Evidence-Based Practice and Applied Nursing Research

The Significance and Background of a Healthcare Problem

Problem Description

Pressure ulcers, localized injuries that affect the skin and the tissues underlying the skin, are a serious problem for the health care system, primarily because most of the incidents occur when a patient is hospitalized. Besides being a major disease burden, they translate to a decline in the quality of life of the affected patient (Marin, Nixon, & Gorecki, 2013). Among the most affected persons are patients suffering from spinal cord injuries because they are expected to stay for long periods of time lying in the same position. The lack of sensation and mobility in these patients has huge implications in their care (Tung, Stead, Mann, Pham, & Popovic, 2015).  In the United States, among other develop economies, the incidence rates are ranging from 1 to 66 percent among hospitalized patients, 4.2 to 23.9 percent among those in nursing homes and 1.5 to 25 percent of the patients in community hospitals. While the problem is considered preventable, it has continued to have a huge impact on the healthcare system and the quality of life of the individual patients, especially in acute and long-term care settings. Hence, there is a need for more concerted efforts to address this healthcare challenge.

Significance of the Problem

With the high prevalence rate of pressure ulcers, there is no doubt that it is a serious problem affecting the society. Billions of dollars are spent each year in the treatment of pressure ulcers and the complications that relate to the condition. Patients are forced to remain in the hospital longer than they should because of this preventable hospital-acquired health problem. The healthcare costs are augmented in the event that the hospital has to deal with the complications arising from the acquisition of the pressure ulcers. Previous studies have indicated that the development of pressure ulcers, alone, pushes up the number of days spent in the hospital by 4-10 days (Leaf Healthcare, 2016). The longer stays in the hospital has been linked to the augmented prevalence of other complications such as nosocomial infections. The treatment cost ranges from $2,000- $20,000 per ulcer, depending on the severity. The cost could be higher in the event of more progressed stages of pressure ulcer because they take longer to treat necessitating longer hospital stays. Indeed, this is a serious issue considering the fact that it is an additional cost to what has been used in the treatment of the condition that led to the hospitalization.

The Current Practice Related to the Problem

Research has indicated that development of pressure ulcers while hospitalized is a serious healthcare challenge that requires immediate response. The efforts to deal with this problem are geared towards identification of the risk factors towards the end of prevention (Marin, Nixon, & Gorecki, 2013). Risk assessment remains the most useful tool for the identification of the risk factors to watch out for in order to prevent the healthcare problem (Coleman, Nixon, Keen, Muir, Wilson, McGinnis, & Nelson, 2016). Currently, the efforts to assess the risk are adopted during admission and continued during the period of hospitalization. By assessing the risk, it is expected that interventions can be customized to the needs of the individual patient. Healthcare providers, in practice, seek to pinpoint the patients at the risk in order to use the recognized preventive strategies. Some of the strategies that are used following the identification of the risk include relieving pressure, regular changes of position, and use of pressure-relieving support tools (Armour-Burton, Fields, Outlaw, & Deleon, 2013). However, regardless of the availability of the evidence-based strategies, the problem persists in various healthcare settings.

Impact of the Problem

Pressure ulcer has major impact on the healthcare organization and the individual patient affected by the condition. The impact emanates from the fact that the patient is expected to remain in the hospital longer and the additional cost of treatment (Leaf Healthcare, 2016). The healthcare system suffers the additional cost of treatment for pressure ulcer (Braden, 2013). Indeed, this is a similar impact on the individual patients who pay for their care. Besides, the individual patient is affected by the additional disease burden with impact on their health behavior, especially given the fact that they have minimal control over the hospital-acquired complications. Pressure ulcer remains one of the leading health issues that affect the health and well-being of the patients.

The “PICO Table

	Example:
P (patient/problem)	pressure ulcer during hospitalization
I (intervention/indicator)	regular change of position
C (comparison)	no changes; other solutions; pressure redistributing devices
O (outcome)	reduction in patients with pressure ulcers

 

The PICO Question

How effective is the change of position among hospitalized patients with spinal cord injuries in reducing the rate of pressure ulcer.

The Search Strategy

The Keywords Used for the Search

After identifying the PICO question, it is critical to come up with the search strategy to find evidence-based studies on which to base the answer. The major elements of the question are the basis from which to come up with the search strategy. The key terms of descriptors are critical in supporting the search for the articles that are relevant for the research. Hence, from the research question, the key terms that will be used are change of position, hospitalized patients, and pressure ulcer.

The Number and Types of Articles

The search was carried out from three main databases, PubMed, PsychInfo, and Ebscohost. The articles searched were written in English and published between 2012 and 2017 in order to get as recent information as possible to answer the PICO question. The keywords were used as the main subject heading for the articles. It was expected that a number of articles would come up following the search, from which a filtering process took place. The process was aimed at ensuring that the articles that were selected are the most relevant to the question. The search gave rise to a total of 376 articles. In this case, the articles were in three main types, quantitative studies, qualitative studies, and meta-analysis (including review of previous studies on the topic). An evaluation was carried out on all the articles to establish relevance in answering the question. The evaluation process started from the title of the article which would indicate the content. Further, the abstract was read to provide more insight into the content of the article.

