The role of Critical Care Nurses working in the Kingdom of Saudi Arabia in the prevention of pressure sores for critically ill patients

Chapter 1: Introduction

1.1. Introduction to the research topic

Healthcare is a major concern for society and the Government, and at the apex of any healthcare structure is the Intensive Care Unit (ICU), a highly specialised unit within the hospitals with highly technology-based equipment, which ensures the safety with the help of highly innovative technologies such as Intensive Care monitors, Sphygmomanometer, Mechanical Ventilator, Respirator/Ventilator etc. and lifesaving medicines, all crucial in the treatment of patients in critical situations (Kaitani et al. 2010). The patients are brought into ICU when suffering from the most serious health problems, in particular the illnesses that are life-threatening and require constant medical monitoring.

Within ICU, patient care is the responsibility of a multidisciplinary team (M.D.T), aiming to provide the patients with possibly best healthcare services so that their situation can be improved. However, due to the factors such as the increased prevalence of chronic diseases, reliance on technology and pharmaceutical agents and higher patient acuity, the environment of ICU may become infectious or hazardous (Jastremski 2002).

While the high quality of care within ICU is crucial, there are numerous problems that may have a negative impact on delivering such quality. Amongst the most important are system failures, communication breakdowns, faulty processes and poor teamwork. Despite a strong emphasis on providing up to date facilities, the ICU can only be as good as its staff. In particular, the quality of intensive care is defined by its critical care nurses (Strand and Lindgren 2010).

1.2.Background information

This research work focuses on one aspect of the intensive care unit; pressure ulcer prevention. Drawing on personal experience, whereby the researcher has observed the problems caused by pressure ulcer development, and its significance within the context of critically ill patients, this paper will explore issues related to the prevention of pressure ulcers in critically ill patients in ICU. In particular, the paper will examine the role of nurses in such prevention.

Pressure ulcers known also as pressure sores or bedsores have become a major global health care concern (Shahin et al. 2009). Pressure ulcers can occur in various areas of the skin and underlying tissue when these particular areas are placed under too much pressure within a short period of time (NHS, 2011). The pressure ulcer can cause pain, disfigurement as well as disruption to the daily routine of the patient (Manzano et al. 2010). On long-term the pressure ulcers can lead to skin openings; skin infections as well as deaths. Pressure ulcers are the second major iatrogenic cause of the death within the developed regions, following adverse drug reactions. In particular, pressure ulcers affect people over 70 years old, what is a combination of various factors such as ageing of the skin; limited blood supply as well as ongoing medical conditions (i.e. infections; diabetes).

As pressure ulcers have been recognized as a common illness amongst the citizens in developed countries, its prevention became of key significance for the national governments, various institutions and organizations dealing with health care services as well as medical staff taking care of people with pressure ulcers. Currently health care professionals introduced a range of various techniques designed to prevent pressure ulcers. For instance, a position of the person with pressure ulcers is regularly changed. Moreover, specially designed cushions and mattresses are used in order to protect the most vulnerable areas of the skin. Further, the patients at risk group are ensured nutritional supplements as well as topical skin protection. A wide variety of techniques used to prevent pressure ulcers threw light on the role of medical staff, critical care nurses, in the prevention process. Their knowledge, skills and attitudes seem to be of key importance for the patients at risk of pressure ulcers (Gillick 2000; Nijs et al. 2008).

A short explanation is also required in reference to choosing the Kingdom of Saudi Arabia as a country of in-depth examination the role of critical care nurses in preventing pressure ulcers. Two reasons need to be highlighted. First of them is the keen interest of the researcher in the health care and medical services in the Kingdom of Saudi Arabia and the improvements of these services over the past decades. This unique interest can be explained by the fact that the researcher is familiar with the KSA’a culture, traditions and language. Second, the researcher believes that there are very limited publications on the problem of pressure ulcers and their prevention in KSA. As pressure ulcers have become a common global occurrence, in particular in the Intensive Care Units, it seems to be crucial to identify the best preventing practices. The researcher believes that the following work will be a contribution to the knowledge of the problem of pressure ulcers in KSA. More importantly, the research work is expected to deliver valuable insight on how the prevention methods, in particular the assistance of critical care nurses to the patients, can be implemented in the Intensive Care Units, not only in KSA but also worldwide.

1.3.Research Questions

To resolve the issue of ideal management of pressure ulcers by nurses working in critical care facilities, this dissertation addressed the following principle research question:

What is the role of critical care nurses in preventing the occurrence of pressure ulcers, and therefore promoting safety and improving the quality of care for critically ill patients?

1.4.Research Aims and Objectives

The overall aim of the following research work is to examine the importance of critical care nurses in the context of preventing pressure ulcers amongst the patients who suffer from critical disease and are unable to move as well as the impact of the nurses on the quality of health care services delivered critically ill patients based on the evidence from the Kingdom of Saudi Arabia. In order to achieve the overall aim, the following research work seeks to focus on the following objectives:

To identify and analyse the critical care nurses’ role in providing safe care regarding pressure ulcer prevention; To establish the relationship between the work of critical care nurses in the Intensive Care Unit and the occurrence of the pressure ulcers amongst the patients; To explore different evidence-based strategies that nurses incorporate into their practice to provide safe practice, so as to prevent occurrence of pressure ulcer; To establish if guidelines exist that will help critical care nurses to provide good evidence based pressure care.

1.5. Rationale of the Dissertation

In comparison to the patients in a general ward, patients in the ICU require more personal attention. Further, the chances of emergency situations arising in the ICU are relatively higher than in the general ward. Owing to this reason, duties and responsibilities undertaken by the nurses in the ICU are more extensive in comparison to those of general ward nurses (Unruh 2003and this may impact on their ability to undertake pressure sore prevention measures.

In this regard, the research aims to explore the role of critical care nurses in the prevention of pressure ulcers. In addition to this, existing practices undertaken by critical care nurses for the purpose of taking care of critically ill patients and preventing the occurrence of pressure ulcer problem will be reviewed. The increasing complexity of care for critically ill patients, as well as the increased severity of the illness, the increasing numbers of patients requiring ICU admission, and the complexities in handling new and innovative care measures cause problems for healthcare professionals seeking to perform their duties and to process clinical information in an effective and safe way (Kaitani, et al. 2010; Unruh 2003).

Chapter 2: Literature Review

2.1 Introduction

A literature review is one of the most important methods for collecting and critically analysing information to establish what exists already about the topic. When employing this method, information is retrieved by reviewing journals, books, research papers and other academic resources. This provides a systematic approach to identify and analyse the most relevant and useful literature in the context of the research questions posed. Literature searches were carried out using a systematic approach and utilising several academic nursing and social science search engines. The Cumulative Index of Nursing and Allied Health Literature (CINAHL) was the main source of materials, although use was also made of several others, including the Applied Social Science Index and Abstracts (ASSIA), British Nursing Index (BNI) and PubMed. Searches were carried out in the following areas: critical care nurses, pressure ulcer preventions, aspiration pneumonia, enteral feeding, strategies used by critical care nurses for preventing the occurrence of pressure ulcer, and so on. The process of the literature search was carried out over a period of 20 days, so that pertinent information could be compiled in regards to the defined research questions. This approach was supplemented by the use of snowballing reference sources from within references, and through discussion with selected academic colleagues who were consulted for suggestions of good literature in the research area.

In addition to this, the literature review method is used as a source of secondary information, as it is a reliable method by which to collect data from the authentic sources in relation to a research study. It is a method through which a large amount of data from already available information can be reviewed in a systematic manner to gather findings, as per the problems associated with the research (Denzin and Lincoln 2000).

