Effects Of Continuous Respiratory Monitoring In Respiratory Patients: A Randomised Controlled Trial

Proposed Title
Effects of continuous respiratory monitoring in respiratory patients: A randomised controlled trial.
In acute situations, respiratory rate is a vital sign with an unremarkable significance that can, foresee patients' mortality rate and need for invasive ventilation. Many studies have found that recording of respiratory rate at a low frequency is consistent with the result of others. Possible cause for the variance in respiratory rate collection incidences may include the general lack of a respiratory rate assessing device outside the ICU and other close-monitoring settings.
Aims: The purpose of this study will be to determine whether continuous electronic monitoring of respiratory rate will benefit respiratory patients during their first 72 hours of admission and its impact on the adverse events.
Design: A randomised controlled trial ' single blinded study will be used to conduct this study.
Setting: The study will be conducted in one general medical ward during the period of March 11th to July 11th 2014, of an urban teaching hospital (Box Hill) with an annual audit census of 48,000 visits.
Method: Patients who met the inclusion criteria will be randomised to one of the two groups. Following their admissions, these patients will be monitored according to either the standard practice or the experimental protocol. In the control group, patients' respiratory rates will be monitored by the standard practice and those in the experimental/study group, respiratory rates will be monitored electronically. Data collection will include patient demographics, medical and surgical history, routine observation including the respiratory rate, the number and type of adverse events and the number patients with adverse events during the first 24 h and 72 h after randomisation and the number of acute changes in treatment for both groups and number of escalation of care.
Outcome Measures: Continuous recording of respiratory rate in respiratory patients will reduce the adverse events will be the measure. A cost effective analysis will also be undertaken. Participants will be notified about the findings as well as the nursing leadership team. The research paper will also be submitted to a professional nursing journal for publishing.


