The main purpose of the paper is to critically appraise a systematic review paper on the topic of nurse’s pressure ulcer related judgment and decisions in clinical practice. The main rational for research on this topic is understood from the background information given for the study in the article by (Samuriwo & Dowding, 2014). The topic of interest is pressure ulcer and research in this area was important because of the prevalence rate of pressure ulcer in 5-32% of hospitalized patients in UK. The burden of pressure ulcer is huge because of pain, suffering and mental stress for patient. Nurses are considered to play an important role in the prevention of pressure ulcer as they are directly involved in taking preventive steps like risk assessment and patient repositioning. However, Samuriwo and Dowding (2014) explained the rationale for conducting systematic review on the topic by stating that the need to review the impact of nurse’s decision making on quality improvement and patient. This was also necessary because pressure ulcer prevention is dependent on integration of judgment and decision making process. Etafa et al. (2018) explained that nurse believed their clinical judgement is better than risk assessment tool to identify risk of pressure ulcer and take adequate actions. Hence, review of more studies was important to understand how nurses take judgment regarding the evaluation of pressure ulcer and pressure ulcer prevention.
In accordance with the systematic review format, the systematic review was guided by statement of PICO question (participant, intervention, comparison and outcome). The PICO table for the research are as follows:
|
Patient or Problem |
Intervention |
Comparison |
Outcomes |
|
Nurses |
Making judgment |
N.A |
Assessment of patient risk of developing pressure ulcer |
|
Nurses |
Make choices or decisions |
N.A |
Pressure ulcer prevention |
|
Nurse |
Judgment and decision making |
N.A |
Management of pressure ulcer |
Hence, the systematic review was based on the following research question:
The study by Samuriwo and Dowding (2014) used systematic review method to gain answer to the research question. The choice of research design is appropriate according to the research aim because the researcher aimed to explore the methods used so far by nurses to take decisions for the assessment, prevention and management of pressure ulcers. Systematic review is an important part of evidence based practice as it allows for a cheaper way to validate the effectiveness of an intervention compared to a new primary research study (Greenhalgh, Howick & Maskrey, 2014). The quality of the study has been evaluated by critical appraisal of the review design and the method used to include studies in the research. According to the PRISMA guideline, use of appropriate eligibility criteria, databases and other information sources, screening process and data collection process determines the credibility and quality of a systematic review paper (Moher et al., 2015).
Eligibility criteria, information sources and protocol:
According to McCrae, Blackstock and Purssell (2015), while conducting systematic review, researchers are expected to follow reporting guidelines. Samuriwo and Dowding (2014) did not follow any guideline for reporting. However, guidelines were followed for findings relevant studies for the systematic review. The eligibility criteria for the study were strictly based on the three research questions. The author explained that only those articles will be included that gave answer to nurse’s judgment and decision making in relation to risk assessment, prevention and management of pressure ulcer. The appropriate of the eligibility criteria was met by excluding those studies that compared nurse’s clinical judgment with existing tools. Other inclusion criteria were inclusion of studies published in English language and those published before 1992. The eligibility criteria for the systematic review are considered appropriate as Samuriwo and Dowding (2014) explained the rationale behind each inclusion criterion. Although the publication date was very old, however justification provided for it validated the inclusion of old publications for the review. The common mistake found in systematic review paper is that reviewers report eligibility criteria after description of the search strategy (McCrae & Purssell, 2015). However, no such errors were found for this paper. Clear and logical eligibility criteria enhanced the quality of the systematic review.
Information sources, search strategy and data collection process:
Samuriwo and Dowding (2014) conducted the search for articles in electronic databases such as CINAHL, Embase, Google Scholar, Medline, PubMed, PsycINFO, and ScienceDirect). According to PRISMA guideline for reporting about systematic review, full electronic search strategy for at least one date base should be mentioned in the paper (Boland, Cherry & Dickson, 2017). This criteria was fulfilled in the systematic review by giving full details regarding the search strategy and limits used for search on Medline.