This chapter identifies appropriate articles selected from a search of the databases, using the criteria stated in English. During the selection process the researcher used search terms of pressure sore prevention; pressure ulcer; critical care nurses; ICU and critically ill patients. A total of 372 articles were found. These sources were further sorted through reading the abstracts. A total number of 32 articles was chosen for detailed use, as these articles were the most relevant to the research topic and hence, they helped the researcher to highlight the issue of the overall quality of services provided by nurses to critically ill patients. Similarly, the researcher selected 24 books which were read in details and used for the research purpose. The researcher chose these particular books from the reading lists suggested by lecturers throughout the study semesters. The literature review will first address the role of the critical care nurse, followed by their role in relation to prevention of pressure sores, followed by discussion of the incidence, prevalence and prevention strategy for pressure sores. A summary of the main issues will conclude this section.

2.2Role of Critical Care Nurses and Multidisciplinary Team (MDT) in the Context of Critically Ill Patients

Critical Care Nursing is a specific field of nursing that requires the utmost care of critically ill patients who are suffering from life threatening diseases or conditions but who are also stable. The duties and responsibilities of such nurses are different from those of general ward nursing staff, as they work in different environments and have unique skills related to the ability to work in the Intensive Care Units and emergency departments in hospitals (Stephens et al. 2006; Gorecki et al. 2009).

Furthermore, critical care nurses are an important part of a multidisciplinary team (MDT), working within the ICU. MDT is comprised of a range of professionals, including experienced physicians, pharmacists, respiratory care technicians, radiologist, anaesthetics, and critical care nurses. The majority of the time, the team works together to deliver outstanding care to the patients who are suffering from a life-threatening disease (Strand and Lindgren 2010; Stephens et al. 2006).

Critical care nurses are of key significance for MDT. They have been provided with a solid professional training in order to deliver possibly best assistance to the seriously ill patients. According to Neumann and DeLegge (2007), critical care nurses play a vital and important supporting role in the treatment of the patients in the ICU; they care for critically ill patients, collecting various information related to the health and conditions of those patients, and provide this information to the doctor, undertaking the prevention of different side effects like pressure ulcers, aspiration pneumonia etc. (Strand and Lindgren 2010). Similarly Neumann and DeLegge (2007) suggested that critical care nurses may have some crucial information regarding the diseases from which the patient is suffering thus are able to handle the more typical emergency complications that occur in ICU. Along with general nursing knowledge, critical care nurses should also possess some additional knowledge regarding severe diseases and related side effects, such as pressure ulcers, and this aspect of critical care nurses knowledge will be explored in the proposed research.

These skills, knowledge and responsibilities make the role of critical care nurse more vital and intensive what seems to be confirmed in the qualitative descriptive studies taken by Elpern et al. (2004). The research was conducted in 21-bed combined medical ICU-non-invasive respiratory care unit at the Rush University Medical Centre in Chicago. The sample for the study was chosen on the basis of convenience sampling and consisted of critically ill patients who had been admitted to intensive care units over the previous 3 months. The total sample size for the study was 39 which was appropriate for the qualitative approach used and it was conducted so as to observe activities and changes in the feeding habits of patients over a period of 276 feeding days. The following study revealed that in the case of critically ill patients, there is a need for some intensive care and treatment as the condition of such patients is quite dynamic and alters dramatically in a matter of seconds. In addition to this, Elpern et al. (2004) also explored the role that critical nurses play in patient advocacy, and found that patients and the family members of patients relied directly on critical care nurses to supply this.

More recently, Thomas (2001) presented key findings regarding the role of critical nurses in the ICU. He concluded that the role of critical care nurses can be sited in the advanced assessment of physical conditions affecting the patient, an essential requirement when commencing patient treatment (Thomas, 2001a).

In addition, according to Erlen and Sereika (1997), critical care nurses have some additional responsibilities compared to general ward nurses. For the purpose of establishing some clear ideas and issues, the authors presented an academic article in which they confronted issues impacting on life sustaining treatments and conditions in the ICU. They conclude that in such situations, critical care nurses must avail themselves of the knowledge and skills involved in using intensive antibiotics, cardio-pulmonary resuscitation, artificial nutrition, and mechanical ventilation, such as are provided to critically ill patients.

The discussion on the wider responsibilities of critical care nurses in comparison with general ward nurses was further continued by Gillick (2000). The author suggested that the scope of the role of critical care nurses is much wider in the treatment of critical patients in the ICU. Gillick (2000) elaborated that in the case of critical patients, dynamism in intensive care became one of the most crucial phenomena to consider. In contingent situations, the nurse has to manage the patient until the doctor arrives. For this reason, all critical care nurses must have intensive knowledge about pathogens, diseases, medications, and important nursing actions required, so that they can handle the case with full proficiency. The author also suggests that the attitude and knowledge required for taking care of critically ill patients is quite different and can only be delivered by a critical care nurses (Gillick 2000). However, given the increased complexity of care required in ICU the more basic nursing processes such as pressure care might take second place. Thus this proposed research will intend to examine this further.

Additionally, Reddy et al. (2006) in a systematic review of 59 Random control trials (RCTs) have also suggested that in today’s scenario; the medical science has become highly developed therefore the role of critical care nurse have emerged as significantly unique. Reddy et al. (2006) identify observed sets of evidence from the literature which have shown the use of new highly technicallised equipments, such as Intensive Care. The researchers reviewed 59 RCT’s which investigated the different techniques and tools used in the Intensive Care Units. They conclude that in such situations, the role of critical care nurses has expanded significantly as critical care nurses hold responsibility for taking care of patients in the ICU. Nowadays, as members of MDTs, critical care nurses’ responsibility became monitoring and handling sophisticated and innovative electronic equipment in order to provide high quality care and medication to critically ill patients in the ICU (Reddy et al. 2006). It might indicate that care has become neglected as part of the critical care nurses’ job due to the growing pressure concerning their new duties. This aspect will also be analysed in the following research.

2.3Pressure Ulcer and the Role of Critical Care Nurses in the Prevention of Pressure Ulcer

Baranoski and Ayello (2008) define pressure ulcers as decubitus ulcers, pressure sores and bed sores. The term ‘pressure ulcer’ refers the etiology and resultant ulcer that occurs due to injuries caused to the skin tissues as a consequence of the continuous pressure of body weight on a specific point. The NPUAP (National Pressure Ulcer Advisory Panel) revised the definition of a pressure ulcer in 2007 and it can be defined as a “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction” (Baranoski and Ayello 2008, p. 254). The usual location of pressure ulcer is over bony prominences, such as heels, sacrum, hips, coccyx etc. (Jastremski 2002). Moreover, Kottner and Dassen (2010) have added that the pressure ulcer concerns a situation in which the skin of the patient is broken down because of staying in one position for a long period of time. Due to continuous pressure on the skin of the body part, which stays in touch with the surface, it becomes reddened, gradually turning into an ulcer wound (Kottner and Dassen 2010). These authors have also underlined that treatment for pressure ulcers is available. However, pressure ulcers are painful and often they constitute a significant obstacle to the daily routine for the patients. Thus, the major focus should be given to prevention of pressure ulcers. More importantly, the authors underline intensive specialized care of patients by critical care nurses who have been given professional training should be regarded as the most effective manner to prevent the occurrence of such ulcers.

2.4 Incidence and Prevalence of Pressure Ulcers

In the context of the topic of pressure ulcers, non-empirical study conducted by Shahin et al. (2008) need to be emphasized. The authors presented a systematic review of the literature considering recent prevalence and incidence of pressure ulcers and discussing the factors related to prevention of pressure ulcer prevalence. The review included existing publications and studies on the occurrence of pressure ulcers in the intensive care units, conducted in various countries across the globe for the period of 2000 to 2005. The study revealed great variations in both prevalence and incidence of pressure ulcers in intensive care patients. While the prevalence of pressure ulcers ranged from 4% in Denmark to 49% in Germany; the incidence varied from 38% in Denmark to 124% in Germany. Further, the authors emphasized the gap between the theory and practice as a key obstacle to successful prevention and treatment of pressure ulcers. They concluded that future research is required in the context of establishing the effectiveness of nursing care on the development of pressure ulcers and their treatment.

