Introduction
In order for a continuous and effective nursing practice, there is the necessity to continuously evaluate and asses work situations where improvement may be attained. To be able to meet this goal, it is necessary that health care learners be able to provide careful analysis of studies and research in order to be prepared in practice. This paper shall try to provide an analysis of the qualitative research report “Using the Ottawa Model of Research Use to Implement a Skin Care Program.” It will try to determine the validity of the study and evaluate the study findings in nursing practice.
Purpose/Objectives
Using the pragmatic Ottawa Model of Research Use to guide the implementation of clinical practice guidelines in a surgical program of a tertiary care hospital, this study under analysis describes the process of implementing an evidence-based skin care program in a surgical department of a large academic tertiary care hospital and aimed to tailor strategies to address the barriers and as well as to implement the guidelines.
Background/Rationale
The background of the study under analysis laid down prevalence of annual survey results pointing out an increase in rates as well as severity of ulcers for inpatient surgical populations. The paper provided data on complications of skin breakdown that are caused by hospitalization aggravating length of stay as well as mortality and morbidity as earlier suggested by Nelson (2003). In addition, it was also reported that pressure ulcers acquired in the hospital is a major issue in quality management that even with substantial prevalence and costs estimated at about 3 million patients of $5 billion annual expense, have remained almost unknown (Bechrich and Aronovitch, 1999) and Beitz, 2001).
What is also emphasized was that skin breakdown lessens the quality of life resulting to burden to patients, their family and their caregivers. However, it has been suggested in a study (Rutledge and Pravikoff, 2000) that after the implementation of a prevention program, there had been a significant reduction of pressure ulcers making the program timely and essential.
Likewise, Graham and Logan (2004) noted that experts earlier pointed out that pressure ulcers can be prevented although the most fitting practice is still under debate despite a lot of skin care research. The study suggested that the increase of synthesized evidence in the form of clinical practice guidelines (CPG) for better programs, it is about time hospitals adapt effective methods into practice. However, the study also noted that even as scientific approaches are considered the hallmark of practice, many clinicians still consider skin care as secondary issue, noting in particular tertiary care hospitals.
As noted, progress is being made on interdisciplinary approach for the prevention and treatment of pressure ulcers as theories are integrated by practitioners (Davis, 2002). It is however necessary that daily routines of clinicians adopt changes and include research evidence that will effect systematic and practical plans. Nevertheless, existing and functional models may guide implementations.
Description of the Project
The study used the Ottawa Model of Research Use or OMRU in organizing the framework using a surgical population comprised 185 beds within 5 distinct adult inpatient units including General and Plastic Surgery, Vascular and Thoracic Surgery, Urology, Neurosurgery, and Otolaryngology and Orthopedics. The OMRU is described as “an interactive model of research use encompassing 6 key elements: practice environment, potential adopters, the evidence-based innovation, transfer strategies, adoption, and outcomes,” (Graham, 2004, p 19). First, it conducted an assessment of the first 3 components which are practice environment, potential adopters, and the evidence-based innovation.
The purpose of the appraisal is to provide a profile that will be classified as either a barriers or supports to integrate innovation in clinical practice. After barriers to research use were identified, it is proposed that proactive strategies are mobilized to address them with tailored strategies on specific situation. The process of implementation were also monitored and outcomes evaluated relating to patients, practitioners, and financial or system results.
In assessing the practice environment, it was taken into consideration that the organization is the most important factor in promoting best nursing practice where environment is always on the move that may enable or constrain effects on occupational performance (Law et al, 1996). Here, it was suggested that barriers to pressure ulcer prevention may include health status of patients, unavailable products, fiscal restraints, lack of a continuous quality improvement framework, and lack of well-disseminated, research-based care guidelines, algorithms, and pathways, high cost of supplies and equipment, staffing problems, as well as lack of consistency within organizations to conduct risk assessments even with available valid and reliable tools (Rutledge et al, 1992).
