Pressure ulcers or decubitus ulcers are a major problem in field of nursing practice. The effectiveness of the different types of mattresses and cushions in the prevention are very important subject to deal with but is poorly studied.
In this paper, evidence based practice will be the foundation in the management and change process. It is an important in nursing field, nursing action requires updated information which needs to be put into practice in that sense nurses need to question the quality of the studies and credibility of findings so it is important to develop critical skills, critique is often seen as first step in learning research process. Evidence-based practice involves a combination of many disciplines, including aspects of multidisciplinary sciences to promote the restoration and maintenance of health in our clients (Davies, 2005). Much literature has been published on this topic in recent years, an evolving subject and concept for specific practices that promote more effective, safer and more efficient ways of caring (Drenkard & Cohen, 2004). According to Kleinman (2004), health care professionals are striving constantly to improve and develop the standards of care. Meeting the challenges require health care providers to be effective leaders who foster a culture and develop partnerships that embraces innovation (Salsberg, 2008).
In this paper, the author change the research question to pressure relieving mattresses and cushion in the relieving of pressure ulcer to provide more specific views and some practical discussions concerning the cushion and mattresses choice that is best for each patient. The pressure ulcer prevention is essential for both the psychological and physical wellbeing of the patient and it will avoid any delay in the rehabilitation process and programmes. The cutaneous and subcutaneous tissue protection on the bone prominence area is very important for those patients who are bedridden or seated in a wheelchair all day (Biondo & Haber, 2006).
Moreover, quality of life factors are important considerations for patients especially those with pressure ulcer problems because such condition affects important bodily functions. The significant effect of pressure ulcer on the quality of life of the patient serves as the impetus for this paper which seeks to examine changes in quality of care after the care provider, has undergone change (Brancato, 2006).
Summary and Critiques of Existing Literatures
A clinical study conducted by Mukai et al (2010) entitled Physiological and care monitoring of anti-decubitus mattress patients presented a well designed an ultrasonic physiological and monitoring system for care that has been designed and developed physiological monitoring especially for the parameters of anti-decubitus (anti-bedsore) in the hospital beds used by the patients. Moreover, they discussed that the bed’s mattresses and cushions are intended to prevent the pressure on the patient’s body surface especially those immobilized patients. Quantitative type of research method was utilized in the study and result was statistically presented. The abstract provides general view and captures reader’s attention swiftly. It is concise in wording and the purpose of the study was clearly mentioned. The abstract also reveals strong statistical significance of anti-decubitus mattresses and significantly mentioned the assumptions. Although abstract encompasses the purpose as well as major findings of the study, some features and information like sample size, method of sampling, place of study were missing. A good example of abstract contains brief information of article representing all the essential details like purpose of the study, design setting, sample size, sampling method, major results and conclusion.
The second article by Melnyk (2005) showed a data and literature review regarding the idea that beds with that lack conventional springs and low-repulsion mattresses can alter the body movements of the patient and can cause ulcer pressure. Data presented that comfortable bed mattresses and cushions indicate improvements relative patient medical condition. The conceptual idea draws mainly from the resource-based view of the researcher which possess valuable, scarce, inimitable, and non-substitutable resources created and sustained competitive advantage. Previous research study was also included. The author also mentioned about another study using hydro fibre dressings which more beneficial but there was no evidence of their cost effectiveness. With the synthesis of previous studies, evidence about the idea that beds with that lack conventional springs and low-repulsion mattresses can alter the body movements of the patient and can cause ulcer pressure needs to be proved thus author clearly stated the aim of the study. Using the critical review of these literatures, the author reveals some prominent features of the present practices in the field. Even though the aim of the study was clearly mentioned, there was a total inadequacy of back ground information. It would be beneficial if author adds his own personal experiences or observations in the introductory part to support the rationale for the study. The introduction of any article should set a scene which identifies the research problem thus providing rationale for the work.
The third article by Wolsley and Hill (2000) discussed the systematic review interface pressure measurement in establishing a protocol for the assessment of support surfaces of the patient. It is being used in the assessment or evaluation of pressure relieving devices to prevent pressure sores. They presented a review of the literature showing the most effective devices to relieve pressure sore for patient care, as well as associated with the decision making in selecting devices including cushions and mattresses. This paper admitted that there is an existing gap in research in this specific filed that need to be assessed with patients in a hospital setting. Their findings suggested an improvement in the use better devices/ materials for probing the effectiveness of different support surfaces clinically.
