introduction The aim of this essay is to critically review the most current literature in relation to pressure ulcers. The main factors will include prevention and management, the healthcare professionals’ perspective, and their knowledge of pressure ulcers. Two primary research studies of which one will be qualitative and one quantitative, will be critically analysed regarding their different approaches when examining the research. This will be achieved by comparing the methodology and the design of both studies and how data analysis was collected and interpreted. The conclusion will highlight the importance of evidence based nursing care and provide a reflection on the research evidence.
Background A pressure ulcer is a wound which develops due to prolonged pressure to an area of the body. Pressure ulcers develop when areas of the skin become damaged due to excessive pressure, friction, and shearing (Dougherty and Lister, 2011). The sacrum, hips and heels are most at risk as these are the boniest prominent areas of the body. The severity of a pressure ulcer usually depends on the magnitude of damage caused to the layers of the skin (Gunnewicht and Dunford, 2004). Although anyone can develop a pressure ulcer, they are more likely to occur in patients who are more vulnerable due to a serious illness, malnutrition, poor mobility, old age, or who suffer from neurological conditions (Nice.org.uk, 2017). According to a report conducted by Mahalingam et al (2014), the expense of treatment for pressure ulcers accounts to approximately £200,000, or 4% of the National Health Service’s (NHS) annual budget each year. This is mainly due to the healing process, compliance of patients, and the types of dressing and methods used in the treatment process. (Mahalingam et al, 2014)
Literature review Previous research studies have revealed that a lack of knowledge regarding pressure ulcer prevention is a contributing factor amongst patients and healthcare practitioners (HCP). Gorecki et al (2010), conducted a qualitative study in the form of semi-structured interviews which consisted of 30 patients across seven different hospitals. The primary focus of the study was to identify a connection between a patient’s Health-Related Quality of life, (HRQL) and the contributing factors related to pressure ulcers. The study found that pressure ulcers had a direct impact on a patients HRQL, with issues such as experience of care, inconsistencies, treatments, and knowledge appearing to be a priority among the patients interviewed (Gorecki et al, 2012). Although most patients commented that the HCP’s lack of knowledge and training had a negative impact on how they felt about living with a pressure ulcer, they also noted that their own knowledge was poor, and felt that the nursing staff provided little information in respect of how the patient could contribute to the care of their pressure ulcer (Gorecki et al, 2012). This shows that because of the lack of knowledge that HCP’s possessed, the patient could not be given the correct information and therefore would have experienced inadequate care. In view of this the Nursing and Midwifery Council (NMC) state that, nurses should practice their skills in line with evidence based practice and maintain their knowledge for safe, effective practice. (Nmc.org.uk,2015) Another study conducted by Collado et al, (2013), also suggests that knowledge and experience is lacking within the healthcare profession. The study consisting of 81 nurses and 46 doctors, showed that nurses received significantly more training than the doctors and provided better knowledge of the types of products used in the treatment of pressure ulcers. Having said that the study also showed that whilst training was provided, it was also forgotten within 20 weeks and knowledge levels returned to their pre-training baseline (Collado et al, 2013). Both these studies suggest that the lack of training and knowledge portrayed by HCP’s has a significant impact on the management and prevention of pressure ulcers. Furthermore, they suggest that better communication between HCP’s and patients could be a key factor when treating pressure ulcers and that by working together the healing time could be reduced, as well as aiding in the prevention of further pressure ulcers developing. However, in contrast to this, it is important to remember that when adequate training is provided to HCP’s, it is their responsibility to ensure that the correct practice is carried out and that they maintain their knowledge by attending training sessions, comply to the NMC code, and adhere to best practice evidence.
