Capstone project –
Submitted by : Ms.Anju Malik Submitted to : The Texila American University In Partial Fulfillment of The Requirements for for the Master of Science in Nursing degree Academic year 2015 -2016
ACKNOWLEDGEMENT I would like to express my sincere gratitude to all who have helped me in completion of my “CAPSTONE “CAPSTONE PROJECT”. PROJECT”. First of all I would like to express my gratitude to our college ONI and its Management for having given me a chance to do my CAPSTONE CAPSTONE PROJECT at MOH hospitals and primary health centers . I am highly thankful for the kind support bestowed on me by the administration and staff of medical specialty wards /units /ambulatory care /A&E/PHC’ /A&E/PHC’ss etc. My special thanks to all the staff especially for nursing heads and supervisors and charge nurses. Royal hospital and Khoula Hospital for extending their help during hands on learning periods, without their support my would not have been possible.
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Texila American University BSN –MSN Program Academic year 2015 till 2016 Capstone Project Real time Practice /Service based Research
Introduction Cellulitis is an acute inflammation of the skin and subcutaneous tissue which is commonly caused by Streptococcus pyogens or streptococcus aureus (Phoenix, Das and Joshi, 2012; Morton and Swartz, 2004). Cellulitis can result in high morbidity and increased financial burdens to health care providers worldwide. Cellulitis is managed by various clinical specialists including Physicians, surgeons, orthopaedics, dermatologist, Primary care physicians and Emergency physicians. Level et al (2011) conducted a large scale study which concluded that cellulitis is best diagnosed by dermatologist/ specialist nurse and these patients can be managed by joint care between primary and secondary services. In 2010, a Cochrane review concluded its inability to name best treatment for the cellulitis patients as no two trials used the same antibiotic and there was lack of standard regime for the comparison (Kilburn et al 2011).The Accident and Emergency (A&E) quality indicators (2010), made recommendation on the effectiveness of care delivered to patients with cellulitis and reduce avoidable hospital admissions and provision of ambulatory care. There have been five set of guidelines issued in relation to cellulitis prophylaxis :Clinical Resource Efficiency Support Team CREST 2005, French Society of Dermatology 2000; Eron 2003; British Society of Lymphology 2010; Stevens 2005 . Cellulitis is one of the common condition treated in Emergency departments, walk in centres and hospital wards. According to National health services Information centre, Department of Health (DH 2011), patients with cellulitis used over 4 00,000 bed days which costs £172.4 to £254.8 million and the mean length of stay was 7.1 days. Cellulitis carries a financial burden and results in increased use of hospital beds. Cellulitis patients may get admitted due to misdiagnosis and lack of facilities in the community and follow up (Beldon and Burton 2005). Nurses and nurse practitioners on the acute medical unit (Medical assessment unit, clinical decision unit) have considerable involvement in the care of patients with cellulitis. The issue to be explored in the study surrounds the understanding and knowledge of acute medical care unit nurses or practitioners in relation to cellulitis management, and how they can 2 contribute towards the improvement of outcomes of cellulitis management. e g a P
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Aim of t he st udy
- The aim of this proposed study is not to replicate any of the
initial work already conducted, which emphasises outpatient antibiotic therapy, choice of antibiotic, diagnosis or risk assessment of cellulitis patients. This study aims to explore the knowledge and understanding of the qualified nurses working in acute medical wards in relation to cellulitis and its impact on length of stay and cost effectiveness. To comprehend that what nurses in acute care understand and feel about looking after patients with cellulitis.
