Contribution Of Ethic Education To Ethical - A Critique

Discuss about the Contribution Of Ethic Education To Ethical.

Resuscitation, endotracheal intubation (ETI) is an important technique utilized for securing proper passage of airway under pre-hospital emergency settings (Eich et al. 2009). However, lack of regular practise of ETI hampers the competence of the medical nurse to carry-out the ETI process (Kim et al. 2014). Moreover, lack of proper exposure to the ETI process results in high rate of failure. ETI under paediatric set-up is a difficult skill to learn and execute. This is because the anatomy of the pulmonary airway of the children is different from those of the adults and standard adult Macintosh laryngoscope is not suitable for the children (Kim et al. 2014). For children Miller’s laryngoscope blade is commonly used and these also demands high-end skill. Moreover, through this direct laryngoscopy, it is impossible to visualise the glottis of the child. In order to overcome the limitations video or optical laryngoscopes can be used (Kim et al. 2014).

This assignment is important because it aims to provide a detailed critique of a research paper that is based on the intubation under paediatric set-up. The required findings of the study will help in the refinement of the laryngoscope procedure undertaken before ETI for pulmonary airway management. The results will also help to reduce the risks or the chances of failure associated with the process of laryngoscopy among the children. Moreover, the study will help to project a laryngoscopy technique in such a way that it can be easily to conducted by a medical staff without facing much hassle or in-depth requirement of laryngoscope instruments handling skills. 

The review of literature was conducted on the basis of the relevant, authentic and recently published articles. The articles were selected from the electronically from the databases like PubMed and Medline. The main keywords that are employed for the Boolean search of the research articles from the electronic databases include intubation AND laryngoscope, optical laryngoscope AND video laryngoscope, children OR child, paediatric, resuscitation, laryngoscope AND randomized control trial, laryngoscope AND miller laryngoscope, child AND cardiopulmonary resuscitation. Only studies, which are centred on the effect of laryngoscope over the human children during the last 15 years, were chosen for the study. According to the reports published by Parahoo et al. (2006) the selection of the keywords should be done in such a way that it highlights the topic of interest. The research articles which are chosen on the basis of the keyword search are scrutinized on the basis of their abstract in order to ascertain the relevancy of the topic discussed in the main body. The detailed inclusion and exclusion criteria, which considered while studying the abstracts, are discussed below.

Critique of research rigor

The paper was selected for critical analysis because it compared four commonly used yet popular intubation devices namely McGrath, AirTraq, GlideScope and Miller under a stimulated scenario of paediatric cardiovascular resuscitation. This study thus can effectively be considered as a unique randomized control research in the field of paediatriclaparoscopy. Novel approach and comparative analysis undertaken in this research design further made it unique as no one before conducted this similar kind of study in this field. Moreover, this comparative study helped in the elucidation of the success rate, time requirement and the efficacy of optical or video laparoscope in comparison to the commonly used Miller’s laryngoscope blade. The results of the study will help in the refinement of the intubation under paediatric set-up. Moreover, the study also aims to decrease the rate of failure or fatal threats associated with laparoscopy before intubation in paediatric conditions thereby helping to provide quality care to the children. 

The aim of the study undertaken by Szarpak et al. (2015) is to perform a comparative analysis in order to ascertain the efficacy of different available video laryngoscopes with Miller laryngoscope during the emergency intubation required atthe time of paediatric cardiopulmonary resuscitation. The aim of the study is clearly discussed as is extremely relevant in present day scenario. According to Eichet al. (2009), paediatric intubation is a complex skill to learn and demands continuous exposure to the said practise in order to maintain the competence. Leone, Rich and Finer (2005)further opined that lack of practise or exposure results in high rate of failure and this failure rate is independent of the professional background of the intubator. Moreover, paediatric intubation done via using traditional process, Miller's laryngoscope blade, does not enable the intubator to view the glottis of the child clearly (Menges and Crown 2005). On the other hand advanced video laryngoscopes enable complete visual coverage of the glottis and thereby aiding to avoid the associated complications of intubation (Kim et al. 2014) Thus the aim of the study conducted by Szarpak et al. (2015) will help to evaluate the efficacy of two techniques underthe parameter of ease of access and efficacy and the subsequent results will help to generate a refined approach for paediatric intubation during cardiovascular resuscitation.

