Quantitative Critical Appraisal
Schultz, A. A., Goodwin, P. A., Jesseman, C., Toews, H. G., Lane, M., & Smith, C. (2008). Evaluating the effectiveness of gel pillows for reducing bilateral head flattening in preterm infants: a randomized controlled pilot study. Applied nursing research, 21(4), 191-198.
Schultz et al. (2008) conducted a pilot study whose control was randomized. In the 1990s there were increasing reports of rising numbers of premature babies suffering from the bilateral flattening of their heads. The study conducted was to provide a solution on alleviating bilateral flattening of the newborns’ heads born before full term as determined by the Cephalic Index (CI). Beam, Berastegui, Greenfield (2017) note that the flattening of the head arises from the disproportional weight between the head and the muscles of the neck. The effects of this imbalance are both physical as well as psychological hence necessitating the intervention of the nursing profession.
The study was feasible since the gel pillows were not expensive. Researcher’s expertise, facility and equipment was a challenge since this was the second research by the unit. Attrition affected subject population resulting in a lack of statistically significant difference between subjects. The study required no randomization as part of ethical considerations.
There has been the identification of previous studies on head flattening as well as their description. Two of the studies by Marsden (1980) as well as Schwirian et al. (1986) compare other mattresses to the water pillow, which is the focus of this study. The other three studies by Cartlidge and Rutter (1988); Hemmingway and Oliver (1991, 2000b) as well as Chan et al. (1993) as quoted by Schultz et al. (2008) compare other different types of mattresses. Overall, the literature on gel pillows is scanty.
The study is missing on relevant theories as well as models from which it is anchored. The references are up to date and useful. The literature review begins with the work of Marsden (1980). Works by other authors builds onto this, and finally, the review is concluded by the recent works of Hemingway and Oliver( 2000b) on positioning protocol effectiveness on alleviating head moulding. The absence of studies that had dealt with measuring whether gel pillows could greatly reduce the bilateral flattening of heads among preterms provided the basis for such a study.
The framework is explicitly presented. Concepts of interest are well defined and described within the framework. Relationships among the concepts are not shown in the framework. There is no model to clarify the relationship.
There is no link between the concepts and the variables within the framework.
The clarity and conciseness of the research questions, the objectives, as well as the research questions, is evident. The questions, hypotheses as well as the research objectives are connected to the research purpose logically to provide the most effective solution, and that is the use of gel pillows (Gray, Grove, Sutherland, 2016).
A relationship between the research objectives, the hypotheses as well as questions and concepts thereof are drawn from the literature review, which was critical in the development of the framework. The study had three variables as follows: – the independent variables which were gel pillows and positioning protocol, the dependent variable, which was plagiocephaly and the research variable, which was standard mattresses. While significant variables have a conceptual definition drawn from the literature review, there is a challenge for their operationalization since there are no theories upon which the study was founded. Demographic variables forming the study include gestational age, birth weight, type of delivery, among others.
A quasi-experimental design was used for the study. It was not suitable since the mode of identification of study subjects was randomized. Therefore, it was not useful in examining all the research hypotheses, the questions, as well as objectives. The gel pillow showed some treatment. The gel is a mixture of water and an antibacterial agent. The design of the gel pillow was such that it could reduce pressure while it provided support, hence its continued use. The standard mattresses which form the extraneous variables were 2.5 cm thick with their exterior covered using a polyvinyl. Campbell and Stanley (2015) point out that in a study, statistical conclusion validity can be threatened by the small number of subjects. The study lacked supporting theories hence affected internal validity. Construct validity was affected because the evaluation of the gel pillow was not sufficient. External validity hampered due to the small sample size since it could not allow for generalizations.
The criteria to involve or exclude participants was described. For inclusion, the study used the age as well as the weight of the infant. While for exclusion, several factors were considered, such as hydrocephaly, microcephaly, deformities of the skull or abnormalities within the central nervous system. Random sampling was used in the study to collect study subjects. The data collection method was sufficient for a representative group. Though random sampling should be unbiased, selection bias of the sample may occur. Such a bias arises if inclusivity within the larger population is not sufficient. The sample size of the study was 81 subjects: 36 of the subjects were male with 45 as female infants. The sample was not subjected to power analysis. If it had been carried out, then on week five, the study subjects would be 29 on either side as opposed to 25 subjects using gel pillow and 27 using the standard mattress. At the 5th week, 29 study subjects were not available for participation accounting for 35.8% of the study participants. The study sample size is too small to warrant avoidance of a type II error (Campbell & Stanley, 2015).
