Evidence-Based Practice comprises the explicit, careful, and prudent use of the most recent best evidence to make healthcare decisions for patients (Aeyard, 2013, p. 15). It entails combining personal expertise and talents with the greatest available clinical evidence acquired from scientific experimentation and experience. As a result, Evidence-Based Practice combines patient values, clinical expertise, and research to determine the optimal care to give to a patient. Education, cumulative experience, and clinical skills all contribute to expertise. Patients have distinct issues, preferences, attitudes, and expectations that must be understood and considered (Jarrett-Williams, 2012, p. 30). A sufficient evidence occurs in primary research, systematic reviews, journals, national clinical guidelines and discussion papers corroborated using sound methodology (Schultz, 2013, p. 62). To meet the objective of this article, the researcher will use reflective writing. Reflective writing derives from reflective thinking which entails identifying an event that happened, analysing the idea or event and thinking critically about the meaning of the concept or event (Schultz, 2013, p. 63). Hence, thoughtful writing reveals personal thoughts, experiences, especially in a learning context.
This paper will reflect on a decision the author made in practice, analyse the solutions given in that context while basing on decision-making theories. Moreover, the article will identify relevant literature and provide the description of the search process and terms for each search. Furthermore, the researcher will present the best evidence and outline the rationale for the selection while critically discussing the reasons why the evidence is of good quality. Additionally, the paper presents a discussion of how the findings may inform future practice and issues that affected the author’s clinical judgment. To conclude, the article discusses alternative solutions for similar scenarios and provides recommendations training and research.
The Clinical Decision
The decision under reflection in this research paper happened when I was on placement at the Acute Stroke Unit. The patients in the Unit (herein referred to as Mrs X) were mainly seeking for thrombolysis treatment, those coming for early rehabilitation and assessment by the therapist and those needing stroke assessments. My assignment was to look after a 67-year-old woman (herein referred to as Mrs X) who had an ischemic stroke, hence had trouble repositioning her and had a high risk of developing pressure ulcers. After assessing her situation and discussing with her and my mentor on the imperativeness of frequent repositioning, and gaining informed consent, I decided to encourage the patient and help her undergo repositioning every six hours. Furthermore, the agreement was that I apply a barrier cream when needed to avert moisture lesions.
Decision-Making Theory
Decision making is a systematic cognitive process leading to the selection of course of action among several possibilities based on values, beliefs, preferences or science (Mallah et al., 2015, p. 106). In a healthcare setting, decision making may need integration of uncertain, ill-structured and potentially conflicting information (Jarrett-Williams, 2012, p. 30). Nurses, doctors, and other healthcare workers make complex decisions that affect clinical outcomes. Hence, deciding the type healthcare intervention can be overwhelming at times since it involves subjects with life-threatening illnesses and competing resources and priorities. Other factors for consideration include decisions on, treatments, tests, whether to provide hospital or home care. Regardless of choice, it is imperative to first, be informed about the issue needing address, determine objectives and making plans to achieve the goals while considering strategies and resources available (Aeyard, 2013, p. 20).
For effective decision making in healthcare, decision-making theories are indispensable (Standing, 2008, p. 124). The principal categories of decision-making theory are: phenomenological and rationalistic (Szymaniec-Mlicka, 2017). Most decision-making models such as cognitive continuum (CCT) relate to the two concepts. Cognitive Continuum Theories include facets such as collaborative, intuitive based, reflective and accountability (Parker-Tomlin, 2017, p. 447). Hammond formulated CCT in 1978. Since then, there have been several modifications by scientists such as Hamm in 1988 to make it suitable for medical theory and practice (Szymaniec-Mlicka, 2017, p. 56). In cognitive continuum theory, rational analysis and intuition are the two modes of cognition that occur at the end of a continuum where scrutiny depicts a slow, controlled and conscious processing while intuition relates to an unconscious, rapid and low controlled processing (figure 1) (Standing, 2008, p. 124).
Figure 1: Cognitive Continuum Theory
Decision making and thinking occur at particular points somewhere in between the continum, and the best mode of thought relies on the specific task characteristics (figure 1). Such decision may not always be rational or intuitive. Health care workers have to match the cognitive processes to the job requirement to be accurate. Even though the modes of CCT lack ranking, CCT provides an impression of hierarchy in decision making thus limiting flexibility movement between modes. However, CCT is efficiently applied in decision making and improving clinical outcomes (Standing, 2008, p. 126).