To identify any knowledge deficits and developmental needs of the nurses working in the acute care setting in relation to cellulitis care management. However the evidence is lacking in relation to kn owledge, understanding and implementation of these guidelines, in the acute care setting. The aim of the
study is to identify the learning needs of nursing team in acute medical care unit in providing an evidence based approach to the management of patients with cellulitis. Background to The study - Symptoms of cellulitis depends on the severity at
the time of presentation and can include tachycardia, hypotension and malaise (Morton and Swartz 2004). All nurses must work towards evidence based practice; therefore it is essential that nurses working in the assessment unit base their practice on current evidence surrounding, treatment, risk factors and antibiotic prescription used in cellulitis management. Another factor affecting the quality of care this client group receives surrounds the constant turnover of medical staff. Thus it is essential that as a trainee advanced practitioner I introduce evidence to the MDT that directly impacts on care delivery ensuring it is safe and effective. It is important to recognize what nurses working in the unit understand of their role in nurse led care. To begin this jou rney there is a requirement on the researcher to understand that what nurses think about their role and responsibility while caring for a patient with cellulitis. Within the assessment unit it is the Trust’s intention to expand their provision of nurse led ambulatory care and 3 this study may be a key to improve continuity and quality of care e g a received by adult patients with cellulitis. P [Type text]
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The literature review is focussed on two areas. Firstly, to search for role of nurses in the acute medical care units in relation to prevention of cellulitis secondly, studies that aimed to define the nurses in relation to cellulitis which impacts on length of stay.
Search Strategy The database used to search were CINHAL, MEDLINE, SCOPUS, NHS Evidence and Cochrane library (intervention and policy). CINHAL is a comprehensive form of information for nurses and allied health care professionals. There are around 4000 unique nursing and allied health subject heading. Medline database has got international literature on biomedicine and health care. Medical Subject Headings (MeSH™) is used to describe the subject of each journal article in this database. SCOPUS is one of the largest Databases with peer review literature. OMSB Evidence provides access to a range of resources through a single interface, including the following healthcare databases: Allied and Complementary Medicine (AMED), British Nursing Index, EMBASE and Medline.
Search Terms Used databases had MESH (medical subject heading). Mesh terms provide a consistent way of retrieving information that uses different terminology for the same concept. Boolean’s operator was used to combine various terms. Nurse* or practitioner, Cellulitis or skin infection, experience or behaviour, management or treatment, nurse* led clinic or nurse*led discharge, Risk or cause. These terms were combined using AND operator .
Inclusion/Exclusion criteria To ensure that all the selected papers are critically appraised, opinion papers were excluded from search as these are seen as weak evidence. The search was limited to last 10 years; this is due to change of practice constantly. OMSB has progressed . towards patient focus care and benchmarking the standards by utilization of Clinical Governance.The OMSB has become target driven in an attempt to optimize care and four hour targets for urgent care, CQUIN targets for overall standards of care in trusts and quality indicators which are based on standards of care for particular conditions are playing key role in initial assessment and in continuation of care. 4 e g a P
Compliance to these guidelines facilitates the costing of conditions so any deviation to the care pathway can result in increased cost to trust. The search [Type text]
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was limited to English papers only due to the cost involved in the translation of foreign language papers. Papers including adult patients were included in the search and any paper including Children or special need adults were excluded. Papers with community or hospital care with cellulitis were included
Reviewing the evidence CASP (Critical Appraisal skills programme) tools were used to critically appraise Cochrane review, systematic review and Randomised control trials. To appraise guidelines TAPUPA (Transparency, Accuracy, purposivity, Utility, Propriety, and Accessibility) was used (Social care Institute for Excellence 2003).Best BET’s guidelines were also used to critically appraise few articles.Best bets was used due to familiarity and used in Journal club at place of clinical practice .
Literature Review A considerable amount of literature has been published on cellulitis. Most of the identified papers are qualitative studies and identified papers are discussed under themes. These studies consist of management of cellulitis, identification of risk factors, out patient management of cellulitis, prophylactic treatment of cellulitis and patient experience. There was limited literature in relation to education and clinical skills of nurses in management of cellulitis. An initial review of literature found on Randomised control trials, Cochrane or systemic review on the understanding and knowledge or role of nurses in relation to cellulitis. The main themes identified in literature are
1. Identify risk factors and causes of cellulitis 2. Evidence based management of Cellulitis 3.Role of nurse in management of cellulitis and patient experience /health promotion Identify risk factors and causes of cellulitis
Halpern, Holder, Longford (2008) conducted a prospective case control study. The aim of the study was to identify ethnicity and other risk factors for acute lower limb cellulitis in OMAN population.150 Patients with cellulitis who required hospital admissions and 300 control group 5 e g a P
patients were recruited over a period of one year.
