Wound care in the community setting: clinical decision making in context

Preoperative and postoperative recommendations to surgical wound care interventions: A systematic meta-review of Cochrane reviews

BACKGROUND

The increasing numbers of surgeries involving high risk, multi-morbid patients, coupled with inconsistencies in the practice of perioperative surgical wound care, increases patients' risk of surgical site infection and other wound complications.

OBJECTIVES

To synthesise and evaluate the recommendations for nursing practice and research from published systematic reviews in the Cochrane Library on nurse-led preoperative prophylaxis and postoperative surgical wound care interventions used or initiated by nurses.

DESIGN

Meta-review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

The Cochrane Library database.

REVIEW METHODS

All Cochrane Systematic Reviews were eligible. Two reviewers independently selected the reviews and extracted data. One reviewer appraised the methodological quality of the included reviews using A MeaSurement Tool to Assess Systematic Reviews 2 checklist. A second reviewer independently verified these appraisals. The review protocol was registered with the Prospective Register of Systematic Reviews.

RESULTS

Twenty-two Cochrane reviews met the inclusion criteria. Of these, 11 reviews focused on preoperative interventions to prevent infection, while 12 focused on postoperative interventions (one review assessed both pre-postoperative interventions). Across all reviews, 14 (63.6%) made at least one recommendation to undertake a specific practice, while two reviews (9.1%) made at least one specific recommendation not to undertake a practice. In relation to recommendations for further research, insufficient sample size was the most predominant methodological issue (12/22) identified across reviews.

CONCLUSIONS

The limited number of recommendations for pre-and-postoperative interventions reflects the paucity of high-quality evidence, suggesting a need for rigorous trials to address these evidence gaps in fundamentals of nursing care.

Internet-based learning programme to increase nurses' knowledge level about venous leg ulcer care in home health care

AIMS AND OBJECTIVES

To test the effectiveness of an Internet-based education programme about venous leg ulcer nursing care on perceived and theoretical knowledge levels and attitudes among nurses working in home health care.

BACKGROUND

Nurses have been shown to have knowledge gaps in venous leg ulcer nursing care. Internet-based learning could offer a means for flexible continuing education for home healthcare environment.

DESIGN

Quasi-experimental study with pre- and postmeasurements and nonequivalent intervention and comparison groups.

METHOD

Nurses (n = 946) in home health care in two Finnish municipalities were invited to participate in the study and divided into intervention and comparison groups. The intervention group received education programme about venous leg ulcer nursing care, while the comparison group did not. Data were collected at baseline, at six weeks and at 10 weeks to test the hypotheses: nurses using education programme about venous leg ulcer nursing care will have higher level of knowledge and more positive attitudes than those not using education programme about venous leg ulcer nursing care. An analysis of variance and mixed models with repeated measures were used to test differences in knowledge and attitudes between and within the groups.

RESULTS

There were statistically significant increases in knowledge levels in the intervention group from baseline to the first and second follow-up measurements. In the comparison group, the knowledge levels remained unchanged during the study. Attitude levels remained unchanged in both groups.

CONCLUSION

Nurses' perceived and theoretical knowledge levels of venous leg ulcer nursing care can be increased with Internet-based education. However, this increase in knowledge levels is short-lived, which emphasises the need for continuous education.

RELEVANCE TO CLINICAL PRACTICE

Internet-based education about venous leg ulcer nursing care is recommended for home healthcare nurses. Education programme about venous leg ulcer nursing care provides flexible method for nurses' learning with feasible and cost-effective access to evidence-based education. Education programme about venous leg ulcer nursing care material can be used in all nursing environments where Internet is available.

Clinical judgment and decision making in wound assessment and management: is experience enough?

The assessment and management of wounds forms a large proportion of community nurses' workload, often requiring judgment and decision-making in complex, challenging and uncertain circumstances. The processes through which nurses form judgments and make decisions within this context are reviewed in this article against existing theories on these on these subjects. There is variability in wound assessment and management practice which may be attributed to uncertainties within the context, a lack of knowledge in appropriate treatment choices and the inability to correctly value the importance of the clinical information presented. Nurses may be required to draw on intuition to guide their judgments and decision-making by association with experience and expertise. In addition, a step-by-step analytical approach underpinned by an evidence base may be required to ensure accuracy in practice. Developing an understanding of the different theories of judgment and decision-making may facilitate nurses' abilities to reflect on their own decision tasks, thereby enhancing the care provided.

