Evidence_Base_Practice-Effect_of_New_Incentive_System_for_High-Risk

EVIDENCE BASED PRACTICE Many common practice of nursing is more connected to tradition than is evidence based. Nurses prefer to rely on their intuition, experience, tradition and hospital policy and procedure instead of research findings for decision making in particular condition. Policies and procedures may have gradually evolved over time without support from any body of scientific evidence. Thus, transitioning to evidence based practice (EPB) is a formidable process. However, nurses need EBP in order to provide the best possible treatments to the patients which indirectly improved the quality of patients’ care. In other word, practices are informed by evidence. Also, EBP is preferable or should be considered since personal experiences and expertise can be misleading and influence judgment. As an example, decades ago nurses were taught the concept of backrub as a way of preventing pressure sore. But it is no longer in practice as new evidence prevail that by doing vigorous backrub it will cause skin breakdown and more harm than benefit to patients especially those who maybe at high risk of developing pressure ulcer such as patients with spinal injury. The aim of this assignment is to compare how by utilizing skills in nursing patients with pressure ulcer will aid in promoting the healing process of pressure ulcer which in turn will be cost effective in relation of lesser materials used and shortened the length of patient’s staying. The topic was chosen because the writer is currently working in Long Term Care Unit whereby 80% of the patients are bed ridden and majority of them had developed pressure ulcers during hospitalization though some had been admitted with existing pressure ulcers. Historically EPB is relatively new in nursing. In 1960’s nursing started to close the gap between research and practice. Followed by utilization of research in 1970’s which was not often recognized due to Medics took over the lead in research based journals and books. However, in 1998, the first EBP nursing journal was published. Definition Evidence based practice (EBP) is a systematic approach to problem solving for health care providers in order to provide the most consistent and best possible care to patients. According to Sackett et al. (1996) it is a practice that is supported by a clear latest rationale, taking into account the patients’ preferences and using ones judgment sensibly and carefully. Though it is old but it is still valid. EBP also help in making decision to justify the practice which optimizes patient’s health and minimizes any potential harm as stated by Standing (2005). By practicing EPB, health care providers will enhance their planning care and keep themselves updated as their practice may not be as current as it could be. One will not be able to act as a role model if she/he is lack of skill and behind time, as highlighted by Thompson(2003)that one needs to develop rationale for their own practice rather than acted as had been told to act in a certain way. This will make a person a more effective role model. Due to increasing sophistication of modern-day Information and Communication Technology and the pervasiveness of the internet, the demands for high standards and quality in healthcare by a well-informed clientele are inevitable, as discussed by Kirschning et al. (2007) and Ziebland et al. (2004). The expertise they possess should be complemented with a sound knowledge of law and ethics so that they will be able to conduct their nursing care services judiciously and effectively. Patients are no longer to be seen as recipients of care but rather as consumers of a service. If they do not like the service, they could choose other service providers which is available in abundance. As Dimond (2008) had argued that all registered practitioners are accountable for their actions in the areas of criminal, civil liability, professional liability and employment, therefore to prevent litigation health practitioner must keep abreast with latest research finding to be able to make sensible judgment. Though many claimed that EBP had gained credibility and acceptance in health professional, unfortunately some had found that EBP is often used inappropriately and not truthfully. Most institutions in which research is done, EBP had been exaggerated by third party for profit purposes which is their prime interest. The writer maybe bias in a way of projecting a particular standpoint drug company or manufacturer of the product. Incidentally, EBP should be aimed at the patient’s best interest and not for financial interests of others. Sometimes there are reports written by an expert in a particular area, thus it is just an expert view which might not be substantiated by evidence. Therefore, expert opinion is not considered to be a strong form of evidence. These are some of the disadvantages of EPB. Some of the barriers to the implementation of EBP are lack of knowledge such as formal education in research and informatics, closed minds (claimed that had been doing it for years thus resist change), lack of access to technology, excessive time demands for clinical work, lack of peer or administrative support and top of the list is an organizational culture that does not value inquiry. Pressure ulcers remain a common problem in all healthcare settings. Much work and research