A Delphi survey of evidence-based nursing priorities in Hong Kong

A Delphi survey of evidence-based nursing priorities in Hong Kong

PETER FRENCH P h D , C P S Y C H O L , R N1, YIN-YU HO M B A , R N

2 and LAN-SUEN LEE B H S c ( H O N S ) , R N3

1Assistant Professor, Department of Nursing & Health Sciences, The Hong Kong Polytechnic University, Hong Kong;2Manager, The Nursing Section, The Hospital Authority, Hong Kong and 3Lecturer, The Institute of AdvancedNursing Studies, The Hospital Authority, Hong Kong

Background

The study reported here began because of an initiative

taken by a postregistration education centre within a

government hospital management system.

One of objectives of the institute was to enhance

nursing research and the major orientation was to

develop evidence-based practice rather than the

research process per se. With this in mind an Evidence-

Based Nursing Practice Project was born.

It soon became apparent that if the evidence-based

practice project were to be most effective, it would

be useful for investigators and recruiters to have

some understanding of the most important and

pressing issues that needed to be addressed within

the Hospital Authority. As such it was decided to

undertake a survey which captured the general

opinion of nurses on the most important evidence

based nursing needs.

The aim

The aim of the study was to identify and prioritize the

evidence-based nursing priorities within the Hospital

Authority. The following applications of the survey

findings were anticipated:

Correspondence

Peter French

Department of Nursing and Health

Sciences

The Hong Kong Polytechnic

University

Hung Hom

Kowloon

Hong Kong

E-mail: [email protected]

F R E N C H P., Y I N-Y U H. & L A N-S U E N L. (2002) Journal of Nursing Management 10, 265–273A Delphi survey of evidence-based nursing priorities in Hong Kong

The purpose of this study was to inform an evidence-based nursing developmentproject within the Hospital Authority, Hong Kong. It considered the specificquestion of: what are the nursing practice issues which need to be addressed as amatter of priority in order to improve nursing practice, the quality of care ordevelop some aspect of nursing practice. A three round Delphi survey was adopted.The methodological problems associated with the use of the Delphi method areaddressed. An expert panel consisting of 190 Department Operations Managers(nurses) was identified. The data collection focused on issues related to nursing skillsand client care and excluded management or educational issues. Agreed categorieswere prioritized in the final round by utilizing a 11-point rating scale. The groupmean score for each category was calculated and rank ordered. The results provided45 categories that reflected the nursing practice priorities that required more re-search evidence to guide practice. The top five ranked items were: nurse patientcommunication, resuscitation, administration of medicines, counselling and nursingdocumentation. The top 10 items were used to inform the advisory and selectionprocesses for the evidence-based practice development project.

Keywords: Delphi, evidence-based nursing, research priorities

Accepted for publication: 18 September 2001

Journal of Nursing Management, 2002, 10, 265–273

ª 2002 Blackwell Science Ltd 265

• To enable practitioners and those who support them,

to select EBP projects which were most beneficial to

patients and of most relevance to the continuous

quality improvement in the hospital.

• To facilitate the selection of principal investigators

for the evidence-based practice project.

• To assist funding bodies to decide which EBN pro-

jects are most worthy of primary research funding.

• To assist the Hospital Authority to plan EBN devel-

opment during the next 3 years.

Review

A number of previous studies have reported that the

identification of nursing research priorities can be un-

dertaken with some degree of success (Lindeman 1975,

Oberst 1978, Myco 1979, Ventura & Waligora-Serafin

1981, Bond & Bond 1982, Goodman 1987, MacMillan

1989). These studies were found to be highly context

specific. In addition the data collection processes were

not the same and systematic comparison of findings was

limited. Chronology was also a complicating factor in

that the opinions of groups of nurses will differ because

of the passage of time and the changes in the health

services and the profession that occur during that time.

The authors concluded that the findings of previous

studies were of limited value for decision-making in

Hong Kong. Although the findings of previous studies

were of limited value the research methodology was

considered to be critically important in the conduct of

the present study and it is this that will be reviewed here.

The reported studies exclusively adopted the Delphi

method to identify nursing research priorities. The

Delphi method has been defined as a method for

structuring a group communication process so that the

process is effective in allowing a group of individuals, as

a whole, to deal with a complex problem (Linstone &

Turoff 1975). Some of the distinctive features of this

research process are:

• The use of a panel of experts for obtaining data.