The study has attrition of 29 subjects. One discontinued by the mother while 28 subjects just dropped out. The use of more than one group may not confer equivalence unless a power of analysis is carried out. There is clarity in the description of the measuring instruments. The 6-in digimatic calliper measured both the antecedent-or-rear diameter and the breath. A measuring tape was used to measure the Occipitofrontal circumference. The digimatic calliper, which measured the antecedent-or-rear diameter and the breath ranged between 0 to 150 mm. The calliper had an accuracy of 0.2 and a resolution of 0.1 mm. Antecedent-or-rear and breath diameters were obtained while placing calliper tips to point at the biggest and most central part of the head for antecedent-or-rare and the biggest point around the head for breath diameter. A measuring tape was wound around the head to cover its largest circumference running from the occipital protuberance to the frontal bosses to measure the OFC.
The description of the process of data collection is clear with the criteria for inclusion and exclusion being communicated. Data collectors were trained on the rights due to research participants and the requirements for inclusion of participants. The training was also given on protocol and documentation of information required for the study as well as the procedures for data collection. The data collection methods addressed the research hypotheses, research objectives and questions which were to assess the ability of gel pillow to reduce the bilateral flattening of the head. Study objectives such as the ability of gel pillow to reduce the bilateral flattening of the head, standard mattresses, as well as positioning protocol, were analysed.
Repeated measures analysis of variance (RM ANOVA) was carried out for establishing whether statistical differences were significant in the CI or Occipitofrontal circumference between the experiment and the control. Data analysis procedures were sufficient for collected data since it controlled those factors that result in variability between subjects. Hence the study had control variables.
There is an easy understanding of the study results. The figures, as well as the tables used, have been vital in the emphasise and synthesise of certain findings. The researcher feels that the postintervention measures must go beyond the five weeks for the use of gel pillow and bilateral flattening of the head to have statistical significance. The results are in line with the study framework. The consistent findings are that any intervention aimed at reducing bilateral flattening of the head has to extend beyond the five weeks time frame (Marsden, 1980; Schwirian et al., 1986). Gel pillows when used among preterms for the first five weeks do not significantly alleviate bilateral flattening of the head is not consistent with previous research findings (Cartlidge and Rutter, 1988; Marsden, 1980; Schwirian et al., 1986). The significant, as well as the non-significant findings, are well explained.
Findings which had statistical significance revealed that nine (11%) of the subjects at the time of entry has a CI of >1.40. The suggestion is that at birth, there was already an undesirable flattening of the head, a situation requiring clinical intervention. Some limitations affecting the study are identified, such as challenges of obtaining consent and attrition (Velte & Stawinoga, 2017). Research findings are generalized to populations of infants with <1500grammes of birth weight. The results are not consistent with those arising from earlier research work since they are limited to 5 weeks.
The research findings do not confer any confidence since there is no statistical significance. The findings have elicited the desire for knowledge with more nurses in the Neonatal Intensive Care Unit seeking for more research. The findings have found a lot of use in trying to inform the public about the best form of care that can be given to infants <1500 g.
References
Beam, C. A., Berastegui, G. R. A., & Greenfield, J. P. (2017). Evaluation of Head Shape in the Pediatric Practice: Plagiocephaly vs. Craniosynostosis. In Common Neurosurgical Conditions in the Pediatric Practice (pp. 61-69). Springer, New York, NY.
Campbell, D. T., & Stanley, J. C. (2015). Experimental and quasi-experimental designs for research. Ravenio Books.
Cartlidge, P. H., & Rutter, N. (1988). Reduction of head flattening in preterm infants. Archives of disease in childhood, 63(7 Spec No), 755-757.
Gray, J. R., Grove, S. K., & Sutherland, S. (2016). Burns and Grove’s The Practice of Nursing Research-E-Book: Appraisal, Synthesis, and Generation of Evidence. Elsevier Health Sciences.
Hemingway, M. M., & Oliver, S. K. (1991). Water bed therapy and cranial molding of the sick preterm infant. Neonatal network: NN, 10(3), 53.
Hemingway, M., & Oliver, S. (2000). Preterm infant positioning. Neonatal Intensive Care, 13(6), 18-22.
Marsden, D. J. (1980). Reduction of head flattening in preterm infants. Developmental Medicine & Child Neurology, 22(4), 507-509.
Schultz, A. A., Goodwin, P. A., Jesseman, C., Toews, H. G., Lane, M., & Smith, C. (2008). Evaluating the effectiveness of gel pillows for reducing bilateral head flattening in preterm infants: a randomized controlled pilot study. Applied nursing research, 21(4), 191-198.
Schwirian, P. M., Eesley, T., & Cuellar, L. (1986). Use of water pillows in reducing head shape distortion in preterm infants. Research in nursing & health, 9(3), 203-207.
Velte, P., & Stawinoga, M. (2017). Integrated reporting: The current state of empirical research, limitations and future research implications. Journal of Management Control, 28(3), 275-320.