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Critical Appraisal

Rebecca Nappi

Bon Secours Memorial College of Nursing

Nursing Research

NUR 4222

Christine Turner

July 7, 2018

Critical Appraisal


The purpose of this paper is to critically critique and appraise the study, “A simulation

Study of the Factors Influencing the Risk of Intraoperative Slipping”. This study was written by

the following authors; J. Nakayama, G. Gerling, K. Horst, V. Fitz, L. Cantrell and S. Modesitt.

One of the authors, John Nakayaa is a gynecology medical doctor (Nakayama et al., 2015, p. 24).

Two authors are members of the systems and information engineering department of the

University of Virginia. This combined medical and technology background is important to the

method of this study since mannequins were used as test subjects in place of humans so a strong

understanding of physics and technology to mimic real life situation is important. This

quantitative study aimed to measure the amount of slippage that could occur during steep

Trendelenburg positioning of patients undergoing gynecological surgery and how this slippage

could be manipulated by using different materials under the mannequins. The title should include

for gynecological surgery because it is misleading that it is evaluating all types of positions that

could result in slippage. The abstract was clear and made it easy to understand the authors goals

and their methods for achieving their goals. The study’s findings were very condensed and

compactly written in the abstract. The report is easy to follow and understand. The language is

appropriate for medical personnel. The authors report that this topic has not been well studied in

the past (Nakayama et al., 2015).

Problem Statement

The report presents causation for the study in their introduction. The explanation for the

need of Trendelenburg positioning is well written and very detailed even presenting the needed

degrees. The study is limited to gynecological surgery and the position this type of surgery

requires. This study would not accurately represent results that could be used for reverse

Trendelenburg or non-lithotomy Trendelenburg positioning which are both frequently used in the

operating room. The authors are very transparent about their studies limitations right from the

beginning explaining that obesity is not well addressed in the study. Obesity is a major factor

contributing to patients slipping and is a desired parameter to be studied for individuals

researching best practice on preventing operating room slippage. The theoretical framework for

this study was based on lived experiences of operating room staff observing patients slipping or

moving on the operating table. This is a very common observation and the known danger and

patient movement is well understood and of major concern. This study attempts to answer the

theoretical question of whether different materials under the patient could eliminate this danger.

Research Methodology

The method of this study was severely compromised by using mannequins as “human

surrogates” (Nakayama et al., 2015, p. 25). They did not have an exact height of the mannequin

but simply said, “average female height” which is disappointing. The exact material of the

mannequin was not obtained but rather just generalization of rubberized silicone and

polyvinylchloride. Baby powder was used on the mannequin to, “better approximate human

skin” two studies were referenced to back their decision to add baby powder which was an

excellent citation. However, the accuracy of this approximation is subjective due to the lack of

human skin and texture. Humans could have been used with no ethical dilemma, no risk of injury

or increased cost to the researchers however the decision to use mannequins was still used. The

weight ranges tested were from 100lbs to 250lbs by 50lbs increments. The use of higher weights

would have increased external validity as it would better reflect the current American body

weight. The researchers did not test any of the surfaces without a sheet under them which

limiting for others to extrapolate their findings and reproduce since using a sheet is typically

never used due to the slickness of sheets. Linear regression models were an excellent choice to

accurately display the variables and the degree of slippage with P values. The same evaluator

was used to measure the angles recorded for each test thus eliminating variability produced by

human error. The evaluator also reproduced the results three times before recording their

findings which increased the accuracy of the findings and gave the study further confidence.

Showing values for both supine Trendelenburg and lithotomy Trendelenburg was an interesting

decision since gynecological surgery is never performed in supine position.

Findings and Discussion

The results were well organized and easy to read from both the written description and

the data tables presented within the report. The author gave opinion several times in the results

which was an interesting decision. The reader could tell when the findings were a surprise to the

author. There was no explanation given as to why the operating room tables made an impact on

the findings. It was stated but never addressed. Addressing that this issue is multi-factorial and

no one variable altered the outcome independently was informative. Understanding each variable

and addressing each one individually but then combined with the others was an excellent

observation by the researcher and documented well. Comparing supine to lithotomy slippage

resulted in an interesting finding and opens the door to more potential research.

Recommendations and Implications

Gel pads are widely used within operating rooms across America and the findings in this

report show it was an inferior product when compared to the other materials, even just the

bedsheet. Although additional research is needed to assess prolonged Trendelenburg and higher

patient weights this report showed some clear understanding of weight implications on slippage

and material. An incidental finding of different operating room tables making an impact on the

results was intriguing and further research is needed.


The study was one of the first of its kind showing the degree of Trendelenburg a patient

could tolerate before they would slip as represented by the mannequin. The study tried to mimic

human skin and weight distribution to best of their capabilities within this design and

methodology. The findings were as expected for lived experience with the outlier of the gel pad

being one of the least appropriate materials. The weight of the mannequin and amount of

slippage was directly inversed when comparing supine and Trendelenburg which led the

researchers to desire additional research on this phenomenon. Trendelenburg positioning is used

every day in operating rooms everywhere and as found in this study slippage occurs. Movement

can lead to serious injuries and should be taken seriously by those working in this field. Patient

safety is every nurses, doctors and organizations top priorities and studies like this help us

protect our patients.



Nakayama, J., Gerling, G., Horst, K., Fitz, V., Cantrell, L., & Modesitt, S. (2015). A Simulation

Study of the Factors Influencing the Risk of Intraoperative Slipping. Clinical Ovarian

and Other Gynecologic Cancer, 7, 24-28.