• Participants do not meet in face-to-face discussions.

• The use of sequential questionnaires and/or inter-

views.

• The systematic emergence of a concurrence of

judgement/opinion.

• The guarantee of anonymity for subject’s responses.

• The use of frequency distributions to identify patterns

of agreement.

• The use of two or more rounds between which a

summary of the results of the previous round is

communicated to and evaluated by panel members

(Loughlin & Moore 1979, Whitman 1990, McKenna

1994).

It has been argued that Delphi studies are all rela-

tively similar. In the first round the respondents are

asked to identify a number of issues related to the

subject at hand. Most frequently mentioned items were

returned to the respondents in subsequent rounds for

re-evaluation and comments regarding the value and

weighting of items (McKenna 1994).

Criticism of the Delphi method tends to focus on a

number of methodological problems, which can be

summarized as follows:

• Scientific respectability (McKenna 1994).

• The criterion for defining the �expert� and the com-

position of the panel (Bond & Bond 1982, Goodman

1987, Reid 1988, McKenna 1994, Williams & Webb

1994).

• Size of the panel and the response rate (Reid 1988,

McKenna 1994, Williams & Webb 1994).

• The large and unweildy amount of information the

process produces (Hitch & Murgatroyd 1983, Proc-

tor & Hunt 1994).

• The formation of the question statement for the first

round (Hitch & Murgatroyd 1983, Proctor & Hunt

1994).

• The meaning of consensus (Reid 1988, Williams &

Webb 1994).

• The feedback mechanism in latter rounds and the

effect on consensus (Goodman 1987).

Some of these issues were considered in more depth

with respect to the current research process and will be

described in more detail in the following paragraphs so as

to demonstrate how the potential pitfalls were dealt with.

Scientific respectability

This issue was considered first as it was believed to be

crucial to most of the decisions made by the research

team. This issue is covert in almost all critiques of the

method yet Mc Kenna seems to be one of the few

authors to remind us that Linstone and Turof admit

that as a research approach, the Delphi survey is more

of an art than a science. (McKenna 1994) He also

quotes Reid (1988) saying that; �she notes that as a

substitute to the qualitative approach, Delphi looks

thoroughly scientific; as an alternative to the Likert

scale it does not�. The present authors, however,

considered that most of the problems in the use of the

Delphi method originate from a lack of commitment

to �scientific rigor�. The confusion in terminology

P. French et al.

266 ª 2002 Blackwell Science Ltd, Journal of Nursing Management, 10, 265–273

associated with the concept often seems to portray this.

We have the Delphi method, approach, technique(s)

and survey. Only the last of these gives any clue about

possible links to long standing research traditions. The

orientation adopted by the present authors was that the

Delphi methodology should be considered as a

descriptive approach which adopts the principles of

survey methodology to refine the responses of a defined

population. One of the most apparent and long stand-

ing issues in this statement is that of the �defined

population� or �expert panel�.

The criterion for defining the expertand the composition of the panel

An examination of the available literature on the use of

the Delphi survey to identify research needs indicates

that many of the previous studies do not seem to

address this issue in the same way. It is not uncommon

to find that practising nurses, nurse administrators,

nurse educators, nurse researchers and non-nurses

variously fall into the category of �experts� on nursing

research needs (e.g. Lindeman 1975, Oberst 1978,

Ventura & Waligora-Serafin 1981, Bond & Bond

1982). There seems to be some inconsistency in the

decisions that are made about the most suitable nurses

to make up an expert panel on the subject of nursing

research needs. It was decided that the group best

placed in the organization to report on the subject

should define the population of �experts�. As such it was

considered that the expert panel should be made up of

key informants taken on the basis of purposive samp-

ling (Field & Morse 1985) In the current study the

expert panel was defined as nurses who:

• have every day experience and know something

about the subject of inquiry;

• are willing to express opinions about the subject of

the inquiry;

• are able to express opinions about the subject of the

inquiry.