The fourth article showing clinical evidences of two cushions effectiveness in the heel pressure ulcers prevention by Heyneman et al (2010) aimed in determining the effectiveness of two cushions in the heel pressure ulcers prevention especially in a geriatric population. In this research study, the researchers utilized two various cushions in preventing heel pressure ulcers named as a bedwide, wedge-shaped, an ordinary pillow and viscoelastic foam cushion. All the 162 participating patients were repositioned every 4 hours lying on a viscoelastic foam mattress. The result of the study shows significant evidences that a bedwide, wedge-shaped and the viscoelastic foam cushion lower the risk of a heel pressure ulcer development compared with the conventional use of a pillow.
The last article by Grioni et al (1996) present a series of evidences and previous literatures regarding the selection of anti-decubitus cushion seats for patients to relieve the pressure sores. In the article, they mentioned that anti-pressure cushion choices have two significant requisites; firstly, there is a need for a correct patient assessment and a complete understanding of the aids properties available. The prescription of the cushions discussed in this paper is not a simple task in that the clinical and physical needs of the patient must be taken into consideration. Overall, the research approach is appropriate to the nature of the study. The description of quantitative research method and experimental design in the literatueres which utilized to find out the relationship between the variables are explicit. The variable clearly identified anti-decubitus cushion sheets and traditional beds as independent variables (or cause), bed sore/ ulcers as dependent variable (or effect). This study is used to find out from existing literatures the relationship between variables as well as previous studies regarding the selection of anti-decubitus cushion seats for patients to relieve the pressure sores. Objectives were mentioned in the tables.
In these articles evidences that pressure ulcer prevention and healing is a complex process that can be complicated by a certain factors. Although with right and appropriate care, some wounds failed to heal in an appropriate fashion and may become more chronic. From different researches and studies reported in literature effective utilization of effective cushion and mattress material for the prevention and healing is important. This will help patients with complicated and non- healing chronic ulcers. Clinical Evidences from these articles and previous studies can be used in the change process in clinical settings.
Proposed Change Method and Assessment of Rationale
Conceptual model for translating evidence into clinical practice by Kurt Lewin will be used to promote change process. This model recognized that translation of research into practice requires a solid grounding in change theory, principles of research utilization, and use of standardized nomenclature. The model has the following six phases: Unfreeze, Change and Freeze (Marquis and Huston, 2008).
The stage 1 of Kurt Lewin’s Change model is the unfreezing. This involves process of understanding that there is a necessary need for a change. The process involved preparation of a situation in which there is a need for a change (Marquis and Huston, 2008). In this stage, orientation to a new set of clinical evidenced-based knowledge about the pressure relieving mattresses and cushion in the relieving of pressure ulcer including a written orientation packet prepares clinical practitioner to possess general skills needed to be competent in caring patients in a clinical setting. They must possess good assessment skills and have good insight and judgment skills in order to anticipate or interpret the needs of the client in health care practice (Hewson M G.2000). The actual clinical preparation for health provider is very essential to learn actual clinical practice and the orientation in new protocols and policies in handling patients’ needs, this method of learning is termed as evidenced-based practice education (Davies 1999, p. 109). In preparing for change process, the discussion of each procedure of pressure ulcers management interventions includes necessary background information, with carefully chosen photographs of actual mattresses and cushions with technically precise illustrations; they can fully understand the topics and enhance the imagination when performing the required skills in practice. Instructions are also presented in format when the skill is one that is used with patients and when the process is appropriate to the skill. This emphasis reinforces the preparation to an organized process is relevant to practice to ensure the patient’s safety and rehabilitation.
The second stage is called Change or transition in which there is a need for a movement to facilitate changes. In this stage training is a part of the process. Possession of knowledge and competency in performing skills and interventions which can be acquired in actual or hands on trainings is essential in this stage (Marquis and Huston, 2008). It involves a combination of many disciplines, including aspects of multidisciplinary sciences to promote the restoration and maintenance of health in our clients (Davies, 1999). The challenges in this stage includes difficulty gaining support financially for the programs and trainings that ensure the effectiveness of skills, practice, leadership and integration of the program with existing practice of care through trainings and seminars and sustainable momentum during the shift of culture. These challenges are not limited to those who implement the change (Young, 2004). Some of the activities practiced in a clinical setting are the provision of the most current information possible for the client and co-professionals using the collaborative approach. During the teaching session and actual learning practice we have provided with clear explanations of the pathophysiological condition and processes of human illness and injury. It integrates information as vital component of clinical practice and evidenced based practice. These activities emphasizes the role of nurses as essential member of health care team, working together to achieve highest possible recovery for every patient. By means of prioritizing diagnoses and interventions specific to altered responses to illnesses and disease conditions, we provide them quality care. Providing case studies for each case so that we can envision the client as a person needing and requiring care and acquire knowledge regarding the specific case is also a factor. We can also foster critical thinking and decision making which very important for every health care professional in clinical practice. These are abilities and skills I have acquired in terms of patient management specifically wound care (Closs, 2004).