When utilising CCT, it is imperative for nurses to consider various sources of knowledge and alternative viewpoints to make reliable and replicable decisions. Moreover, CCT emphasises the use of evidence best practice. Evidence-based decision making entails integrating knowledge, expertise, research evidence and patient preferences using the limited resource to choose from a discrete range of options (Aeyard and Sharp, 2013, p. 20). Studies show that, in a clinical setting, nurses primarily rely on information from colleagues followed by other by information from other guidelines and protocols (Aeyard and Sharp, 2013, p. 22). Though many nurses appreciate the importance of consulting primary research to aid in decision making, a significant number of them think it is a tedious process or a time waster. However, it is imperative to effectively use research, expertise and patient preferences to make effective decisions that promote positive clinical outcomes.
I followed the policy guidelines both for the hospital and as suggested by National Institute for Health and Care Excellence (NICE) that, in caring for such patients, use of the nutritional supplement, skin massage should be avoided (NICE, 2014). Moreover, as guided by NICE, there was no application of subcutaneous fluids to prevent pressure ulcers since the hydration status of Mrs X. was adequate. System aided judgments uses assessment tools, policies, guidelines, and problem-solving frameworks to make useful clinical judgments (Jarrett-Williams, 2012, p. 30). For effective assessment and decision making, the patient went through risk assessment which included, skin assessment for lesions, mobility assessment, stability in sensation and occurrence of previous pressure ulcers. The evaluation found out that Mrs X. could not reposition herself. Also, there was a need to use Norton Risk-assessment scale to determine the physical mental, activity mobility and incontinence conditions of Mrs X. and established that she was at medium risk (NICE, 2014). The focus for skin risk assessment included skin integrity in areas of pressure, variations in color and variations in firmness, heat, and moisture due to incontinence. Other factors included edema, inflammation and skin moisture.
Collaborative decision making occurs when people work together to reach a compelling conclusion. According to Nurses and Midwives Code (NMC), collaboration is vital in achieving patient-centered care. CCT requires cooperation and patient peer aided judgment. Consequently, I presented my solutions and sought advice from my mentor. There was also the need to discuss the importance of frequent repositioning with the patient. After seeking informed consent from the patient, she needed to reposition after every 6 hours. Moreover, reflective judgment was essential in managing the patient. Previously, I had encountered a similar case in which I utilised individualised care plan to improve recovery. Therefore, in treating Mrs X. there was a need to consider the outcomes of skin and risk assessment, need for pressure relief, advising on repositioning, helping with repositioning, other comorbidities, and patient’s preferences.
Legal, Ethical and Professional Issues
Healthcare workers must care for patients, prevent harm and promote positive patient outcomes (Jarrett-Williams, 2012, p. 30). By performing illegal or unethical actions or inactions in the provision of healthcare, nurses may face suspension or removal from Nurses and Midwives Code (NMC) register, punishment from employment tribunals, criminal prosecution and compensation claims (NICE, 2014). I had a legal duty manage the condition for Mrs X since she was under our care. Hence there was need prevent the disease from worsening and ensure she is frequently repositioned and given pressure reliefs to prevent lesions. Moreover, it was necessary to seek informed consent from the patient before instituting any intervention. Also, Mrs X had to undergo mental assessment guided by Mental Capacity Act (Department of Health, 2005).
Literature Search Process
Before the literature search process, I explored guidelines on the management of Ischemic Stroke survivors thus referring to NICE instructions (2014). The next process was to formulate research question on the topic using PICOT tool. According to (Aeyard and Sharp, 2010, p. 30), PICOT tool is vital in performing a literature search and formulating research questions. The research questions ii, “Do patients with ischemic stroke, and trouble repositioning have a high risk of developing pressure ulcers?” The abbreviations in the tools stand for, population, intervention, comparison, outcome, and time (Table 1).
