Prevention Strategies for the Development of Pressure Ulcers

This assignment will examine the process and methods used when gathering empirical evidence, for a chosen based care issue, using different search strategies and medical databases. An appraisal and discussion of the chosen evidence will also be made, identifying how the evidence was gathered and its relevance to the chosen based care issue. The process of collecting such evidence and the importance of its use will be reflectedupon using a specific reflective model.

The practice based care issue which has been chosen is ‘prevention of pressure ulcers’. A pressure ulcer is an area of localised damage to the skin and underlying tissue (EPUAP, 2009) which develops when there is persisting pressure on a bony site, obstructing healthycapillary flow , leading to tissue necrosis (Lyder, 2003).The rationale for selecting this type of research is due to the high prevalence rate of pressure ulcer among patients and the current lack of knowledge concerning guidelines of pressure ulcer prevention (Moore & Price, 2004). I am very interested in this topic and feel a deeper knowledge of pressure ulcer development and risk assessment tools will enable me to provide better clinical practice. According to Davies (2008) health care professionals are striving constantly to improve and develop standards of care which evolves from the integration of research evidence, clinical expertise and patient needs and values (Institute of Medicine, 2001),this is also known as evidence-based practice.

The reflective model that I will be using is

Rolfe et al

(2001) ‘what’ model which composes of three main areas, what? So what? Now what? This model aims to identify the following; what was I trying to achieve? What is my new knowledge of understanding? What information is needed to face a similar situation again? Ichose this particular model compared to John’s model of reflection (1994) as I found it the easiest model for organisation and meaning to the process of reflection.

.Reflection involves accessing previous experience to help in developing tacit and intuitive knowledge (Johnsand Freshwater, 2005) and the main principles of reflection include becoming mindful, understanding and learning from experience. Reflection facilitates an evaluation of one’s own practice, both as individuals and with their teams (Sines, Saunders & Burford, 2013). It is vital that Nurses reflect and practice reflectively as it allows them to learn from experience and make better future judgement, becoming critical practitioners and facilitating excellent patient care.

The critique model I will be using for the critical appraisal and discussion is the Critical Appraisal Skills Program (CASP) as it is a clear tool which identifies the worth of the articles I have found (CASP, 2013).

Critical Appraisal

After researching for relevant articles, I decided to choose three of the most relevant articles to critically appraise. Each of these three articles involves a study evaluating the effectiveness of prevention strategies for the development of pressure ulcers.

The first single blind randomised control study by Webster et al (2011) aimed to evaluate the effectiveness of two pressure-ulcer screening tools against clinical judgement in preventing pressure ulcers. This study had a very clear and focused objective which stimulated the reader to continue reading due to the study avoiding the use of jargon or buzz words (Carr, 2001). This was an experimental and correlation study showing the link between two factors with the aim of producing quantative results. 1231 patients were randomly allocated to either a water low or ramstadius screeningtool or to a clinical judgement group. Randomised Control Trials (RCT) are comparative studies with an intervention group and a control group; the assignment of the subject is assigned through randomisation(Melnick & Everitt, 2008). The advantages of using RCT are that it removes potential of bias in the allocation of participants and that randomisation tends to produce comparable groups; that is, measured as well as unknown or unmeasured prognostics factors and characteristics at the time of random allocation will be balanced (Friedman, Furberg & Demets, 2010).

The researchers ensured that patients allocated were excluded if their hospital stay was expected to be less than 3 days or if they had been in hospital 24 hours prior to the baseline assessment occurring. This is to allow thorough and regular direct observation of the incidence of hospital acquired pressure ulcers, allowing the researcher to attempt to control the studies validity and reliability (Marshall, 2004).

In a research study it is vital that the researcher ensures that the subjects are aware of the process of the study and have given informed consent. In the case of this study, for pressure ulcer screening and observation, consent was not required. However, signed consent was sought from any patient who developed a pressure injury in order to validate the assigned pressure ulcer through clinical photography. The researchers also obtained institutional ethics approval which included the right to access the patient’s medical record for audit purposes. The incidences of hospital acquired pressure ulcers were similar between all groups.

The authors found no evidence to show that two common pressure ulcers risk assessment tools were superior to clinical judgement to prevent pressure injury. The authors felt that resources associated with the use of these tools might be better spent on careful daily skin inspection and improving management targeted at specific risks. This is supported by the work of Sarabahiand Tiwari (2012) who suggests a regular and rigid schedule of inspection must be followed as part of the patient’s daily routine. Nurses undertaking the trial were more familiar with the Water low scoring system which could have led to contamination in the clinical judgementgroup. The limitation of this study is that they did not use patients from acute settings who could be at risk and therefore cannot use these results as a representation of all hospital settings.

The second randomised controlled study by Nixon et al (2006) aimed to compare whether differences exist between alternating pressure overlays and alternating pressure mattresses in the development of new pressure ulcers. This criterion for this study involved participants aged at least 55 years who had been admitted to vascular, orthopaedic, medical, or care of elderly wards, and had limited mobility.

The methodology used for this study was pragmatic, open, multicentre and randomised controlled trial. An open label study is where the investigator and experimental units knows which treatment the experimental unit is to receive. Although this type ofstudy is simple and easy to design, it could cause the individual to favour the type of treatment, leading to possible bias (Ambrosisus, 2007). A multicentre method involves the study being conducted by several institutions. An advantage to conducting a multicenter is that it increases the number of patients available to participate (Bhandari & Joensson, 2011), which in the this trial is a large 1972, leading to the findings beinghighly likely to be representative of what would happen in usual clinical practice.