had been done on pressure ulcers for many years all over the world. What is pressure ulcer' Pressure ulcer is a localized damage to the skin and underlying tissue due to pressure, shear and friction as defined by National Institute for Health & Clinical Excellence (2003). Besides bony prominences such as sacrum, heels, shoulder blades and greater trochanter of the hip, Arnold (2003) added that patients with oxygen tubing, especially nasal cannulae, intravenous catheter, tracheostomy tubes and pulse oxymeter in situ may add to pressure–related skin injury. For many older persons, hospitalization results in functional decline despite cure or repair of the condition for which they were admitted. Hospitalization can result in complications unrelated to the problem that caused admission or to its specific treatment for reasons that are explainable and avoidable. The presence of a pressure ulcer affects patients in many ways. For example, the wounds are painful (Hopkins et al, 2006) and malodorous, especially when there is a large amount of devitalized tissue and anaerobic bacteria in the wound bed. They can exude profusely, particularly during the early inflammatory phase (Iocono et al, 1998) and require frequent dressing changes. It is estimated to cost £4300 to £6400 per patient who develops a pressure sore. Similar findings have been noted in the Netherlands (Haalboom, 2000), where pressure ulcers have been found to be the third most expensive condition. This is due to prolonged hospitalization and the intensive nursing care required and was also supported by Posnett and Franks (2007). Having working in Long Term Care Unit where 80% of the patients are bedridden, pressure ulcer become or is a potential problem. It affects patients hospitalization days as well as burden on nursing and economy, as stated by Beckrich & Aronovitch (1999) and Graves et.al (2005a,b). Thus, the writer had chosen the topic of new system for high risk pressure ulcer patients on wound healing and cost effectiveness. The writer is working in Long Term Care Unit which consists of 40 beds. All the patients are bed ridden, age ranging from twelve to 80 years old. Eighty percent of them under status of no code that is no active resuscitation to be performed should they develop medical emergency such as heart attack. Based on the nature of the unit, all the patients are susceptible for developing pressure ulcer as supported by Horn et.al (2002) and Whittington & Briones (2004) that 14.3% to 15.6% pressure ulcer are common in acute care setting such as Intensive Care Unit and 27.7% in long term care facilities. The writer works as a Head Nurse. The ward is staffed by one Head Nurse and four Charge Nurses. The other 20 nurses are Staff Nurses and 12 Nursing Assistants. The charge nurses have more than ten years experience working in nursing homes in their countries prior to working in this hospital. They have good clinical experience of handling long-term patients especially with pressure sores. In contrast, the junior nurses mostly are freshly graduated and recruited from third world country. Each Staff Nurse team-up with a junior nurse and taking care of six to eight patients. From the figure we can see that the ward is under staffed. Ideally it should be one in four, nurse to patient ratio. There are two factors linked to the development of pressure ulcer that is intrinsic and extrinsic factors. Some examples of intrinsic are nutritional status, reduced mobility, extreme age, sensory impairment, incontinence, vascular disease and level of consciousness. In extrinsic factors are pressure, shearing, friction, moisture, poor moving and handling, and medication. By introducing EBP in this area could improve the standard of care for the patients. In those days in the 70’s, the bedridden patients were turned two hourly and given four hourly backrub. This was supported by Maylor (2001) that the act was the traditional method. Though by doing this therapeutic treatment would have provided comfort and facilitated blood circulation, it would have caused skin breakdown which progressed to development of pressure ulcer. In addition, soap was used in giving the back rub followed by application of spirit on the skin. Both these items caused dryness of skin and play a part in reducing the protective barrier of skin. Baby powder was used after bed bath which formed cake under the skin folds. It made matter worse if patient is obese especially around the belly and groins. But with the advancement of EBP no vigorous massage is allowed except for gentle message and to avoid bony prominence. No soap, talcum powder or lotion allowed to be applied on the skin at all. Although pressure ulcer had been well researched in western countries but very few had been done in this part of the world where the setup and culture is different. Findings of the research of others maybe the same but what to be implemented may not be the same as mentioned earlier due to difference in culture, education background, lifestyle and the climate. The purpose of this study was to ascertain the faster healing of pressure ulcer which leads to cost effectiveness and effective pressure ulcer management strategy by focusing on skilled nursing. Prior to this trial, all nursing staff were briefed and convinced of the purpose of this trial. Randomized controlled trials (RCT) was used whereby five patients were