Table 1: PICOT tool (Aeyard and Sharp, 2013)
Population
Female Above 60 Years old
Interest
Managing pressure ulcers in ischemic patients
Context
Post-Stroke
Outcome
Pressure Ulcers
Time
While in Hospital
Literature appraisal
To find the best evidence, I performed a literature search that helped me determine a wide range of sources appropriate to the condition I was handling (Appendix 2) (Aeyard and Sharp, 2010, p. 27). Synonyms of the keywords were used to ensure a thorough search (Table 2 and Appendix 2).
Table 2: Search Strategy Showing Keywords (KW), Synonyms, and Boolean Operators
KW 1
AND
KW2
AND
KW3
S1
Pressure Ulcers
Ischemia
Patients
S2
Pressure
Ischaemia
S3
Ulcers
Ischaemic
The “healthcare” databases in the library informed the literature such process. I examined and selected the most relevant material for my subject area. When keying in the search words, individually, a large number of matches were generated (see appendix 4). The search databases were PubMed, MEDLINE and MedGen (table 3).
KW1: Pressure ulcers OR Pressure OR Ulcers OR Decubitus Ulcer
KW2: Ischaemia OR Ischaemic OR TIA OR Anemia
KW3: Patients
Table 3: Search Results
Database
PubMed
MEDLINE
MedGen
Mallah et al. (2015)
X
X
McInnes et al (2014)
X
X
X
Bhattacharya & Mishra (2015)
X
X
X
Agrawal & Chauhan (2012)
X
X
Anders et al. (2010)
X
X
X
After combining the search terms, the results were narrowed using the Boolean operators to either limit or expand search terms for individual database results.) (Aeyard and Sharp, 2010, p. 15). The first process was to identify the keywords (see appendix 2). To limit the number of sources, I established the inclusion and exclusion criteria (see appendix 3). The inclusion criteria were, articles published from 2012 to date, English language articles, managing pressure ulcers, studies conducted in inpatient settings and those involving adult participants. The exclusion criteria were, articles published before 2012, reports not written in the english language, articles without a specific perspective on managing pressure ulcers, studies conducted in outpatient settings and those involving children participants. When searching the articles there were a large number of hits in PubMed, MEDLINE and MedGen (see appendix 4) hence there was a need to narrow down the search criteria to exclude articles published more than five years ago (see appendix 5). When deciding on the material to use in the study, there was a need to use the Critical Appraisal Skills Programme (CASP) (see appendix 6). As such, articles were analysed based on, clarity of aims of the study, appropriateness of the methodology and research design, the value of research, data analysis, the relevance of recruitment strategy and data collection. Other factors included ethical considerations and interviewee bias.
By critically examining a research material, one can ascertain strengths and limitations of the research (Greenhalgh, 1997, p. 740). The research papers for review in this study are those written by McInnes et al. (2014) and the other by Mallah et al. (2015) were selected since they were the most recent. Moreover, the two through review of the scope of the study, other articles were dismissed as irrelevant to the study. The inclusion criteria were articles written in English and involving adult participants. Moreover, the reports should have been published within the last five years and exploring patient experiences. Both of the articles were analysed by the use of CASP tool (2013) see appendix 6.
The paper by Mallah et al., (2015) focused on “The Effectiveness of a Pressure Ulcer Intervention Program on the Prevalence of Hospital Acquired Pressure Ulcers.” Since it was a prospective research design involving 468 patients admitted to the hospital between 2012 and 2013, the study findings are replicable in other populations with similar characteristics. The lead researcher is a medical doctor and also works at the King Abdulaziz Cardiac Center in Riyadh and the division head in the cardiac imaging section. The paper had several peer-reviews to improve its credibility. Mallah et al. found out that, multidisciplinary approach, skin care management and efficient use of Braden scores and barrier creams helps in the management of HAPU (Mallah et al. 2015, p. 107).
The main strength of the article was that it involved women, including those above 60 years old hence increasing relevance to my research. Moreover, there was the identification of research gaps, a suggestion for practice and seeking of ethical approval. Since it was a prospective study, the researchers were able to allow calculation of incidence, clarify temporal sequence and allow examination of multiple effects of a single exposure (Cooley, 2014, p. 10). However, since the lead author participated in data collection, there was a risk of data collection bias. Additionally, loss to follow up arose hence affecting the study outcomes. The strengths of the research paper indicate the high quality of choosing it for this study (Greenhalgh, 1997, p. 743).