Papanikolaou, 2012, conducted a study which focused on the provisions available to elderly patients for pressure ulcer prevention. The study involved senior community nurses and their views regarding the different service descriptions of pressure ulcer preventative care. This study revealed that although other factors such as treatment management and effects on patients’ lifestyles were important, the main factors that stood out was treatment affordability and availability of equipment (Papanikolaou,2012). In February 2016, the NHS England North Region Pressure Ulcer Summit estimated that the cost of treatment for a grade four pressure ulcer was £14,108 per patient(North Region Pressure Ulcer Summit, 2016). In 2010 the NHS National Patient Safety Agency (NPSA) produced a report stating that a zero-tolerance approach to pressure ulcer prevention must be rolled out across the NHS. They state that by monitoring nutritional status, changing position regularly and observing patients skin will enable staff to recognise the risk for pressure ulcers before they develop (Npsa.nhs.uk,2018) However this can prove difficult in community nursing as nurses have to rely on family and carers to complete these tasks competently and follow the care-plan accurately. It is important that senior community nurses take into consideration the presence of a carer when deciding on the general provision of a care package, and training in the use of pressure relieving aids (Papanikolaou, 2012).
To obtain the two primary research articles needed to complete this assignment, the university libraries main search engine Discover was accessed. This gave an A-Z of databases of which CINAHL was chosen as it is wildly used as an effective research tool for nursing professionals. To access specific articles, individual phrases for each field was applied, these included ‘pressure ulcers’, and ‘prevention’. This produced 71,327 studies. To reduce the number of articles to a more manageable number an advanced search was carried out and an inclusion criterion was applied. This focused on articles that included a full text and were peer reviewed, this decreased the number of articles to 50,000. A time scale of articles published in the last ten years was added as well as limiting the search to only include the words pressure ulcers. This resulted in a total of 19,939 articles. By adding additional words to the search field which included ‘treatment’ and ‘views’ the result was reduced to 49 articles which was manageable. The exclusion criteria included all non-primary research articles, systematic reviews, grey literature, patients under the age of eighteen and articles that were not transcribed in English. From the 49 articles researched, a qualitative study which related to the prevention and management of pressure ulcers, and a quantitative study which relates to knowledge and attitude were chosen.
methodology The first research study chosen for this assignment was a study conducted by Newham and Hudgell, 2015. The aim of the study was to determine what it is like to follow the development in practice for the prevention and management of pressure ulcers (Newham and Hudgell, 2015). A qualitative approach was taken for this study as the aim of the results was to interpret and describe staff views, as well as what motivates them in practice. Qualitative research is a term used to identify a study that explores the human experience and perceptions of individuals or groups. It is based on the premise that to explore and understand social phenomena, interpretation is central to the study. Qualitative research methods that are inductive, holistic, interactive, and flexible are used to gain an insight into people’s perspectives of a specific topic (Parahoo, 2014). Using qualitative research in nursing allows the researcher to address issues or problems that are beneficial to healthcare professionals. Historically, qualitative studies have been ranked lower in a hierarchy of evidence as they were viewed weaker forms of research design, however, because nursing is a trained discipline, it is thought that qualitative methods are better when having to answer questions that have not been addressed or when a new perspective is needed in practice (LoBiondo-Wood and Haber, 2006).
In contrast to Newham and Hudgell, (2015), Gill and Moore, (2013), used a quantitative approach for their study to identify the relationship between pre-registered nurses’ knowledge of pressure ulcers and their attitudes to them. Quantitative research is used when concepts or variables need to be measured objectively, and can be examined by numerical and statistical processes. This means that the results from a study can be replicated in a similar setting using the same method and a similar sample, consequently allowing the findings to be generalisable to similar populations, however in contrast to this there are limitations of empirical observations when trying to understand the human phenomena (Parahoo, 2015).
Research Design Newham and Hudgell, (2015), used a semi-structured interview process as the design method for their qualitative research. This is used when the researchers aim is to determine the views of the participants using a combination of pre-determined questions which can be enhanced by follow up probes. Using a semi-structured interview would allow the researchers to explore the complexity of the issues in depth and from a realist ontology that would recognise mind-independent and mind-dependent objects, which meant that they could account for not only the fact of pressure ulcers but also the complexity of the issues affecting their prevention and management (Boghossian, 2006). The use of semi-structured interviews in this study was to obtain evidence of the prevention and management of pressure ulcers from the experience of staff caring for patients who are at risk of developing them. In contrast to this the quantitative study used a survey design to determine the student nurses’ attitudes and knowledge of pressure ulcer prevention. This type of design meant that the participants were restricted to the response options on the questionnaire and therefore could not elaborate their views. (LoBiondo-Wood and Haber, 2006) Surveys are used in quantitative research to collect information from all or part of a population, about their views, beliefs, behaviour, and attitudes to topics.
