S. José Closs

Patient risk factors for pressure ulcer development: Systematic review

OBJECTIVE To identify risk factors independently predictive of pressure ulcer development in adult patient populations? DESIGN A systematic review of primary research was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor studies. DATA SOURCES Fourteen electronic databases were searched, each from inception until March 2010, with hand searching of specialist journals and conference proceedings; contact with experts and a citation search. There was no language restriction. REVIEW METHODS Abstracts were screened, reviewed against the eligibility criteria, data extracted and quality appraised by at least one reviewer and checked by a second. Where necessary, statistical review was undertaken. We developed an assessment framework and quality classification based upon guidelines for assessing quality and methodological considerations in the analysis, meta-analysis and publication of observational studies. Studies were classified as high, moderate, low and very low quality. Risk factors were categorised into risk factor domains and sub-domains. Evidence tables were generated and a summary narrative synthesis by sub-domain and domain was undertaken. RESULTS Of 5462 abstracts retrieved, 365 were identified as potentially eligible and 54 fulfilled the eligibility criteria. The 54 studies included 34,449 patients and acute and community patient populations. Seventeen studies were classified as high or moderate quality, whilst 37 studies (68.5%) had inadequate numbers of pressure ulcers and other methodological limitations. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status. Skin moisture, age, haematological measures, nutrition and general health status are also important, but did not emerge as frequently as the three main domains. Body temperature and immunity may be important but require further confirmatory research. There is limited evidence that either race or gender is important. CONCLUSIONS Overall there is no single factor which can explain pressure ulcer risk, rather a complex interplay of factors which increase the probability of pressure ulcer development. The review highlights the limitations of over-interpretation of results from individual studies and the benefits of reviewing results from a number of studies to develop a more reliable overall assessment of factors which are important in affecting patient susceptibility.

How effective are patient-based educational interventions in the management of cancer pain? Systematic review and meta-analysis

ABSTRACT This review aimed to quantify the benefit of patient‐based educational interventions in the management of cancer pain. We undertook a systematic review and meta‐analysis of experimentally randomised and non‐randomised controlled clinical trials identified from six databases from inception to November 2007.Two reviewers independently selected trials comparing intervention (formal instruction on cancer pain and analgesia on an individual basis using any medium) to usual care or other control in adults with cancer pain. Methodological quality was assessed, and data extraction undertaken by one reviewer with a second reviewer checking for accuracy. We used random effects model to combine the effect estimates from studies. Main outcome measures were effects on knowledge and attitudes towards cancer pain and analgesia, and pain intensity. Twenty‐one trials (19 randomised) totalling 3501 patients met inclusion criteria, and 15 were included in the meta‐analysis. Compared to usual care or control, educational interventions improved knowledge and attitudes by half a point on 0–5 rating scale (weighted mean difference 0.52, 95% confidence interval 0.04–1.0), reduced average pain intensity by over one point on 0–10 rating scale (WMD −1.1, −1.8 to −0.41) and reduced worst pain intensity by just under one point (WMD −0.78, −1.21 to −0.35). We found equivocal evidence for the effect of education on self‐efficacy, but no significant benefit on medication adherence or on reducing interference with daily activities. Patient‐based educational interventions can result in modest but significant benefits in the management of cancer pain, and are probably underused alongside more traditional analgesic approaches.

The Yorkshire BARRIERS project: diagnostic analysis of barriers to research utilisation

The study identified barriers to research implementation experienced by nurses, midwives and health visitors in five trusts and one health authority in Yorkshire, UK. Funk et al. (Appl. Nurs. Res. 4(1) (1991a) 39, Appl. Nurs. Res. 4(2) (1999b) 90) developed the BARRIERS to research utilisation questionnaire over 10 years ago, but no replication, in size (n = 1989) and extent, of that study appeared to have occurred. The staff population (n = 4501) were sent the BARRIERS questionnaire. 44.6% (n = 2009) were returned. Findings suggested nurses need time to read and apply research; authority to change practice; critical appraisal skills, an understanding of statistics and support of managers and peers (particularly doctors) to achieve successful practice change.

Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools

BackgroundThere is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment.MethodsWe searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach.ResultsWe retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a ‘gold standard’ significantly hinders the evaluation of tools’ validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations.ConclusionsThere are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence.

Patients' night-time pain, analgesic provision and sleep after surgery.

One hundred patients were interviewed about their experiences of pain and sleep following abdominal surgery. This information was supplemented by data on analgesic provision which were gathered from medication charts. Pain was the most commonly reported cause of night-time sleep disturbance and analgesics helped more patients to get back to sleep than any other intervention. About half of the patients felt that pain was worse at night than during the day. An examination of patterns of analgesic provision revealed that the number of doses given peaked at two points during the 24-hour cycle. The highest numbers of doses were given between 8 a.m. and 12 noon and 8 p.m. and 12 midnight. Fewer doses were given at night, between midnight and 4 a.m. Analgesic provision at night, therefore, did not appear to be explicitly related to need. The assessment and control of post-operative pain at night requires further attention in order to optimize pain control and promote sleep.

Assessing the quality and usability of smartphone apps for pain self-management.

OBJECTIVE To evaluate smartphone apps intended for self-management of pain using quality assessment criteria and usability testing with prospective users. DESIGN 1) Survey and content analysis of available apps; and 2) individual usability study of two apps. SETTING University of Leeds, United Kingdom. PARTICIPANTS Forty-one participants (aged 19-59 years) with experience of chronic or recurrent pain episodes. METHODS We undertook a survey, content analysis, and quality appraisal of all currently available mobile phone apps for self-management of pain. Two apps were then selected and assessed with usability testing. RESULTS Twelve apps met the inclusion criteria. The quality assessment revealed wide variation in their clinical content, interface design, and usability to support self-management of pain. Very little user or clinician involvement was identified in the development of the apps. From the usability testing, participants stated a preference for an interface design employing a lighter color scheme and particular text font. Although very few participants were aware of pain-reporting apps prior to participation, many would consider use in the future. CONCLUSIONS Variation in app quality and a lack of user and clinician engagement in development were found across the pain apps in this research. Usability testing identified a range of user preferences. Although useful information was obtained, it would be beneficial to involve users earlier in the process of development, as well as establishing ways to merge end user requirements with evidence-based content, to provide high-quality and usable apps for self-management of pain.

Patients’ verbal descriptions of pain and discomfort following orthopaedic surgery

The concepts of pain and discomfort are poorly differentiated in the literature. This study of 417 post-operative orthopaedic patients examined their use of language to describe pain and also discomfort. Their pain descriptions were assessed for congruence with the widely used McGill pain questionnaire (MPQ). The findings confirmed that there was an overlap in the descriptions of pain and discomfort, but that pain tended to be described as an internal phenomenon, while discomfort was frequently related to environmental stimuli. The use of analogy was commonly used to describe pain. There was considerable use of words not included in the MPQ. This suggests that regional and international variations in vocabulary may render the MPQ unsuitable for indiscriminate use in Anglophone countries. Implications for improving pre-operative information provision and post-operative assessment of pain and discomfort are briefly presented.

The BARRIERS scale: Does it 'fit' the current NHS research culture?