The study by McInnes et al. (2014, p. 41), which was quantitative, focused on the role of patients in pressure injury prevention (PIP) among acute care patients. The lead researcher is a licensed Clinical Social Worker and Clinical Case Manager. The central themes of the paper were patient participation, patient views, and pressure injury prevention. The study participants were adults above 18 years from a neurology ward admitted to the hospital, at least 24 hours before enrollment to the research. The study found out that patient requires education and supportive partnership with healthcare staff to facilitate appropriate pain relief and quick recovery from pressure injuries.
The main strength of the research is that it occurred in a hospital setting involving patient with pressure injury hence relevant to my research question. The study sought ethical approval from St Vincent’s Hospital (Sydney) and the Human Research Ethics Committee thus depicting the researchers’ efforts to abide by ethical guidelines in research. The limitation of the study was that it chose a small convenience sample of participants. Hence the results may not be replicable, and however, respondents were from hospital wards (neurological and orthopedic) which include a patient having the high risk of pressure ulcers. The strengths highlighted above indicate the high quality of choosing the paper.
How the Findings of the Selected Papers Inform Future Practice
This research identified reliable evidence to support the use of repositioning and patient education and supportive partnership with healthcare staff to facilitate appropriate pain relief and quick recovery from pressure injuries. The paper by Mallah et al., (2015, p. 107) supports my decision for regular and frequent repositioning and application of barrier cream when necessary, to enable quick recovery and prevent the formation or worsening of pressure ulcers. Thus my decision was Evidence-Based. NICE guidelines recommend that patients are encouraged to reposition at least four hours to avert pressure ulcers an promote positive clinical outcomes. Moreover, there was no need for the application subcutaneous fluids to prevent pressure ulcers since her hydration status of Mrs X (NICE, 2014).
Medical interventions require substantial evidence to ensure effectiveness. NICE guidelines are some of the useful sources. However, since NICE guidelines mostly provide recommendations, it is imperative to refer to other systematic review papers. Patients with pressure ulcers always find it hard to reposition due to pain. My patient needed help to reposition herself. Moreover, there was a need to educate her on the importance of repositioning and efficient management of her condition (McInnes, 2014, p. 41). Some nurses either ignored or were not willing to provide awareness and education to search patients on the importance of repositioning. Moreover, the findings show that there is need to take into account factors such as time, costs and patient comfort. This evidence could have helped me decide the type of body cream, appropriate bedding to aid in quick patient recovery.
Regarding the second research paper, patients require education and supportive partnership with healthcare staff to facilitate appropriate pain relief and quick recovery from pressure injuries (McInnes et al. 2014, p. 41). The findings, according to McInnes, show that one of the significant factors affecting patient recovery is awareness, knowledge, and involvement. Ensuring patient participation in health care decision making helps them to appreciate the importance of the mediation process. Moreover, collaborating with other staff members promotes efficiency and effectiveness in achieving positive clinical outcomes. Hence consulting with patients, the hospital management, which is also part of the cognitive continuum, may be utilised alongside scientific evidence to make effective decisions.
Conclusion
Decision making in healthcare may be a multifaceted process involving the use of personal preferences, experience, and scientific evidence while depending on the available resources. This paper has identified substantial evidence which supports the use of barrier cream, frequent repositioning in ischemic patients with pressure ulcers. However, one of the issues with the potential to impede the decision is compliance by the patient. While some patient may need extensive counseling to accept a particular medical intervention, the need may arise to put more effort, on the part of the medical practitioner or nurse to help patients comply with the intervention. It is imperative to ensure that patients are comfortable and willing to participate in the treatment process.
According to the evidence presented before, it is possible to include patient preferences in decision making about repositioning and use of barrier creams. According to the studies, and other anecdotal evidence, four-hour repositioning, is one of the most effective methods to prevent pressure ulcers. Therefore, in future, instead of the six-hour cycle that I used for repositioning, I will implement a four-hour period in combination with other methods such as pressure redistribution and friction reduction, Norton risk-assessment scale and pararectal bootees where possible (Lospitao-Gómez, 2017, p. 77). The placement and the research performed have increased my knowledge and experience in the decision-making process and how to improve my nursing practice.
References
Aeyard, H. & Sharp, P., 2013. A Beginners Guide to Evidence-Based Practice in Health and Social Care.