Home care nurses' decisions about the need for and amount of service at the end of life

AIMS

We explore home care nurse decision-making about the need for and amount of service by clients and families at the end of life. We identify factors nurses refer to when describing these decisions, situated within contextual features of nursing practice.

BACKGROUND

Home care nurses are often responsible for decisions which have an impact on the access of clients and families to services at the end of life. Understanding how these decisions, are made, factors that are considered, and contextual influences is critical for improving access and enhancing care.

METHODS

Qualitative data were collected between 2006 and 2008 from two samples of home care nurses: the first group (n = 29) recorded narrative descriptions of decisions made during visits to families. The second group (n = 27) completed in-person interviews focusing on access to care and their interactions with clients and families. Data were analysed with thematic coding and constant comparison.

FINDINGS

Participants described assessing client and family needs and capacity. These assessments, at times integrated with considerations about relationships with clients and families, inform predictive judgements about future visits; these judgments are integrated with workload and home health resource considerations. In describing decisions, participants referred to concepts such as expertise, practice ideals and approaches to care.

CONCLUSION

Findings highlight the role of considerations of family caregiver capacity, the influence of relationships and the importance of the context of practice, as part of a complete understanding of the complexity of access to care at the end of life.

How do children's nurses make clinical decisions? Two preliminary studies

AIMS AND OBJECTIVES

To gain an understanding of how children's nurses make clinical decisions.

BACKGROUND

Several studies have explored how nurses make clinical decisions and the factors that may affect the decision-making strategies used. However, the results of these studies are contradictory. Further, little is known about children's nurses' decision-making strategies.

DESIGN

The think aloud technique.

METHODS

Nurses (n = 12) from three surgical wards and nurses (n = 15) from three medical wards in a Scottish children's hospital were presented with clinical scenarios and asked to think aloud. The verbal protocols were analysed to provide an indication of how children's nurses made decisions. Whether there were any differences in decision-making between experienced and less experienced nurses and between graduates and non-graduates was also explored.

RESULTS

Analysis of verbal protocols obtained using the think aloud technique suggested that all the nurses in the sample used a hypothetico-deductive (analytical) model of decision-making. Further, all participants appeared to use backward reasoning strategies regardless of their level of expertise. This is a characteristic of non-expert decision-making. Experienced and less experienced nurses collected similar additional information before planning nursing interventions, supporting the conjecture that they were functioning at a non-expert level in relation to decision-making. No differences were seen in the information collected by graduate and non-graduate nurses.

CONCLUSIONS

The decision-making strategies of children's nurses need exploring further and further research is needed to identify factors that may affect decision-making strategies. Several strategies to support nurses' clinical decision-making have been proposed but need testing to ascertain their effectiveness.

RELEVANCE TO CLINICAL PRACTICE

In clinical practice nurses make numerous decisions throughout the course of a shift. Sub-optimal decision-making strategies may adversely affect the quality of nursing care provided. It is imperative, therefore, to ascertain how nurses make clinical decisions and the factors that may influence the decision-making strategies used.

Diagnostic practise in nursing: A critical review of the literature

The purpose of this article is to critically review and synthesize the literature related to the general concepts and the process of diagnosing the client's condition, and the possible variables which influence diagnostic practise in nursing. It is suggested that statistical theories are capable of capturing the diagnostic process and offer an effective means to predict diagnostic decisions. Studies underpinned by information-processing theory argue that diagnosing a patient's condition follows a hypothetico-deductive model that consists of specific stages. Those who hold a phenomenological perspective remark that there is yet another form of diagnostic practise: intuitive reasoning, which plays an important role in diagnosing the patient's clinical condition. Other related studies suggest that diagnostic practise is contingent on some personal, psychosocial, and structural variables. Regrettably, these studies offer no conclusive explanation to delineate diagnostic practise in nursing. Based on the literature reviewed, a conceptual framework is suggested to help articulate the underlying structures and processes of diagnostic practise in nursing.

Barriers to evidence-based practice in primary care nursing - why viewing decision-making as context is helpful

AIM

This paper reports a study examining the barriers associated with research knowledge transfer amongst primary care nurses in the context of clinical decision-making.

