This assignment will be set around evidence based practice (EBP) and the nursing part of EBP will be discussed throughout this essay. There will be two parts to this discussion, part 1 will be a clinical question chosen personally, and being researched through the internet using a variety of databases. The end result will then be discussed on how the question performed, and whether it was either easy to research or changes had to be made gain greater or less results. Below is the clinical research question that was chosen personally. The clinical research question: “Do silver dressings work on healing ulcer wounds or is there other dressings that show greater results”? Researching this question, Ovid was used. 687 results appeared, this was too high of a result. So the research question was reworded “Are Silver dressings more effective than other dressings on open wounds”? Again using Ovid, on an advanced search, this yielded 0 results. The question was then rephrased to, “Is there supporting evidence that silver dressings work on the healing of ulcer wounds?” 350 results appeared which was just over half the results I obtained from the first research question. However, this was okay but still a little too much.
After this a different database was tried, the CINAHL database, on this research the question had been broken down into words; silver dressings supporting evidence, healing open wounds, this yielded 0 results. Ovid was the best site to ask this research question as even though the results were too much, I still had a good amount of hits, as for the CINAHL database this did not show any results. Therefore, Ovid does show to be a good research database. When researching this question, it was not clear enough, the question needed to be a bit more thorough when written, the results reflected off this by achieving 687 results and 350 on Ovid. Ovid was used first as it is a well-known website, which is also a database used widely for nursing and medical journals. Regardless of how popular both databases are the research questioned failed as either too much or zero results appeared, and could not be met in the middle.
On reflection receiving 687 hits and then 350 is far too much and no matter how much the question was rephrased and broken down no results were satisfying. This question had too much academic material and could not be lessened in any way for the chosen topic. I think that next time the MeSH database could be used to research the chosen question, this would increase more of a chance of a wider and more in depth result and maybe reworded using medical terms. Part 2 – The Critical Analysis of a Randomised Control Setting using the Casp Tool It has been 10 years since evidence based practice (EBP) appeared. It was the early 1990’s when EBP was first introduced and since then it has made a significant impact on health services (Reynolds, 2000).
Evidence based nursing is about making right choices towards a patient and towards client care. This may involve different decisions being made for treatment choices, provisions of services and competence. The one meaning of evidence based practice is that it uses the “best of evidence in making decisions about patient care” (Sackett et al, 2000). When the decision is being made about a patient and their care, the best available evidence should be used in their practice. The nurse should reflect on the requirements, values, circumstances and preferences together with their own professional experience, skills and when making choices for the patient (Moule et al, 2009).
The paper that has been chosen is a randomised control trial (RCT). Nelson, (2011) describes a RCT as being used to answer questions on two or more interventions and the difference it would have made on a trial (Nelson, 2011). Nurses who are applying clinical decisions, evidence based research must be used. It is also important that all clinicians have the admittance to clinical trials and to understand these clinical trials, so well-versed decisions are made on the best dealings with interventions that are open, this created PICO. This is a database that helps medical professionals to decide if the question that was asked in the trial is of high value, this will then help them to make a decision, on the value of one paper over another. The chosen research paper which a randomised controlled trial is being used, because alternating pressure mattresses together with alternating pressure overlays are being used for the avoidance of pressure ulcers (Nixon et al 2006).
This essay will be using a critical appraisal skills programme, which contains 11 questions, to help decide whether or not this paper is of good quality. This assignment is to assess a pre-selected research paper using the Critical Appraisal Skills Programme, which is known as the CASP tool, this is a standardised assessment tool. The CASP tool will be used to evaluate the consistency, validity and practicality of the research issued. (CASP, 2010). Together with this, the CASP tool will also be used study the research paper to see whether or it has an element of reliably extrapolated. Dr Amanda Burls was the person who created the CASP tool back in 1993. Her aim for this programme was to help individuals improve on their skills on the basis of healthcare decisions by finding and critically assessing the best scientific evidence. (CASP, 2010). Roland, (1998), describes this as being vital in all aspects of healthcare, especially nursing. This is because randomised control trials (RCT) are seen as the gold standard for answering questions towards efficiency, in evidence based practice (EBP) (Sibbald, R, 1998).
The hierarchy of evidence is a framework for ranking evidence, and second to the top lies RCT (Evans, D, 2003). This trial defines whether or not the trial has a cause-effect relationship between the treatment given and the conclusion. The RCT will also decide the cost effective outcome of the trial (Sibbald, R, 1998). This study asked a clearly focused question, the study did describe in detail of how they were to pick participants out of the population. They all weighed around the same, they looked at medical issues, and most important what type of skin condition these participants had. The study was using grade 1 and 2 ulcers from the Braden scale and participants who did not have ulcer wounds at all to their skin. Furthermore, participants who were developing grade 3 or 4 ulcer wounds were removed from the trial. They took into account the main consideration of the participants, by asking consent from the patients or if patients were not able to communicate appropriately they would retrieve consent from relatives until the patient was able to communicate.