Agrawal, K., & Chauhan, N., 2012. Pressure ulcers: Back to the basics. Indian Journal of Plastic Surgery, vol. 4, no. 3, pp. 244-254.
Anders, J. H.-K. (2010). Pathophysiology and Primary Prevention. Deutsches Ärzteblatt International, vol. 107, no. 21, pp. 371-382.
Bhattacharya, S. &. (2015). Pressure ulcers: Current understanding and newer modalities of treatment. Journal of Plastic Surgery, 48(1), 4-16.
Cooley, C. (2014). Evidence-based Practice for Nurses Barker Janet Evidence-based Practice for Nurses. Cancer Nursing Practice vol. 13, no. 9, 10.
Greenhalgh, T. (1997). How to read a paper: Papers that go beyond numbers (qualitative research). BMJ vol. 7110, no. 315, pp. 740-743.
Jarrett-Williams, T., 2012. Clinical judgement and decision making for nursing students Learning Matters. Nursing Standard vol. 23, no.26, pp. 30-30.
Lospitao-Gómez, S., 2017. The validity of the current risk assessment scale for pressure ulcers in intensive care (EVARUCI) and the Norton-MI scale in critically ill patients. Applied Nursing Research vol. 38, pp. 76-82.
Mallah, Z. N., 2015. The Effectiveness of a Pressure Ulcer Intervention Program on the Prevalence of Hospital Acquired Pressure Ulcers: Controlled Before and After Study. US National Library of Medicine, vol. 4, no. 10, pp. 106-113.
McInnes, E. C., 2014. The Role of Patients in Pressure Injury Prevention: A Survey of Acute Care Patients. BMC Nursing vol. 13, pp. 41.
NICE, 2014. Pressure Ulcers: Prevention and Management. Retrieved November 2017, from National Institute for Health and Care Excellence: https://www.nice.org.uk/guidance/CG179
Parker-Tomlin, M., 2017. Cognitive continuum theory in interprofessional healthcare: A critical analysis. Journal of Interprofessional Care vol. 4, no. 31, pp. 446-454.
Schultz, C., 2013. Reflective Practice in Nursing. Journal of nursing vol. 46, no 5, pp. 62-64
Standing, M. 2008. Clinical judgement and decision‐making in nursing–nine modes of practice in a revised cognitive continuum. Journal of Advanced Nursing, vol. 4, no 13, pp. 45-56
Szymaniec-Mlicka, K., 2017. The decision-making process in public healthcare entities – identification of the decision-making process type. Management, vol. 1, no. 21.
Appendix 1: Detailed Search Strategy
Using keywords in appendix two, literature search was conducted in PubMed, MEDLINE, and MedGen. Searching results required limitation of the search results by varying the search criteria for keywords KW1 to Title (TI) rather than the Abstract (AB) to limit the hits. Boolean operators aided in combining keywords. “AND” helped in focusing search results and “OR” to expand the hits, table 2 below shows limitation by year of publication of the literature (2012-2017). All the articles, Mallah et al. (2015), McInnes et al. (2014), Bhattacharya & Mishra (2015) and Agrawal & Chauhan (2012) were found both in PubMed and MEDLINE. Further narrowing down the search by limiting the search criteria for articles published between 2012 and 2017 eliminated the article by Anders et al. (2010). Elimination of the report by Bhattacharya & Mishra (2015) was due to its principal focused on a review of existing literature and not carrying out the actual scientific study.