The organization had a history of continuous quality improvement (CQI) focus and had a coordinator to support quality initiatives by clinical teams, unit councils, and special task forces. It also has a program management model that integrated all aspects of hospital care for surgical patients. Using the Braden Scale for skin integrity assessment, the annual Pressure Ulcer Prevalence (PUP survey was conducted.
Under the assessment of potential adopters — bedside clinicians, patients, and families — knowledge, skills, and attitudes or motivation were considered. Deterrents were identified as low priority, lack of interest, lack of time, and failure to form meaningful partnerships among stakeholders in the care settings.
In the assessment of evidence-based innovation, it was pointed out that relative advantage, compatibility, complexity, observability, and trialability, affect the adoption of an innovation. The assessment showed that there had been “fewer barriers than facilitators for the project. The OMRU suggests that when the barriers related to the practice environment, potential adopters, and innovation have been managed, strategies should be designed to disseminate the new practice for use,” (Graham and Logan, 2004, p 20).
Outcome
The study pointed out an outcome as the upgrading of mattresses to 100% of the 185 surgery beds, the expansion of the PUP survey to a regional basis, increased consultations of 25% over a 3-month period related to stage 2 ulcers and higher consistency in accurate assessment and appropriate treatment interventions. From the analysis of their consult records, a specific skin care approach is needed for patients 70 years of age and older, given their risk factors.
Likewise, further improvement plans included specialized strategies for elderly patients, physician and student education, standardization of products for advanced stages of ulcers, and expansion of the OR CQI project to capture a 30-minute postoperative skin assessment in the PACU. Reasonable-priced cushion for patients sitting in chairs has been under way as adequate number is to be purchased. In addition, increase of ambulation and nutritional interventions are being explored.
Conclusion
The study concluded that in a large tertiary hospital, a multidimensional, multidisciplinary approach is needed if any real sustained change is to occur. Likewise, the study suggested that an overall plan is needed for the implementation of widespread evidence-based quality initiatives. It was also concurred that the Ottawa Model of Research Use was necessary in keeping the project on track and preventing necessary information gaps.
It is however noted that adoption and implementation of changes takes longer as the environment is considered complex and in large groups. There is the need to continuously observe the environment for support or threats in implementation, sustain commitment among leaders, and enough resources both in staffing and materials in order to attain goals.
Practice
A key role of the clinical nurse specialist in this situation where skin care in tertiary hospital setting is the focus is to influence practice by fostering research use by practitioners. It is necessary to properly evaluate the environment, organization, resources, the peoples involved from patients, practitioners to leaders as to their attitudes, skills and knowledge about the situation or case, as in skin ulcer among surgical populations.
It is suggested that developing and implementing clinical innovation, information from the organization, the prevailing organizational practices, as well as end users and consumers are equally important. It is also important that continued vigilance in the changes of effective research-based practices is encouraged within the nursing practice. However, these will be naught without resources the full support from the organization. The Ottawa Model of Research Use in this process proved to be useful and relevant and that it could be as well adopted in other qualitative studies in nursing practice.
Reference
Beckrich K, Aronovitch SA. (1999). “Hospital-acquired pressure ulcer: a comparison of costs in medical vs surgical patients.” Nursing Economics 7, pp. 263-271.
Beitz, J.M. (2001).” Overcoming barriers to quality wound care: a systems perspective.” Ostomy Wound Management, 47 (3), pp. 56–64.
Davies, B. (2002). “Sources and models for moving research evidence into clinical practice”. JOGNN. 31 (5), pp. 469–473.
Law, M., Cooper, B.A., Strong, S., et al (1996). “The person-environment-occupational model: a transactive approach to occupational performance.” Canadian Journal of Occupational Therapy 63 (1), pp 9–23.
Nelson, E.A. Bradley (2003). “Dressings and topical agents for arterial leg ulcers.” Cochrane Review. The Cochrane Library. Issue 4. Chichester, UK: John Wiley & Sons, Ltd.
Rutledge, D.N., Donaldson, N.E., Pravikoff, D.S. (2000). “Protection of skin integrity: progress in pressure ulcer prevention since the AHCPR 1992 guideline.” Online J Clin Innovation 3 (5) pp. 1–67.