Pressure ulcer (PU) is damage to the skin and the tissue underneath, it occurs when pressure is applied to the same area of skin for a long period of time which cuts off blood supply (NICE,2014). I have chosen PU as I have come across it in every placement and the care provided to prevent and treat it interests me.
There is significant priority in hospitals as there is a high occurrence of PU in hospitals (Graves N, Zheng H 2014). Evidence based practice(EBP) is a collection , evaluation and integration of research, combined with clinical expertise and looking at patients and families values and preferences, to update clinical decisions making (Sackett et al., 2000). Nurses use evidence to plan and promote health and best practice, they make person-centered, evidence- based judgement and decisions to ensure high quality care (Ellis 2013). NMC states that all care has to be carried out based on the best available evidence. Patients should be supported and empowered to join in with health professionals to improve services (Hartley,2013). Critical appraisal is to ensure that the evidence meets the patients' requirements, specific needs, and the patient's preferences.
The EBP hierarchy orders the research methods based on precision and strength. 'Different types of hierarchies based on different question types (NHMRC). Quantitative randomized control trials are gold standard as it is able to provide a lot more convincing evidence, (Evans,2003) doesn't agree and said the quantitative randomised control only answers a few questions and doesn't deliver clear results.
Qualitative research is a multifaceted approach that looks at culture, society and behaviour through an analysis and synthesis by looking at people's opinions. Data is collected by a variety of ways such as observation, interviews and focus groups (Hogan, Dolan and Donnelly,2009). Qualitative research I have chosen explores nurses perception of a pressure ulcer prevention care bundle (Roberts et al.,2016). To critique my paper, I will be using the critical appraisal skills programme(CASP). I found my research paper on the British nursing index (BNI), using key terms such as qualitative ,quantitative and nursing. I filtered my results by search from 2008 to 2018. The aim of this study was to 'assess nurses perceptions of the usefulness and impact of a pressure ulcer prevention care bundle and intervention' (Roberts et al.,2016).
Researchers conducted a study variety of nurses where they implemented PUPCB (pressure ulcer prevention care bundle) on wards. To be eligible they had to be in either permanent full or part time employees and employed during the INTACT (INTroducing A Care bundle To prevent pressure ulcers) trial. Nurse unit manager and researcher identified a criteria such as speciality and years' experience. Purposive sampling was used to recruit four to five nurses from each hospital. Purposive sampling is called judgemental sampling as it is the deliberate choice of the participant due to the qualities the participant has. It is a non-random technique which doesn't need underlying theories and set number of participants. The researcher decides what needs to be know and sets out to find the people who can and willing to provide information by knowledge or experience(Bernard. R. 2002). Purposive sampling provides researches with justification to generalize the study and provides a wide-range of non-probability sampling techniques for the researcher to draw on. However, it is based on the judgement of the researcher meaning possible researcher biases. Harder to convince the reader that using purposive sampling has achieved theoretical/analytic/logical generalisation (Dissertation.laerd.com,2018). Purposive sampling was effective when recruiting four to five nurses from each hospital. There were only four to five nurses from each hospital, not all nurses views were represented, however the study did use purposive sampling in order to improve generalisability. The finding in this study would may not have been relevant for implementation (Sullivan N et al,. 2013).
This study did semi-structured interviews based on the methodology. Semi-structured interviews are in-depth where the respondents answer open-ended questions therefore are widely used by healthcare professionals (Jamshed,2014). Interviews were conducted by a trained research assistance on site at a site which was convenient for the participant. It is recommended participants should have the choice of venue (Clarke 2006), however it is not always possible and it doesn't necessarily affect the interview. Semi-structured interviews are based on an interview guide, is a schematic presentation of questions or topics that need to be explored by the interviewer ( DiCicco-Bloom and Crabtree 2006).Study had 4 main domains and eight questions and prompts, interviews lasted around 20 minutes. It is useful to have a 'prompt list' as it can ensure that the key issues have been addressed, this is crucial as it can affect the participants response (Jamshed,2014). The questions used comprise the core question and associated questions related to the main question.(Creswell JW,2007). Price 2002, suggests that interviewers find it difficult to think quickly in interviews and deciding how far to probe. The interview was digitally recorded and transcribed for analysis. Recording the interviews is an appropriate choice however can cause controversy between the researcher and the respondent. Recording makes it easier for the researcher to focus on the content and verbal prompts (Jamshed,2014).
This study had a sample of 18 participants who were eligible which is insufficient as not all views would be represented in the findings. A large sample size makes the results more precise (Hayat 2013), makes the study more reliable and efficient (Faber and Fonseca,2014). This will increase external validity of the study which increases the internal validity in the study (Kukull and Ganguli 2012).