The study was
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of over 3, 00,000. Patients were interviewed by dermatologist and demographic
data
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systemic
risk
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multivariable regression method was used to calculate the significant predictor variables. This study concluded that there is relationship between ethnicity and risk of developing cellulitis. White ethnicity is at higher risk of cellulitis and no systemic illnesses were identified as increasing an individual’s risk of presenting with cellulitis. Researchers were blinded to the patient’s ethnicity in the control group.
Another prospective study was conducted by Bjornsdottir et al (2005), aim of this study was to identify the risk factors associated with cellulitis and identification of preventable risk factors which can impact on infection related morbidity, cost and improve patient management. 100 Subjects and a 200 control group were used in a university hospital. Questionnarie was used as a data collection tool along with examination of lower limbs and microbiological samples collected from the feet. This research identified various risk factors which were independently associated with cellulitis; previous cellulitis, presence of Staphylococcus aureus or b-haemolytic streptococci in the toe webs, pressure of leg ulcers, prior saphenectomy, and tinea pedis interdigitals was associated with cellulitis. This study identified that improved awareness and management of underlying risk factors can reduce the incidence of cellulitis . This was good study, well constructed and was able to identify risk factors for cellulitis. 6 e g a P
Evidence based management of Cellulitis [Type text]
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Leman and Mukherjee (2005) undertook a double blind placebo, randomised controlled trial on 81 patients with lower limb cellulitis requiring intravenous antibiotics. Comparison of flucloxacillin alone or combined with benylypenicillin to treat lower limb cellulitis. Clear inclusive and exclusive criteria were documented. Patients with known penicillin allergy, hepatic and renal problem were excluded from this study. SYSTAT software for data analysis was used. This study was unable to provide any evidence to support the use of either of the treatments. In this study patient dropout was high, inappropriate randomisation like penicillin allergy was identified as weakness. The dermaotology clinical trials networks PATCH2 trial (prophylactic antibiotics for the treatment of cellulitis at home 2) was a multicentre randomised trial (Foster et al 2012). 60 Participants were given penicillin for 6 months against placebo 63 participants. There was no statistical difference seen in reduction of cellulitis rates for penicillin for prophylaxis. There were promising results for long term prophylaxis (one year). Patch 1 trial is underway at present which is assessing one year prophylaxis of penicillin. Kilburn, Featherstone, Higgins and Brindle (2010), conducted a Cochrane review on the interventions for cellulitis. 25 Randomised control trials were included and 2488 participants with age range of 1690 years. Best treatment for cellulitis was not defined due to use of different antibiotic in the studies. Further recommendations were made to conduct randomised control trials where same type of antibiotic are 7 e g a P
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Johnson et al (2007) conducted a randomised single centred trial to see the effects of cycloidal vibration along with standard treatment can reduce the length of time for the treatment of lower limb cellulitis. This study has few drawbacks. It was single centred and there were only 18 participants in treatment and 18 in control group. Participants prescribed with antibiotic treatment were included. It was unclear that how participants were randomised and neither participants nor researchers were blinded. The finding of this study suggested that there was early recovery in the treatment group . Overall this study was weak evidentially . Level et al (2011) conducted a service improvement study with an objective that severe limb cellulitis is best diagnosed by dermatologist and managed with shared care between dermatologist and secondary care. This study included 635 patients, which were refred to dermatologist cellulitis service. 407 patients were mana ged as outpatient either with oral antibiotics or outpatient intravenous antibiotics and only 18 patients were admitted to hospital and rest of the patients had other diagnosis. All these patients were reviewed within 72 h ours. This study highlighted that early diagnosis, correct treatment and follow up of cellulitis can avoid hospital admissions and reduce financial burden to the trust. This was a service improvement study so no ethics approval required.