The identification of the expert panel in previous

Delphi studies also seems to have been hindered by the

fact that operational definitions of the term �research in

nursing� are rare or at best vague. This is important

because assumptions about the term �nursing�, by both

the investigators and the informants, can contribute to a

great deal of confusion about the data that is required. If

nursing research is taken to be any research undertaken

by a nurse then the expert panel will be broadly defined

as a consequence. It will include educational and

management research and the participation of nursing

faculty and nurse administrators in the expert panel

would be plausible. It was thought to be important for

this evidence-based practice survey that nursing should

mean the interaction of nurse and client and nursing

research should mean clinical nursing research.

Size of the panel and response rates

It seems that the optimum size of �expert panels� is

uncertain merely because of the large variations in the

number of respondents reported in various studies. In

the clinical nursing research priority surveys described

above the range of respondents was from 190 to 575. In

other surveys the range has been reported as being from

as few as 10 to as many as 1685 (Reid 1988). It is

obvious that there is no clear criterion for the sensible or

useful size of an expert panel. In addition to the optimum

size of the panel there is also some concern about

response rates. Some reports seem to be affected by some

insecurity in which investigators often avoid mentioning

the response rate or even the size of the group originally

approached. It seemed to the current investigators that

the response rate is only of significance in understanding

how representative the respondents are of the identified

population of experts. Taking into consideration the

decision that key informants should be willing

respondents, then those who do not respond are clearly

unwilling and should be regarded as undesirable

informants anyway. In a Delphi survey the sample size

should only be of concern where the majority of people

approached in the first round do not respond and where

attrition exacerbates this lack of representation over the

subsequent rounds of the survey. In fact one should

question the assumption that the researcher should only

survey those who responded to the previous round.

There seems to be no sensible rationale for this at all. It

may be necessary where previous responses are being

refined and qualified but it seems illogical in the final

stages of the survey when prioritization is taking place. It

will be observed later that the authors broke from the

precedent of surveying respondents only from previous

rounds for this very reason.

The large and unwieldy amount of data

This is largely to be expected when using qualitative

data. The most important effect of this in a Delphi

survey, however, is the effect on the second round

response rate. All respondents in the first round gener-

ally receive all of the responses from their peers in the

second round. The perusal of such data can provide a

daunting task for the second round informants and may


ª 2002 Blackwell Science Ltd, Journal of Nursing Management, 10, 265–273 267

be responsible for a further decline in response rate.

One of the ways in which this can be avoided is by

analysing the data using judges who categorize the data

independently and come to a consensus on a final cat-

egory list. In the current study the three members of the

research team did this. The process largely consisted of

removing duplications and items of identical meaning,

and items that were considered to be education or

administration focused.

The formation of the question statementfor the first round

Previous studies on nursing research priorities often

demonstrate variations in the question statement

adopted for the first round. Three of the most influential

studies, i.e. Goodman (1986) Bond & Bond (1982),

Lindeman (1975), adopted the question first used by

Lindeman. Respondents were asked to give what were

considered to be �burning issues for research develop-

ment in nursing� (Goodman 1987). For the present

study the use of the word nursing was considered to be

too vague. Does it mean research conducted by nurses,

on nurses, about nursing or of relevance to nurses? Is

administration and nurse education considered as nur-

sing? There were many contentious answers to these

questions and the research team had to make the

decision that the definition of nursing practice resulted

in the exclusion of nurse education, organizational

management and administration topics.

By taking account of the aims of this survey the

following research question was formulated. What are

the nursing practice issues that need to be addressed as

a matter of priority in order to improve nursing

practice, the quality of care or develop some aspect of

nursing practice? This research question was consid-

ered to operationalize the concept of evidence-based

nursing practice without actually using the term. The

reason that it was not considered acceptable was that

it was a relatively new term to most practitioners and

it was felt that its use may unnecessarily confuse the

informants.

The pilot study, described later, indicated that

respondents needed to be reminded that nursing prac-

tice as opposed to education and administration was the

focus of the survey.

Research design

Three rounds of data collection were found necessary

because they aimed to achieve three sequential

processes of generating, categorizing and prioritizing

the research issues.

First round (generating)

The purpose of the first round was to generate sugges-

tions for evidence-based practice research by giving one

stimulus question to encourage a �brainstorming� effect.

In the first round it was considered important to

emphasize the clinical practice aspect as the first round

question fixes the focus of the subsequent rounds.