Across the health care systems, monitoring critically ill patients and recording their vital signs are considered to be a routine procedure (Hong et al., 2013). Even though it is a simple bedside task to perform, many clinicians fail to record it accurately despite its usefulness in clinical decision making (I. Smith, Mackay, J., Fahrid, N & Krucheck, D., 2011). From the literature accessed, it was evident that respiratory rate is the least recorded variable among the vital signs (Butler-Williams, Cantrill, & Maton, 2005). One study found that, many in patients showed a mean respiratory rate of 29+/-1 per minute and had their respiratory function deteriorated at least 8hours prior to cardio-pulmonary arrest (Schein, Hazday, Pena, Ruben, & Sprung, 1990). Another researcher highlighted that majority of times clinicians record respiratory rate between 18-22 breaths per minute in observation chart where the real rate would be 11-30 breaths per minute (Kory, 1957).Many researchers highlighted that elevated respiratory rate has remained as a strong and reliable predictor of deterioration and cardiac arrest in internal medicine patients (Fieselmann, Hendryx, Helms, & Wakefield, 1993; Subbe, Davies, Williams, Rutherford, & Gemmell, 2003). The focus of this study is to find out continuous electronic respiratory monitoring will benefit the respiratory patients in reducing the adverse events during their first 72 hours.
Background Information
During hospitalisation, monitoring vital signs in sick patients are unavoidable, as they play an integral part in clinicians' decision making to prevent adverse events (Evans, Hodgkinson, & Berry, 2001). Vital signs comprise of blood pressure, pulse rate, respiratory rate, temperature and oxygen saturation which have been and are still the main aspect of clinical assessment. Even though these vital signs are considered as 'vital', regrettably, these are not monitored accurately and sometimes can be misleading (Ahrens, 2008). Many studies highlighted, among the vital signs, respiratory rate is the least recorded vital signs despite its importance in detecting subtle changes in patient's condition (S. Smith, Fraser, J., Plowright, C., Dennington, L., Seymour, P., Oliver, G. & MacLellan, C., 2008). Changes in respiratory rate is thought to be a highly reliable and sensitive indicator of early deterioration in patients(Parkes, 2011), but many researches have shown that, respiratory rate as the least recorded and the poorly documented vital sign even when patients are diagnosed with respiratory conditions(Cooper & Buist, 2008).
Many hospital in patients who suffer from unexpected cardio-pulmonary arrests show signs of early deterioration 24 hours prior to arrest (Buist, Bernard, Nguyen, Moore, & Anderson, 2004). Patients who have compromised airway function are at risk of rapid deterioration. Early detection in patient's condition can prevent rapid deterioration and serious adverse effect by monitoring physiological changes (National Patient Safety Agency (NPSA), 2007). According to the National Institute for Health and Care Excellence (NICE) (2007), 'respiratory rate is the best indicator of a sick patient and it is the first observation that will indicate a problem or deterioration on condition'. It is therefore crucial that all clinical staff especially nursing staff is confident in recording respiratory rate accurately.
However, respiratory rate is the only vital sign that still monitored manually in acute clinical setting across the health care system (Lovett, Buchwald, Sturmann, & Bijur, 2005). Manual measurement of respiratory rate can be challenging and nurses can be least bothered to measure it because more time and effort is needed to measure the variable accurately (Philip, Richardson, & Cohen, 2013). Non-invasive machine for monitoring respiratory rate can relieve nursing staff of collection of some vital signs information, reducing workload and associated stress and reducing the impact of human error (Donnelly et al., 2013).
Currently the researcher's institution practices standard monitoring of respiratory rates in high risk medical patients outside ICU and high dependency unit. Patients with serious co-morbidities are increasingly allocated on general wards. As patient's acuity has increased, it has a negative impact on patient care. Patients with composite health issues are more likely to suffer rapid physiological deterioration that often can be preventable if optimal care is provided (Cretikos & Hillman, 2003). CRITICAL LITERATURE REVIEW
Search Strategies
To identify relevant published article through a thorough systematic databases, a literature search strategy was used. The critical review was undertaken by using keywords and electronic database of medicine/nursing CINAHL, Ovid Medline, PubMed, The Cochrane Database of Systematic Reviews, Science Direct & Google scholar. The keywords, used were importance of respiratory rate, deteriorating patient, neglected vital sign, electronic monitoring and nurse's compliance. Numerous filters were also used to narrow the focus of the search strategy like human research studies only, available as full-text papers randomized controlled trials/, meta-analysis/, prospective studies/, randomized controlled trial.pt multicentre study.pt etc.
There were not enough studies conducted in general ward to know nurses' compliance rates in recording respiratory rate and use of automated monitoring. Hence the search strategy was broadened to studies conducted in triage in emergency department and surgical/post-operative ward. Initially a 10-year limit was set, but, to include some of the relevant information, more dated (1957) literature referred to in this paper resulted in a widening of the year limit. The search was limited to English language, and only full text articles were included.
A total of 310 were accessed; of these 32 were retrieved after using the filters to narrow it down as they appeared to relate to the topic, but only 16 articles were found to be relevant to this topic and were included in the review. One peer-reviewed double- blinded clinical paper and a consensus conference paper were also selected to review the study.
One of the key findings in the literature identified is that an abnormal respiratory rate is a strong and reliable indicator of impending adverse events such as cardio-pulmonary arrest. There were several studies investigated about the importance of vital signs documentation especially respiratory rate in triggering early detection of acutely ill patients.