Data synthesis in a systematic review paper is done by the process of screening research studies, extracting data from research articles and assessment of rigour or biases in included research studies (Bouncken et al., 2015). The screening of articles was done by reviewing abstract of the articles using inclusion and exclusion criteria. After this, the full text articles were review by authors and other consensus to select final articles for the systematic review. The credibility of the screening process is understood from the review of literature search and study selection diagram which clearly defined the number of articles obtained through database search and additional hand searching. Details on the number of articles excluded during the screening and the reason for exclusion was also provided. 17 studies were finally included in final synthesis out of which one was a systematic review paper. The screening process indicates use of rigorous method for the selection of most suitable and high quality research paper in the systematic review. Ng et al. (2014) argues that development of high quality systematic review requires rigorous screening method and use of at least two reviewers is needed to enhance the validity of the review. Similar step was taken by Samuriwo and Dowding (2014). However, this might have been a time consuming process and efficiency of the systematic review could have been improved by use of screening technologies like EndNoteX5.
The next step after screening phase is data abstract and collection of all findings from the systematic review. The data abstraction and synthesis was done by comparing the data and findings the patterns or connection in research findings. The rigour in data extraction process is understood from the fact that each paper was independently extracted by the reviewers and read multiple times. The study was summarized after a consensus was reached between all reviewers regarding the research findings. The summary of articles was developed after going through the above research process. Bobrovitz et al. (2015) explains that reaching a consensus during systematic review helps to resolve any discrepancies during the data extraction process. Clarity in data extraction is also seen as each summary table were separated according to type of outcomes it provided (For example, pressure ulcer risk assessment, pressure ulcer prevention and pressure ulcer management). The summary table covered source, design, sample size and results. Hence, the implementation of rigorous data synthesis method indicates the quality and reliability of the research evidence.
Systematic review design is vulnerable to many biases and such biases are controlled by researchers by reflecting on options to increase the methodological rigor of study during the planning phase (Almeida & Goulart, 2017). The same approach was taken by the assessment of rigour and quality of research studies. This is understood by critically appraising research papers based on the type of study design. For each study, the assessment of rigor in research study was done by considering the clarity of research question, suitability of research design, presence, ethical issues, sample recruitment and data collection process and evaluation of research findings. However, one limitation of the systematic review is that the author did not described the method to assess risk of bias for individual study. No independent risk of bias assessment tool was used and biases were examined only for sample size and population. Use of evidence based tool that could assess all types of bias in included studies would have enhanced the quality of the systematic review. Drucker, Fleming and Chan (2016) argues that many factors can lead to bias in systematic reviews such as competing interest, publication bias and evidence selection bias. Hence, awareness of types of bias is important for reviewers as they conduct systematic reviews and apply them into clinical practice.
From the overall critical appraisal of the quality of data synthesis method, it can be said that rigorous method was used to assess quality of the included studies. The similarities among studies were considered by the identification of common meaning in research. These were represented in the form of themes related to the research question. Snilstveit, Oliver and Vojtkov (2012) stated that identifying key themes facilitates identifying meaning and similarity in different research papers. In addition, results for individual themes were also accurately displaying increasing the credibility and clarity of the systematic review.
The results section is the most important part of the systematic review as it provides all bottom line outcome of the review. As per PRISMA guideline, the results section of the systematic review starts with numerical statistics on numbers of studies screened, assessed for eligibility and included in the research (Shamseer et al., 2015). Samuriwo and Dowding (2014) defined all this by the use of search strategy flow diagram. 17 studies were included in the final review and the overview and characteristics of included studies were provided. The number of studies obtained for each outcome variable like risk assessment, interventions, severity and treatment of pressure ulcer was provided. The author clearly defined the characteristics of individual studies too which helped to judge the evidence based on research evidence hierarchy (Noble & Smith, 2015). For example, systematic review, randomized controlled trial, semi-stricture interview, quasi-experimental study and many other research designs were used in the selected research papers. The setting used for conducting the research was also described. Hence, it can be said that systematic approach was used to present research findings.