The outcome was also considered very carefully (Nelson, 2011). The study was carried out as a Randomised Control Setting (RCT) because the trial was based on two types of mattresses. Participants who were involved were randomised to either mattress. The right research was used for the RCT because the mattress and overlay are interventions which satisfy two or more interventions suitable for the RCT. However, comparing the two for any differences hence intervention and comparison granted, there is no control service. This determines this to be unethical as the patient is being denied patient care by not treating the risk that we know is there. The participants were accurately randomised. They used an independent secure, automated telephone system used with 24 hour randomisation. This is to ensure allocation concealment. Minimisation was used to so that the groups were equal. Minimisation was also used on centre existing pressure ulcers, speciality and type of admission. Those who participated were assigned to an alternating mattress, within 24 hours of being admitted through a certain hospital. The main limitation of the trial was that there was absence of blinding from the outcome of the assessment.
However, taking the trial into account it is most likely to be impossible to achieve. This is due to the lack of disguising the mattress and is unethical for a more seriously ill patient. The bias of the trial was minimised to some extent, this was done by the clinical research nurses and the ward staff, and they were collecting skin samples for assessment. Although, the nurses were not blinded by the treatment, so the care given cannot be vindicated. Being blinded to this trial is not needed, for patients who have been bought into hospital for a long stay, will be lying on a mattress in a bed, no matter what the situation and cannot really affect the trial, for the nurses they should not have to be blinded either, as turning a patient regularly is a part of patient-care and should not be any different due to a trial being in place. Blinded does not matter in this study. All participants were accounted for in the conclusion. They describe how patients felt uncomfortable on certain mattresses and requested a change. They took into account that participants preferred the mattress to the overlay for comfy reasons.
They also mentioned that certain patients had to be taken out of the trial due to pressure sores becoming greater or death. This did reduce the number of participants involved in the trial which they also mentioned. It does appear that the groups were treated equally, however there is the whole thing about patients requesting alternative devices because they was not satisfied with what they were given, also the nurses took it upon themselves to change people over as they saw fit, the nurses could be bias because they might have personal preferences of one device over the other. Furthermore the results can be applied to the population because the statistics of the study show that there was not much difference between the two. A significance criterion is a proclamation of how improbable a result must be, if the null hypothesis is accurate, then to be considered significant it would have to be 5%. The power analysis is applicable when concern is with the correct rejection, or not a null hypothesis. In many circumstances, if there is a difference or not, the issue would be less determining and would rather get a more refined evaluation of the outcome for the size of the population. The power calculation was used in this trial.
Overall, 113 people had pressure ulcers at randomisation, (55%) healed during the trial and 34% in overlay and 35% in mattresses. The results were given as a percentage of people experiencing outcome. The reasons for the percentage of people who had a significance effect from developing new pressure ulcers, were those who came from the acute condition ward, or had presence of a wound, or some skin trauma, also including, age and diabetes. This trial was not statistically significant because the p value was more than 0.05, the P value was 0.7, so because that is over the 0.5 it is not statistically significant. There was no differences found within the trial between the treatments. However, this does not mean clinical insignificance, it is actually clinically significant because it gives us information on which to base clinical decisions.
Clinical status can be gained by calculating a confidence interval measured by mean, median and proportion. 95% confidence interval which is a range of values within which the true population quantity would fall 95% if the study was to be repeated. One hundred and six (10.7%) people in the overlay group and 101 (10.3%) people in the mattress group developed one or more new grade 2 pressure ulcers. The difference in the proportions of people with a new pressure ulcer (overlay − mattress) was 0.4% (95% confidence interval − 2.3% to 3.1%). In the adjusted analysis the odds ratio for developing a new pressure ulcer using the overlay compared with the mattress was 0.94 (95% confidence interval 0.68 to 1.29) indicating no difference between the surfaces in the odds of developing a new pressure ulcer.
Overall, the people preferred the mattress over the overlay presuming for comfortable reasons. The point of the trial was to find out whether there was a difference in result, and it ended with no difference between two interventions. The trial and results all seemed too narrow for confidence intervals. This end result gives readers of the study confidence in using either devise. This is because there is only a narrow difference between the upper confidence limit and the lower confidence limit. This was a good trial; there was a lot of randomisation used. It was a quite large sample used for the trial, so no matter what was changed, it could not make a difference. Another important part of this trial was the statistical information in respect of cost. At £4000 for an alternating pressure mattress and £1000 for an alternating pressure mattress, it would be financially more cost effective to use the cheapest option. However, it is important to notice that 230 participants of the trial, who were given the overlays, requested a different device, opposed to the 186 who were given the mattress. However, the decision being made to which devise will be used within healthcare, should be decided on patients situations and not for financial reasons.
CASP (2010) Critical Appraisal Skills Programme: making sense of evidence about clinical effectiveness: 11 questions to help you make sense of a trial: http://www.casp-uk.net/wp-content/uploads/2011/11/CASP_RCT_Appraisal_Checklist_14oct10.pdf
How to Cite. Evans, D. (2003), Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12: 77–84 Hierarchy of evidence: a framework for ranking evidence
Nelson, A. (2011), what is a Randomised Controlled Trial? Evidence Based Nursing 2011; 14:4 97-98
Nixon, J., Cranny, G., Iglesias, C., Nelson, E.A., Hawkins, K., Philips, A., Torgerson, D., Mason, S. and Cullum, N. (2006), Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. British Medical Journal; 332:1413
Sackett, D. Rosenberg, W. Muir Gray, J. Haynes, R. Richardson, W. (1996) Evidence Based Medicine: what it is and what it isn’t. British Medical Journal; 312:7023, 71-72 Sibbald, B. Roland, M. (1998) Understanding Controlled Trials: Why are randomised controlled trials important, British Medical Journal 1998:316:201