The BARRIERS scale was developed in the US as a method of identifying the main barriers to research utilisation reported by nurses. However, its appropriateness for assessing such barriers in the UK is not clear. The current drive for evidence-based practice makes it desirable to assess the availability of an instrument to measure the progress of nurses who have implemented research. Information about the appropriateness of the BARRIERS scale for use in the UK would allow its potential as a monitoring instrument to be assessed. This paper is a section of a wider study aimed at producing a general picture of the underlying types of barrier to the implementation of research findings. Objectives included exploring those factors which acted as barriers to research implementation; assessing the construct validity and the internal consistency of the BARRIERS scale in the UK; and identifying barriers which might be excluded or added in future studies. A census survey of practice nurses and nurses from two hospital and two community trusts within one health authority, and one community trust from another health authority, was undertaken. The BARRIERS questionnaire was sent by mail to 4,501 nurses, with a 44.6% response rate. Exploratory factor analysis was used to identify key factors underlying the 29 items of the BARRIERS scale which acted as barriers to the utilisation of research findings. Four factors were identified, which were conceptualised as: the benefits, quality and accessibility of research, and resources for implementation. These were similar, but not identical, to factors identified in the original US study. One factor appeared mainly to be concerned with critical appraisal, which could be considered to be a facilitator rather than a barrier. More than one-fifth of the original items were not included in the UK model. Under-reported (mainly research issues) and additional barriers (mainly organisational issues) were identified. The four-factor solution was roughly comparable with that derived in the US, although fewer items were retained (22 instead of 28), and some of the factors were conceptually a little different. It was concluded that the internal reliability of the four-factor solution was fair. The scale may not be suitable for use in the UK without further development: a scale which includes positive as well as negative aspects of research culture, with a greater emphasis on organizational issues, may be more useful.

Painful leg ulceration : a prospective, longitudinal cohort study

This study aimed to explore the relationship between pain mechanism, pain intensity, and leg ulcer characteristics using a 6‐month longitudinal cohort study in a community setting in the north of England. Patients with leg ulceration referred consecutively to district nurses were invited to participate (n=96). The main outcome measures were pain intensity using daily visual analogue scores, leg ulcer characteristics (etiology, size, location, duration), and LANSS (Leeds Assessment of Neuropathic Symptoms and Signs). Results suggested that type, duration, position, and size of the leg ulcer had no effect on average daily pain scores. Using the LANSS questionnaire, 43.5% of respondents reported symptoms suggestive of a neuropathic mechanism to their pain. Patients with neuropathic symptoms had higher average daily pain scores (p<0.001). Fewer people had healed ulcers at 6 months with neuropathic symptoms compared with those with no neuropathic symptoms (30.8 vs. 52.1%). It would seem that the severity of pain can not be predicted by the type, size, position, or duration of ulceration. Patients who scored positively for neuropathic symptoms had higher average daily pain scores and fewer had healed leg ulcers at 6 months compared with those who did not experience neuropathic signs and symptoms.

How do the attitudes and beliefs of older people and healthcare professionals impact on the use of multi-compartment compliance AIDS?: a qualitative study using grounded theory.

Background: Low adherence of older people to multiple medicine regimens is of widespread concern, and multi-compartment compliance aids are frequently supplied to older people in an attempt to improve their ability to take all their medicines at home. However, the evidence base for the use of such aids is very limited, and there is some evidence that they are used inappropriately.Objective: We aimed to determine how the attitudes and beliefs of older people and healthcare professionals impacted on the use of multi-compartment compliance aids by older people living at home.Method: This was a qualitative study using grounded theory. Semi-structured interviews were conducted with 15 older people (mean age 82 [range 72–92] years) living independently in the community and receiving primary healthcare from two health service organizations in a large northern UK city. We then interviewed 17 healthcare professionals working in primary, secondary or intermediate care and involved in the provision of multi-compartment compliance aids.Results: Maintaining independence and remaining in control was important for all the older people interviewed, and professionals supported the view that this influenced patients’ attitudes towards using their aid. Some patients saw the aids as helping to maintain independence, others as casting doubt on their independence. The aids were often issued without discussion with the patient. The patients largely agreed that the aids did not help with memory problems and that the decision to issue an aid could be seen as paternalistic. A minority of patients had difficulties using the aids.Conclusions: Careful multi-disciplinary assessment of older people is required before a compliance aid is provided. The views of the older person must be considered and respected. Further research is required to produce an evidence base for the use of such aids in this group of people.