Quantitative research covers a range of methods with systematic investigation of social phenomena, using numerical and statiscal data. It uses measurement and sets out to analyse data to find trends and relationships in order to verify measurements made (Watson, 2015). Quantitative research I have chosen explores pressure ulcer related pain in community populations. To critique this paper I have chosen the CASP tool. The aim of this research is to estimate the prevalence of pressure area related pain in the community population. The study identified extent and type of pain suffered in the community with PU and indicated need to systematic and regular pain assessment and treatment (McGinnis et al.,2014). This study used a prevalence survey, and a cross sectional study, the urban population of 259,536 and rural population of 307,190 over the ages of 18 years. Study used community nurses which was beneficial as there were able to screen all eligible patients. Site 1 had a total 1,680 and site 2 had 102 whom were eligible to take part in the study. Cross -section study is an observational study, the researchers don't intervene they record the interviews . Data is collected at a specific point in time and used to assess the prevalence of an illness or disease (CSRO,2015).Observational study is also called epidemiologic study. Epidemiological research involves the frequency and distribution of disease in population. Patients were asked two questions relating to PU pain by community nurses who were trained in data collection process. Site 1 assessed patients on the community nurses case load in residential homes, rehabilitation units, specialist palliative care units. Site 2 assessed patients on the community nursing caseload locally. The other participants were unsuitable as they were; too unwell, end of life, unconscious, patient confused, communication difficulties and other. Also paediatric, obstetric and psychiatric patients were excluded also where it is ethically or clinically inappropriate by the community nurse.
Focus on patients experience is a key element in the NHS which has been reinforced through reviews and policies (Department of health 2008).Effective SU involvement involves making decisions and who to involve, methods to use and matching methods to suit the purpose. WHO's states' people have a right and duty to participate individually and collectively in the planning and implementation of their care (WHO,1978).Involving SU can lead to more acceptable and accessible health services (Nilsen et al 2006). Ladder of participation is a framework that's illustrates the different levels of which a SU can become involved and level of involvement an organisation has reached. EBP is important part of 'person-centered care' as it considers the behaviour and practice of nurses. The nursing code has EBP in four main principles; prioritise people, preserve safety, practice effectively and promote professionalism and trust. EBP 'always practice in line with the best available evidence (NMC 2015,pg7). A barrier to evidence-based nursing are doctors, nurses doubt the ability of doctors to remain up-to-date with issues of daily practice, however doctors don't always notice patient-related aspects. Nurses' perspective doctors more willing to take advice from physiotherapists or dieticians and nurses focus more on comfort and care whereas doctors tend to focus on cure (Hannes et al.,2007).Effective service users involvement means making decisions about who to involve and what methods to use. Education can overcome barriers, by providing people with booklets, leaflets, journal supplement. Educational materials will raise awareness of the desired change, layout can influence into changing behaviour (NICE,2007).1611
Change theory of Nursing was by Kurt Lewin, who theorized a three-stage model of change as unfreezing-change-refreeze model. Unfreezing involves finding a method of making it possible to allows people to let go of an old pattern that was counterproductive. There are three methods of achieve un-freezing which are to increase the driving forces which direct behaviour away from the existing situation, decrease restraining forces that negatively affect movement and lastly the two methods combined. Moving stage is process of change in thoughts, behaviour and feeling. Refreezing stage is establishing the change so it changes to 'standard operating procedure (Nursing-theory.org,n.d). Nurses perception of a pressure ulcer prevention care bundle is one of the research papers I have discussed. To change the practices an assessment of staff's practices and inconsistences will be unfreezing phrase. Unfreeze stage re-examines current practices, organization culture and beliefs and values of the trust (Marquis &Huston,2014). In this study the researcher looked at current pressure ulcer prevention and looked at how it could be improved to make it more effective for both nurses and patients.Pasmore,2011 states that unfreeze phase goal creates controlled crisis which make team members feel uncomfortable with their current practices therefore increases the driving forces and decreasing the restraining forces. The moving phase would happened when research team developed a pressure ulcer prevention care bundle and delivered it to nurses through a posters, brochure and DVD, also nurses received training on encouraging active participation in their care. Nurses need time to understand the change and allowed to adjust to the process being implemented (Lewin,2011). Communication is needed to ensure nurses focus on the objectives (Marquis &Huston,2014). The refreezing phase was when the nurses went to their wards after training with a new knowledge, they were able to re-evaluate the patients which increased patient satisfactions (Marquis & Huston 2014) . Support and training was provided and were encouraged to incorporate it their routine practice (Lewin,2011). In this study the refreeze phase significantly reduced rated of PU incidence in the intervention group. Observing clinical practice is an effective way to identify any barriers as it allows you observe behaviours and interactions, it provides a useful method of monitoring progress and it can be repeated. Additionally it enables a detailed analysis of behaviour and eliminates a reporting bias. However there are disadvantages is that when watching people their behaviour can change and it can be hard to gain consent and a skilled observer is needed so it minimising the influence on the person who is being observed. Education can overcome barriers, by providing people with booklets, leaflets, journal supplement. Educational materials will raise awareness of the desired change, layout can influence into changing behaviour. Conferences, workshops and training can be used to educate healthcare professionals, there can be interactive workshops which are effective in changing behaviour.