Also Tannen et al. (2004) conducted a research on pressure ulcers prevalence. The study has quantitative character and focused on two countries, the Netherlands and Germany. While the main objective of the research study was to establish measurements for managing the prevalence of pressure ulcers in healthcare facilities in the Netherlands and Germany, the research also delivered valuable insight into the role of critical care nurses. The sample was collected on the basis of purposive sampling measures. The research had a form of the standardized questionnaire that was conducted amongst the patients suffering from pressure ulcers in 42 Dutch and 10 German acute care hospitals. The patients were examined by the nurses working in the participating units. The sample size was 8734 in the Netherlands and 2832 in Germany. The research study showed that the frequency of pressure ulcers to be higher in the Netherlands (22%) than in Germany (12%). Age and length of stay in hospital had the highest impact on the occurrence of PU. The major limitation of the research study was that the research could not be generalized, as the samples that were used for the study were not representative of the population of Germany and Netherlands. Participation in the research study was voluntary and it did not comply with random selection or quotas (Cresswell 2003). However, the study can be considered useful, in that it provides some clear and direct reasons for the occurrence of pressure ulcer highlighting the role of critical care nurses (Tannen et al 2004). On the basis of the analysis of the results from this research work, it can be concluded that there may be scope for further research in this area across Europe, and that PU are potentially an important issue for CCU nurses worldwide (Tannen et al 2004). Therefore this proposed research will explore the aspect of pressure sore prevention in ICU nurses role.

2.5 Causes of Pressure Ulcers

Most pressure ulcers have been observed by researchers (Shanin et al., 2009; Thomas, 2001b; Lyder, 2003) to occur in two groups of patients. Those groups are with injuries who are also critically ill and the elderly. The healing of a pressure ulcer does not take place in reverse sequence because there is no replacement of lost tissue by the body during the time in which a pressure ulcer is developing. For example, once the pressure ulcer is at stage 4, it remains at that stage, even when it starts healing (Tannen et al 2004).

Rees et al. (1999) conducted intensive quantitative study on the major causes of the occurrence of pressure ulcers. The primary aim of the research was to throw light over some well known causes of pressure ulcer. The researchers conducted their research on the patients who were suffering from various chronic diseases. The sample size for the research was 124, which included 104 male and 20 female respondents. The researchers undertook observation method to determine the prime causes of ulcers, due to chronic pressure. As per the results of the research work, it has been revealed that the rate and intensity of pressure ulcer was higher in the patient, who were suffering from chronic diseases. The researcher observed that most patients suffering from chronic diseases were not able to walk and many could not even move. In such cases, the tissues of the patients started to become destroyed and painful sores appeared on the skin of the patients; this is exacerbated in chronic patients (Rees et al. 1999). The following research might indicate that patients in ICU also are immobile due to being ventilated and anaesthetised and thus this aspect will be addressed in the proposed research.

Further, Rees et al (1999) also revealed that because of constant and excessive pressure on tissues, the tissue did not receive a proper supply of blood and oxygen, which is essential for the growth and development of tissues and other organs. Due to improper supply of oxygen and other nutrients like blood, the tissues could not survive. In addition, sitting in the same position for a long time could lead the patient towards the starting of tissue breakdown process. This breaking down of the tissues became the primary cause of wounds, which are known as pressure wounds (Rees et al 1999). The prime limitation of this research study was that it only applied an observational method for the purpose of collecting important information regarding the research topic. This method can have several failings especially in the context of patients suffering from pressure ulcers. The condition of such patients generally remains unstable, making continuous observation a difficult task for the researcher. Further, for ensuring the accuracy of observation, there is a need to deploy a huge amount of time and effort. However, the research study did establish the extent to which the occurrence of wounds was due to chronic pressure ulcers (Rees et al 1999).

2.6 Methods of Pressure Ulcer Prevention

Following investigations into the causes of pressure ulcers Thomas (2001) investigated the extent to which certain criteria, in particular nutrition, might help in the prevention of the condition. Research conducted previously( Rees et al 1999, Tannen et al 2004) found that immobility or poor nutrition was a key factor in ulcer development. Thomas(2001b) in an academic treatise papare reported on an observational study undertaken in 1999 in order to reveal some prime causes of pressure ulcers. The main focus of the research was on the impact of nutritional supplements in the occurrence of the pressure ulcer in the critically ill patients. The researcher conducted his research on critically ill patients, who had lost their mobility and were highly dependent upon nurses and care takers for the accomplishment of basic necessities. In the research, the researcher compared the impact of oral supplements on the occurrence of ulcers. These supplements were tested on 33% of the sample group. However, the research revealed no significant differences between the treatment group and the non- treatment group in terms of pressure ulcer incidence. (Thomas (b) 2001).

Similar research was conducted by Thomas (2001b). The author also highlighted lack of significant impact from oral nutritional supplements on the occurrence of the pressure ulcer. However, he postulated that in the case of enteral feeding, in which the patient is not able to take the nutritional supplements orally, an adequate amount of protein and fat is compulsory for the prevention of pressure ulcers. In this direction, critical care nurses need to have some of crucial considerations and knowledge regarding eternal feeding practices for critically ill patients (Thomas 2001b).

In most cases of patients suffering from pressure ulcers, improper nutrition is a common implicated factor. The Thomas(2001b) found a lack of a significant amount regarding the fluid intake on the bodies of patients with pressure ulcers. In addition it was found that a lack of proper protein and haemoglobin in the blood is also one of the most prominent reasons for pressure ulcer (Artinian et al. 2006). Owing to this, the role of critical care nurses in providing highly nutritional supplement through eternal feeding increases

Thomas(2001b)’s review of research into nutritional supplementation has also its limitations. The major problem is that the author focused on the studies that examined small sample sizes. Mathie and Camozzi (2005) note a small sample is not sufficient to represent a large population. Further, observation methods were selected as the research approach.

2.7 Adverse Impact of Pressure Ulcers

A study conducted by Gibbons et al. (2006) presented evidence pertaining to the negative affects of pressure ulcers on patients in the acute care environment. The research setting included 42 Dutch and 10 German acute care hospitals. The respondents included in the sample were patients suffering from pressure ulcers. The sample size was 8734 in and impact of pressure ulcers on the overall quality of the health of affected individuals. Gibbons et al. (2006) conducted the research on pressure ulcers cases registered at medical Centre’s between August 2004 and February 2006. The research study identified 46 different categories of impact of pressure ulcers, including physical impact, financial impact, health related impact, social impact, impacts on relationship between client and health care professionals and psychological impact, etc. (Gibbons et al. 2006).

The major strength of the research study was its comprehensiveness and sample size. The objectives and aims of the research study were so comprehensive that they include a number of different aspects related to pressure ulcers and their impact. Such aspects include reasons for the occurrence of pressure ulcer, impact of pressure ulcer, measures for curing the disease and so on. However, there were several limitations associated with the breadth of the research study. Extracting viable and relevant information is quite time consuming when investigating such a large population and can affect the depth of the recommendations (Gibbons et al 2006).

The following part of the literature review has discussed causative aspects of pressure sores and highlighted both the high prevalence and serious effects on patient health of such sores. At the same time, the review proved that prevention of pressure ulcers is possible. Given their potential gravity, it is crucial to examine the most effective manners of prevention as well as to explore the role that ICU nurses may play in such prevention.

2.8Treatment and Prevention of Pressure Ulcers

Prevention of pressure ulcers is necessary for the reasons covered above. Every appropriate step should be taken by doctors and nurses to heal ulcers when they occur and to prevent the formation of more ulcers (Elliott et al. 2008).