Teaching sessions and discussions in this stage is very important because you can maximize your learning through acquiring knowledge derived from the application of concepts and theories. You can actually discuss and clarify some information and clinical practices during these sessions. Helping one another in achieving proper knowledge and competency in nursing practice is also innate with this kind of forums. The discussion of each skills in practicing effective anti-ulcer management begins with an overview of pathophysiology followed by the manifestation and complications is very effective especially when it is being relate with the actual experience in handling wound care patients . Focuses on diversity and demonstrate the contributing factors are also a necessary to produce basic knowledge and application of nursing theories and principle (Brancato, 2006).
The last stage is termed as freezing. This stage is about the establishment of stability once the necessary changes have been made. Institutions must initiate the stability development of an effective use of mattresses and cushions to relieve or prevent the pressure ulcers. This change process must increase the knowledge, skills and competency of nurses and other health care provider and allow them to understand the importance of their new roles (Marquis and Huston, 2008).The change must help them in other transition by assisting other team members in understanding effective methods of care in the clinical setting constantly. This stage will produce knowledge and competitiveness among the people involved in the change process. Knowledge and competitiveness is a product of experience and effective learning process which is essential in actual clinical practice of nursing profession. It is largely based on innate potentials and motivations afforded by the familiarity of a learning environment. The richness or intensity of the inculcation of knowledge, positive values and skills of a person is not simply based on the innate capacity of one to evaluate, think, reason and interact in a learning situation. It equally depends on the quality of the change and experiences which are either limited by the individual’s ability and will to choose or by what is desirable to her which is readily accessible in the environment. This will determine the path of being effective and competent nursing practitioner (Davies, 1999).
This stage provided and maintained theoretical and clinical competence of the practice (Hagger & McIntyre, 2000). Nursing professionals need to prepare the next generation of nurses to provide competent and quality care to patients. To be an effective health care provider, this kind of care management provided me with individual appraisal ability of one’s self competency and enhanced my education based on practices and trainings taken previously during undergraduate, graduate studies, workshops, trainings, continuing education, and preparation for teaching seminars or modules including the written and on site orientation (Lichtman et al., 2003).
The rationale for the use of this model and the analysis of the cases mentioned in this study is geared toward a familiar setting where nurses and other health care provider will have the hospital resources knowledge needed to implement successful change process in the field of decubitus ulcer prevention. Once the phase of change concludes, they will be able to concentrate on specific needs invoking patient care process (Lichtman et al., 2003). They will become more confident in her pedagogical techniques for sharing skills, experience, and knowledge, coaching, and supporting other team members in their learning which are essential elements of effective caring process (Freiburger, 2002). These behaviours are not automatic or innate to individuals; all can be learned through education and practices of the profession. The outcome will be measured through assessment methods and tool to be utilized in order to evaluate the effectiveness and the result of the study. The assessment plan will be implemented and evaluated according to the objectives and goals of the treatment and care. The outcome will be analyzed to identify if the goal was met at the end of patient care.
According to Kozier & Erb (2008) wound prevention and management is an example of clinical skills education which refers to formal examination designed to enhance the skills or knowledge of nursing educators or practitioners. Through this new knowledge and skills about pressure relieving mattresses and cushion in the relieving of pressure ulcer, the ability to learn actual clinical practice and the orientation in hospital protocols and policies in handling patients’ needs will be achieved. Recent studies have reported gaps between nursing practice and researches (Brancato 2006) and identified different challenges that prevent the evidence to clinical practice to translate into clinical settings (Oleguo, 2005). These challenges in applying evidence-based practice such as effective used of cushion and mattresses to prevent pressure ulcer in clinical settings have been consistent across researches. One challenge is that, in the generation and development of new medical and nursing knowledge, the resistance of profession has often been incorporated with the new ways of practice (Young, 2004).
The study suggests that much recent practices are based frequently on tradition, experience and intuition, rather than validation of science. Furthermore, the growing numbers of studies and researches designed to develop and improve practice at the staff nurse level cannot make nurses improve their skills, research knowledge and understanding. They frequently lack nurse’s formal training such as scientific inquiries (Oleguo, 2005).