BACKGROUND

The research literature on barriers to nurses' use of research knowledge is characterized by studies that rely primarily on self-report data, making them prone to reporting biases. Studies of the barriers to evidence-based practice often fail to examine information use and behaviour in the context of clinical decision-making.

METHODS

A multi-site, mixed method, case study was carried out in 2001. Data were collected in three primary care organizations by means of interviews with 82 primary care nurses, 270 hours of non-participant observation and 122 Q-sorts. Nurses were selected using a published theoretical sampling frame. Between-methods triangulation was employed and data analysed according to the principles of constant comparison. Multiple linear regression was used to explore relationships between a number of independent demographic variables (such as length of clinical experience) and the dependent variable of nurses' perspectives on the barriers to their use of research knowledge.

RESULTS

Three perspectives on barriers to research information use emerged: the need to bridge the skills and knowledge gap for successful knowledge transfer; information formats need to maximize limited opportunities for consumption; and limited access in the context of limited time for decision-making and information consumption. Demographic variables largely failed to predict allegiance to any of the perspectives identified.

CONCLUSIONS

Researchers should consider using decision-making as a contextual backdrop for exploring information use and behaviour, avoid relying solely on self-reported behaviour as data, and use a variety of research methods to provide a richer picture of information-related behaviour. Practice developers need to recognize that understanding the decisions to which research knowledge is to be applied should be a characteristic of any strategy to increase research uptake by nurses.

Impact of tele-advice on community nurses' knowledge of venous leg ulcer care

AIM

This paper reports a study assessing the impact of the provision of expert tele-advice to community nurses in enhancing their knowledge of leg ulcer care.

BACKGROUND

Community nurses have traditionally been responsible for the care of patients with leg ulcers. However, access to expert medical and nursing advice has been restricted to the local hospital environment. The introduction of e-health and telemedicine have created opportunities to provide online and immediate access to wound care expertise from centres of excellence to primary health care staff in managing patients' wounds in their own home.

METHOD

A stratified randomized controlled trial was used to examine community nurses' knowledge before and after the provision of expert tele-advice. A knowledge measurement tool comprised of 40 multiple-choice questions was adopted, with correct responses identified by a panel of wound care experts. The questions covered the three themes of dressings, management and physiology, with different levels of difficulty categorized as easy, medium or difficult. The tool was administered before and after the intervention (12 weeks) to both the experimental and control groups.

RESULTS

Statistically significant improvements were observed only for the experimental group in the areas of dressings and management, as well as in the medium level questions. No statistically significant improvement was seen for the easy questions, as there was little room for improvement because of preintervention high scores. For the difficult questions, it was thought that more time would be needed for a more positive outcome.

CONCLUSIONS

The results suggest that tele-advice can be of great benefit to community nurses in enhancing their knowledge in the practice of leg ulcer care. This will have significant implications for more efficient use of human resources and cost effectiveness in wound care.

Benefits and challenges of nurse prescribing

BACKGROUND

Since 1999, all health visitors and district nurses in the United Kingdom (UK) have received additional education to permit their registration as independent prescribers from a limited list of medicinal products. Little research has investigated how more than 20 000 health visitor and district nurse prescribers have implemented their new role since the evaluation of the pilot sites.

AIMS

The aims of the study were to describe prescribing practices of health visitors and district nurses, the factors (contextual and professional) which enable and facilitate nurse prescribing, and views about the Nurse Prescribers' Formulary.

METHOD

A mail survey was conducted of all health visitors and district nurses working in three trusts in southern England. A 74% response rate was achieved (n = 91).

FINDINGS

Most respondents prescribed less than three times a week, with district nurses prescribing significantly more than health visitors (P </= 0.001). Over two-thirds of the sample found nurse prescribing at least moderately helpful to their professional role and over four-fifths reported that they were more than moderately confident nurse prescribers. A range of information sources was identified as helpful, regarding both new products and for continuing educational needs. Over two-thirds reported that the current Nurse Prescribers' Formulary did not cover their prescribing needs, and a number of factors were identified as hindering prescribing. Most respondents said that their general practitioner/primary care team was at least moderately supportive of their prescribing role.

LIMITATIONS

The survey was conducted in three primary care trusts in southern England, which may be unrepresentative of trusts elsewhere in UK.

