“Cavanagh C et al. (2005) A survey of newborn blood spot screening practices.
British Journal Of Midwifery.13 (3) 160-164”
A Critique and Implications for Practice
The aim of this paper is to critically evaluate a research article and appreciate its relevance to practice and education. A research critique checklist (Nieswiadomy, 1998) and key questions for critically evaluating research (Clarke, 1991) will be used as a framework for this critique. The study being critiqued is “A survey of newborn blood spot screening practices” by C Cavanagh et al. (2005). Two of the researchers are pilot and implementation co-ordinators for the UK Newborn Screening Programme Centre (UKNSPC) as well practicing midwives, which is appropriate for carrying out this research. The third researcher is a professor and chair of children’s nursing research, which givesweight and validity to this study, as her status suggests she is an expert in the field of child health and therefore it appears there is no vested interest on her part. The project was funded by the National Health Service (NHS) research and development fund, which is considered a strengthas these funds are distributed through a competitive process, with each bid being assessed against published criteria. The fundbenefactorsare obliged to account regularly to the NHS Executive for the use of these funds, which implies the research is not geared towards the generation of income ( text/80521w19.htm1st July, 2005). The researchers acknowledge the help and support they received from other health care workers such as the Royal College of Midwives, GreatOrmondStreetHospital and the Institute of Child HealthClinical Standards Advisory Group.
The title of the article reflects the focus of the study, however the population was not identified(Cutcliffe and Ward, 2003). The abstract, as suggested by Nieswiadomy (1998) is between 100 and 200 words. It provides an accurate synopsis of the paper, clearly stating methods and findings, and is presented in an interesting format, which encouraged further reading (Cluett and Bluff, 2004). The abstract leads the reader to believe that the study would identify best practice and stimulate the initiation of professional guidelines, but this isnot fully achieved from this study alone (Cutcliffe and Ward, 2003). The suggested need for further training and investigation, however,is fully identified.
Within the introduction of this paper the researcher describes the background of the supporting agencies and their involvement in this area, which is considered to be adequate. However,the primary aims of the study arenot made clear until later in the introduction,which leaves slight confusion as to its aims. A basic survey design was used for this research, which therefore made it appropriate for the paper not to contain a hypothesis or null hypothesis. There is also little evidence of a theoretical framework within this study (Cutcliffe and Ward, 2003). The researchers do not comprehensively refer to similar research prior to embarking on this study, however, several referencesaremade to the lack of research available in this area, with suggestions that current practices are difficult to ascertain. The reasons put forward for carrying out this research were to identify training needs, inform the development of guidelines and highlight further investigations. Suggestionsthat midwifery textbooks are not supported by evidence and preferred teaching methods are taught by mentors, greatly warrants investigationand therefore this study can be regarded as important (Cutcliffe and Ward, 2003)
The method used was a two part study using a survey design, which is clearly stated by the researcher. This method is quite common and used as the basis for audit, where repeated measures of routine information are collected (Rees, 2003). It does not focus on measuring casual relationships between variables, therefore it is appropriate that no key variables are mentioned (Cutcliffe and Ward, 2003). It consists of a cross sectional survey of midwives and student midwives, undertaken in two parts with sample sizes of 125 and 101. The tool consisted of a questionnaire which was piloted by midwives who were part of the Process Measures Standards Pilot Steering Group, which resulted in questions being revised. Carr (2003) suggests that carrying out a pilot study to ensure that the definition of the research question and the aim of the study, explicitly enhances the achievable use of the tool (Carr, 2003). Rees (2003) suggests that irritating features of a questionnaire include participants being faced with choosing from a range of alternative options where none apply. A pilot study can add validity, by highlighting where a respondent may not be truly describing their own views.
The first part of the study invited 196 community midwives from six maternity units to complete the questionnaire via a pre-paid postal reply. The selection criterion was that the blood spot test was performed as part of their normal duties. The survey design includes some basic demographical questions, which Rees (2003) suggests, gives comparison with those in the wider population, and gives indication of the representative sample, thus adding to the studies credibility. The second part of the study, involvesquestionnaires being distributed to midwives and student midwives attending the annual RCM conference, May 2004. The sampling strategy could be regarded as one of the strengths of the paper since delegatesattending the RCM conference would be from around the country therefore taking into account different regional practices, this also includes a wide range of skill sets from students to highly trained practitioners. Unfortunately, the space provided in this journal does not permit the inclusion of the entire questionnaire, so the quality of the design cannot be judged (Rees, 2003)
Ethical issues are not discussed in this paper, however, the design of the study suggests this was not a significant limitation. Guidelines on the medical research involving human subjects with regards to ethics committees,state that research involving NHS clients, client notes or undertaken on NHS premises, specifically require ethical approval (Royal College of Physicians, 1996 cited in Cutcliffe and Ward 2003), therefore formal ethical approval may not have been required as this study did not meet these criteria. However, Robinson (1996) states that he feels there is little discussion of ethical issues with regards to protecting staff, and questions if midwives sometimes feel obliged to take part in such research. The researcher states that an explanation was given to all participants and consent was indicated by completion of the questionnaire. However, midwives and student midwives attending the RCM conference may have felt an obligation to conform to their peers. A question of adequate reliability and validity was also considered as completing such a questionnaire in the presence of peers could result in an inclination to give socially acceptable answers, and so accuracy can never be 100% (Rees, 2003), Rees (2003) also states that privacy can have an affect on the accuracy of data collected. The researchers stated that no identifying information would be obtained, thus safeguarding anonymity.