The induction statement used for the first round was:

�Please note that this is a survey of CLINICAL

NURSING PRACTICE research priorities which fo-

cus on issues related to nursing skills and client care,

NOT management or educational research priorities.

We assume your answers also reflect the experience

of nurses in your team because of your central

position�.

Question:

�What are the common nursing practice issues

which your team experiences and which would

possibly benefit from further systematic enquiry?�

Second round (evaluating)

Using the responses from the first round a list of cat-

egories were generated. This round of the survey aimed

to produce the most representative list of categories by

asking the informants to comment on the appropriate-

ness of the categories identified by the analysts and to

make suggestions for renaming the categories if neces-

sary. The informants were also asked to give additional

research categories if they thought there were any seri-

ous omissions.

The second round aimed to refine the categories by

asking informants the question:

Do any of the following categories need renaming in

order to describe the research issue better?

Third round (prioritizing)

In this round the agreed and refined categories were

presented to the informants for them to prioritize by

rating each one on an 11 point scale.

The research team decided to include examples of

actual responses received in round one to better illus-

trate each research category. A maximum of three

examples for each category was provided. The whole

population of the defined expert panel (195 DOMs)

were invited to take part in this round.

P. French et al.


Data collection

The informants

In selecting the �expert� panel it was decided that the

informants should have some knowledge of nursing

research principles and some aspect of their job should

require that they are conscious of nursing research and

development in their role. A further requirement was

that the expert panel should represent all areas of

nursing practice within the Hospital Authority. Given

that it was felt inappropriate and impractical to survey

the whole nursing population it was necessary to

identify the group who were key informants and best

placed to understand nursing team perceptions of

clinical research issues. The group identified consisted

of Department Operational Managers, who in the

Hospital Authority were all nurses. Department

Operational Managers are unit nurse managers who

are responsible for an average of three to four wards

or similar units. They are accountable to a Chief of

Service who is invariably a physician and a General

Manager (Nursing). It was believed that this popula-

tion was the most appropriate choice as they were

ubiquitous, most likely to have higher educational

qualifications and had responsibility for promoting

continuous quality improvement within a clinical

management system.

The pilot study

A pilot study on the first round was thought to be

necessary for two reasons. First to test the effect of

the opening question and secondly test the commu-

nicability of the round one questionnaire and the

covering letter and thirdly to estimate the ease of

return and the consequent response rate of the target

group. Many of the suggestions given by respondents

were inappropriate to the purposes of the survey, in

that they were related to management/administration

or nurse education. A second pilot study was

conducted in order to test the effect of modifications

which had been made to focus on the informants on

clinical practice and client care. This stated explicitly

that management and educational issues were not

required in this survey. Although the actual data

collection procedure still produced some irrelevant

responses these were dramatically reduced as a con-

sequence of the pilot studies.

Results

Informant compliance and response rates acrossthe survey

The expert panel consisted of 195 Department Opera-

tions Managers. All of them were approached in round

1. The response rate for round one was 69% (n ¼ 135).

The 135 respondents from round 1 were approached

for round 2. The response rate was 83% (n ¼ 113). To

increase the subject pool the research team decided to

approach the whole of the expert panel again. A 73%

response rate was achieved (n ¼ 144). Forty-three per-

cent of the expert panel (n ¼ 84) responded to every

round and 88.2% of them (n ¼ 172) participated in at

least one round.

First round analysis

The analysis

In order to eliminate a small proportion of irrelevant

responses the three researchers independently judged

whether the responses were speciality specific (i.e.

would not be relevant in any other field) and whether

they were management or education oriented rather

than practice related. The majority view was then

accepted in every case (i.e. 2 of 3) The suggestions were

then grouped together to form common categories by

one researcher and the other two gave opinion on the

acceptability of the categories produced. The categories

produced were then collated and utilized as the basis of

the second round.

A total of 600 items were received from 135

respondents. The items were then rationalized by three

researchers independently and the consensus category

list was utilized as the basis for the second round data

collection.