CONCLUSIONS

The level of reported prescribing by health visitors and district nurses in this study indicates that they are not acting as substitute prescribers for general practitioners of the products in the limited formulary. Implementation of a major role change such as nurse prescribing requires a number of conditions, including adequate education/preparation, a formulary that meets practitioners' needs, and acceptance by the practitioners themselves.

The work of district nurses: first assessment visits

BACKGROUND

District nurses are the largest group of community nurses in the United Kingdom and overall responsibility for assessing and planning how patients' and families' needs are met remains an essential element of their role.

AIM

To explore the nature of the knowledge required by district nurses to carry out first assessment visits and the relationship of this to the decisions they make.

METHODS

An ethnographic design was used. The sample was 11 district nurses and the principal data collection methods were participant observation and two semi-structured interviews. The first interview, which took place immediately after the visit, was designed to explore general areas in relation to assessment and particular issues from the visit (phase 1). Following analysis of the phase 1 interview and fieldnote data, questions for the second interview were generated to facilitate further exploration and clarification of important issues that had arisen (phase 2). The second interviews were conducted approximately 1 year later and data were collected during 1997 and 1998.

FINDINGS

The findings revealed a breadth and depth of community nursing knowledge that seemed to incorporate an amalgam of theoretical (knowing that) with practice-based (knowing how) knowledge. The findings depict the range and scope of knowledge in use by district nurses and reflexive character of the assessment process, and challenge the use of theoretical models that remove knowledge from the context in which district nurse-patient interactions take place.

CONCLUSION

The information search in assessment was paced to cope with the uncertainty that existed in many of the complex multifaceted situations encountered by the district nurses. Understanding assessment as a paced process was linked to making the best judgement at the time of the visit.

The home care experience as perceived by the caregivers of Chinese dialysis patients

The caring issues perceived as crucial by caregivers in home-based dialysis, have never been systematically studied in any depth in Hong Kong. This research aimed to explore various characteristics of the home care experience perceived by caregivers. Thirty caregivers of home dialysis patients were interviewed using a phenomenological approach. Selection was by convenience. The interviews were conducted in the outpatient clinic following receipt of the informant's consent. The instrument consisted of two aspects designed to elicit the phenomena. The caregivers' responses seemed to indicate that caregiving is likely to have financial, emotional, social and health-related implications.

'Universal' concepts

It is assumed that the concepts of moist wound healing and wound-bed preparation are universally accepted and practised. However, the reality is that they are too often ignored, says Mark Collier

Quality of life in leg ulcer assessment: patients' coping mechanisms

An increase in autonomous practice and the need to evidence professional update puts demands on individual nurses to reflect on their knowledge and practice. Community nurses have become expert at managing wounds, particularly leg ulcers, and using a variety of assessment strategies. However, reflections focused on the expert patient and their coping mechanisms may suggest that holistic assessment and treatment of these patients requires consideration of additional factors. The introduction of quality of life (QoL) tools may provide the rationale for an individual patient's nursing care in this specific context. Placing emphasis on the social and psychological impact of living with a leg ulcer - from the patient's perspective - may direct collaborative assessment and informed decision making.

Nurses' views about pain and trauma at dressing changes: results of a national survey

Research findings and professional concerns that patients still experience pain and tissue trauma at dressing changes led specialist nurses to develop a postal questionnaire to elicit the views of 1000 nurses with an interest in wound management. The questionnaire asked practitioners to identify the primary considerations underpinning their approach to pain and tissue trauma at dressing changes, the strategies they adopted, and the factors which determined their treatment choices. The higher than anticipated response rate (37%) illustrates the importance nurses attach to this aspect of practice. The practitioners' main considerations during dressing changes were the need to prevent trauma to the wound (47%) and to avoid causing the patient pain (34%). Significantly, 81% noticed that patients experienced most pain when dressing products were removed, highlighting the need to re-emphasise the principles of moist wound healing. A total of 225 respondents (60%) were aware of dressings specifically designed to prevent pain and trauma during dressing changes. Practitioners also had the freedom to use the product of choice all (61%) or most (36%) of the time. However, respondents also demonstrated confusion about the properties and availability of many dressings. Recommendations for practice include reviewing the number of dressings currently available, together with ongoing education and update on all wound management dressing products and related issues.