table 4 for data that were available in the original study report.6 Our sample was larger because we sampled nursing staff from 9 ICUs; nonetheless, the response rate was equivalent to the response rate in the study by Grap et al6 (47% and 45%, respectively). The Houston sample was more experienced than the Richmond sample. Whereas our overall sample had a lower percentage of respondents with a baccalaureate degree (64% vs 70%), the percentage increased to 78% when patient care assistants were removed from the sample and only nurses were examined.
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We were unable to show evidence for reliability of the survey. The use of mixed response formats (eg, Likert-type and visual analog scale) and survey content (ie, oral care and practices for positioning the head of the bed) makes it difficult to determine the best approach to testing the psychometric properties of this measurement scale. Evaluation of internal consistency produced dismal results, suggesting that the items are not derived from a common construct. Evaluation of instrument stability showed variable correlation for each item, but the clear majority of items did not support adequate evidence of stability.
Temporal instability of the survey instrument will produce measurement error and, by definition, the results will not be a good predictor of future behavior.8 On the other hand, low temporal stability is characteristic of "state" measures, those perceptions that are subject to fluctuation. We would expect survey responses to change after staff exposure to this project and other sources of information about prevention of ventilator-associated pneumonia. However, examination of test and retest mean values showed no response pattern that would indicate a change in reported practice during the testing interval; differences between test and retest means for survey items were not statistically significant. We recommend revising the survey and retesting evidence for reliability. Nevertheless, despite failure to establish evidence for adequate reliability of the survey, cross-sectional use of the survey in 2 geographically separate samples of ICU nursing staff produced generally equivalent findings.
In the original study, Grap et al6 did bedside observations on 5 days. They reported results from 77 surveys and 170 patient bedsides, a 2.2-fold greater number of patient data than survey responses. To maintain that 2.2-fold difference, we calculated the number of days needed for bedside data collection by unit after the survey responses were tabulated and assuming mean daily ICU census of 109 patients. We stratified the number of observations by each unit’s response rate for the survey and stopped bedside observations in the saturated units. The mean daily census on the randomly selected observation days was 90 patients during the data collection times. Together, these factors resulted in a 2.4-fold greater number of observational data than survey responses. Whereas observations were not directly matched with survey responses in either study, our stratification of bedside observations matched observations with unit survey responses, controlling for disparities in unit practice and culture.
In a separate report, Grap et al10 observed the elevation of the head of the beds of 170 patients from 3 ICUs and reported mean elevation of 19°, compared with 33° in our study. They found no significant differences among units or for nonintubated versus intubated patients; however, they reported a significant difference in elevation of the head of the bed between patients receiving mechanical ventilation and those who were not, with higher elevation used in the patients who were not receiving mechanical ventilation. We found a significant difference with higher elevations of the head of the bed in nonintubated patients independent of study unit; we did not collect data on mechanical ventilation status.
Grap et al10 found no differences in elevation of the head of the bed across nursing shifts. In our study, bedside data collection time normally occurred between 7:30 AM and 10:10 PM. A significant inverse correlation was found between time of data collection and elevation of the head of the bed, but the magnitude of the relation was negligible (r = –0.11, n = 405, P = .02), and the relationship was observed for nonintubated patients only. Apparently, the head of the bed is not substantively lowered to promote sleep; however, we did not collect data between 10:10 PM and 7:30 AM, when planned sleep time for ICU patients is most likely to occur.
On the basis of the comparison of findings from our study and the study by Grap et al,6 we conclude that ICU nursing staff
On the basis of the findings from our study only, we additionally conclude that the Oral Care and Patient Positioning Survey6 has insufficient evidence of reliability and that ICU nursing staff elevate the head of the bed more in nonintubated patients than in intubated patients.
Implications for practice primarily are derived from the extended generalizability of the findings of Grap et al6 provided by this replication study. Together, the studies increase confidence in the validity of the findings, at least in 2 geographical areas of the United States: Richmond, Va, and Houston, Tex. ICU nursing staff document oral care less often than they self-report providing it, but they appear to elevate the head of patients’ beds in accordance with self-reports. Revision of the survey may improve congruence between self-reports and documentation of oral care.
Despite recommendations for elevation of the head of the bed 30° or more to decrease risk of aspiration pneumonia,1–3,10,11 intubated patients appear to be placed in positions with lower elevations of the head of the bed. Some data suggest that positioning the head of the bed is influenced by patients’ comfort and the prevention or treatment of adverse effects.11 More research is needed about the basis for decisions about elevation of the head of the bed and about patients’ outcomes with elevations that are intermediate between supine and 30° and alternative positions such as semiprone with the head down 15° to 20°.12
| In this replication study, the priority rating given for oral care was greater than the priority rating given in the original study. However, backrest elevation for intubated patients still does not meet recommended levels.
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Reducing the risk of aspiration pneumonia is an important dimension in the domain of critical care nursing practice. If we are to make serious strides in preventing nosocomial pneumonia, we must practice according to the best evidence. The current best evidence is elevation of the head of the bed 30° or more. At least 1 trial is under way to determine optimal interventions for oral care.13 Research is needed to establish the optimal frequency and to test the effects of oral care interventions on patients’ outcomes.
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ACKNOWLEDGMENTS |
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To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
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REFERENCES |
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This article has been cited by other articles:
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C. L. Cason, T. Tyner, S. Saunders, and L. Broome Nurses' Implementation of Guidelines for Ventilator-Associated Pneumonia From the Centers for Disease Control and Prevention Am. J. Crit. Care., January 1, 2007; 16(1): 28 - 37. [Abstract] [Full Text] [PDF]
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