Sampling The population of the quantitative study comprised all pre-registered nurses from one university. A sample size of sixty students were used with the employment of a non-probability convenience sample. This type of sampling method is generally used when the researcher wants to find participants who are readily available and who fit with the criteria of the study. However, the drawbacks with this type of sampling method is that some elements are not guaranteed to be included in the study, and the results cannot be generalised to an entire population (Kandola et al, 2014). In view of this, Gill, and Moore, (2013) could be criticised for producing a piece of research that is considered bias because the sample does not represent the entire population of nursing students. This would suggest that there is a weakness within the study as it is not stated whether the sample size was statistically determined. The sample size of the qualitative study consisted of 72 staff nurses and healthcare assistants covering three hospitals in the same area. The population target was nurses and HCA’s that provided physical care daily. Twenty-five participants from each trust were selected with a view of completing twelve faces to face interviews whilst the others completed the online survey. These numbers were determined partly for pragmatic reasons. (Newham and Hudgell, 2015). This means that the sample method could be considered as purposive sampling because the researcher only wanted to include staff that had knowledge and experience of caring for patients with a pressure ulcer. Purposive sampling is used in qualitative studies as it allows the researcher to deliberately choose the target audience, on the basis that they can provide the necessary data needed for the research study. However, when choosing this method of sampling, the researcher must be guided by the question and avoid choosing samples that may be more convenient as this would give unrealistic results for the study (Parahoo, 2014)
Data collection The methods used in the qualitative study were in the form of semi-structured interviews. The process for collecting data were online surveys which were based on four open ended questions related to pressure ulcers, and face to face interviews. The online survey provided text boxes for answers and were designed to expand to 2000 words, with a help button which provided explanations and prompts which were like the researcher prompts used in the face to face interviews (Newham and Hudgell, 2015). The advantages of this method are that the respondents may have a clearer picture of what the researcher wants to know and be able to answer the questions appropriately. The main problem with online surveys are that whilst some respondents may produce a lot of information to the questions, there are some who may only respond with one or two sentences for each question answered, therefore this may mean that the results of the study could be viewed as inaccurate and ungeneralizable. In comparison, Gill, and Moore, (2013) chose a questionnaire, with the first section consisting of basic demographic questions. These types of questions are used to identify the characteristics of a population, such as age, gender, employment status and ethnicity. Thirteen questions on the attitudes to pressure ulcer prevention were based on a four-point likerd scale, completing the second section of the questionnaire, whilst the third section contained twenty-six closed- ended questions. A Likert scale is a list of statements where respondents can only choose one answer, for instance the choices would be strongly agree to strongly disagree.
Data analysis Data analysis is a crucial part of the research process, as it allows researchers to make sense of the information collected before it is presenter to the reader. The type of data collected determines which type of analysis is required (Parahoo, 2014). Gill and Moore, (2013) used statistical analysis to summarise the data for their quantitative study. A statistical package for social sciences for windows was used to summarise the data, this is a software package that was developed by SPSS Inc. in 2009. This is a widely used program in education and research, and because of its potential it is also widely used by healthcare researchers (Techopedia.com, 2018). By using this program, the researchers were also able to further analyse the data to interpret relationships between the participants’ attitudes, experience, knowledge, and competence. To achieve this the researcher used the Mann-Whitney U test, this is used to test whether two independent samples of observations are drawn from similar distributions. One of the advantages of this test is that the two samples under consideration do not necessarily need to have the same number of observations or instances (Explorable.com, 2018). Newham and Hudgell, (2015) used thematic analysis to gather data from both the interviews and the survey. Although this type of analysis is common practice in qualitative research, it is hardly ever recognised. Advantages for using thematic analysis in data collection is that it can give the researcher flexibility, however this can also prevent them from developing specific guidelines for higher phrases and can potentially isolate the researcher when deciding what areas of the research to focus on (Braun and Clarke, 2006).