Jankowaski (2010) postulates that it is very hard to treat pressure ulcers therefore it is necessary to prevent their occurrence as far as possible. It is crucial to take care of skin, so as to prevent the development of pressure ulcers. For intact and normal skin, one should wash the skin with warm water and mild soap to reduce irritation and dryness. Clothes and bed sheets should be kept dry and the skin should be protected from sweat and urine. One should also apply lubricants, and different lotions prescribed by the doctor so as to prevent drying out of the skin. Nurses and doctors should avoid massaging bony areas (Jankowski 2010). These issues will be further examined in the following research in relation to nurses knowledge and behaviours.

Moving and changing positions is another measure by which to prevent pressure ulcers. Persons with pressure ulcers should be helped to move as much as possible. If a person cannot move from their bed, they can still engage in motion based exercises. The body of the patient should be moved as often as possible within the bed, at least every two hours (Rice et al 2005). Persons who are in wheelchair should shift their weight every 15 minutes. There should be use of pillows, special foam cushions or medically approved sheepskin to reduce pressure and keep bony areas from touching hard surfaces. The support surfaces should be dry and smooth without any wrinkles. There must be regular turning of the patient as support surfaces do not completely remove pressure (Jankowski 2010). Considering the fact that the ICU patients are mostly immobile, these issues seem to be of key significance and they also need to be addressed in the following research.

There are some aspects of pressure ulcer prevention that are discussed in the research review by Reddy et al. (2006). They detail evidence from relevant RCTs (Randomized Controlled Trials), which focuses on repositioning as one of the major mainstays in most protocols for pressure ulcer prevention, although there is insufficient evidence regarding precise recommendations and specific turning positions and regimens for patients who have impaired mobility. The study also determined that patients with nutritional impairments should be given dietary supplements (Reddy et al. 2006).

However, there is lack of clarity regarding the superiority of specific topical agents over simple moisturisers for patients with impaired skin. The review concluded that use of support surfaces, repositioning of the patient’s body, optimisation of nutritional status and moisturising of sacral skin are some of the appropriate preventive measures for pressure ulcer. However, there are some limitations of the review. These limitations are as follows: there is incomplete reporting of the RCTs. The researchers used only selected features from a previously developed checklist; this represents a major limitation as this checklist might not match with some conditions of the research studies selected. There is need to do further research as the sample is heterogeneous and the generalizability of the interventions for preventing pressure ulcer needs to be confirmed so that their effectiveness to differentiate patient populations and settings can be confirmed (Reddy et al. 2006).

A further research study by Simon et al. (2009) was sponsored by the American Dietetic Association’s Nutrition Care process. From the quantitative study, it can be concluded that it is necessary to provide adequate nutrition to critically ill ventilated patients, so that there is no damage to the cells and tissues due to lack of protein, fat and oxygen. Therefore, enteral feeding for the proper nutrition of critically ill patients is also necessary.

The above research findings indicate the role of critical care nurses becomes significant, as it is necessary to take care of patients and apply preventive measures, so as to ensure no occurrence of pressure ulcer as far as possible(Kottner and Dassen 2010). Lyder (2010) also focused on the criteria that affect the development of pressure ulcers, including lack of physical movement of the patient, irregular diet and improper supply of nutritious substances in the body of the patient. Lyder asserted further, that in the case of critically ill patients, a number of different physical characteristics like weight loss, low BMI, the inability to eat independently, dehydration, and so on are risk factors for pressure ulcers. Such physical problems derive from an unhealthy diet and poor supply of nutritious substances (Lyder 2010).

When avoiding such dietary imbalances that cause complications like Diarrhoea, there is a need for critical care nurses, who possess intensive knowledge about combination of proper nutritious factors included in the diet of a critically ill patient in order to prevent the occurrence of pressure ulcers and other complications. According to Lyder(2010), frequent monitoring and intensive care is the only measure by which to successfully prevent the occurrence of such risk factors, which only can be provided by the critical care nurses .

In addition to this, Garber, (2003) continued the debate, stating that a static and rigid body posture and inconsistent supply of blood to the skin and tissues are the most important reasons behind the existence of pressure ulcers. The author conducted his research with the help of a retrospective review of electronic medical records of patients suffering from the problem of pressure ulcers in Houston VAMC. In the research, the records of 102 patients were examined. The results of the research showed different measures of preventing pressure ulcer could not be utilised without the help of a professional. Critical care nurses received comprehensive training for handling patients, who were unable to move without any support. For this reason, they are crucial for preventing pressure ulcer (Garber 2003).

In addition to this, Unruh (2003) also stated in his article that the role of critical care nurses is quite vital in the context of prevention of pressure sores or diabetic ulcers. The research work was aimed at revealing the role of nurses in the ICU, specifically those who have expertise in taking care of critically ill patients, in the prevention of adverse conditions in the cure and prevention of events such as pressure ulcers in patients. For this purpose, the author conducted an intensive research study with the convenience sample of some of major acute care hospitals of Pennsylvania during the time period of 1991 to 1997. For the purpose of the accomplishment of the objectives of research, the curative rates and facilities provided to patients with pressure ulcers during the period of 1991 to 1997 in hospitals were recorded. In the research study, the researcher selected a qualitative approach for the research (Unruh 2003). The researcher concluded that phenomenon of specialised nurses for managing critical care services is a necessity and that critical care nursing is a sophisticated area, which is implicated in the prevention of the pressure ulcer (Unruh 2003).

The major strength of the research study was the usage of the most authentic and viable sources of data for secondary research. Information provided by the sources was confirmed and processed previously, thus the researcher need not to invest much time with this concern. Further, a lack of practical information was also evident, as one of the major limitations associated with the research study. In this way, on the basis of a critical analysis of the research study, it can be concluded that the research study is quite effective for making different theoretical concepts clear to the reader. In the context of practical knowledge, the study did not provide any significant findings (Unruh 2003).

2.9Strategies Adopted by Critical Care Nurses for Preventing Pressure Ulcers

Pressure ulcers are also one of the most common problems faced by critical care patient (Roberts et al. 2003). The patient needs to bear a lot of pain and complications because of pressure ulcers. Therefore the role of critical care nurses becomes vital in preventing the occurrence of pressure ulcer. For the purpose of preventing the pressure ulcer, some crucial strategies can be adopted by critical care nurses (Matos et al. 2010).

In relation to this, Foreman et al. (2009) have suggested that there are a number of techniques, which can be adopted by critical care nurses. As continuous pressure is placed on the body part, lack of mobility of the body is the prime reason of pressure ulcer, the nurse should try to decrease the duration of pressure (Foreman et al. 2009). For this purpose, the nurses should change the position of the patient at regular intervals. The nurses need to prepare a proper schedule for this purpose. By doing so the pressure points will be changed frequently and the risk of a pressure ulcer developing will be minimised (Reilly et al. 2007).

In addition to this, Thomas (2001) also emphasised that there must be a pressure redistribution system for disabled patient. In regards to this, the author proposed the mattress system and cushion system. In his literature the author also showed the qualities of the mattress system in the context of critically ill patients. In the mattress system, the nurses need to put emphasis on enlarging the contact area between surface and patient. For this purpose, the nurses can utilise different mattresses for the disabled, comprised made of air and foam (Thomas 2001).

Along with this, for minimising the pressure between the body of the patient and surface, nurses can also use a cushion system, in which they can use a cushion for minimising the overall pressure created by the continuous contact of the body and surface area (Reddy et al. 2006).

In an article written by Jankowski (2010), it was stated that the care of critically ill patients requires nursing intervention which is planned and designed in such a manner, so as to prevent the formation of a pressure ulcer. Critical care nurses can avoid pressure injuries when they give regular and consistent attention to assessment, nutrition and appropriate positioning of the patient within appropriate time-frames. Critical care nurses have to plan and tailor repositioning schedules according to the needs of each individual patient, so that they are able to prevent development of pressure ulcer (Jankowski 2010). This approach will be further analysed in the proposed research in order to examine whether the ICU nurses are applying such strategies in practice.