The results of this study show a 64% response rate to the first questionnaire and according to Rees (2003) a response rate of over 50% reduces the potential of a biased response. The second questionnaire was completed by approximately 13% (101) of delegates attending the RCM conference, however, this was an opportunistic audience. The paper utilised statistics in a very limited way, with most data presented within the text, which is appropriate given the design of the study This could be consider as a strength of the paper as the results do not appear to have conjured or manufactured (Cutcliffe and Ward, 2003). Only two tables were used to present data that was considered appropriate to the aims of the study. Clear data is shown in Table 3, which presents the brand names of lancet devices used. A bar chart is used to present the results of midwives preference for pre-test preparation and is clear, easy to understand and is consistent with the statements made in the text. The results clearly show a variety of different practices in relation to every area of the newborn blood spot sampling.
The findings of this study clearly support what the researcher was trying to achieve, which was to gain a more comprehensive understanding of current midwifery practices for newborn screening blood spot sampling. Is author appears honest, open and clear about the weaknesses (Cutcliffe and Ward, 2003) and identifies that the coherence between reported and actual practises remains to be established, as a limitation to this study was practices not being observed. As stated earlier ethical considerations with regards to where and when the questionnaires were completed may add weight to this suggested lack of coherence. Areas of consistency and wide variation in practice where reported. The results are interpreted based on the original study aims, going step by step through the procedure and suggesting evidence that either supports or does not support current practises. Possible challenges have been put forward as well as suggestions as to why certain practises may be used. For example, a recognition that the guidelines drafted by the UKNSPC suggesting information is to be given at 28 weeks, may present a challenge to implement. Foot warming has been suggested as a ritual, as the practice has been shown not to have any effect on crying or sample time, and yet the researcher identifies the challenges of convincing midwives. The researcher is honest in reporting that no evidence could be located with regards to foot cleaning, however, to suggest that disinfection of the skin should be discontinued due to inconsistencies without any evidence to back up the statement is considered to be a biased opinion and a generalisation. The positioning of the baby was not discussed in detail, only to highlight that variations where identified, even though evidence supports a baby should be cuddled securely. The researcher rightly identifies major concerns raised by this study as the use of lancet devices and the high percentage of midwives not adopting universal persuasions. These concerns are discussed in more detail, with suggestions of possible risk factors to both the newborn and the midwife.
The article concludes by identifying that little is know about how midwives prepare and carry out newborn blood spot sampling and consistent practices are not often evidence based. A suggestion to implement agreed guidelines for practice was not backed up with how this would be implemented, and by whom. The urgent need identified for determining best practice in areas lacking in research should also include the suggestion for further research to identify the most cost effective automated device to perform the test as risks have been identified.
Newborn blood spot sampling, as stated, is a procedure routinely carried out by midwives and student midwives. The many variations identified in the procedure consisting of non evidence based practice are a very worrying prospect, with the particular concern that these skills are being passed from midwife mentor to student midwife. As recommended in this paper there is a need for a national concise and evidence based guideline which needs to be available to all practitioner. As research is lacking in a number of areas this may not be feasible at this time, however, a lot of mentioned practices have been suggested to be ritual with many not following already established supporting evidence. These are the practices that need to be urgently addressed. Student midwives are at the forefront to challenge out of date practices and practices which go against evidence based research. The challenge is to equip them with the most up to date best practice in order to influence change. Another very worrying comment to be suggested in this article is that midwifery text books are not supported by evidence based practice with relation the newborn blood spot sampling. I would recommend that university lectures are fully up to date and aware of any flaws that may be apparent in recommended texts. Many skills taught in universities are in one skills session, leaving the student vulnerable to picking up “bad” habits in practice. A recommendation that all clinical skills included in the midwifery program should be re visited on a half yearly or annual basis and registered midwives should have basic skills such as newborn blood spot sampling incorporated into there regular mandatory updates.
Newborn blood spot sampling has the potential to be considered as an easy, basic skill that requires minimal training. With this evidence bringing to light potential unsafe practice, the recommendations should be taken as a matter of urgency.
References
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Cavanagh C et al. (2005) A survey of newborn blood spot screening practices. British Journal of Midwifery.13 (3) 160-164
Cutcliffe J R and Ward M. (2003) Critiquing Nursing Research.Bath. Bath Press
Robinson J. (1996) It’s only a questionnaire: ethics in social science research. British Journal of Midwifery. 4 41-46
Carr J. (2003) Improving questionnaire response rates. Practice Nursing.14 (4) 171-174
Rees C. (2003) Introduction to Research for Midwives.London. Books For Midwives
Cluett E R and Bluff R. (2004) Principles and practice of research in midwifery.London. Baillière Tindall
Clarke E. (1991)Key questions for critically evaluating research. Research Awareness Module 10. London. DistanceLearningCentreSouthPark Polytechnic. 66-67
Barker DP, Willetts B, Cappendijk VC (1996) Capillary Blood Sampling: should the heel be warmed? Archives of Disease in Childhood Fetal and Neonatal Edition 74(2) F139-F140
Vertanen H, Fellman V, Brommels M (2001) An automatic incision device for obtaining blood samples from the heels of preterm infants causes less damage than a conventional manual lancet Archives of Disease in Childhood Fetal and Neonatal Edition 84 (1) F53-F55
The United Kingdom Parliament: Health, Nurses
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