Ethical issues The qualitative study conducted by Newham and Hudgell, (2015) stated that ethical approval regarding their study had been sought and granted by the university ethics research committee, whilst research and development approval was obtained from each individual trust. However, the quantitative study by Gill and Moore, (2013) failed to state if ethical approval had been granted for their research study. The consideration of ethics is important when conducting research studies within the healthcare service because of the need for anonymity. Some of the ethical issues that must be adhered to by the researcher are that participants are fully informed about the process of the research and what will happen with the data collected, all participation must be voluntary and free from coercion with the participants having the choice to withdraw at any time. (Ethicsguidebook.ac.uk, 2018). There did not appear to be any ethical issues within either of the research studies selected for this essay.
Findings and recommendations The findings within the qualitative study suggest that the need to manage and prevent pressure ulcers was high profile within each of the trusts. The study also found evidence to suggest that the political and managerial impositions of prevention and management resulted in improvements and a reduction in incidences by means of increased standards or a reduction in division of practice in some trusts, this may be due to improvements in communication between neighbouring trusts. another finding from the study found that the detection of a pressure ulcer in some patients had the potential to become a safeguarding issue, with nurses being asked if the injury was preventable. The quantitative study concluded that although nursing students had a positive attitude to pressure ulcer prevention, they had sufficiently poor knowledge about the subject. The researcher also suggests that the information obtained could be used as a baseline that would assist in directing future training and education within the clinical and university settings. These suggestions could provide the intent of improving clinical outcomes for patients and assist in the prevention and management of pressure ulcers within the NHS.
Evidence Based Nursing
Evidence based nursing requires health-care practitioners to be able to identify a specific clinical question, find evidence by conducting a critical review of the most relevant literature, and all evidence should be appraised before applying to a clinical patient situation (Beyon and Slattery, 2013). The importance of evidence based practice is to enable nurses and other healthcare professionals to provide good quality care and improve outcomes for their patients, by demonstrating the efficient management of the health service (Burns and Groove, 2007). The nursing and midwifery council, (NMC) also state that nurses are accountable to society, to provide a high quality of care so therefore it is important that nurses reflect, evaluate and update their knowledge in line with best practice (NMC,2015). Evidence based nursing promotes the application of research evidence as a basis on which to make healthcare decisions, which is why it is important to search for knowledge logically (Burns and Grove, 2007). Research can have a positive impact on patient outcomes if new knowledge is transformed into clinical forms that can be implemented effectively across an entire care team (ref) Although evidenced-based practice has been shown to improve decision making in clinical practice and therefore improve patients’ health outcomes, there seems to be a few factors which prevent healthcare professionals from accessing the literature. One of those factors is a lack of time. Heiwe et al, (2011), conducted a study which aimed to measure the healthcare professionals’ attitudes towards EBP. Although the HCP showed a positive attitude to EBP, and believed they had the necessary skills to interpret and understand the evidence, they also expressed that a lack of time was a major barrier when it came to accessing new and updated research (Heiwe et al, 2011). Another limitation which can have a detrimental impact on EPB, is when nurses fail to see the point in research because they have a lack of understanding of electronic databases, lack of autonomy or not enough time. As the number of patients increase, so do the challenges of providing safe effective care within a small time-frame. Inadequate technical training can prevent nurses from accessing new research studies, therefore limiting their knowledge of best practice for their patients (Rose, 2007) One key value which EBP is based on is the need for productivity when using health-care resources. In order to achieve the best possible outcome for the patient the best choice of intervention will lead to the best use of resources. When considering the rational for decision making it is important to look at the strength of the evidence and to choose the one that is most likely to produce best clinical outcomes. It is also important that student nurses understand the principles of EBP before they qualify. The NMC includes specific standards of proficiency that students are expected to achieve as part of their learning which includes being able to access research and discuss the findings, identify examples of the use of evidence in nursing interventions and ensure that research findings and new evidence is incorporated into practice.