The title of the study conducted by Szarpak et al. (2015) says, “Comparison of intubation through the McGrath MAC, GlideScope, AirTraq, and Miller laryngoscope by paramedics during child CPR: a randomized crossover manikin trial”. Thus the study title of Szarpak et al. (2015) succinctly describes the purpose of the study, methodology undertaken to conduct the study and the chosen group over which the study was designed to be conducted. This kind of formulation of the title by Szarpak et al. (2015) goes in accordance with the concept of research paper published by Parahoo et al. (2006). According to Parahoo et al. (2006), the title of the study must be designed in such a way that it at once gives the important highlights of the study to the readers. An ideal study title must clearly highlights the target group of the study, the aim of the study and the methodological approach (Parahoo et al. 2006). Apart from the study title, the abstract framed by Szarpak et al. (2015) also provide the readers a rough overview of the entire study without any miss of the crucial points. Szarpak et al. (2015) divided the abstract in to four parts including background, methods, results and conclusion. Each part of the abstract is written in a consisted manner, however, not missing any important detail of the study. The framing of the abstract further satisfies the concept opined by Parahoo et al. (2006) in the domain of abstract writing.

Determination of the sample size is a crucial part of any research study because sample size helps in determining the significance of the statistical analysis (Suresh and Chandrashekara 2012).  The participants of the randomized crossover trial conducted by Szarpak et al. (2015) included the resuscitation trainees of the International Institute of Rescue Research and Education (Warsaw, Poland) who have no known prior experience in the process of paediatric intubation with video laryngoscopes but have previous exposure ro conventional Miller laryngoscope. Szarpak et al. (2015) included total of 102 paramedic trainees.Parahoo et al. (2006) is of the opinion that it is the duty of the researcher to clearly state that number and the nature of the focus group or the sample that has been selected for the study. According to Parahoo et al. it helps in the refinement of the external accuracy of the experiment while retaining the universality of the study. Szarpak et al. (2015) have also documented the age, gender, level of education and experience under workplace settings of each of the participants of the focus group separately and have represented the process of sample recruitment via a flow-chart based on CONSORT statement. According to Ross (2012) differential classification of the focus group or the respondents on the basis of their gender and age further helps in the refinement of the data analysis and the obtained results and this in turn help to increase the quality of the study.

According to research report published by Parahoo et al. (2006), blinding is acrucial part of randomizedcontrol trial. It is undertaken in order to prevent unconscious and conscious bias. LoBindo-Wood and Haber (2014) further stated that selection of randomization as the main process for conducting a research study is beneficial because randomization helps in the reducing the selection and the confounding bias such that the participants of the study become the true representatives of the selected group of population. Study conducted by Szarpak et al. (2015) selected the candidates for the focus group under strict inclusion and exclusion criteria. This helped to reduce the outcome reporting bias arising out of incomplete reporting while ensuring both representativeness and homogeneity of the sample (Greenhalgh 2014). Selected participants of the study conducted by Szarpak et al. (2015) who have prior experience with Miller laryngoscope were given 45-minute training on anatomy of the paediatric respiratory system and techniques employed in video laryngoscopes. After training with each device of the video laryngoscopes, participants were allowed to take a 20-minute rest followed by intubation test. In order to avoid observation based learning effect, participants were not allowed to view each other during the time of the test.According to Greenhalgh (2014), this approach furnishes two different meaning of ascertaining the outcomes that arecapable of reducing the chance of bias while increasing the accuracy of the findings.The demographic of the participants were kept identical in terms of experience and this gain helps in the improvement of the overall accuracy of the outcomes (Parahoo 2006). Ross (2012) further opined that accuracy and dependability of tests could be increased via proper handling of the participating individuals in an identical manner. This helps in decreasing the influence of confounding variables. However, Szarpak et al. (2015) did not mentioned that whether the participants were completely blinded about the aim of the study while they are asked to filled a questionnaire about their experience while taking the test. According to Greenhalgh (2014), blinding of the participants of the focus group help in the reducing the bias effect of the study.

The exclusion-inclusion criteria of prospective focus group selection were clearly stated in the study. The study here excluded women who are suffering from diabetes, preeclampsia, obesity, hypertension and multiple pregnancies. According to Ross (2012), the criteria of inclusion and exclusion must be stated clearly. Greenhalgh (2014) further opined that determination of these guidelines helps to increase the accuracy of the study.

The study of Szarpak et al. (2015) observed proper ethical regulations that are required to carry out randomize control study (Thompson et al. 2006). Szarpak et al. (2015) haveincluded the participants of the study only after taking a written consent from all the 102 participants. Required approval from the concerned authority was taken over the randomised crossover trail design of the study before initiation. The aim of the research satisfies the ethical principal of non- malfeasance which states that the healthcare professionals must not provide ineffective treatment that has chances to harm the patients (Parahoo 2006).