Changes in head-of-bed elevation, prone positioning and continuous lateral rotation are some of the activities that can be included in the repositioning schedule of critically ill patients by critical care nurses. The head of the bed should be maintained at 30 degrees or lower, so as to prevent pressure ulcers in bedridden patients. This prevents shearing injuries, particularly in the area of the sacral region. Critical care nurses should take care to ensure that there is no pressure over bony prominences. Nurses can avoid friction and shearing when positioning patients with the help of use of transfer aids, such as, slings or slide sheets (Jankowski 2010).

In addition to this, Strand, and Lindgren (2010) have also added further that frequent and careful skin assessments, moisture management, frequent repositioning, and maximization of nutritional support with safe and careful enteral feeding are common critical care nursing interventions that can be used to effectively prevent the development of pressure ulcers (Strand and Lindgren 2010). Critical care nurses should always ensure safe enteral feeding.

2.10 Chapter Summary

In summary, on the basis of the findings from the literature detailing the issue of pressure ulcer management by nurses in ICU settings, it can be revealed that the quality of care for critically ill patients is highly dependent upon the level of skill and knowledge possessed by critical care nurses (Couchman et al. 2007), in particular the knowledge of positioning, nutrition, skin care and equipment. All these aspects will be covered in the data collection processes.

The research question of the following dissertation has been defined in the introduction. Nonetheless, based on the literature review, the researcher identified also two sub-questions that will help to give the most accurate answer to the research question. These sub-questions are:

Can the quality of care be improved in regards to the physical conditions for critically ill ventilated patients in the ICU, when critical care nurses focus on the aspect of pressure ulcer prevention Do guidelines exists that assist critical care nurses to improve the quality of care of critically ill ventilated patients focusing on the prevention of pressure ulcers

The literature review is followed by the methodology chapter that describes how the researcher intends to address the research question.

Chapter 3: Research Methodology 3.1. Introduction

The following chapter will discuss the research method designed to examine the research questions posed and identified from the literature review and the writer’s personal experience.

A research methodology is an integrated phenomenon describing the nature of a research work, based on a number of different aspects that have been included within the research framework (Rubin and Babbie 2010). Different aspects related with the research work implied in this research work include research approach, research design, research methods, data collection methods, data analysis and ethical considerations. For the purpose of identifying the answers to the research questions above, a research plan has been designed, which as is discussed below.

3.2. Aims of the research methodology

The overall aim of the research methodology section of this paper is to provide comprehensive information regarding the method or procedure involved in the research process undertaken in the work. The information provided with the help of this section, will aim to enhance the reader’s understanding regarding the different perspectives associated with the research design and framework. The major emphasis of the topics, which will be discussed in this section, will express comprehensive and competent information, which can help accomplish all the objectives of the research work, in the most effective and efficient manner.

3.3.Research approach:

The research questions focus on processes that are dynamic and therefore, require methodologies that are iterative, flexible and reflexive, and that can explore complexity rather than outcomes.(Crotty 1998, Berg 2011) In this research, namely “the role of critical care nurses in the prevention of pressure ulcer”, the research progresses from a general scenario to a specific one. Understanding the nurse’s perceptions and their role in pressure sore prevention is a core element of the following research. In the following research it is achieved by discussing personal experiences and individual ideas. Hence, the qualitative methodology seems to be more appropriate.

A deductive research approach is being employed, which is a top down approach in which the researcher seeks to examine the basic theory and then, apply such theory in the empirical research. Further, the researcher intends to establish and explore the relationship between the role of critical care nurses and the prevention of pressure ulcers in the ICU. Such an approach demands a more elaborate and intensive exploration of the hidden aspects related to roles and responsibilities possessed by critical care nurses in the prevention of pressure ulcers (Marczyk et al. 2005).

Qualitative research, as a method of deductive research aims to develop understanding of people and explore the phenomena and processes that influence them (Mays and Pope 1996; Bowling 2002). This form of inquiry takes its approach from the way in which, theory and categorisation emerge from the collection and analysis of data (Silverman 1993; Bergh and Ketchen 2009). In qualitative research, various methodological approaches exist, which are selected on the basis of the purpose and outcomes of the study. For example, the purpose of the study is to investigate and understand nurses’ experiences, behaviours and interactions in relation to pressure sore prevention in ICUs, thus the methodological approach to be followed will be a survey and semi-structured interview (Holloway and Jefferson 2000).

Deductive research approach is selected for the purpose of conducting research in the most effective manner, as the design provides an effective framework for the exploration of qualitative data retrieved from different data collection techniques like survey through the questionnaire method and semi-structured interview. (Bergh and Ketchen 2009).

In this research, firstly, an analysis of the common roles and responsibility of nurses working in the intensive care unit (ICU) will be undertaken using the survey method using a questionnaire (Hancke 2009). In addition to this, in the second step of the research work, qualitative information will be revealed with the help of the inferences drawn from the interviews with critical care nurses. These interviews are intended to explore the context of nursing critically ill patients, in relation to their general role and specifically in relation to pressure ulcers. This systematic approach will allow the researcher to understand the context of the research work.

3.4.Rationale behind the selection of research approach

The research topic is quite specific and intensive, focusing directly on the care given in intensive care units and the role of nurses appointed in such units. For the purpose of revealing the most appropriate and a rational outcome of the research work, there is a need for an intensive and focused research framework to uncover the different hidden aspects related to the research context (Creswell 2003). The prime rationale behind the adoption of this is outlined in the next section. As the following research aims to examine the nurses role in pressure sore prevention several qualitative approaches seems to be appropriate to use. Considering the fact that the study intends to improve the knowledge about the role and activities of nurses in ICU’s in relation to their prevention of pressure sores the research adopted an exploratory descriptive approach. It is crucial to understand why other qualitative approaches have been rejected. Phenomenology would have helped to explore the ‘lived experience’ of the critical care nurses. However, such approach would depart from key focus of the research. In turn, the case study offers the opportunity to have an in-depth insight into nurses’ behaviours in the context of the environment of care. However, the following study intends to explore what the nurses’ role is currently rather than explore the role in relation to the environment of care (Bergh and Ketchen 2009). Other well-known qualitative methods such as ethnography or grounded theory do not align with the nature of the research work. The ethnography method concerns the experience of an individual regarding the research context. Thus the data collected via this method is limited and would not provide all necessary information for the following research. In turn, ground theory focuses on hypothesis and theory formulation and hence, it is also inadequate to this context. The awareness and understanding of various qualitative methods is crucial in order to sustain the validity, generalisation and reliability of the data collection process within the allocated time frame (Parahoo 1997; Maxwell, 2005; Mays and Pope, 2006; Silverman, 1993).

3.5.Methodology

In order to examine in details the role of critical care nurses in the prevention of pressure ulcers, the following research uses an exploratory survey research design (Creswell 2003). Such design will help the researcher to focus on various aspects of the role and responsibility of the critical care nurse from the perspective of the nurse. The researcher chose questionnaire and semi-structured interviews as the most adequate data collection methods, allowing explore the research topic (Parahoo 1997).