The design of this study involved patients beingallocated to either an alternating pressure overlay or an alternating pressure mattress, within 24 hours of hospital admission, with the expected length of stay of at least seven days. Clinical research nurses assessed skin status twice weekly for 30 days and then once a week up to 60 days for the development of pressure ulcers. A limitation of this study is the lack of blinded outcome assessment due to difficulty in disguising or masking the mattresses, however, according to Khan, Kunz, Kleijen & Antes (2011) only few observational studies manage to implement appropriate measures to achieve blinding. The researcher tried to combat this through independent skin assessments which were taken by the Nurses to avoid any bias.Ethical approval for this study was approved by theNorth West multicentre research ethics committee and local ethics committees in order to undertake this research. This study had a clear aim to evaluate the effects on pressure ulcer risk and was able to undertake the study with fairly low rates of ulcer incidence, meaning the patients were subjected to minimal harm.The most important issue arising in the ethical review of scientific research involves preventing human participants, is risk of harm (Smith & Waddington, 2013)therefore it was extremely important that the researchers were able to conduct this study with low incidence rates.

The results of this study were that the patients allocated to either an alternating pressure overlay or alternating pressure mattress that developed a new pressure ulcer of grade 2 or worse did not differ, highlighting the need for other preventive measures.

The final study by Moore et al (2011) aimed to compare the incidence of pressure ulcers among older persons nursed using two different repositioning regimens. The researchers aim is very clear, evaluating the effectiveness of positioning patients 3 hourly and 6hourly at night time. The methodology used was a pragmatic, multi-centre, open label, prospective and cluster-randomised controlled trial, similar to the study above, the findings are highly likely to be representative of what would happen in usual clinical practice due to a multicentre approach being commonly accepted as providing a more representative population (Luchetti &Amadio, 2008). Cluster randomised control trial involves randomizing professionals so it is much easier to keep the intervention separate from the control groups but methodological, statistical and ethical issues must be taken into account in making sense of cluster trials(Gilbody & Bower, 2010). This study did indeed ensure that ethical approval was received by participants before the study commenced.

The results obtained through the research were that repositioning patients with a pressure ulcer every three hours at night, using the 30 degree tilt, reduces the risk of pressure ulcers compared with usual care which issupported by the recommendations of the International pressure ulcer prevention guidelines (2009). Arguably, the research is well written with a good amount of supporting literature, stating clearly the incidence of pressure ulcers with a good rationale for the studies aim. This study included results of other similar researchers who have found similar results of repositioning, giving scope for further research such asDefloor et al (2005). The limitation of this study is that the target of 398 participants was hard to find which caused the variance in the size of the clusters to be different, which could have had a major effect on the research gathered. Another limitation is that most participants were 80 years or older which means it cannot be a representative of most patients, as expected.

Reflection

Using the Rolfe et al (2001) reflective model, I will evaluate the actions in undertaking my searches and what I found. As mentioned above, the stages of the reflective model includes what? So what? Now What?

The first stage (what?) involved the process of searching for my articles in relation to the subject issue‘pressure ulcer prevention’. Using the databases,Pubmed, Scopus and JSTOR I searched for articles using key words such as, prevention, pressure ulcer, pressure sore and risk assessment. In order to limit the amount of results gathered I used the Boolean operators ‘and’ and ‘or’ as well as advanced searches such a ‘UK based’ and ‘No older than 2005’; ensuring a realistic amount of hits were gathered, relevant to the subject issue. In order to identify relevant articles, I read through the titles and abstracts, as this gave me an idea of how relevant the articles were. Once I read through a few studies, I was able to choose 3 studies to critically evaluate.

The second stage (So what?) involved identifying the difficulties which I encountered when conducting the search. I found the searching quite challenging as many of the results either came back as a large amount of hits or a small number of hits based around irrelevant research to my subject. Using keywords and re wording phrases such as ‘pressure sores’ instead of ‘pressure ulcers’ enabled me to widen my search.

The final stage (Now what?) involved reflecting on the search which I had undertaken as well as the results obtained. I had to conduct many different searches and keywords to find effective results. The problem I encountered was that many results obtained were regarding wound care and not prevention; if I was to repeat this search again I would ensure I put ‘NOT wound care’. I feel further exploration of medical databases would be beneficial for future research to give me a better understanding of search terms and criterion available.

Prior to carrying out this assignment, I was certain that risk assessment tools played a major part in the role of pressure sore prevention. However, risk assessments such as water low, have been criticised due to its poor validity, particularly for the tool to underestimate the numbers at risk (Pancorbo & Fernandez, 2006). Thestudies which I have critically evaluated have made it clear that observation and repositioning is key to pressure sore prevention. As identified by Guyatt et al, (2000) Nurses do not feel sufficiently competent to be able to appraise research findings because they lack the necessary understanding of information retrieval techniques, research design and data analysis and therefore it is important that Nurses are educated in pressure sore management, for clinical practice to be effective.

This assignment has expressed the importance of evidence based practice for effective clinical practice,although contradictory findings from different sources and a lack of critical appraisal skills can make interpretation of evidence difficult.

It has taught me the value of observation when caring for patients and made me become mindful of reading and evaluating research to learn and improve my clinical practice. I am aware that repositioning and skin integrity checks are a major pressure ulcer prevention and that risk factors such an nutrition also need to be monitored closely, I feel I will confidently use the knowledge I have obtained when in practice.

This assignment has put into perspective the importance of identifying all factors when caring for a patient and aiming to prevent pressure sores. For future development I would like to do further research on methodology as I believe this will help me to evaluatethe studies in much more depth, especially seeing ascertain study methodological designs are likely to be more reliable compared to others.

Conclusion

In conclusion, this essay demonstrates an effective search strategy for research studies on ‘preventing pressure ulcers’ which have each been critically appraised.

A reflection on the process of the research was carried out using Rolfe model of reflection (2001) highlighting learning outcomes as well as encouraging me to exploreimprovements for my future practice and search strategies.