(Fieselmann, Hendryx, Helms, & Wakefield, 1993) used a retrospective case-control study on 12 non-intensive medical unit to assess whether respiratory rate has the ability to predict risk of deterioration in medical patients. Their study found that, in internal medicine patients, an elevated respiratory rate has remained as a strong and reliable predictor of deterioration and cardiac arrest. A total of 150 patients were included in the study for a period of 20 months. Out of which (n=59) in patients who had suffered from cardiopulmonary arrest and (n=91) inpatients without cardiac arrest. The study has shown a sensitivity of 0.54 which is not a positive predictive value in determining the problem and a specificity of 0.83 in foreseeing cardiac arrest in patients, if the respiratory rate was >27/minute over a 72-hour period. These findings were similar to another prospective study conducted by(McFadden, Price, Eastwood, & Briggs, 1982) on 60 consecutive acute admissions to a geriatric unit. This study confirms that an accurately measured elevated respiratory rate >25 breaths/ minute in geriatric population is a strong indicator in predicting deterioration which is a valuable diagnostic tool. They assessed 142 patients (N=82, 1st group and N=60, 2nd group). Most of the time (62%), nurses recorded a lower respiratory rate between 20-22 breaths/minute, where the measurement should be down to 23%. Both studies were retrospective in nature and had used smaller number of sample which would have limited the outcome of the study in showing positive predictive value of abnormal respiratory rate.
Similar study conducted by (Subbe, Davies, Williams, Rutherford, & Gemmell, 2003) also showed that an accurate recording of respiratory rate is a crucial step in recognising deteriorating patients. Significant changes in respiratory rate are of much important to discriminate stable from unstable patients. The strongest study design which demonstrated this is a prospective observational cohort study was conducted in Singapore by (Hong et al., 2013), evaluated the importance and predictive value of vital signs on 1025 patients. It was clearly understood from the study that, among the vital signs, respiratory rate and SPO2 were the most reliable vital signs in predicting clinical deterioration in acutely ill patients. However, the study's main finding revealed that, vital signs alone cannot make prediction in clinical outcomes for patients. This study also emphasized the importance of treating patients as a whole rather than treating numbers. This was a more robust study with a sample size of 1025 patients compared to other studies mentioned above in stating the importance of monitoring respiratory rate accurately.
Whilst these above mentioned studies have all found that abnormal respiratory rate predicts physiological deterioration in critically ill patients, none have accessed the variability in monitoring respiratory rate or whether the predictive factor could be better monitored by other means such as continuous electronic monitoring.
Along with variability in manual recording of respiratory rate, other concern raised and identified is poor documentation of respiratory rate despite its importance. Many studies were emphasized on poor documentation of vital signs, especially respiratory rate causing delay in providing appropriate care to the patients in the general ward settings.
As in regard to poor documentation of vital signs, especially respiratory rate (J. Chen et al., 2009) conducted a MERIT study, a cluster randomised controlled trial of the 23 Australian hospitals to understand the rate of documentation of vital signs prior to patients deterioration and to test the effectiveness of introducing a medical emergency team (MET) on the rate of such documentation. From the study, the result showed significant proportion of missing vital signs in many hospitals. In a peer- reviewed double blinded clinical paper done by (Butler-Williams, Cantrill, & Maton, 2005) also points out how badly the respiratory rate has been missed or ignored. In both studies, with the introduction of MET, a significant improvement in recording vital signs were found. It was also noted that, among the vital signs, respiratory rate was the least recorded (p<0.01) variable in pre and post introduction of MET.
A retrospective study conducted by (Ludikhuize, Smorenburg, de Rooij, & de Jonge, 2012) in a medical-surgical ward to assess all parameters that were collected and documented before the adverse effect <48 hours. It was noted that, even with the introduction of modified early warning score, respiratory rate was charted only in 30-60% of the patient assessment. Similar study done by Leuvan & Mitchell (2008) has also found that poor documentation of respiratory rate. The study agrees with the findings of Chen et al, (2009) mentioned earlier, the lack of measurement and poor documentation of vital signs may jeopardise patient's health and well-being.
Moreover, (S. Smith, Fraser, J., Plowright, C., Dennington, L., Seymour, P., Oliver, G. & MacLellan, C., 2008) conducted a five year audit of nursing observations on ward patients. The result of the study revealed, despite the importance of respiratory rate in ill patients, problems have been identified the way they are monitored and documented. Among the vital signs, respiratory rate was the least monitored variable. A quasi-experimental study done by (McBride, Knight, Piper, & Smith, 2005) also agrees with the findings of Smith S et al. From the study, it was found that, baseline data for respiratory rate before the introduction of new observation chart and modified early warning score was poor. An improvement of 38% noted with the introduction of new observation chart.
Hence, all the studies mentioned above have shown that respiratory rate is the least monitored and poorly documented variable. With the introduction of new observation chart and MET system, the rate of documentation has improved. But no one questioned about its reliability and identified alternate method of recording respiratory rate in critically ill patients to prevent rapid deterioration.
Another problem identified along with poor documentation is manual method of monitoring respiratory rate. In the past, vital signs monitoring were largely depend on manual methods. With the advancement in technology, monitoring is made possible by automated machines to sense and show a variety of physiologic keys. Many studies found that manual methods to be unreliable and respiratory rates are often guessed in acute care settings (Leuvan & Mitchell, 2008). Few studies commented on reliability of electronic monitoring over manual method of counting.