Questionnaire:

The questionnaire is a very useful tool of primary data collection. The researcher intends to use the questionnaire in order to gain a detailed understanding of the nurses’ knowledge of pressure sore development as well as their importance in preventing these developments (Bergh and Ketchen 2009). Such questionnaire enables the researcher to have greater control over the information gathering as well as to reveal practical and hidden information about the research context. The information gained during the data collection process is a sole property of the researcher and is used for the purpose of retrieving the most crucial results (Jackson 2008). The questionnaire offers a series of open-ended and close-ended questions. There is also a space left for additional comments from the interviews. The range of questions was based on the information collected during the extensive literature interview. The questions regard different aspects of pressure sore development and prevention that the nurses should be familiar with. The open ended portion of the questionnaire will allow the researcher to collect qualitative information as well as the quantitative data collected from closed questions. The questions asked in the questionnaire are also related to the perceptions of nurses regarding the different measures adopted in the ICU for the purpose of preventing the occurrence of pressure ulcers in critically ill patients (Parahoo, 1997; Mays and Pope, 1996). The examples of the questions used in the questionnaire are presented in the appendix. In turn, the opportunity to leave comments was given by the researcher in order to gain additional information that might provide the researcher with completely new insight into the research topic and that might reveal important issues and problems that the researcher was not aware of before the questionnaire was conducted. The data gained through the questionnaire has a primary character, thus it is original and unique (Hancke 2009). The primary data collection through the questionnaire was chosen for several reasons. First, it is “an efficient way of collecting responses from a large sample “(Saunders et al., 2009:362). It also allows the respondents to remain anonymous. Second, the questionnaire helps to gain the comprehensive data. In addition, through this method a sample group can be selected for interview later allowing for more accurate assumptions to be made regarding the potential for the results (Jackson 2008).

Semi-structured interviews

Semi-structured interview as a data collection method was chosen on purpose, as the researcher perceives such interview as a less formal way of gathering information compared to the fully-structured interview although semi-structure interview also have a question structure, as presented in Appendix A. Semi-structured interview give the respondents the opportunity to speak frankly and shape the discussion in various directions, in particular to talk about these issues and aspects that the respondents regard as the most important. More importantly, semi-structured interview allows the research to adapt to the situation and to ask questions, depending on the answers given by the respondents. The interviews’ questions were formulated based on the extensive literature review. The researcher decided to focus on the issues and problem that are believed to need further analysis and research (Silverman 2005, Denzin and Lincoln 200 ). Interviews are intended to be scheduled for one hour of time but with a flexible approach to allow for availability of participants and the requirement of the interviews. The interviews will be conducted in Arabic in order to give the respondents the opportunity to discuss fully their ideas, opinions and perceptions, as it is their native language. Using English in the research might be a significant obstacle to gaining possibly most accurate data, as the respondents might have a problem in speaking openly and expressing their opinions in English. The interview is expected to evaluate the nature of knowledge and opinions of the nurse about pressure sore prevention in ICU as well as their approach to working with the patients having pressure sores. Nonetheless, the following interview will provide the researcher with detailed information on the views and experience of the participants in the particular settings and it will not be generalized to other settings.

3.6 Limitations of the research methods

The researcher is aware of the limitations of the chosen data collection methods and aims to minimize them. First, the primary data collection methods require significant amounts of time, effort and investments from the side of the researcher. Nonetheless, the researcher is willing to make these efforts as the researcher intends to deliver the most reliable and valid information throughout the research process in order to answer the research question in the most accurate way.

Analysing the questionnaire first, the questions might be imprecise or inaccurate. Therefore, the respondents might understand the questions in a different way than the researcher actually intended. In order to minimise such risk, the researcher decided to conduct the pilot study. Such study included a group of 5 nurses. The pilot study helped the researcher to check the level of difficulty amongst the respondents as well as to obtain some assessment about the reliability of the questionnaire which will be very helpful in detecting the weaknesses and grey areas. It was crucial in order to amend the questionnaire prior to the final presentation. Further, the uncomfortable environment can also have an impact on the questionnaire’s results. Hence, the researcher ensured the respondents about the questionnaire anonymity as well as that the participation in the questionnaire did not have an impact on the working conditions of the employees who agreed to participate. Such guarantee was given to the respondents after the researchers discussed it with the Head of the Intensive Care Unit (Creswell, 2003; Parahoo, 1997).

3.7.Sampling and Sample design

Recruiting the sample:

Recruiting and selecting the research sample was of key significance for the researcher, as it allowed the researcher to obtain a feasible proportion of the population upon which the study can be carried out in the most effective and efficient manner (Parahoo, 1997). For this study of nurses working in ICU, the researcher regards the technique of non-probability sampling with convenience sampling as the most appropriate as such technique gives the opportunity to volunteer to take part in the research. Non-probability sampling represents a valuable sampling technique that can be used in research which follows a qualitative method. The researcher is aware that subjective judgement, derived from both literature and practice is needed while using non-probability sampling (Marczyk et al. 2005). The process of selecting the sample will start with the identification of the most appropriate population in this case. The researcher believes that such population will constitute all qualified nurses working in ICU’s within two large hospitals in the capital city in KSA, Riyadh. These hospitals are Al Hammadi Hospital and King Fahed Medical City. Nonetheless, the focus group will be critical care nurses, as they are the most suitable group to reveal the techniques and measure in place for preventing pressure ulcers in critically ill patients and the role they play in the practical application of such techniques and strategies. The researcher identified the following criteria of choosing the sample group:

Working as a qualified nurse in ICU’s in 2 major hospitals in the capital city in KSA Having two years experience in working with critically ill patients. Being in permanent employment

All the nurses working in the ICU will be informed about the survey by printed notices on the notice board. The research will be conducted amongst the eligible participants during the meeting organized by the researcher, when the nurses will be asked to fill up the questionnaire. Additionally, the questionnaires will be left in the ICU’s along with information sheets and envelopes in which to return them for these nurses who were not able to participate in the meeting (Sapsford and Jupp 2006).

The respondents who return the questionnaires will be directly approached to be invited to participate in the interview. Such approach will allow the researcher to select a range of nurses based on their responses in the questionnaire to find out in more depth their ideas. For the purpose of designing a sample with respect to this study, convenience sampling was undertaken; this is a form of non-probability sampling that gives equal opportunity to individuals and groups to volunteer to participate in the survey (Parahoo 1997 Creswell 2003). In this type of sample design, the selection of the sample from a uniform population is undertaken by inviting respondents to participate in the survey. This type of sampling design is very easy to carry out and has few rules. The sample design is an integrated activity, which includes the selection of a sample, focusing on the demographic characteristics of the sample, understanding the approach and viability of the research work for the respondents included within the sample (Maxwell, 2005; Jackson, 2008).

Sample size

The qualitative research is characterized by the lack of set criterion for sample size. Polit Hungler and Beck (2000) suggest that sample size is determined by data saturation where no new information is achieved. The determination of its adequate size is also crucial. Sample size should not be so large that the researcher has to employ a huge amount of time as well as efforts in surveying the sample. In turn, too small sample size underestimates the variation, accuracy and authenticity of the data (Saunders 2003) and hence, does not bring positive outcomes to the research.

Having considered these limitations, the questionnaire will be available to all staff in ICU’s in two chosen hospital who will meet the criteria stated above. Following the short conversations with the Heads of the Intensive Care Units in these hospitals conducted by the researcher, it is expected that the survey will have approximately 80 respondents. Moreover, a selected sample of 20 nurses will be used for the interviews. This sample size justifies the purpose of the research providing a modest number upon which to derive a conclusion. Another reason for choosing relatively small sample size is that the research has a voluntary character. The researcher is aware that the questionnaire will not attain a 100% response rate despite the fact that the questionnaire targets a significant group of critical care nurses working in two large hospitals in KSA.

3.8. Ethical considerations related to the research work

The major principles of research ethics is that the participants should not experience any negative consequences caused by participating in the questionnaire as well as that the participants should give a written consent that they are willing to participate in the study. Therefore, a consent form is provided to the respondents prior to their involvement in delivering responses, so that they can become aware of the rationale of the study ( Parahoo 1997). Ethical approval for this study will be sought using QMU ethical procedures and also from the hospitals concerned. All participants must be ensured that their privacy is safeguarded, as all collected information remains anonymous and confidential. The researcher aims to follow the ethical procedures in the research by allocating each participant a numeric identifier known only to the researcher. In a dissertation work, keeping the personal details of the respondents secured is the prime ethical requirement (Silverman 1993). Furthermore, all semi-structured interviews will be transcribed using encrypted software and stored on a secure computer. All questionnaire’s and transcripts will be kept in a secured cupboard in a locked room. Participants will also have a right to withdraw from the study at anytime with no explanation being required. (Cresswell 2003) Participants can become upset as some questions may bring back traumatic memories or cause offence. It is a challenge for the researcher to balance ‘harm’ and benefit’ of the research(Parahoo1997)

The researcher is also aware that conducting research ethical issues can become a very critical problem for nurse researchers. Having nurses as a target group can place the researcher in a problematic situation as the participants might consider the researcher as ‘nurse’ rather than as a person conducting academic study. The participants may tell the researcher information not wanted or information of clinical situations that were dangerous or harming to patients. . In order to avoid such situations the researcher must carefully consider all the ramifications of their research process in ethical terms. These ethical considerations are treated by the researcher very seriously. The researcher intends to make these considerations a solid base for the research work in order to achieve completion of the dissertation successfully (Willis et al. 2010).

