Exploring Evidence-Based Practice in Nursing: A Case Study on Research Methods

The essay will discuss evidence-based practice (EBP) in nursing, with a focus on personally selecting a clinical question and conducting research using various internet databases. The analysis of the research outcome will determine if changes were necessary to improve or reduce results. The chosen clinical research question is: "Do silver dressings effectively heal ulcer wounds or are there other dressings that yield better results?" Ovid was used for this research and generated 687 results, which was considered too high. Consequently, the research question was reformulated as "Are silver dressings more effective than other dressings for treating open wounds?" An advanced search on Ovid yielded 0 hits.

The question was then modified to "Is there evidence supporting the effectiveness of silver dressings in healing ulcer wounds?" This search produced 350 results, slightly over half of the initial research question's results but still deemed acceptable yet excessive.

After unsuccessfully trying a different database, the CINAHL database, and breaking down the research question into specific words, such as silver dressings, supporting evidence, and healing open wounds, there were no results found.

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Comparatively, Ovid yielded a large number of hits despite being overwhelming. In contrast, the CINAHL database did not show any results. Thus, Ovid proves to be a reliable research database. The lack of clarity in the initial research question is reflected in the high number of results obtained on Ovid (687) and 350 on Ovid. Ovid was chosen initially due to its reputation as a widely-used website and database for nursing and medical publications. However, both databases failed to provide satisfactory results, with either an abundance or total absence of relevant information.

After careful consideration, it was determined that the excessive number of hits received, first 687 and then 350, was deemed to be too high. Despite efforts to rephrase and simplify the question, the results remained unsatisfactory due to the academic nature of the topic. It is recommended that for future research purposes, a broader and more comprehensive approach should be taken by utilizing the MeSH database and possibly incorporating medical terminology during the process of rewording.

In Part 2 - The Critical Analysis of a Randomised Control Setting using the Casp Tool

Since its emergence in the early 1990s, evidence-based practice (EBP) has had a significant impact on health services over the past ten years (Reynolds, 2000).

Evidence-based nursing involves using appropriate evidence to make well-informed decisions for patient care, including treatment options, service provisions, and competency (Sackett et al, 2000). To ensure optimal choices for patients, nurses must consider their requirements, values, circumstances, and preferences along with their professional experience and skills (Moule et al, 2009).

The text highlights the significance of a randomized controlled trial (RCT) conducted by Nelson (2011), which evaluates various interventions. Nurses who rely on evidence-based research for clinical decision-making must consider RCT findings. It is crucial for all clinicians to have access to and comprehend clinical trials in order to make informed decisions regarding interventions. To facilitate this process, the PICO database was developed, aiding medical professionals in assessing the relevance of research questions asked in trials and prioritizing papers based on their value. In Nixon et al.'s (2006) study, an RCT was employed to investigate the effectiveness of alternating pressure mattresses and overlays in preventing pressure ulcers.

The Critical Appraisal Skills Programme (CASP) was developed by Dr. Amanda Burls in 1993 as a standardized assessment tool for evaluating the quality of research papers. Its main objective is to improve healthcare decision-making skills by critically analyzing scientific evidence. CASP consists of 11 questions that assess research consistency, validity, and practicality (CASP, 2010). Furthermore, CASP helps determine if the research paper has been reliably extrapolated. In healthcare, especially in nursing, it is crucial to critically evaluate evidence based on randomized control trials (RCTs), which are considered the gold standard for assessing effectiveness in evidence-based practice (EBP) (Roland, 1998; Sibbald, R., 1998).

The hierarchy of evidence is a framework for ranking evidence. The second highest ranking in this framework is the RCT (Evans, D, 2003). The RCT determines if there is a cause-effect relationship between the treatment and the conclusion. It also assesses the cost effectiveness of the trial (Sibbald, R, 1998). The study asked a focused question and provided detailed information on participant selection. Participants were similar in weight and had specific medical issues related to their skin condition. The study included participants with grade 1 and 2 ulcers according to the Braden scale, as well as individuals without ulcer wounds. Participants developing grade 3 or 4 ulcer wounds were excluded from the trial. Consent was obtained from participants or their relatives if the patients were unable to communicate effectively until they were able to do so.

The study considered the outcome carefully (Nelson, 2011). It was conducted as a Randomised Control Setting (RCT) with two types of mattresses. Participants were randomly assigned to one of the mattresses. The RCT was the appropriate research method as the mattresses and overlay are interventions suitable for this type of study. However, there was no control group to compare the two interventions and determine any differences, which is unethical as it denies patient care. The participants were accurately randomized using an independent secure, automated telephone system that operates 24 hours to ensure allocation concealment. Minimisation was employed to ensure equal groups based on center existing pressure ulcers, speciality, and type of admission. The participants were assigned to an alternating mattress within 24 hours of admission to a specific hospital. The main limitation of the trial was the lack of blinding in the assessment outcome.