Appendix 2: Keywords
Table 1: Keywords
Table adapted and modified from Aeyard and Sharp (2013)
Keyword 1 (KW1)
Keyword 2
(KW2)
Keyword 3
KW3
Pressure Ulcers*
Ischemia
Patients*
OR
OR
Pressure*
Ischaemia
OR
OR
Ulcers*
Ischaemic
OR
OR
Decubitus Ulcer*
TIA
OR
OR
Database
No. of hits
No. of hits
No. of hits
PubMed
1,219,165
486,625
5,019,743
MEDLINE
4,579
6,334
104,852
MedGen
943
1,112
6,041
Appendix 3: Inclusion and Exclusion Criteria
Inclusion
Exclusion
Rationale
Article Published from 2012 to date
English language articles
Managing pressure ulcers
Studies conducted in inpatient settings
Adult participants
Articles published before 2012
Articles not written in the English language
Reports without a specific perspective on managing pressure ulcers
Studies conducted in outpatient settings
Children Participants
To use updated evidence
I understand English
I am interested in pressure ulcers in ischemic
My placement was in inpatient setting during internship
I dealt with adults during placement
Appendix 4: Total Number of Hits
Keyword 1 (KW1)
AND
Keyword 2
(KW2)
AND
Keyword 3
KW3
HITS
PubMed
MEDLINE
MedGen
Comments
Pressure ulcer
Ischemia
patients
391
125
90
Pressure ulcer
Ischaemia
Patients
393
197
101
Pressure ulcer
TIA
Patients
2
473
45
Ulcers
Ischemia
patients
1892
144
30
Ulcers
Ischaemia
Patients
1892
222
78
Ulcers
TIA
Patients
15
556
300
Decubitus Ulcer
Ischemia
patients
309
75
34
Decubitus Ulcer
Ischaemia
Patients
309
107
53
Decubitus Ulcer
TIA
Patients
0
20
9
Appendix 5: Keywords by year of publication
AND
AND
HITS limited By The year 2012-2017
PubMed
MEDLINE
MedGen
Comments
Pressure ulcer
Ischemia
patients
391
16
30
Pressure ulcer
Ischaemia
Patients
393
18
55
Pressure ulcer
TIA
Patients
2
23
20
Ulcers
Ischemia
patients
1892
16
35
Ulcers
Ischaemia
Patients
1892
18
50
Ulcers
TIA
Patients
15
25
10
Decubitus Ulcer
Ischemia
patients
309
15
5
Decubitus Ulcer
Ischaemia
Patients
309
12
4
Decubitus Ulcer
TIA
Patients
0
13
3
Appendix 6: Critical Appraisal Skills Programme (CASP) tool (CASP, 2013)
Mallah et al. (2015)
McInnes et al (2014)
Clarity of aims of the study
Yes, “to determine the effectiveness of the multidisciplinary intervention and to evaluate which factor of the intervention was most predictive of reducing the prevalence of Hospital-acquired pressure ulcers (HAPU) in a tertiary setting in Lebanon.”
Yes. The study aimed to survey inpatients on their perceived roles in Pressure Injury prevention and factors that inhibit or enable patients to participate in PIP
Appropriateness of the Methodology
The study used prospective research design. Hence the researchers were able to allow calculation of incidence, clarify temporal sequence and allow examination of multiple effects of a single exposure.
The study used both qualitative and quantitative methods; numerical data was analysed descriptively while free-text through content analysis thus the methodology fit the study
Appropriateness of Research design in addressing aims of the research
The research discussed in detail reasons for using the research design
The study reviewed in detail reasons for using the research design
Appropriateness of recruitment strategy to aims of the research
Respondents consisted of an adult patient admitted to the hospital from 2012 to 2013.
The purposive selection was used to get respondents from orthopedic or neurology ward. The patients were to be more than 18 years old and have been in the hospital for more than 24 hours
Data collection addressing the research issue
Data were collected through interviews, observations and clinical test hence appropriate for the study.
Yes, Data collection was in the hospital where the patients were. There was the use of interview guide with both closed and open-ended questions.
Consideration of relationship between participants and researcher
The researcher actively formulated the research questions and did the data collection thus presenting a potential for bias. However, the use of research assistants minimised the risk of bias.
The researcher actively formulated the research questions and did the data collection thus presenting a potential for bias. However, the use of research assistants minimised the risk of bias.
Consideration of Ethical Issues
Yes. The study sought approval before beginning. Data was kept securely and study approved by ethics committee
Yes. The study sought permission before starting. The local ethics committee approved the study. There was no indication of informed consent for participants
Sufficiency of Data Analysis
Descriptive and content analysis informed the study. Moreover, there was an analysis of multiple logistic regressions.
Content analysis and descriptive analysis.
Clarity of Statement of findings
There was a clear explanation of the study findings relating to the research objectives.
There was a clear explanation of the study findings relating to the research objectives.
Value of the research
The study expresses the usefulness of the results, suggestions made and policy and improvement of clinical practice
The study reveals the usefulness of the conclusions, recommendations made and strategy and advancement in clinical practice