Second round analysis

There was an 83% return rate to the second round of

survey. All the suggestions on renaming the categories

were compiled. The research team refined the categories

accordingly. Some categories, e.g. sleep care, health of

Table 1Target panel and response rates at each round of the survey

Round Target panelTotal number ofrespondents Response rate

Round 1(generation)

195 135 69%

Round 2(categorization)

135 113 83%

Round 3(prioritizing)

195 144 73%



Table 2Rank order of research priorities according to the mean

Rank Category Examples (as stated by respondents) Mean SD

1 Nurse/patient communication • Skills & concept of nurses 8.07 1.65• Effect on patients' satisfaction & compliance• Skills in breaking bad news

2 Resuscitation • Nursing competency 7.99 2.113 Administration of medicine • Causes of medication error 7.77 2.234 Counselling • Nursing competency on counselling 7.72 1.74

• Needs of patients in long-term illness• Needs of the carers

5 Nursing documentation • Nurses' skill 7.68 2.04• Staff confidence

6 Pain management • Various relief methods 7.64 1.89• Assessment of non verbal cues• Choice of analgesia

7 Wound management • Frequency of dressing 7.61 1.95• Choice aseptic lotion• Wound healing by different dressing methods

8 Pressure sores prevention& management

• Norton score and any other score system 7.39 2.22• Comparison of pressure relieving device• Developing of protocol

9 Clinical risks • Prevention of fall in geriatric patients 7.25 2.08• Patients' feeling towards restraint• Incident reports review

10 Infection control • Gowning of visitor before entering ICU 7.16 2.21• Hospital acquired disease• Staff knowledge on universal precaution

11 Post-operative care • Stress & recovery 7.07 2.02• Pain relief• Counselling

12 Patient education • Paediatric asthmatic 7.02 1.95• Effect of training programme on MH patients• Learning needs of cancer patients

13 Caring behaviour • Perception difference between nurse & patient 6.93 2.3214 Occupational hazard • Needle-prick injury 6.9 2.11

• Staff awareness• Nurses' perspective on chemotherapy & radiation hazard

15 Health assessment • Nurses' competency in interpreting assessment data 6.88 2.28• Develop a psychiatric clinical assessment tool• Validate assessment tool for psychogeriatric patients

16 Observation skill • Vital sign 6.88 2.4317 Pre-operative care • Effect of preoperative visit 6.86 2.22

• Relationship between preoperative skin care & wound infection• Choice of disinfecting lotion

18 Rehabilitation & recovery • For incontinence patients 6.85 2.03• Prevent & delay the cognitive deterioration in demented patients• Motivation of the long stay chronic patient to takepart in the rehabilitation programme

19 Patient comfort • Nurses' role 6.8 2.08• Needs in attending personal hygiene of patients

20 Ethical decision-making • Relationship between nurses code of ethic & decision-making 6.8 2.1• On withdrawing treatment of terminally ill patients• Relatives' & nurses' perspective in Euthanasia

21 Loss & Bereavement • Debriefing for nurse & patient 6.79 2.05• On Chinese family

22 Patient anxiety & stress • Release of anxiety of elderly by touching & company 6.77 1.77• Need to face court hearing & charges for criminal offences• Stress copying of carers

23 Care delivery model • Relation between individual care delivery system and 6.76 2.19patient's length of stay

• Evaluate the quality of client care after implementingthe Name Nurse System

• Case management & the CPNS

P. French et al.


Table 2Contd.

Rank Category Examples (as stated by respondents) Mean SD

24 Oxygen therapy • Safety & comfort 6.7 2.13• Proper administration

25 Support to family & carer • Improving the success rate in long-term care by giving 6.63 2.04support to the carer

• Ways to decrease parental stress & anxiety when theirchildren are admitted

• Recovery process of relatives from traumatic experience26 Patient satisfaction • Patients' satisfaction survey 6.58 2.3227 Quality of life • Impact of physical disability 6.55 2.15

• In terminally ill cancer patients• For long stay Schizophrenic patients

28 Care of patients with catheter • Frequency in changing an indwelling catheter 6.52 2.05& drainage tubing • Bladder training by regular clamp & release method

• Use of normal saline in endotracheal tube suctioning29 Management of problem • Interpersonal skill of nurses 6.51 2.32

• Use of behavioural modification30 Family support & care • Effect of parents' touch on high risk infant 6.49 2.15