As in regard to electronic monitoring of respiratory rate, (I. Smith, Mackay, J., Fahrid, N & Krucheck, D., 2011) have done a multi-centre non-randomised medical device use to compare the effectiveness of electronic sensor monitors against manual counting in post-operative patients. The difference in respiratory rate by manual against automated was equal to or > 4 breaths/minute. The study has shown a positive correlation between the two respiratory monitors than manual which proved that the automated respiratory sensor is reliable, easy to use and patient friendly that can detect subtle changes in patients that intermittent manual counts cannot provide.
A prospective study conducted by (Krieger, Feinerman, Zaron, & Bizousky, 1986) have documented the inaccuracy of respiratory rate by qualified and highly trained nurses' in ICU. Despite the inaccuracy, the study also highlighted the necessity for continuous respiratory monitoring in critically ill patients for better outcome. (Chen, Reisner, Gribok, McKenna, & Reifman, 2009) conducted a retrospective study on trauma patients before and during hospital transportation to explore the reliability and diagnostic use of an automated respiratory monitor. The study showed that, reliable respiratory monitor is reliable in detecting respiratory pathology and catastrophic haemorrhage in trauma patients. A cross-sectional study done by (Bianchi et al., 2013) evaluated the effectiveness of an electronic sensor monitor for respiratory monitoring over usual care method. The result of the study has found that, new electronic sensor monitor is highly capable of detecting tachypnoea in patients than standard method. Additionally, (DeVita et al., 2010) in a conference highlighted the significance of vital signs monitoring accurately in all ill patients. DeVita et al., (2010) have also recommended if possible patients' in the acute areas should be monitored closely using the advanced monitoring technology to detect subtle changes.
However, only a few studies have identified that electronic monitoring is more reliable than standard monitoring (Smith, et al. (2011) and Bianchi, et al. (2013). In fact, none of the above studies have ever investigated whether continuous electronic monitoring of respiratory rate will benefit respiratory patients in general ward settings which is the focus for this study.
To conclude, after the implementation of track and trigger system along with introduction of new vital sign observation chart, the studies shown have identified improvement in monitoring vital signs, especially respiratory rate. Respiratory rate being the predictive factor in patient deterioration, nurses' cannot simply guess or omit this valuable sign. With the introduction of continuous electronic monitor, researcher is hoping to see prompt detection of deterioration and reduction in adverse events in respiratory patients. A number of questions therefore arise from this;
' How can vital signs monitoring be made effective especially respiratory rate?
' Is continuous respiratory monitoring an option to detect subtle changes in deterioration?
' How beneficial would it be for respiratory patients?
' Can continuous electronic monitoring help respiratory patients in ward settings?
' Will it reduce adverse effects in respiratory patients?
Hence, the above questions highlight the necessity for continuous electronic monitoring of respiratory rates in respiratory patients and its effects on adverse events.