The researcher also recognizes misuse of the research data as an unethical practice. Thus the information collected from the respondents is only used for the purposes of the following dissertation and it will not be made accessible to any third party for their personal use (Kimmel 2007). The researcher treats compliance with ethical considerations as a great priority, as the researcher aims to protect his image as a person of great moral and ethical value.

3.9. Issues of rigour within the research work

The issue of rigour can bestow significant adverse impact over the authenticity and viability of a research work as non-rigorous explanation of the research approach, data etc can significantly affect the quality of the research. Mainly the issue of rigour is embedded with qualitative data when used in the research work. Rigour can be explained as a measurement of the authenticity of the qualitative information collected from different data sources In this case from the questionnaire’s and interviews. Another reason for the emergence of the issue of rigour in a research work is the interpretation of points of view and findings by different researchers. It is helpful in analysing the credibility of the main findings obtained from the responses of the study participants if the transcripts are given to another qualified nurse researcher to analyse to ensure expert validation of the findings (Parahoo 1997). Reflexivity is another form of rigour that emphasises independent reflection, and is contingent on the pre-conceptions, beliefs and personal values that affect the interpretation of output. Reflexivity allows the researcher to explain their impact on the research. In this case the researcher is an ICU nurse and therefore may have own ideas already that might influence the research done. This reflexivity improves credibility of the work as it accounts for the researchers knowledge, bias and beliefs. (Parahoo 1997, Creswell 2003)In this context, it is essential for the researcher to understand the context of all the data collected and analysed along with the literature used in the research work and to interpret the findings of the data and literature in the context of the present research question. In this scenario, the misinterpretation of any information provided from different literature sources can lead to false conclusions or results (Willis et al. 2010).

Rigour can also be helpful for making judgments regarding the results of analysis of the authenticity of quantitative information retrieved with the help of a survey through the questionnaire method. At times, respondents may not complete all survey items fully or honestly, especially when the subject matter may be considered sensitive. Additionally, the researcher may also face problems regarding interpretation of the responses made by the respondents in the most effective manner (Padgett 1998). In this context, it is essential for the researcher to manage the overall process of research with the participants on the basis of recognition and emphasis on honesty, fairness and integrity, so as to debrief the findings properly.

All these situations enhance the intensiveness of issue of rigour within the research work. The validity of the research topic can also be reduced because of this issue.

3.10. Research governance

Research governance mainly includes a collection of regulations, standards and principles related to good practices in any field, which are helpful to attain continuous improvements through the research process. In academic research, governance is done on the basis of the interest mediation despite intra-academic priorities. The governance of the research should be always done in a flexible and opened way and include a peer review procedure in the research process (Goransson 2010). In this series, the following research is governed in properly with the inclusion of peer reviewed literature sources. Research governance is a knowledge intensive process, which requires excellent views of the researcher to be incorporated throughout the overall research process.

3.11.Data analysis

According to Cresswell (2003) analysing data in multiple forms is a challenging task for qualitative researchers. Further, Parahoo (1997) suggests that data analysis in qualitative research commences during data collection process. Following this process, the researcher will systematically analyse the data to make sense of what has been said and will organize data in logical order. The organization of primary data reflects the organization of the questionnaire and the semi-structured interview. It is expected that the results from the questionnaires will generate some data that can give simple statistical analysis such as how many nurses had knowledge of the prevention of pressure ulcers in ICU. The semi structured interview data will be subject to a coding approach whereby codes will be allocated to bits of information text and then categories and themes generated that can be further analysed. The qualitative data gained in this research work may be different from the previous research studies found conducted to investigate similar topics. In the process of data analysis comparison to previous research results allows for discussion to be developed in relation to the research results. (Marczyk et al. 2005).

In addition to this, the quantitative data analysis method is also used in order to analyse the primary data collected from the survey questionnaire. With the help of the quantitative data analysis method, a graphical representation of the data presentation is possible. With the help of the quantitative data analysis process the data would be analysed with full accuracy and authenticity. Both these data analysis procedures are mutually complementary and the qualitative procedure would be quite helpful to support the results gained through the quantitative process (Willis et al. 2010).

3.12. Limitations of the study

No research process is perfect in itself, because despite the best efforts of the researcher some deficiencies remain in the work based on some unavoidable problems. Some of the limitations have been described earlier in the text .For example, the research process is affected by some limitations; for example, the following dissertation also has some specific limitations. The major limitations of this dissertation work are stated below:

Sample size: Selection of the appropriate sample size is a critically important process, as without an appropriate sample size, the research results cannot attain a full degree of authenticity. The researcher believes that the questionnaire will attract a significant number of participants and expects that a number of returned questionnaires will allow provide authentic and reliable information. In turn, the interview are expected tp include 20 participants and will be followed by transcribing the work. As the researcher is employed on the full-time contract, it seems to be a limitation. Use of questionnaire: Questionnaire response rate might be low. It is not rare that people are not aware of the importance of such research. Moreover, the research is time-consuming and people are often not willing to make efforts if they cannot see any personal benefit. Further, the limitation can also be the design of the questionnaire which might result in problems with gaining all needed information (Parahoo 1997) Finally, the primary data collection method has a limitation in that the respondents might give inaccurate information during responding the survey questionnaire. (Marczykn et al. 2005). 3.13. Chapter Summary

This chapter has discussed the research method and approach used to explore the research question The data collection methods used for the survey approach, that of questionnaire and semi-structured interviews methods applied for retrieving primary information. Iin the survey through questionnaire method and interview an intensive survey of critical care nurses working with different hospitals and healthcare centres will be conducted. Information retrieved through these different methods will explore the role played by critical care nurses in preventing pressure ulcers in critically ill patients.

Chapter 4: Discussion

The literature review revealed a number of different areas of information related to critical care nurses, and their roles and responsibilities in caring for patients susceptible to pressure ulcers. In this context a number of different roles and responsibilities were identified as specific to critical care nurses; differing from those assigned to general ward nurses. This section aims to present some discussion relating to the research work, offering ideas in relation to the limitations of the study and opportunities to influence nursing practice.

4.1.Discussion on the study

The study presented in the paper is primarily focused on the role of critical care nurses in the prevention of pressure ulcer in critically ill patients. For the purpose of exploring the most feasible outcomes, and producing a logical and considered conclusion to this research, a number of different literatures and research papers have been reviewed; these are aimed at proving the significance of critical care nurses in the context of prevention of pressure ulcer.

Some articles reviewed include that of Strand and Lindgren (2010), Simon, Faut and Wooley (2009), Reilly, Karakousis, Schrag and Stawicki (2007), Nijs, Toppets, Defloor, Bernaerts, Milisen and Berghe (2008), have revealed that the role of critical care nurses is crucial in the treatment of critically ill patients. As per the findings in the literature review section, critical care nurses are seem to have some intensive and distinguished responsibilities, as well as authority in comparison to general ward nurses. These responsibilities are related to the use of intensive antibiotics, artificial nutrition, mechanical nutrition and cardio-pulmonary resuscitation (Erlen and Sereikal 1997). Critical care nurses also share the responsibility for repositioning patients’ schedules and consistently assessing the nutrition mix and positioning within the appropriate time frames to prevent pressure sore development. In regards to the prevention of pressure ulcers, critical care nurses focus on the lateral rotation of the patient, pressure over bony prominences, and alteration in head-of-bed elevation to maintain prone positioning (Jankowski 2010). Consistent assessment of skin, nutritional support and positioning of patients is done by critical care nurses to manage the moisture balance over the body and to allow for careful enteral feeding (Strand and Lindgren 2010). In this context, it has been identified that in the case of critically ill patients, there is a need for intensive care and attention from nurses.