The process led to the identification of five articles that were most relevant to the research question. The articles are included in the matrix table given in the appendix. The studies identified were as follows: one was a quantitative experimental study; two were qualitative descriptive studies, while two were reviews of previous studies on the topic under study. The reviews were selected because they contained review of scientific studies carried out previously and the sample in form of the number of studies reviewed.

Two Research Evidence and Two Non-Research Evidence Sources

For the purpose of answering the research question, the research evidence used was from clinical trials (experimental studies) and a review of the previous results on the same topic. Two of the articles that were used which included this sort of evidence were: “Patient repositioning and pressure ulcer risk—Monitoring interface pressures of at-risk patients” by Peterson et al. (2013) and “A systematic review of risk factors for the development and recurrence of pressure ulcers in people with spinal cord injuries” by Marin, Nixon and Gorecki (2013). The research evidence is considered as such because the evidence is provided out of an empirical research process or a review of previous studies, also carried out empirically. The research, from which the evidence is drawn, is designed such that it answers a particular question or tests a hypothesis. They also include a process of collecting and analyzing data from a sample of participants.

Apart from the research evidence, the researcher also relied on non-research evidence. Two of the articles that are a source of this evidence are “Costs of Pressure Ulcer Prevention Is it really cheaper than treatment?” by Branden (2016) and “The Financial Impact of Pressure Ulcers” by Leaf Healthcare (2016). The evidence is characterized a being non-research because it is not founded on an empirical research process. They are either single organizational studies or opinions or summaries of non-research work. They do not adhere to the strict rules of empirical research. The findings cannot be generalized to any population.

The Recommended Practice Change

Repositioning patients regularly is the proposed solution to the problem of pressure ulcers, affecting patients suffering from spinal cord injury because of their limited mobility. Repositioning is suggested to be effective in preventing sustained high pressures (Peterson, Gravenstein, Schwab, van Oostrom, & Caruso, 2013). However, the study indicated some previous efforts targeted to identifying the impact of this strategy in reducing the rate of the problem in hospital settings. There are mixed findings in terms of the impact of this strategy, some suggesting that it does not have a positive impact on the problem (Peterson et al., 2013). The problem could be in the failure to make this initiative the standard of care in healthcare settings. This means that the efforts should go beyond changing of position, to making the strategy a part of an institutional and cultural change.

Marin, Nixon, and Gorecki (2013) look at the importance of beginning with a thorough assessment of the risk factors in order to implement the most workable strategy for the prevention efforts to be more effective. Identification of the risk factors is the beginning place towards understanding the intervention that is necessary based on the risk and the severity of the pressure ulcer for those who have already developed. Coleman et al. (2016) indicated that it is not logical to use the preventive measure to all patients, including those not identified as having the risk of suffering from the pressure ulcer. This indicates the importance of the optimal use of the resources by targeting those in utmost need of the intervention. Therefore, this is the basis for the proposal of the most effective means of assessing the risk and the magnitude before implementing the strategy.

Repositioning by nurses is one of the most effective strategies in preventing the occurrence of pressure ulcer, but should be part of major changes within the healthcare organization to ensure its efficacy. Repositioning works through changing the position of impact in order to prevent a lot of pressure causing the occurrence of ulcers (Peterson et al., 2013). This is especially critical for the patients who are not able to move or turn because of the nature of their conditions. Hence, the nurse has the responsibility of repositioning or turning the patient on a regular basis, depending on the level of the identified risk. For example, for the high-risk patients, the change in position can be done every one hour. Hence, the implementation of the strategy should be customized to the needs of the patient.

Tung et al. (2015) proposes the clinical practice guidelines (CPGs) for assessing and preventing pressure ulcers, specifically targeted to individual suffering from spinal cord injury. The preventive measures are relevant for both in and out of hospital care because such patients’ care is a long-term process. Thorough skin and risk assessment are the basis for the development of the personalized care for such patients. Armour-Burton et al. (2016) proposes major changes in the nursing practice to ensure effectiveness in the prevention and reduction of the rate of pressure ulcer. The use of regular repositioning by the nurses should be part of the change in the culture and practice of nursing for it to be effective in meeting the objective. Where such changes are in place, healthcare facilities will be effective in cutting on the cost of care for the patients suffering from this preventable health problem.