Research Aim, Objectives or Hypotheses
To explore and interpret whether continuous electronic monitoring of respiratory rates can benefit respiratory patients from rapid deterioration and its effects on adverse events. The hypotheses that replicate relationship statements, such as the following:
Null hypotheses: Respiratory patients in the general ward settings will not benefit from continuous electronic monitoring of respiratory rates.
Alternate Hypotheses: Continuous electronic monitoring will benefit the respiratory patients in the general ward settings in detecting subtle changes in deterioration.
Research Design
A randomised controlled trial will be chosen to investigate the effect of continuous electronic monitoring of respiratory rates in respiratory patients and its impact on adverse effects. A randomised controlled trial (RCT) is the clinical equivalent of a true experiment, and is the 'gold standard' for testing cause-and-effect relationships in clinical research (Thompson, 2004). Even though, conducting an experimental study can be challenging, they are the only way that nurses and midwives can generate research relevant to their knowledge and evidence requirements (Shields and Watson, 2013). The reason to choose this study design is due to the ability of randomised controlled trials to eliminate selection bias and thereby making them the top technique to acquire evidence on the outcome of health care interventions.
Quantitative and qualitative researches are the two main research methodologies available to the researcher. For this study, a quantitative research methodology will be used which parallels the positivists' paradigm. There are four main types of quantitative research designs: descriptive, correlational, quasi-experimental and experimental (Shields & Watson, 2013).The goal of this research study will be to generalise findings from sample to the bigger target population, therefore the method of choice will be quantitative study- experimental design.
The study will be conducted in a medical ward of Box Hill Hospital which is a public tertiary teaching hospital of south eastern suburb of VIC, Australia.
Population and sample
In this research, the study population will be all admitted patients in one medical ward (30 beds) with inclusion and exclusion criteria (see page no.) during March 11th 2013- July 11th 2014 (4months). An estimated number of patients admitted in the ward (approximately 200 patients) per month were obtained from the ward unit manager.
A convenient sampling or incidental sampling technique that is a form of non-probability sampling will be used that uses the most easily accessible and available people to participate in the study. The researcher being the employee of the same institution, it was easily identified that the proposed setting will have the most medical patients with respiratory conditions.
Sample size
Defining the ideal sample size for a study convinces a suitable power to detect statistical importance. Therefore, sample size is a crucial phase in the design of a planned research protocol especially an experiment involving human or animal subjects (Wittes, 2002).
To determine the sample actually studied is representative of the target population, a sampling strategy will be used. According to (Campbell, Julious, & Altman, 1995), the sample must be representative of the population from which it is drawn for the outcomes of the study to be generalizable to the population as a whole. To calculate the appropriate sample size, we will need to specify the following; standard deviation of the variables (s.d), clinically relevant difference (), the significant level ( ) - 0.05, and the power (1-) - 80%. Standard difference is calculated as /s.d (Jones, Carley, & Harrison, 2003).
If the true difference in the experimental and control means is 10, then we will need to have 64 patients in the experimental and 64 in the control group to be able to reject the null hypothesis that the population means of the experimental and control groups are equal with probability (power) 0.8 and the type 1 error is 0.05.
n=1+2C(s/d) 2
n=1+2x7.85 (20/10)2=1+2x7.85 (2)2= 1+2x7.85x4= 63.8=64

