Spilsbury and her team have investigated the impact of pressure ulcers on patients and recorded their experiences with a view to investigate into the quality of life of these patients. All the researchers are Registered Nurses with a PhD except for Iglesias who has a PhD. They are all based in the University of Leeds in the UK. Iglesias is from the University of York in UK.
Their study has been done well and with good intentions. I understand that their aims are targeted at improving the services to mankind. Pressure sores are a common cause of misery in many patients. The study and the paper are commendable. The facts are clearly presented.
The phenomenon of interest.
The phenomenon of interest has been clearly identified as the effect of treatment and the experiences of the inhospital patients having different illnesses with pressure ulcers which are a significant health problem and the resulting quality of life. Pressure ulcers prevalence in UK, USA and Canada ranges from 5-32% ( Kaltenthaler et al, 2001).
The significance of undertaking such a study has been highlighted in the introduction. The affected are the older generations, seriously and neurologically compromised with motility problems and badly nourished (Banks, 1998). Cost of pressure ulcer treatment is between £1.4 and £2.1 per year in the UK National Health service. This cost is mostly for the nurses for dressing the ulcers, repositioning the patients to prevent worsening of the wounds, monitoring and risk assessment. The job of ensuring good management of pressure ulcers lies with the nursing staff.
Quality of life has been defined in various terms by different researchers. Here the patient’s subjective experiences of the pressure ulcers contributed to the quality of life. There is limited information on this aspect in research as evidenced by the literature review. The “disability paradox” has been spoken of. Occasionally people with chronic illness do not speak of a poor quality of life while normal healthy people may do so (Albrecht and Devlieger, 1999).
Individual expectations decide what quality of life is and so it becomes a construct. The expectations may change with changed circumstances (Carr et al, 2001).
Investigating the experiences of the patients under the circumstances was unique in that these experiences could not be generalized or quantified. They may change in another setting and other circumstances. Individual patient’s perceptions were to be studied and they were very different with each person. These entailed that the study be qualitative. The health and quality of life of the patients were the main considerations. How and why pressure ulcers develop and how they should be managed so that the patient has a good quality of life is the thought behind the study.
The final target would probably be to design and implement a program which would ensure the good quality of life in the inpatients who have the various systemic illnesses. They should not develop pressure ulcers and if they do, their life should not be one of misery due to the associated pain, smell, appearance and fluid leakage. They must be able to move around without inconveniencing others or even without making it obvious to others who may shy away from them due to the sight or smell.
Purpose
The purpose has been expressed explicitly. It was to enquire about how patients with pressure ulcers rated their health and quality of life, what their experiences were in developing the ulcer or what was the cause of it arising, whether it could have been prevented, whether some avoidable carelessness on the patient’s part or in the method of management of the systemic illness caused it and whether the present management is good so that they are assured of a good quality of life. The vista of information obtained would be used to define the factors in improving the quality of life in a patient who stands the risk of developing pressure ulcers and those who are in the throes of it.
The significance to nursing has been also implied. The quality of nursing care could be improved as the patients depend on others to “treat, manage and care for the ulcers” (Pg. 494). The study further could be providing information on how best to shorten hospital stays and how the nursing staff could help assuage the patient’s emotional distress, discomfort and pain of the ulcers. This may actually come in useful to help the patient’s ongoing treatment for the systemic illness too. Health care professionals can learn from the experiences of these patients in this study and make necessary changes in their management of dressings, implement preventive measures and be informed about the comfortable positioning of patients.
Method
Considering that patients are being surveyed and most of them elderly, the semi-structured interviews were just the right method. Rigid questionnaires may not have been tolerated by the ill participants. The interviews allowed greater scope for the participants to express their feelings and give the right perspective to the questions framed by the researcher.
The questions too were not the same for all the participants. As the aim was to elicit maximum information, some differences of opinions and information were expected. Though the interviews began in almost the same way with pre-designed general questions, the progressive questions were created according to the participant’s answers. These interviews were made in a relaxed two-way conversational manner where even the interviewers were asked questions as clarifications for the patient’s doubts on the illness or treatment. The interviewers went prepared for such a contingency. The method was definitely compatible to the aims of the research and the circumstances where ill participants were being dealt with. Interviews could be stopped when the participants felt distressed and continued later. The method was also adequate in eliciting maximum information on the patient’s opinions and woes. However as the aim was to extract the patient’s experiences only, this method could be considered sufficient.