In addition to this, with the help of literature, it has also been revealed that pressure ulcers are undeniably one of most painful conditions faced by those critically ill patients who are not able to move independently. As they have to remain in the same position for a long period of time, their tissues and cells becomes damaged due to the continuous pressure on particular areas. This tissue damage gradually results in wounds developing in the absence of proper care and attention. The occurrence of such wounds, or pressure ulcers, is of concern to those working in ICU settings (Landrum 2011).

Therefore, the role of critical care nurses, in this regard, has become more vital, as they are pursuing intensive skills and qualifications regarding the care and treatment of patients in the intensive care unit. In the intensive care unit of a hospital, a number of different critical care cases are handled with the help of MDTs. The MDT is comprised of competent professionals, including experienced physicians, pharmacists, respiratory care technicians, radiologists, anaesthetics, and critical care nurses. The team shares the responsibility of handling emergency and life threatening cases (Norma 2000).

Within such a team, critical care nurses are identified as a crucial component (Stephens, et al 2006). There is a need for expertise care and attention, which can only be provided by specially trained critical care nurses.

Along with this, the work of authors like Thomas, Sexton and Helmreich (2003), Elpern, et al. (2004), Strand and Lindgren (2010), etc., have also shed some light on the role of critical care nurses in the ICU. On the basis of the findings from different literature covering similar topics, it is apparent that critical care nurses make use of crucial information about critical diseases experienced by patients, when handling complex and emergency situations. Special training and guidance is provided to critical care nurses for managing the flow of medical treatment provided to the patients in ICU, so that they can deal with basic requirements of the patients (Neumann and DeLugge 2007).

Along with this, this research has also explored intensive measures and strategies undertaken by critical care nurses in order to prevent the occurrence of pressure ulcers in critically ill patients. By providing intensive care and attention, nurses can reduce the chance of occurrence of ulcer due to continuous pressure on the skin of patient (Maklebust and Sieggreen 2001).

In this way, on the basis of the discussion made on the findings of the research work, it has been shown that there are different factors and characteristics, which are responsible for the intensive role of critical care nurses in the treatment of critically ill patients. Further, in the context of the prevention of pressure ulcers, critical care nurses have intensive skills, knowledge and experience, which help them to prevent pressure ulcers in a most effective manner. Therefore the following research will be a contribution to this body of knowledge by exploring the situation of ICU nurses working in the Kingdom of Saudi Arabia as well as by analysing their role in prevention of pressure sores.

4.2.Limitations of the Research proposal and suggested further research

The proposed study has focused on the role of critical care nurses in the context of the prevention of pressure ulcers in critically ill patients. Although, the context of the research work is quite comprehensive and broad, for the purpose of generalising the findings intensive further research is required. The research, which has been presented to date has provided some information regarding the significance of critical care nurses in the treatment of critically ill patients. However, the span of the topic is quite vast, as it includes a number of additional aspects, in which critical care nurses can play an intensive role. In this scenario, different research is recommended in the future to investigate the role of critical care nurses in other fields of research also. The critical analysis of the role of critical care nurses can be reflected in a quite effective manner with the help of some intensive research and study of different perspectives related to the diversified roles undertaken by critical care nurses.

The main limitation of the study was related to theoretical aspects, which have constrained the findings from ‘generalisability’. Since the study is confined within the specific population area, which cannot be covered on a broad scale, there is a lack of inclusion of the perspective of critical care nurses, who are working in large hospitals in big cities. This restricts the findings of the study on broader scale( Parahoo 1997) . A key intention of this research is to highlight the role of critical care nurses in managing patients suffering from pressure ulcers, so that issues of enteral feeding and pneumonia can be analysed properly. In this context, experiences of nurses handling patients in ICU are shared within the study. Along with this, the study is confined in expression and formulation to those issues faced by critical care nurses in providing appropriate treatment to the patients in the ICU. The study is limited to expressive theory, which can be put into practice by nurses for the purpose of managing critical patients. There is broad scope for future studies to focus on other treatment areas, which are addressed by critical care nurses.

Chapter 5: Recommendation and conclusion

In the paper, different aspects of the roles and responsibilities of critical care nurses have been demonstrated in relation to pressure sore prevention. This section will provide some concluding remarks regarding the overall findings of the research work. In addition to this, the section will also present some recommendations to critical care nurses, so that the effective prevention of pressure ulcers can be undertaken.

5.1. Recommendation

As per the findings in the whole paper, the pressure ulcer is one of the worst after-effects associated with a number of different critical disease in which the patient becomes unable to move or change position. In this context, the role of critical care nurses becomes quite vital. and the strategy adopted by critical care nurses could be effective and helpful in the prevention of pressure ulcer. In this context, some important recommendations, which will allow nurses to prevent the occurrence of pressure ulcer in critically ill patients, in the most effective manner are as follows:

Critical care nurses should be made aware of how far technological changes in the field of medical science affect their care. A number of different new and innovative technologies and tools have been introduced and critical care nurses need to be kept updated and made aware of different technological changes, so that they can incorporate different new techniques in the treatment of critically ill patients. Hospital management should also be required to provide intensive training to critical care nurses, so that they can use new tools and technologies in the most effective manner. With the help of this measure, critical care nurses will be able to prevent the occurrence of pressure ulcers. Pressure ulcers are one of the worst after effects of critical disease, which create painful conditions for the patients and so hospital management should ensure intensive training be made available to general ward nurses to handle critical cases during emergencies. Family members of the patients should also be provided with intensive knowledge and practice so that they can also take care of patients. This will help in the prevention of the occurrence of pressure ulcers in critically ill patients (Ferrell and Coyle 2006).

These are some key measures, which can prove quite helpful in the prevention of pressure ulcers, which are quite painful for critically ill patients.

5.2.Conclusion

The ICU (intensive care unit), within a hospital, is designed for the purpose of providing intensive treatment to patients who are suffering from different critical diseases or who are in the critical stages of a disease. The ICU is designed for the purpose of combating life threatening diseases. In addition to this, there are a number of different factors, which make the responsibilities of people working in the ICU more intense and elaborate than those elsewhere.

In this context, the research paper threw some intensive focus over the roles and responsibilities possessed by critical care nurses, that are considered to be an integral part of the intensive care unit. On the basis of the findings, it can be concluded that critical care nurses hold different and distinguished responsibilities when compared to general ward nurses. That is to say that there are some unique intensive skills, qualifications and experiences required from critical care nurses.

The paper has focused on the role of critical care nurses in the prevention of a painful and intensive disorder, namely the pressure ulcer. The findings of the paper have shown that the pressure ulcer is a disorder, which takes place as a side effect of different critical diseases when the patient has lost the ability to move. Due to the continuous pressure on the skin tissues, the tissues and cells of the skin of the patient get destroyed, which gradually converts into painful wounds in the absence of the proper care and attention.

Critical nurses are trained in providing intensive care to critically ill patients, so that the risk related with the occurrence of pressure ulcer can be mitigated in the most effective manner. In addition to this, it also can be interpreted on the basis of the findings of the paper that different strategies undertaken by critical care nurses for the purpose of preventing pressure ulcer are quite comprehensive and intensive in the context of critically ill patients. On the basis of such strategies, critical care nurses can be distinguished from general ward nurses.

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