Inclusion Criteria
1. Age > 18
2. English Speaking
3. All patients admitted with respiratory conditions
Exclusion Criteria
1. Refuse to give consent
2. Severe medical conditions preventing participation
The study will be conducted in medical wards of Box Hill Hospital which is a public tertiary teaching hospital of south eastern suburb. From 10 acute care units, two medical units will be selected to conduct the study.
Participants Recruitment Procedures
All patients admitted in the medical ward diagnosed with respiratory conditions will be asked by their attending nurse for permission to be participated in the study. Those who agree will be seen by the research nurse who will explain the purpose and expected outcome of the study to the patient and assess their eligibility for the study. After the patient has signed informed consent, patients will be randomised to continuous electronic or standard recording of respiratory rate using simple randomization performed with the use of a concealed using a sealed, opaque envelopes containing a tag named either ' continuous electronic monitoring' or 'standard'. Then the patient will be monitored according to the assigned protocol. Patients allocated in the control group will have their respiratory rate monitored according to the standard hospital protocol (4 hourly monitoring of vital signs- respiratory rate (manually), for first 24 hours, later 6 hourly if patient is stable).Those in the experimental group will have their respiratory rate monitored continuously by automated machine according to the study protocol for the first 72 hours.
Owing to the nature of the intervention, it will not be possible to blind the nurses to the treatment allocation. 'Blinding or concealment' to the researchers makes for a much more rigorous study which is used most commonly in clinical trials. Blinding means that some pertinent information is hidden or withheld from those conducting the research and, from the participants, thereby no contamination or influence from those applying the research (Shields and Watson, 2013).
Data Collection Methods
There are different ways of measuring the variables interest. We can use one or more data collection methods. The main data collection methods include observation, physiological measurement, personnel or group interviews, questionnaires and other records. For the exploration of an efficacy of precise practice activities, a physiological or biological measurement is found to be better suited (Osbourne & Schneider, 2013). Physiological data collection methods are generally reliable unless there is a technical problem due to their objectivity, precision and sensitivity.
Data will be collected through an observation chart audit by an independent staff member not associated with the research project. Person collecting the data will be given extensive education regarding data collection method. A documentation checklist will be prepared by the researcher specifying the time and frequency of monitoring, method of monitoring (manual or electronic). The data collection sheet will also include patients' demographic variables including time of admission, clinical status, total number of patients with adverse events 24-h intervals, number of major events in both groups in the first 72 h after randomisation, change in treatment during the study period, adverse effects and medical alert and outcome of alert. Additionally a questionnaire can be utilized to assess nurses' perception on the new intervention introduced and effects of the outcome. Researchers will conduct random audits to ensure accuracy of the data collected.
Prior to data collection, the researchers will conduct a meeting with all unit managers and the nurse in charges from all participating units to explain about the procedures. Before the study, the researcher will educate the ward staff on the manoeuvre of the monitor but not on data interpretation. Prior to study, the ward nurses' will have the opportunity to familiarise with the electronic monitor. A data recorder will be connected to the electronic respiratory monitor to record the data to determine the compliance with the electronic monitoring. The recorder will be removed after the study period (72 hours) and the data will be off-loaded for analysis.
Internal and External Validity in Quantitative Research
Both internal and external validity are important to the validity of the overall research study. Strategies will be used to reduce the threat to internal validity: The most common threats to internal validity are selection bias, history, maturation, test-retest, attrition, and regression towards the mean. Internal validity relates to whether the intervention had a real measurable effect on the outcome. External validity refers to the generalizability of a study's finding to other populations or settings (Osbourne & Schneider, 2013).
Strategies will be used to reduce the threat to internal validity:
Subjects will be randomly assigned into control or experimental group to ensure the effect of history is equal in both groups.
Same participants will not be tested to measure the effect.
Data collectors will be kept 'blind' as to which participants are assigned into what groups and will train data collectors thoroughly. To maintain objectivity, the researcher will be detached from the study not to influence with their personal experiences and values.
Statistical Analysis
For the analysis to be more precise, a statistical advisor will be recruited to assist the researcher. For the analysis to be more precise, a statistical advisor will be recruited to assist the researcher. Statistical analysis will be carried out using the statistical packages SPSS and Excel. Quantitative data will be calculated for all variables and analysed using descriptive statistics after entering into a spread sheet. Chi- square analysis will be undertaken to determine the differences between the two groups.
Ethical Consideration
According to Johnston, (2009), 'Ethics refers to a system of principle which can critically change previous considerations about choices and actions'. However, there are three value systems (science, society and nursing) with which nurses have to deal with when they partake in research that can build strains and dilemmas in nursing.
For a research to be effective, the researcher should focus on major ethical issues that can come across in research to protect the human and animal subjects. Major ethical principles in research studies (Aita & Richer, 2005, as cited in Offredy & Vickers, 2010) are as follows:
' respect for autonomy
' beneficence
' justice
There are three practices linked with the ethical principles that protect these rights (Jonsen, 1996 as cited in Offredy & Vickers, 2010) as follows:
' informed consent
' risk-benefit assessment
' Fair -selection.
Informed consent
An informed consent is the first and foremost ethical issue that can be seen in research studies. Armiger describes 'it as a person knowingly, willingly and wisely, and in a clear and manifest way, gives his consent". An explanation of the procedure/intervention will be given to the participants in a language which the participants can read and understand. Then a consent form will be given to the participants that will be signed and witnessed if they are willing to enter into the study.

Principle of beneficence (do not harm)
The ethical principle of beneficence refers to the Hippocratic "be of benefit, do not harm". Beauchamp and Childress, propose that "the principle of beneficence includes the professional mandate to do effective and significant research so as to better serve and promote the welfare of our constituents". The researcher will take every measures to avoid doing harm to the participants.
Respect for anonymity and confidentiality
Confidentiality and data protection: According to Levine 'confidentiality means that individuals are free to give and withhold as much information as they wish to the person they choose'. All data pertinent to participants will be treated confidentially by coding data or giving them pseudonyms. All confidential information will be stored in a locked cabinet under authorised security.
Respect for privacy
According to Levin "privacy is the freedom an individual has to determine the time, extent, and general circumstances under which private information will be shared with or withheld from others. Prior to the investigation, all goals, tools and methodology will be discoursed with the potential subject and the research personnel.
Researcher must debrief at the end of a study if the subjects experience a high level of discomfort. According to Treece and Treece (1957) 'debriefing refers to explaining the exact aim of the study and why the disclosure was not full'.