The opinions of the nursing staff who managed the dressings could also have added to the management of the pressure ulcers which was in the phenomenon of interest but this had not been done. This additional information could have helped in the perspectives being investigated. The aim was to produce a better quality of life with better management of the ulcers. This study could be completed with a guide to the approach as the rest of the interview depended on the interviewer and the participant.
Sampling
The researcher has described the selection of participants. They were 23 inpatients in the medical, elderly care, orthopaedic and vascular surgery wards from four NHS hospitals. As there was a larger randomized controlled trial going on at these places, clinical research nurses were entrusted to identify willing patients who were not in the other trial and who had chronic conditions or pressure ulcers. The nurse informants were appropriate as they were the ones who knew most about the inpatients.
Data Collection
The information collected included the general health of the participants, the pressure ulcer details but the focus was on the human experiences involved. Semi-structured interviews were used to gather data. The interviews were transcribed verbatim in order not to miss anything that the participant said and stored in qualitative data analysis management software package to facilitate easy retrieval. Saturation of data has not been mentioned. The collection procedures were not given in detail.
Ethical considerations were not forgotten. Approval for the study was provided by the Multi-centre Research Ethics Committee, the Local Research Ethics Committees and the research governance and management departments of the participating centres. Patients were informed of the study and how their narratives would be used. They were allowed the option of withdrawal at any point of time. Written consent was obtained and the assurances of anonymity and confidentiality were given. These confirm that the protection of the human participants was addressed.
Data analysis
Thematic analysis was done by the researchers themselves. The themes and sub-themes were identified. However further work was done by two other researchers who did the rigour of analysis and coding. This further increased the trustworthiness of the findings and ensured that no manipulation was done so we can assume that the researchers were true to the data. Reflexivity was thereby possible (Hammersley & Atkinson 1995). The authenticity of the conclusions have been left open for consideration by others (Mays and Pope, 2000). The reader may understand the procedures on how to thematically analyse the data as the details have been given. The rigour of the analysis has not been explained.
Credibility
The credibility or validity or fittingness of the data are mentioned. The participants recognize the experiences as those of self and carer.
Auditability
The reader is able to follow the researcher’s thinking. Participants were aware of the difficulties of dependence when pressure ulcers occur. Some needed help in the form of ‘care packages’ from the social services. Home carers and day centres were asked for. Most of the younger ones felt themselves a burden to others, even family members. All these reduced the quality of their life. They have tried to make changes in their home to reduce their dependability. The development of the ulcers and the different levels of pain were described in detail. Many limited their movements to avoid delaying healing. They were depressed about the ulcers. The reader could document what he has learnt.
Fittingness
The findings are useful outside the study situation as these are practical points and are the frank experiences extracted without giving any hint to the patients that a research is involved. The opinions were from the heart as they were in the process of experiencing the difficulties of pressure ulcers. Any situation in any other place would have similar findings with minimal differences (Lincoln and Guba, 1985). However generalization is not possible as only a small group had been studied. The findings are definitely useful to even to those who did not participate. They may be sufferers or have someone in their homes who has pressure ulcers. The strategy used is compatible to the study.
Findings
The findings are presented with contextual detail. 21 of the 23 patients were living in chronic conditions. This helps to understand the impact of pressure ulceration in these dismal situations (Spink, 1999). Most patients had accompanying severe illnesses but it was their pressure ulcers which were bothering them. The findings were based on three themes in the interview: contextual detail, patient’s experience of developing an ulcer and patient’s experiences of the care that he obtained. The development of the ulcer was further detailed as perceived cause, description, and impact of ulcer. The experience of care was detailed as dressings and treatments, pressure equipment like mattresses and cushions and professional attention. The findings were similar in other studies (Fox, 2002, Langemo et al, 2000).
