NSG 660 Unit 1 practice question refinement example

From "Nobody Uses These Things" to an Answerable Question: Four Drafts and a Search Record on Incentive Spirometry After Abdominal Surgery

Student Name

Department of Nursing, Herzing University

NSG 660: Scholarly Practice

Instructor Name

January 13, 2026

From "Nobody Uses These Things" to an Answerable Question: Four Drafts and a Search Record on Incentive Spirometry After Abdominal Surgery

Where the Question Started

The question began as a complaint at the nurses' station on a composite 30-bed general surgical floor. A colleague, charting at the end of a day shift, said: "We hand every post-op patient one of these incentive spirometers, we chart 'IS encouraged' every four hours, and nobody uses these things. Half of them are still in the plastic bag at discharge. Do they even work?"

That remark is kept here as it was said, because it contains the whole practice problem in an unsorted form. It mixes three different questions: whether the device works, whether patients use it, and whether our charting means anything. It names no population beyond "every post-op patient," no comparison, and no outcome that anyone could measure. A database cannot answer it. The work of this unit was to narrow it, one visible step at a time, into something a search could answer, and to keep a record of what each narrowing ruled out.

Draft 1

"Does incentive spirometry work after surgery?"

What was added: the device and the setting. What was ruled out: the adherence and charting questions, set aside for now because they depend on the first answer. If the device does not help even when used, the charting is a separate problem; if it does help, adherence becomes the main problem. What is still wrong: "work" has no outcome attached, and "surgery" includes cardiac, thoracic, bariatric, orthopedic, and abdominal operations, whose lung risks differ a great deal.

Draft 2

"In adults after abdominal surgery, does incentive spirometry prevent lung complications?"

What was added: the population narrowed to adults having abdominal operations, which are most of the patients on this floor, and an outcome, lung complications. What was ruled out: cardiac and thoracic surgery, where patients go to other units and where chest drains and sternotomy change the picture, and children, who are not on this floor. What is still wrong: there is no comparison, and "lung complications" could mean anything from a finding on an X-ray to a patient needing intubation.

Draft 3

"In adults after abdominal surgery, does incentive spirometry, compared with no incentive spirometry, reduce postoperative pulmonary complications?"

What was added: an explicit comparison. What it ruled out: comparisons with other devices such as positive pressure breathing, which this floor does not use. What is still wrong: "no incentive spirometry" does not describe what the patients on this floor would actually get instead. Nobody here would be left without breathing exercises, walking, and pain control. The real comparison is not device versus nothing; it is device plus the usual care versus the usual care alone. The outcome is also still a research outcome, not something a nurse could see on a shift.

Draft 4, the Working Question

"In adults on a general surgical floor after open or laparoscopic abdominal surgery (P), does incentive spirometry added to deep breathing, directed coughing, and early walking (I), compared with deep breathing, directed coughing, and early walking without the device (C), change the rate of postoperative pneumonia or a new need for supplemental oxygen before discharge (O)?"

What was added: the comparison now matches the floor's real alternative, and the outcome includes something a nurse sees directly, a patient newly needing oxygen, next to pneumonia, which is diagnosed and recorded. What was ruled out: atelectasis on X-ray alone, since many patients have minor changes that never matter clinically, and lung function measures, which this floor does not record. A time frame was left out on purpose: "before discharge" is the only period the floor can observe, and adding 30-day outcomes would pull the question toward studies this floor cannot act on.

The Search

Searching was done after Draft 4, not before, so the question would not bend toward whatever an early search returned. PubMed was searched directly; Cochrane reviews were looked for separately; CINAHL was searched through the university library for nursing studies on adherence. The PubMed record is given in full because its counts can be repeated.

The limits were chosen one at a time. Publication type was limited to trials and reviews because the question asks whether a device changes an outcome, which needs a comparison. English was applied because the writer cannot read other languages well enough to appraise them, and this is stated as a limit, not a quality filter. Adults were kept because the floor has no children. No date limit was applied: the trials this field still cites in guidelines date from the 1990s and 2000s, and a ten-year limit would have removed most of the evidence a reader would expect to see.

What the Search Returned

Screening titles and abstracts from steps 5 and 6 gave 14 records worth reading in full. Two stood out at once. A Cochrane review of incentive spirometry after upper abdominal surgery, covering 12 trials and 1,834 participants, found no evidence that the device prevents pulmonary complications, and noted that none of the trials reported whether patients actually used it (do Nascimento Junior et al., 2014). A guideline from the American Association for Respiratory Care advises against using the device alone and recommends it only alongside deep breathing, coughing, early mobilization, and good pain control (Restrepo et al., 2011). A randomized trial in a different surgical population, bariatric surgery, found no difference in low oxygen levels or pulmonary complications when the device was removed from routine care (Pantel et al., 2017). This last study falls outside the population in Draft 4, but it tested exactly the comparison the draft asks about, and it was kept for the comparison grid in a later unit with its population difference noted.

The Final Question, and Its Weakest Part

The final question is Draft 4 unchanged. The search did not change it, and that is recorded as a result: the question was set before the evidence was seen, and the evidence can now answer it or fail to.

The part the literature is least likely to answer is the comparison. Very few trials hold deep breathing, coughing, and walking constant and add or remove only the device, and none of the upper abdominal trials measured how often patients used it. The literature may therefore be able to say that the device, as usually given, adds little, without being able to say whether a device that patients actually used would help. That gap is also the colleague's original complaint about the unopened plastic bags, and it is the point where this question reconnects with the adherence problem set aside in Draft 1.

References

do Nascimento Junior, P., Módolo, N. S., Andrade, S., Guimarães, M. M., Braz, L. G., & El Dib, R. (2014). Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews, (2), Article CD006058. https://doi.org/10.1002/14651858.CD006058.pub3

Pantel, H., Hwang, J., Brams, D., Schnelldorfer, T., & Nepomnayshy, D. (2017). Effect of incentive spirometry on postoperative hypoxemia and pulmonary complications after bariatric surgery: A randomized clinical trial. JAMA Surgery, 152(5), 422-428. https://doi.org/10.1001/jamasurg.2016.4981

Restrepo, R. D., Wettstein, R., Wittnebel, L., & Tracy, M. (2011). Incentive spirometry: 2011. Respiratory Care, 56(10), 1600-1604. https://doi.org/10.4187/respcare.01471