nursed by a charge nurse who had skill in wound management and the other five patients in control group were nursed by a Staff Nurse. The reason why RCT was chosen is to determine the effectiveness of the treatment or intervention. Both groups age ranging from 40 to 70 years old. The period of trial was three months. Braden scale was used since it had been practiced and all the staff was familiar with it. Data were collected weekly for three months. At the end of the trial it was found that those patients nursed by the charged nurse had the rate of wound healing faster than the control group, in addition to less material used for the dressing. This could be due to the fact that the charge nurses used their skills and knowledge effectively in dealing with their patients as compared to junior nurses who is lack of experience and expertise. As Young (1997) argued that there are many dressing products available in the market that it was difficult to choose the appropriate one, thus the experience charge nurse was able to use her expertise in doing the dressing. According to Bux and Malhi (1996), research had indicated that there were health providers use inappropriate dressings due to lack of knowledge and experience. Inappropriate use and mix of wound dressings is financially wasteful and may lead to potential harm to patients with resultant litigation as expressed by Young (1997). In view of strong economy of this country, cost is not an issue here as all the citizen and to some extent the foreigners get free medical treatment. However, budget should be exercised to channel to other more meaningful way such as campaign for public awareness, community involvement as well as in-service training for staff. The findings of this trial was presented to the Senior Managers Committee meeting for approval to have additional charge nurses and in-service education for all the junior nurses. Being a military based hospital, there was a lot of protocol to adhere to before it could be presented for approval. This is the only limitation encountered by the writer. In this paper, the writer will do critical analysis on the article by Hiromi Sanada, Gojiro Nakagami, Yuko Mizokami, Yukiko Minami, Aya Yamamoto, Makoto Oe, Toshiko Kaitani and Shinji Iizaka (2009) published in International Journal of Nursing Studies. The article was chosen to develop empirical knowledge to provide EBP as well as due to the similarity of the condition at the writer’s practice area that affect patient care. In the introduction, the title is appropriate, albeit, it is slightly long as highlighted by Cook DA et al. (2007) that the title should be concise and accurate. The research question was clearly identified. The researchers involved were from Department of Gerontological Nursing/Wound Care Management, University of Tokyo, Tokyo, Japan. They have the necessary experience and insight to undertake this research and it is relevant to the topic. Burns (1989) in her view had stated that the quality of the research should be supported by high qualification of a researcher to maintain validity of the research. The abstract is clear and refer to the reasoning for the intervention. In the literature review, nothing mentioned whether any pilot study was carried out before hand. This article is a primary source in comparison to other researches done earlier on whereby the focus is on materials and devices. It was not been evaluated by peer but it was under study supervision of Professor Hiromi Sanada who had full access to all the data in the study and bear the responsibilities for the integrity and the accuracy of the data analysis. This study was done in hospital setup, no mention about the particular or specialty of this hospital, 39 institutions in the study group and 20 institutions in the control group. Types of patients are stage 111 or worse pressure ulcers in that hospitals with exclusion of those in a medically poor condition, 67 patients of the introduced group and 38 patients in the control group. No random sampling was done and no numbers of participants mentioned but they were the Wound, Ostomy, Continence Nurses (WOCN’s) with less than four years experience but had undergone six months special training to be in the team in management of pressure ulcers. Research is often categorized as qualitative or and sometimes quantitative. Burns and Grove (2001) stated that quantitative research depends on data collection and analysis within a traditional scientific philosophy. However, Strauss and Corbin (1990) expressed that qualitative research produces findings not arrived by means of numerical procedures or any other mode of quantification. In this research, they had chosen cohort study. Since the sample taken was small, it was likely to be less reliable due to chance variations. Data collected every week for three weeks. Rate of healing of pressure ulcers assessed by changes in DESIGN score and medical costs. Data analysis was clearly described but due to writer lack of knowledge in this field, found it full of jargon. Nevertheless, computer package was used to analyze the data. All the 59 participants had consented to participate in the study. The study protocol was approved by Japanese Association of Enterostomal Therapy Nurses/Wound Ostomy and Continence Nurses. There were no conflict of interest, no incentives offered and no funding was used for this study. Critique