Implementing the Recommendation

Stakeholders

Implementation of the recommendation for repositioning of the patient at risk of suffering from pressure ulcer will involve nurses at different levels. The nurses will be trained on the role they will assume in the change process based on what part they play in the continuum of care. At the administrative level, the nurse director and the nurse manager will play the role of instigating the change process and providing the resources necessary for the change to occur. The nurse educator will educate the other nurses on the importance of the change. The bedside nurse and infection control nurse will be the real implementers of the change because they are in direct contact with the patient. For instance, they will assess the risk and the regular repositioning of the patients.

Potential Barriers to Change

No change is readily accepted in healthcare settings because changes come as a way of altering the status quo and disturbing the comfort zone. The nurses who will be most affected by the change could be the most resistant. For the nurses, the regular assessment and repositioning of the patients will mean an increase in the demand for their attention. In most health care settings today, there is a challenge because of the global shortage of nurses. This means that they already have a lot that they have to do in taking care of the patients. The nurses might be opposed to the increase in the demand for their service. The nurses who have been repositioning the patients like three times a day might find it challenging to increase the frequency. This is an even greater challenge if the organization does not have adequate staff.

Strategies to Overcome the Barriers

One of the ways of overcoming the barriers is offering training to the nurses on the importance of the proposed change. The nurse educator has an important role of training the nurses on the benefits the proposed change will have on their care process. For the nurses, the change will have benefits because it will reduce the long hospital stays caused by the development of the pressure ulcers. The reduction of the stays will cut on the time required to take care of the patients. Another strategy for reducing the resistance is providing the nurses with more resources, including adequate staffing and resources, along with increasing their compensation to enhance motivation. The healthcare organization can manage the extra cost by cutting on the cost necessary to cater for the patients who develop pressure ulcer. From a cost-benefit analysis, the benefits of preventing pressure ulcer outweigh the cost of implementing the strategy.

Indicator to Measure the Outcome

Evaluation of the outcome of the intervention is critical. The process will involve the collection of data to indicate whether or not the objective has been achieved. In this case, the objective is reduction of the rate of pressure ulcer in the setting within which the intervention has been implemented. The indicator of success will be the achieved reduction of the rate of pressure ulcer among the patients in the healthcare setting. If the outcome of the evaluation indicates a decrease in the number of those suffering from the pressure ulcer, it will be concluded that the strategy is effective. If not, more changes will be necessary.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evidence Matrix

Authors	Journal Name/ WGU Library	Year of Publication	Research Design	Sample Size	Outcome Variables Measured	Level (I–III)	Quality (A, B, C)	Results/Author’s Suggested Conclusions
Armour-Burton, T., Fields, W., Outlaw, L., & Deleon, E.	Critical Care Nurse,	2013	longitudinal research design	a 41-bed unit	A reduction in pressure ulcer from the level of Spring 2003 through Summer 2006 ranging from 0.0% to 18.92%, with a mean of 4.85%. to 0.0% for 17 of 20 quarters, through 2011.	I	A	the authors concluded that implementation of the intervention (surgical progressive care unit) in preventing the development of hospital acquired pressure ulcer
Coleman, S., Nixon, J., Keen, J., Muir, D., Wilson, L., McGinnis, E., & … Nelson, E. A	BMC Medical Research Methodology	2016	A descriptive study	2 acute (1 district general hospital and 1 large teaching trust) and 2 community NHS Trusts (Thirty-four nurses)	The pre-test was critical in establishing the effectiveness pressure ulcer risk assessment instrument.	I	A	the researchers proposed the development of a pressure ulcer risk assessment tool, beginning with a screening phase, including the skin status for distinguishing between the patients in need of primary prevention and the ones in need of secondary prevention/treatment and using color in supporting pathway allocation and decision-making
Marin, J., Nixon, J., & Gorecki, C.	Spinal Cord	2013	A systematic review	five studies included 18 RFs	identification of spinal cord injury (SCI)-specific risk factors (RFs) for the development and recurrence of pressure ulcers (Pus)	I	C	Various risk factors categorized a “sociodemographic, neurological, functional, clinical, biological and medical care management” were identified as relating to pressure ulcer. However, more research as the current one was limited by the number of studies.
Peterson, M. J., Gravenstein, N., Schwab, W. K., van Oostrom, J. H., & Caruso, L. J.	Journal Of Rehabilitation Research & Development,	2013	a descriptive, observational study	23 bedridden patients at risk for pressure ulcer formation	Repositioning has the potential for reducing the occurrence of pressure ulcer is implemented as part of standard practice.	II ‘	B	lack of awareness among the care providers on the effect of their efforts, such as repositioning is the reason for the lack of conclusive evidence of efficacy
Tung, J. Y., Stead, B., Mann, W., Pham, B., & Popovic, M. R.	Journal Of Rehabilitation Research & Development	2015	review	100 studies	Researchers identified four technology classes of technology for self-management: “computer-based educational technologies, interface pressure mapping technologies, electrical stimulation, and telemedicine programs.	II	B	Self-management strategies are found to be effective in preventing pressure ulcer among patients with spinal cord injuries.