Role of nurse in management of cellulitis and patient experience /health promotion A qualitative study was conducted by Carter, Kilburn and Featherstone (2007) to explore the patient’s view on the management of cellulitis in the secondary healthcare setting. Data was collected retrospectively and identification of data was carried out from the discharge coding system of the respective hospital. A sample of 80 patients was identified and these patients were invited for participation and were provided with an information pack which outlined the aims of the study. The Local Research Ethics Committee approval was taken and consent was approved from all the participants. 24 Patients took part; 9 patients were interviewed individually and via telephone and 15 attended face to face interviews and it was audio recorded as well. Grounded theory methodology was used due to limited information of the research topic, which was underpinned by Glaster and Strauss (1967) theory. Three researchers worked together, one conducted telephone interviews and second researcher conducted interviews face to face. Third researcher transcribed the data after listening to the tapes and reading field notes. The main themes which emerged from this study were that participants felt tha t early diagnosis and treatment was essential for rapid recovery, prevention of recurrence and complications. Another point was highlighted as participants felt that there was inconsistency in the 8 e knowledge of health care professionals and information provided to patients (Miller, g a P
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2002). It was a good qualitative study and aims were clearly stated. Sample size was appropriate and methodology was clearly stated. There were three researchers involved in this study which limited the chan ces of bias. Data collection and data analysis was done effectively and results were highlighted . Seaton, Bell, Gourlay, Semple (2005) study researched nurse led management of uncomplicated cellulitis in the community. An observational study was un dertaken; 114 patients and 230 retrospective controls were selected. A m anagement protocol was developed for the specialist nurses for the ambulatory management of cellulitis patients with intravenous antibiotics. These patients outcomes were compared before and after receiving the treatment. Patient group direction (PGD) was used when required to prescribe antibiotics. The duration of intravenous therapy, admissions, readmissions and outcomes were compared. Outcomes of the study demonstrate that using a well structured and well supervised protocol, specialist nurses can result in effective management of cellulitis , resulting in reduced readmission rates and input from medical staff. Inclusive and exclusive criteria were clearly written. This was well constructed study which highlighted the role of nurses in the management of uncomplicated cellulitis and same kind of study can be undertaken in ambulatory care services or short stay wards.
In Concusion Cellulitis is a common skin infection which may include dermal and subcutaneous infection of skin (Hay 2004). Infective organisms involved are Haemolytic streptococci (Bernard et al 1987), Staphylococcus aureus (Erikson et al 1996), a nd Methillin resistant Staphylococcus aureus (MRSA) - related cellulitis (KluytmanasVandenbergh 2006). Main risk factors which were identified were leg ulcers,wound, athlete’s foot,pressure ulcer,leg odema (Dupuy)1999; Roujeau 2004). Some factors which are associated with re-occurance of cellulitis are obesity, lymphodema, (Cox 2006, ) tinea pedis, smoking and local injury. There are no national guidelines like NICE for the treatment of cellulitis even though there are British Lymphology society guidelines ( 2010) and CREST guidelines( 2005 ) Research Question
What do nurses in Acute Medical Care Units understand about actual or prospective impact of their role in improving outcome of patients with cellulitis? 9 e g a P
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Overview of the study The research study is an interpretive phenomenology qualitative study to understand the experience of nurses looking after patients with cellulitis. Green and Britten (1988) argue that qualitative studies can answer the questions which quantitative study cannot address. A qualitative method could highlight the feelings and what one particular procedure /intervention mean t for a particular group of population .Interpretive research tradition is suitable for this study as researcher can not only understand but can also discover possibilities and wisdom from the participants in relation to cellulitis (Polit and Beck ) Data Collection When considering the data capture tool the researcher must consider how the tool will answer the study aims and research question. Therefore focus group and Indepth semi structured interviews using a conversational style have been selected for this study.