Szarpak et al. (2015) used R statistical package for Windows and the obtained results were represented via mean standard deviation or absolute percentage or numbers. Wilcoxon signed rank test was again used to verify the results. McNemar test was employed to analyse the possible difference in the success rate of the study and multivariate regression analysis models were employed to analyse the impact of age, sex, work-experience and education level over the efficacy of the blind intubation. P value of less than 0.5 was considered to be statistically significant.Ross (2012) stated that use of more than one statistical tests is helpful to comparison the results in order to evaluate the significance.

According to Parahoo (2006), it is the duty of the researcher to discuss the limitations of their own study. Szarpak et al. (2015) highlighted Manikin approach as the main limitations of their study this is because Manikin studies can never fully substitute the studies carried over the human models. Moreover Szarpak et al. (2015) stated that the intubation devices used have not been compared under the situation of randomized, crossover and controlled trial. 

The results of the statistical analysisperformed by Szarpak et al. (2015) showed that the success rate of the endotracheal intubation (ETI) video laryngoscopes was higher than direct laryngoscope done via using Miller Laryngoscope. The statistical significance of AirTraq, GlideScope and McGrath in comparison to Miller Laryngoscope include P

The guidelines of the European Resuscitation Council (2010) emphasizes the delivery of continuous compression of chest within a few interruptions as possible encompassing frequent break for airway management efforts. An airway management effort is considered to be an essential factor in both pre-hospital and in-hospital paediatric intubation. However, intubation is a technically challenging skill to learn and demands continuous exposure to the process in order to prevent the deterioration of the skill Hubble et al. (2010). Here lies the main physiological implication of the study as it helps in the elucidation of a new yet innovative technique for paediatric intubation. Video (McGraph or GlideScope) or optical laryngoscopes (AirTraq) is easy to operate under paediatric set-upand does not demands regular practise to prevent skill deterioration and is quick to execute (Szarpak et al. 2015).According to Manica et al. (2013) prolong length of the intubation done via the use of the traditional laryngoscopes results in the development of the laryngeal lesions along with the increase in the incidence of subglottic stenosis. Thus application of the video or optical laryngoscopes will help to reduce the chance of developing paediatric complications during intubation. Moreover, according to Fiadjoe et al. (2016), direct yet prolong laryngoscope procedures in paediatric set-up is associated with numerous complication and thus proper assessment of the larynx via video laryngoscope and then triggering the intubation will help to avoid complications under paediatric set-up.

According to European Resuscitation Council (2010), team of nurse who are under the resuscitation team should be concerned in ensuring the safety of the patient. The ground of patient safety and subsequent comfort falls under the principal duty of the nurse operating the patient. According to Hazinski (2012), it is the duty of the nurse to assure the comfort and the safety of a child during any form of treatment as children are unable to express their sense of discomfort clearly. Hence forming intubation via video or optical laryngoscope will help to reduce the discomfort of the children. Moreover, according to the reports published by Szarpak et al. 2015, video laryngoscope is fact and accurate technique and thereby further helping to reduce the children level of discomfort.  The use of the optical or video laryngoscope goes in favour of the ethical principle of beneficence and non-malfeasance (Cannaerts, Gastmans and Casterlé 2014). According to the ethical principle of beneficence, it is the duty of the healthcare professionals to provide maximum benefits to their clients and thereby contributing health and well-being (Cannaerts, Gastmans and Casterlé 2014). The reports published by Szarpak et al. 2015 revealed that video or optical laryngoscopic technique is more superior to the Miller’s laryngoscope blade as it is fast and helps in the proper view of the glottis and hence reducing the complications of intubation and thus providing comfort and benefit to the child. The use of optical or video laryngoscope technique also goes in accordance to the ethical principle of non-malfeasance, which promotes obligations towards intentional harm (Cannaerts, Gastmans and Casterlé 2014). 

Conclusion

Thus from the above critical analysis of the research paper published by Szarpak et al. 2015 it can be concluded that optical or video laparoscopy is one of the best suited methodsduring the emergency situation in hospitals. It can be considered as a safe and alternative for other conventional method used for paediatric endotracheal intubation (ETI). Thestudy further stated McGrath, GlideScope, and AirTraq intubation devices are fast, safe, and easy to use. The use of the optical or video laryngoscope technique does not cast any intentional harm to the child on contrary it helps to undertake refinement of the intubation technique, reducing the child’s harm from the long-term therapy. Thus the study eliminates the requirement of expertise skills and regular practise of laryngoscopy by the medical staffs in order to avoid unsuccessful cases of ETI. Moreover, different laryngoscope approach is required for children because of the different anatomical of the children’s throat in comparison to that of the adults. Miller’s laryngoscope fails to view the glottis of the children clearly. The use of video laryngoscope will promote clear view of the glottis of the child and thus eradicating the complications arising out of prolong intubation. Within the stated limitations of a randomized manikin study, this researchproposes that inexperienced healthcare professionals might earn certain benefit from using video laryngoscope devices during emergency airway management of a child. However, it must be taken into consideration that endotracheal intubation (ETI) must be preferably done under the controlled supervision of the experienced physicians and paramedics. The study is unique in the domain of paediatric intubation and proposed advancement in this domain. The study scores high in the grounds of title formation, compact abstract framework, selection and elaboration of sampling methods, statistical analysis and elimination of the confounding bias. However, study could not highlight that whether the participants were aware about the aim of the study as this may also impose a bias effect on the end results.