In case of outcomes obtained for individual studies, Samuriwo and Dowding (2014) presented findings for individual outcome separately. The evaluation of studies related to use of risk assessment methods by nurses indicated that very nurse use risk assessment tools as they more confident about their clinical judgment. The study also explained reasons for low use of risk assessment tool because of time constraints and variations in timing of assessments. This is consistent with the study by Al-Ghamdi (2017) as this study also revealed heavy workload and lack of time as a barrier to application of risk assessment tool for pressure ulcer prevention by nurses. In relation to the outcome of interventions used by nurse for pressure ulcer prevention, it was found that nurse’s choices related to prevention were dependent on overall health status of patient, perception of patient and their family, state of their skins and perceived risk of ulcer. In addition, the study also reported use of decision tree to engage in decision making for pressure ulcer prevention. However, lack of enough studies related to the use of decision making tree affected the reliability of research evidence. The quality of research findings was stated by considering the research design and the applicability of the findings in real setting. The precision in research is also seen by use of confidence intervals and other statistical variables.
A complete discussion section in a systematic review paper includes a summary of research findings, discussion on the application of evidence to local setting, identification of study limitation, implications and recommendations for future research. All these elements were accurately presented by the research study by Samuriwo and Dowding (2014) .Samuriwo and Dowding (2014) explained that more research has been done regarding pressure ulcer risk assessment process and there is less number of studies for pressure ulcer prevention. Some limitations were that reasoning process affecting nurse’s decision was not explored in the included study. Very few studies were found applicable to be applied in local setting because of limitations like small sample size and lack of similar findings in other studies. Overall the review suggested gap in the nurse’s judgment regarding prioritization of care and delivery of care. As the study revealed lack of robust studies related to nurse’s judgment, it is recommended to conduct future studies to identify the strategies that can reduce barriers faced by nurse in decision making related to pressure ulcer prevention.
Conclusion:
To conclude, Samuriwo and Dowding (2014) used rigorous and extensive review method to extract validated and high quality research papers related to nurse’s decision making about pressure ulcer management. The author’s considered all criteria to enhance the quality of systematic review, evidence synthesis and appraisal of included studies. There were very limitations. The articles revealed lack of strong studies related to nurse’s decision making on pressure ulcer prevention. It is recommended to review the limitations found in included studies and address them in future practice to inform pressure ulcer care in clinical setting.
References:
Al-Ghamdi, A. (2017). Factors Affecting Nurses’ Compliance in Preventing Pressure Ulcer Among Hospitalized Patients at King Abdulaziz University Hospital. American Journal of Nursing Science, 6(5), 387.
Almeida, C. P. B. D., & Goulart, B. N. G. D. (2017). How to avoid bias in systematic reviews of observational studies. Revista CEFAC, 19(4), 551-555.
Bobrovitz, N., Onakpoya, I., Roberts, N., Heneghan, C., & Mahtani, K. R. (2015). Protocol for an overview of systematic reviews of interventions to reduce unscheduled hospital admissions among adults. BMJ open, 5(8), e008269.
Boland, A., Cherry, G., & Dickson, R. (Eds.). (2017). Doing a systematic review: A student’s guide. Sage.
Bouncken, R. B., Gast, J., Kraus, S., & Bogers, M. (2015). Coopetition: a systematic review, synthesis, and future research directions. Review of Managerial Science, 9(3), 577-601.
Drucker, A. M., Fleming, P., & Chan, A. W. (2016). Research techniques made simple: assessing risk of bias in systematic reviews. Journal of Investigative Dermatology, 136(11), e109-e114.
Etafa, W., Argaw, Z., Gemechu, E., & Melese, B. (2018). Nurses’ attitude and perceived barriers to pressure ulcer prevention. BMC nursing, 17(1), 14.
Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: a movement in crisis?. Bmj, 348, g3725.
McCrae, N., & Purssell, E. (2015). Eligibility criteria in systematic reviews published in prominent medical journals: a methodological review. Journal of evaluation in clinical practice, 21(6), 1052-1058.
McCrae, N., Blackstock, M., & Purssell, E. (2015). Eligibility criteria in systematic reviews: a methodological review. International journal of nursing studies, 52(7), 1269-1276.
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., … & Stewart, L. A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), 1.
Ng, L., Pitt, V., Huckvale, K., Clavisi, O., Turner, T., Gruen, R., & Elliott, J. H. (2014). and Abstract Screening and Evaluation in Systematic Reviews (TASER): a pilot randomised controlled trial of title and abstract screening by medical students. Systematic reviews, 3(1), 121.
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