Focus group Focus group discussions will be conducted to get an awareness regarding the ideas or feelings in relation to cellulitis. The benefit of using focus group is that large numbers of participants are allowed and this acts as a stimulus to encourage discussion and debates (Happell 2007). Ashby et al (2005) and Mansell et al (2004) also encourage that focus group can provide in depth information. The researcher will conduct two focus groups of a population of 7 to 8 in a focus group. Benner and Ketefian (2008,page 290) identify the main disadvantage would be that some interviewee’s may feel intimidated and unable to get their message across due to lack of confidence or due receiving criticism from other team members.( Mansell et al 2004).This shortcoming can be overcome by having a person to organise the group and the setting and recording equipment and taking extra notes, leaving the researcher free to manage the group dynamics (Pollit and Beck 2010). Having a list of pre-set questions informed from the literature, keeps the group interview focused. The researcher can also invite staff members to contribute. Personal invitations will 0 1 be sent to participants ( Lane et al 2001) , with venue, date and time for the focus e g a P
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Several participants will be invited to participate in individual interviews and will get the opportunity to talk about their feelings and understanding pertaining to cellulitis . Each participant will be allocated a pseudonym and identified on a tracking sheet. Field notes taken from the focus groups will inform individual interviews . The Interviewing technique used will be open ended which is appropriate in qualitative research. The interviews will be based on the findings from the focus group but then move on more specific questions. Interviews are the most common source of qualitative data collection (Green and Thorogood 2009). Interviewing involves dialogue between the researcher and the respondent. The researcher directs the questions to answer the study aims and thus a semi structured approach will be adopted. This allows the researcher to set the agenda and use the list of questions to guide the interview (Sechrist and Parvikoff 2002). Using this approach encourages respondents to relax and exchange of ideas and offer responses which are not pre determined. The interviewer would be able to use prompts such as non verbal cues like head nodding. Probes like “anything else you want to add” would help the interviewee to say more about the selected topic.
One of the advantages of semi structured respondents are not faced with multiple choice questions. Open ended questions would encourage the respondents to reflect more freely. The sense of personal safety is created by being respectful and non judgemental to participant and. It also allows a balance to deveop between the interests of respondent and researcher, leading to the development of a trusting relationship and a free flow of information ( Benner and Ketefian 2008). The disadvantage of interviews is that it provides information about wh at people say rather than what they practice (Green and Thorogood, 2009).
Recording interviews All the interviews would be audio taped and digital recording would be conducted due to its high quality. Quality of sound would be essential to capture as it would not only tell the researcher what is being said but also about how it has been said. Audio recording would also ensure that the emotions are captured. Field notes will be taken after the interview and would work as observational quality and would 1 capture sarcasm and body language (Sapsford and Jupp 2006). 1 e g Conducting the interviews a P
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Communications skills will be the core requirement for conducting interviews. The interviews will be carried out by the researcher who has a nursing background and knowledge of the topic area. Nurses communicate and take medical and social histories in daily practice but conducting a semi structure interview needs experience and skill to create balance between listening and focus on next questions based on previous. The researcher will conduct a practice interview, with a member of staff not involved in the study. This will be helpful in picking up nonverbal clues and gaining confidence, it will also identify area for personal development (Whiting 2008). The interviews will be conducted by asking simple general questions will be asked about the area interviewee’s work to build a rapport (Spencer et al 2003). The interviewer will use prompts when required but will also en sure that no leading questions are asked. (DiCicco –Bloom and Crabtree 2006).
Data analysis The researcher intends to employ secretarial support to transcribe data from the focus group and individual interviews and these will be transcribed verbatum. The accuracy of the transcribed data will be checked and rechecked to avoid any transcription errors (Silverman 2011).The audio taped focus group interview data, will be played and replayed to gain some insight into the issues faced by staff when caring for patients with cellulits. The typed focus group interview data and field notes will be cross referenced against the transcribed data. This data and findings from published literature will then be used to focus individual interviews. Once individual interviews are completed they will be transcribed and gain cross referenced against the audio tape . The researcher will become immersed in the data to gain a more indepth insight into the problem. This process will be follow with each interview informing the next until saturation is achieved. Whilst this approach is intensive it will allow the researcher to develop the interview schedule to answer the research question (Silverman 201). Interpretive approach for data analysis was based on Grbich (1999) theory of data analysis.