• Sibling visit in PNICU• Mother accompany children undergone anaesthesia

31 Psychosocial care • Non pharmacological approach in treatment of mental patients 6.37 2.16• Psychosocial intervention on chronic mental illness• The importance in the psychosocial care of patients

32 Venepuncture & infusion • Improve the technique in blood taking 6.36 2.3• Effect of using 5% dextrose in IV infusion• Frequency in changing the IV set

33 Support groups • Effect on parents with very low birth weight babies 6.35 2.16• Role of self help group in renal rehabilitation• Impact for cancer patients

34 Positioning & lifting • On cardiovascular & pulmonary functions 6.34 2.12• Frequency of position turning in unconscious patient

35 Continence care • Bladder training 6.3 1.91• Use of laxative• Bowel preparation for intestinal investigation & surgery

36 Hospice care • Needs of the dying patient 6.28 2.19• Effect of hospice care

37 Deliberate self harm • Causes of teen suicide 6.21 2.19• Causes of suicide in elderly & intervention• Suicidal risk inventory

38 Preparation for discharge • Relationship with high failure rate of HWH & SWS placement 6.21 2.21• Effectiveness of telecare• Effect on reducing anxiety & readmission rate

39 Exercise & mobilization • Effect of early ambulation 6.13 1.84• Selection of patient• Early ambulation & bone healing

40 Admission of patients • Evaluation on preadmission service 6.13 2.22• Effect on patients' compliance & co-operation• Needs of emergency case & clinical case

41 Environmental effect • Family environment on health of high risk infant 6.09 2.18• Hospital environment fostering dependency or independenceof patients

• How hospital environment affecting the psychological wellbeing of patients

42 Stroke management • Nursing care for stroke patients 6.08 2.14• Provision of individual designed wheel chair

43 Patient adaptation • To change of body image 6.08 2.2• To disability• To chronic illness

44 Patient violence & aggression • Causes and implication 6.07 2.3• Alternatives in violence management

45 Ventilator breathing • Humidifier temperature 6.06 2.15



China migrants, alternative medicine, patient advocate,

organ donation were added, some categories were

deleted and some were combined. The list of research

categories was finally reduced to 65 items.

Third round analysis

A total of 144 responses were received. The research

priorities were ranked according to the mean score of

each category. Table 1 shows the rank order of mean

scores of the categories for the whole set of informants.

Table 2 gives the category along with three examples of

each category in the exact words used by informants.

Only items with mean scores of 6.0 and above were

considered priorities. This criterion is the mid-point of

the 11-point rating scale adopted for the third round.

Discussion

It is believed that the findings produced reliable and

valid data to achieve the purposes of the survey. It is

uncertain whether a survey of �bedside� practitioners

would have given a radically different result. Given that

the �expert panel� is in a better position to act on the

findings of the survey because of their key position in

the system it was believed that their perception would

be more valid in the area of policy decision-making and

implementation. Confidence in the reliability of the

findings was believed to be rooted in the successful

specification, and response rates of the �expert panel�.Reports of this level of participation are rare in other

Delphi surveys and some success in this study could be

attributed to the definition of the expert panel as �key

informants within the organization�. The utility of the

data seems to have been maximized by focusing the

study question on clinical nursing practice. Because of

the shaping of the first round mind-set and its rein-

forcement in subsequent rounds it seems that the

accuracy of responses was enhanced at every stage.

Conclusion

The survey provided a list of evidence-based nursing

research needs and the top 10 were adopted as priority

areas. The following advice was given by the research

team and numbers 1, 2 & 4 acted upon immediately by

the Hospital Authority Head Office Nursing Section to

guide the process of promoting evidence-based nursing.

• The overall list should contribute towards the nursing

sections decisions on nursing practice research pri-

orities.

• The top 10 lists should be used to recruit researchers

to the evidence-based practice project one as a sti-

mulus for the generation of research projects in the

priority areas and two as one criterion for accepting

projects on a preferential basis.

• A repeat of round 3 of this survey should be con-

ducted on a random sample of RNs in the hospital

authority in order to check the reliability of the

findings of this study.

• Delphi surveys should be undertaken to identify

nursing management and nursing education research

priorities.

• These surveys should be repeated every 3 years to

keep track of the changing perceptions of EBN pri-

orities.

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A Delphi survey of evidence-based nursing priorities in Hong Kong

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