The contexts of their living conditions determined the quality of life as perceived by them. Pressure ulcers themselves affected the emotional status of the patients who were distressed by the pain, fluid leakage, smell and discomfort along with the limitations in mobility. Another significant response was the reaction of the nursing and health professionals. They were unable to understand fully what the patients were going through and least bothered about the pain they are suffering. A little more information from the managing carers could help them in assisting the healing process. Delayed healing and other health problems were troubling them.
Attributing blame for the ulcers on the health professionals was one mechanism of coping (Bury, 2005). Prevention of these ulcers may be more significant and cost effective than treating the ulcers (Touche Ross, 1993). Preventive measures may be welcomed by the people who have a risk of developing them.
Limitations of the study
The pain, suffering and non monetary causes were not investigated well. This was understood as a limitation in this study. Findings from a qualitative research also cannot be generalized. It was not possible to indicate the consequences of the time that had elapsed after the chronic conditions began. Moreover not all the patients revealed their full history of chronic conditions. Data collection needed to be improved.
Conclusions
The conclusions, implications and recommendations of the study do provide a context in which they can be used. By highlighting pressure ulcers, “including management of dressings, providing information (in particular about realistic time expectations for healing), undertaking preventative interventions and understanding the importance of what is already known about this topic”, the significance of the study to nursing is implied. Pressure ulcers are a significant health problem and Nursing staff have a major role in the prevention, treatment, management and care of pressure ulcers, limited research on the impact of pressures, ulcers and their treatment on quality of life”. This study has found that pressure ulcers have a physical, social, emotional and mental impact on patients. Pressure ulcers are significant in the patient’s life from illness to full recovery, perceived from increased hospital stays and ongoing treatments. The nursing staff are not aware of the pain and difficulties involved in pressure ulcers. The health professionals need to respond to the patients’ observations and cooperate in preventing the ulcers and improving their involvement and the standards of management. The conclusions reflect the study findings.
Implications
The conditions that determine quality of life are not stable. So these findings are relevant and could be referred to. Recommendations for future study are mentioned. Researchers are challenged by the pressure ulcers and their management. The impact of cost effective management may be a question that has to be answered. A broader perspective of personal and social costs may also be studied. Future research has many challenges.
References
- Albrecht, G.L. & Devlieger, P.J. (1999) “The disability paradox: high quality of life against all odds”. Social Science & Medicine 48, 977–988.
- Banks, V. (1998) “Nutrition and pressure area management”. Journal of Wound Care 7(6), 318–
- Bury M., Newbould J. & Taylor D. (2005) “A Rapid Review of the Current State of Knowledge Regarding Lay Led Self Management of Chronic Illness: Evidence Review”. National Institute for Health and Clinical Excellence.
- Carr, A.J., Gibson, B. & Robinson, P.G. (2001) “Is quality of life determined by expectations or experience? British Medical Journal 322, 1240–1243.
- Fox C. (2002) “Living with a pressure ulcer: a descriptive study of patients’ experiences”. British Journal of Community Nursing 7(6 Suppl.), 10, 12, 14, 16, 20, 22.
- Hammersley M. & Atkinson P. (1995) “Ethnography: Principles in Practice”. Routledge, London.
- Kaltenthaler, E., Whitfield, M.D., Walters, S.J., Akehurst, R.L. & Paisley, S. (2001) “UK, USA and Canada: how do their pressure ulcer prevalence and incidence data compare?” Journal of Wound Care 10, 530–535.
- Lincoln, Y.S. & Guba, E.G. (1985) “Naturalistic Inquiry”. Sage, Beverley Hills, CA.
- Mays N. & Pope C. (2000) “Quality in qualitative health research”. In Qualitative Research in Health Care, 2nd edn (Pope C. & Mays N., eds), BMJ Books, London.
- Spilsbury, K., Nelson , A.., Cullum N., Iglesias, C. , Nixon,J. and Mason, S. (2007) “Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. Journal of Advanced Nursing 57(5), 494–504 doi: 10.1111/j.1365-2648.2006.04140.x, Blackwell
- Spink, M.P. (1999) “Making sense of illness experiences”. In Qualitative Health Psychology: Theories and Methods (Murray M. & Chamberlain K., eds), Sage, London, pp. 83–97.
- Touche, Ross X. (1993) “The Cost of Pressure Sores.” Touche Ross and Company, London.