Thematic analysis-
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(Glaser and Straus date) One of the main aims of thematic analysis is to identify emergent themes from the audio tapes and field notes. Thematic analysis requires repeated listening to audio tapes and reading field notes (DiCicco-Bloom and Crabtree 2006). It assists the researcher to identify principal themes emerging from interviews. It facilitates the summary of key points from the interviews (Atkinson and Heritage 1984). Thematic analysis technique is favoured by Wilkinson (2011) involves a step by step approach to data analysis. Individual statements relevant to study aims are identified and tagged, then numerically coded, these are then brought together under themes and then reduced accordingly. Related concepts will be grouped together to facilitate the coding process. Coding of data will continue till all the data is coded and put under various themes pertaining to the study aims (Grbich 1999 page 218-238). Questions asked during interviews and focus groups will guide the coding and analysis of the dataIt is imperative that rigour is shown at this stage as this adds to to the veracity and strength of the findings (Grbich 1999.)
Validity and reliability In quantitative studies reliability and validity depends on the selection of the data capture tool and the tests used to analyse the data ensuring that the results can be reproduced in future studies. The qualitative interview is the data capture tool used in this study. Each interview is unique interaction and not replicable. The reflexive notes taken by the researcher allows for independent scrutiny of the the study findings. The Researcher will ensure that their thematic content analysis is reviewed by colleagues not involved in the study (Green and Thorogood 2009). This process ensures the trustworthiness of data is demonstrated throughout the study ensuring that data produced is focused on the respondents viewpoint and not reflecting researcher’s perspective (Polit and Beck 2006). An account will be kept of the methods, preconceptions, behaviour, procedure and decision making involved in data analysis and data collection. Validity of response in this study will be enhanced by the presence of the researcher, who can clarify the questions and can also seek the clarification from the respondents.Researcher will ensure the principles of 3 beneficence and non-malfeasance are endorsed throughout the study as 1 e recommended through Declaration of Helsinki (World Medical Association2000; g a P
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British Sociological Association BSA 1992). Ethical approval Anyone carrying out research with staff or staff in the MOH in OMAN has to apply for Ethical approval from Research Ethics committee. This study is related to the knowledge of nurses and service evaluation, so it will not need National health services ethics approval (National Research Ethics Service 2007). Local trust will be informed about the study. Ethics approval will be applied to the University.
Confidentiality/ consent According to World Medical Association (2000), privacy and confidentiality of participants should be respected. Researcher in this particular study has conducted a pilot interview to become more acqintistiq to the semi structure interview process. Researcher will ensure that discussion should not be part of everyday gossip. Participants will be assigned with a pseudonym so that they cannot be identified. Researcher will remove any identifying characteristics on the records. Date will be encrypted to maintain the confidentiality. Data will be stored with the consent of interviewee’s.
Conclusion This study has got potential to contribute towards the development of a learning package for the nurses of acute care unit. It will also contribute towards development of nurse led pathway for cellulitis. This study will be presented as a presentation in the department and trust. This research will also be presented in the form of poster along with the recommendations for the future. This study has got potential to present to Journals like Emergency nurse, Journal of Advanced Nursing and, Clinical Nursing so that it can have impact on the nurses working in ambulatory care and acute medical units. It will be very beneficial to conduct a quantitative study to check the improvement in the knowledge of nurses in relation 4 to cellulitis. 1 e g a P
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Limitations This study is limited to acute medical care staff and it would be beneficial to conduct on surgical and orthopaedic wards, due to admissions to these wards as well. This study used two methods of data collection focus group and semi structured interviews , by adding observational method along with previous two methods ; it would have triangulated the study and more trustworthy. Using more than one researcher would have reduced the bias in data interpretation.
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