References

Cannaerts, N., Gastmans, C. and Casterlé, B.D.D., 2014. A contribution of ethics education to the ethical competence of nursing students: educators’ and students’ perceptions. Nursing ethics, 21(8), pp.861-878.

Eich, C., Roessler, M., Nemeth, M., Russo, S.G., Heuer, J.F. and Timmermann, A., 2009. Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians. Resuscitation, 80(12), pp.1371-1377.

Fiadjoe, J.E., Nishisaki, A., Jagannathan, N., Hunyady, A.I., Greenberg, R.S., Reynolds, P.I., Matuszczak, M.E., Rehman, M.A., Polaner, D.M., Szmuk, P. and Nadkarni, V.M., 2016. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. The Lancet Respiratory Medicine, 4(1), pp.37-48.

Greenhalgh, T., 2014. How to read a paper: The basics of evidence-based medicine. John Wiley & Sons.

Hazinski, M.F., 2012. Nursing Care of the Critically Ill Child-E-Book.Elsevier Health Sciences.

Hubble, M.W., Brown, L., Wilfong, D.A., Hertelendy, A., Benner, R.W. and Richards, M.E., 2010. A meta-analysis of prehospital airway control techniques part I: orotracheal and nasotracheal intubation success rates. Prehospital Emergency Care, 14(3), pp.377-401.

Kim, Y., Kim, J.E., Jeong, D.H. and Lee, J., 2014. Combined use of a McGrath® MAC video laryngoscope and Frova Intubating Introducer in a patient with Pierre Robin syndrome: a case report. Korean journal of anesthesiology, 66(4), pp.310-313.

Langford, R. and Young, A., 2013. Predicting NCLEX-RN success with the HESI Exit Exam: Eighth validity study. Journal of Professional Nursing, 29(2), pp.S5-S9.

Leone, T.A., Rich, W. and Finer, N.N., 2005. Neonatal intubation: success of pediatric trainees. The Journal of pediatrics, 146(5), pp.638-641.

LoBiondo-Wood, G. and Haber, J., 2014.Reliability and validity. Nursing research-ebook: Methods and critical appraisal for evidencebased practice. Missouri: Elsevier Mosby, pp.289-309.

Manica, D., Schweiger, C., Maróstica, P.J.C., Kuhl, G. and Carvalho, P.R.A., 2013. Association between length of intubation and subglottic stenosis in children. The Laryngoscope, 123(4), pp.1049-1054.

MengesJr, J.E. and Crown, L.A., 2005. Doctor, which type of blade do you want to use now? A Brief History and Review of Direct Laryngoscope and Laryngoscope Blades. Am J Clin Med, 2(2).

Parahoo, K. 2006. Nursing research : principles, process and issues. London: Palgrave Macmillan

Ross, T., 2012. A survival guide for health research methods.McGraw-Hill Education (UK).

Suresh, K.P. and Chandrashekara, S., 2012. Sample size estimation and power analysis for clinical research studies. Journal of human reproductive sciences, 5(1), p.7.

Szarpak, L., Karczewska, K., Evrin, T., Kurowski, A. and Czyzewski, L., 2015. Comparison of intubation through the McGrath MAC, GlideScope, AirTraq, and Miller laryngoscope by paramedics during child CPR: a randomized crossover manikin trial. The American journal of emergency medicine, 33(7), pp.946-950.

Thompson, I. E. et al. 2006. Nursing Ethics. 5th ed. Edinburgh ; New York: Churchill Livingstone Elsevier.

Tobias, J.D., 2015. Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes. PediatricAnesthesia, 25(1), pp.9-19.

White, M.C., Marsh, C.J., Beringer, R.M., Nolan, J.A., Choi, A.Y.S., Medlock, K.E. and Mason, D.G., 2012. A randomised, controlled trial comparing the Airtraq™ optical laryngoscope with conventional laryngoscope in infants and children. Anaesthesia, 67(3), pp.226-231.