To conclude, researcher will take all potential measures in to safeguard subjects from possible harm (physical, psychological or social) throughout the research or after the results been published.

A major strength of this study is that, the researcher is using only 2 data collectors to audit the charts which will reduce the inter-observer variability. Secondly, the design proposed for this study is with randomisation that will reduce the chance of bias. In this study, nurses are aware of the purpose of the study, no blinding potentially will influence their practice in measuring respiratory rate.. Furthermore, the study performs only at one medical ward will contribute a further limitation in generalising the findings.
The estimated project time for the research will be four months. The researcher will make use of the Gantt chart outlined below, to as suggested by Polit and Beck (2010), to demonstrate the time frame for the research proposal activities.

Estimated Time Frame

Project Funding
Even though, there will be a number of options for nurses and midwives in Australia seeking financial assistance to pursue scholastic interests, but applications for research grants can be highly competitive.
Royal College of Nursing, Australia (RCNA), National Research and Scholarship Fund (NRSF), and Australian Nursing Federation (ANF) are the main funding bodies. There are many Commonwealth schemes and foundations that offer funding for specific research areas. The National Health and Medical research Council (NHMRC) is Australia's leading expert body promoting the development and maintenance of public and individual health standards provides the majority of funding in Australia (Schneider, 2013).
Moreover, hundreds of non-government organisation (NGO) grant schemes in Australia; the Australian Cancer Research Foundation, Australian Rotary Health Research Fund, Kidney Health Australia, National Heart Foundation of Australia offer 'Grant-in-Aid' for research from which funding may be obtained. In addition to this, there are numerous charitable organisations offer funding for research (Schneider, 2013).
For the funding, the researcher will apply through to Box Hill Hospital Research Committee where they have allocated funds for staff who conduct research projects. More over the researcher will also apply for funding to RCNA (Royal College of Nursing, Australia) and ANMF (Australian Nursing & Midwifery Federation) as they offer annual research scholarship/grant for nurses.
The likelihood for successful outcome is improved, when active and efficient grants management skills are used to mastermind the development of a program proposal and the oversight of the funded project. For a beginner or even an experienced nurse researcher, preparing a research application budget may appear a daunting job (Ingersoll & Eberhard, 1999). Budget management difficulties can be minimized with an accurate and a thorough budget during the proposal stage once the project is funded.
Proposed Budgets
No Budgeting Categories Required Unit Costs/unit Amount
1 Personnel
Principle Researcher X1 $ 3,000 $ 3,000.00
Data Collectors X2 $ 50 $ 100.00
Statistician X1 $ 230.00 $ 230.00
2 Travel Expenses
Local travel expenses x5 $ 25.00 $ 125.00
3 Equipment
Rainbow acoustic sensors X2 $ 240.00 $ 480.00
Data recorders X2 $ 50.00 $ 100.00
Printer and copier X1 $ 86.00 $ 86.00
Memory stick 4 GB X1 $ 12.00 $ 12.00
Filing Cabinet X1 $ 50.00 $ 50.00
4 Stationeries
Printing paper X1 $ 6.99 $ 6.99
Pens & Markers x1 pk $ 10.82 $ 10.82
Large Envelopes X3 pk $ 5.50 $ 16.50
5 Other Expenses
Meeting expenses and refreshments X10 $ 25.00 $ 250.00
Monetary incentives for participants 128 $ 2.00 $ 256.00
Unforeseen expenses X1 $ 300.00 $ 300.00
Total $ 5,923.31

Dissemination of Findings
Nurses and midwives add to the development of quality service provision through the sharing and reporting (dissemination) of their research findings and activity reporting the result of clinical innovation and best practice (Albarran & Scholes, 2005)). Disseminating research findings is an integral part of the research process. It is sometimes said that if the findings are not published, it is as if the research has not been done (Whitehead & Schneider, 2013).
The results from this study can be used to make recommendations for future practice and policy development. The results from the research will be shared through a presentation and a written report to the relevant authorities of the hospital. Participants will be notified about the findings as well as the nursing leadership team. With the help of experienced colleagues and previous issues of known journals, an appropriate journal will be identified. These research findings will be submitted to publisher who will promote and accept studies carried out by novice researchers.

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