However, it is highly unlikely to achieve trial success due to the inability to disguise the mattress, which is unethical for seriously ill patients. The trial's bias was somewhat minimized by the clinical research nurses and ward staff who collected skin samples for assessment. However, since the nurses were not blinded to the treatment, the care provided cannot be justified. Nevertheless, blinding is unnecessary as patients staying in the hospital for a long time will always be lying on a mattress and it would not significantly affect the trial. The nurses should not have to be blinded either, as regular patient turning is a part of routine patient care. Blinding is not a relevant factor in this study. All participants were included in the conclusion, which acknowledged that some patients felt uncomfortable on certain mattresses and requested a change. The participants' preference for the mattress over the overlay was considered based on comfort reasons.

The text states that certain patients had to be removed from the trial due to pressure sores worsening or death, resulting in a decrease in the number of participants. It is mentioned that the groups in the trial were treated equally. However, there were issues raised about patients requesting alternative devices and nurses changing patients' devices based on personal preference. This potential bias could have influenced the results. Nevertheless, the study's statistics indicate that there was not much difference between the two groups, suggesting that the results can be applied to the general population. A significance criterion, stating how unlikely a result must be if the null hypothesis is true, was set at 5%. Power analysis, on the other hand, is relevant when determining whether to reject or accept the null hypothesis. In this trial, power calculations were utilized to obtain a more precise evaluation of the outcome for the population size.

During randomisation, a total of 113 individuals had pressure ulcers. Among these, 55% were able to heal during the trial. Out of those who experienced healing, 34% used overlay while 35% used mattresses. The results were presented as percentages of people who achieved the desired outcome.

Several factors contributed to the development of new pressure ulcers, including being from the acute condition ward, having a wound or skin trauma, age, and diabetes. However, this trial did not yield statistically significant results with a p value exceeding 0.05 (p=0.7). This means that there were no observed differences between the treatments in this trial.

Nevertheless, it is important to note that lack of statistical significance does not necessarily imply clinical insignificance; instead, it provides valuable information for making clinical decisions.

The clinical status can be determined by calculating a confidence interval, which includes the mean, median, and proportion. A 95% confidence interval represents a range of values that would encompass the true population quantity 95% of the time if the study were repeated. In the overlay group, 10.7% (106 individuals) developed one or more new grade 2 pressure ulcers, while in the mattress group, 10.3% (101 individuals) had the same outcome. The difference in proportions between these groups (overlay - mattress) was 0.4%, with a 95% confidence interval ranging from -2.3% to 3.1%. After adjusting for other factors, the odds ratio for developing a new pressure ulcer using the overlay compared to the mattress was 0.94, with a 95% confidence interval of 0.68 to 1.29. This suggests that there is no significant difference between the two surfaces in terms of the odds of developing a new pressure ulcer.

Overall, the participants preferred the mattress over the overlay for comfort. The trial aimed to compare outcomes between the two interventions and found that they were similar. However, the trial did not have enough data to establish confidence intervals. Nonetheless, the small difference in confidence limits provides reassurance for readers using either device. The trial was well-executed with randomization and a large sample size, minimizing potential impact from changes. It also provided important cost information, showing that an alternating pressure mattress costs £4000 while an overlay costs £1000, making the cheaper option more cost-effective. Notably, out of 230 participants who received overlays, more requested a different device compared to 186 participants who received mattresses. Nevertheless, patient circumstances should be considered when choosing a device rather than solely relying on financial reasons.

References:

CASP (2010) has created a program called the Critical Appraisal Skills Programme to assist in understanding clinical effectiveness evidence. They have developed a checklist with 11 questions that can aid in comprehending a trial. The checklist is available at: http://www.casp-uk.net/wp-content/uploads/2011/11/CASP_RCT_Appraisal_Checklist_14oct10.pdf.

Evans (2003) emphasizes the significance of the hierarchy of evidence and presents a framework for evaluating healthcare interventions according to the ranking of different types of evidence in the Journal of Clinical Nursing (pp. 77-84).

To access onlinelibrary.wiley.com/…0.1046/j.1365-2702.2003, simply click the provided link.

Nelson, A. (2011) provides a comprehensive explanation of the concept and importance of Randomised Controlled Trials (RCTs) in nursing practice in the article "What is a Randomised Controlled Trial?". RCTs are widely used in Evidence Based Nursing as a reliable research method to obtain unbiased and trustworthy results in clinical trials.

The study titled "Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial" was conducted by Nixon, J., Cranny, G., Iglesias, C., Nelson, E.A., Hawkins, K., Philips, A., Torgerson, D., Mason, S. and Cullum, N. in 2006 and published in the British Medical Journal; 332:1413.The following text includes two citations from different sources. The first citation is from an article titled "Evidence Based Medicine: what it is and what it isn't" by Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, R., Richardson, W. published in the British Medical Journal in 1996 (312:7023, 71-72). The second citation is from an article titled "Understanding Controlled Trials: Why are randomised controlled trials important" by Sibbald, B., Roland, M. published in the British Medical Journal in 1998 (316:201).