In This Issue of JWOCN

The randomized controlled trial (RCT) is now considered the gold standard design for generating level 1 evidence for the efficacy of a particular intervention. This design is comparatively new; the first widely acknowledged RCT was published in 1948.1 Since then, both the US Food and Drug Administration and the European Medicines Agency have established criteria for determining adequate evidence for documenting the efficacy of a new drug before it becomes available to the public. More recently, the supremacy of the RCT and the demand that we use this design as the exclusive means for establishing efficacy has been challenged by advocates of comparative effectiveness research, which attempts to combine clinical outcomes, patient preference, and cost to determine the comparative effectiveness of specific interventions or complex management approaches. Advocates of comparative effectiveness research raise multiple interesting arguments related to the RCT, focusing on differences between establishing efficacy and effectiveness in daily practice, the cost of RCT, difficulties meeting quality demands when evaluating certain populations such as frail elderly patients who experience chronic wounds, and the need for sophisticated research teams led by appropriately qualified doctoral-prepared researchers. I concur that this level of sophistication is needed to answer many questions, such as the extensive Phase III RCT required for approval of a new drug. I would also argue that we have elevated this design to such a high status that we have lost sight of its potential to provide evidence for answering everyday questions.

In this issue of the Journal, Dea Kent reports on an RCT that evaluated a just-in-time educational intervention placed on a wound-dressing package to traditional packaging. This article qualifies as a must read not only because of its clinically relevant and useful findings, but also because it explodes several myths that I believe are attached to the RCT. Dea is not doctoral prepared; she sought assistance from colleagues while designing her study. Her research team comprised herself, several work colleagues who assisted her to execute the study protocol and collect data, and a statistician who helped with data analysis. The study was executed with a modest budget. An industry partner provided product only; they had no input into the study design, data collection or analysis, or the generation of her article. The Journal is interested in all original data, including individual case reports, case series, observational studies, case control, and comparative cohort studies. However, we are especially interested in RCTs because they provide the most robust means of answering both large and small questions that lie at the heat of our day-to-day practice. I personally challenge you to read Dea's excellent article and consider how you might apply this robust research design to one or more questions that you ask when caring for your patients.

This issue's Wound Care section continues with a review of clinical experiences with one- versus two-stage surgical reconstruction of pressure ulcer defects. Tereze A. Laing, Neville Ekpete, Shane Oon, and Sean M. Carroll report on 108 patients managed by two-stage surgical reconstruction for high-stage pressure ulcers. You will want to read this thoughtful article to increase your understanding of the clinical outcomes of this traditional approach to surgery as compared to surgeons who advocate a one-stage approach.

Gerri Slowikowski and Marjorie Funk investigated factors associated with pressure ulcer development in a surgical intensive care unit. This clinical question is especially relevant because all critically ill patients typically qualify as at risk for pressure ulceration based on validated instruments such as the Braden and Waterlow scales, but not all will go on to develop an ulcer. You will want to read this article to evaluate factors that potentially interact with pressure ulcer risk scale scores to determine which intensive care unit patients require the most aggressive preventive intervention programs.

Bibliometric analysis is a technique used to analyze trends in publications related to a specific topic. Hong-Lin Chen, Duan-Ying Cai, Wang-Qin Shen, and Peng Liu report a bibliometric analysis of pressure ulcer research from 1990 to 2009. You will want to read this interesting article to appreciate the growth of knowledge and interest in this field and to identify the institutions and individual researchers who have exerted the greatest impact in pressure ulcer research.

Concept analysis is another scholarly technique used to evaluate trends and the impact of specific concepts important to our daily practice. Kevin Emmons and Vicki Lachman describe a concept analysis of palliative wound care. You will want to read this insightful narrative to improve your understanding of the concept of palliative care (which goes well beyond end-of-life care) as well as the concept of wound care within this larger framework.

This issue's Ostomy Care section opens with a WOCN Center for Clinical Investigation funded research report from Sharon Aronovitch, Robbie Sharp, and Laurel Harduar-Morano about the influence of contact with a WOC nurse following ostomy surgery and its impact on health-related quality of life. You will want to read this article to determine the impact of contact with a WOC nurses on recovery at home following ostomy surgery and to gain insight about satisfaction with a professional nurse following this major life event.

Eva Carlsson, Ina Berndtsson, Anne-Marie Hallen, Elisabet Lindholm, and Eva Persson report a study that evaluated concerns and quality of life immediately prior to, during, and following ostomy surgery for colorectal cancer. This article qualifies as a must read because it follows the trajectory of shifting concerns expressed by patients as they are introduced to the necessity of ostomy creation, as they navigate the surgical process and as they recover in the home care setting.

This issue's WOC nurse consult also focuses on ostomy care. Lee Ann Krapfl and Shirley Zurcher describe a case and ask probing questions about the care of a critically ill patient following creation of a jejunostomy. You will want to read this special feature of the Journal in order to sharpen your critical thinking skills when managing patients with high-volume output ostomies.

This issue's Continence Care section opens with a cross-sectional study that evaluates the effect of age on various characteristics of constipation. This article qualifies as must-read information because it is the first published study to examine the influence of age on clinically relevant elements of constipation such as frequency of bowel movements, abdominal bloating, and abdominal pain.

This issue's Clinical Challenges describes the case of a 70-year-old woman with jejunostomy and gastrostomy tubes that were not well stabilized, causing them to leak effluent around the insertion site. You will want to read this popular feature in order to sharpen your knowledge and skills about moisture-associated skin damage caused by exposure to effluent, as well as techniques to prevent and treat this common problem.

This month's Research Spotlight by Joyce Pittman and Tamilyn Bakas is notable because it contains essential knowledge about designing and selecting instruments for data collection. Whether you are a researcher, clinical investigator, or a clinician, this article qualifies as a must read because of the knowledge it provides about how to select an instrument that is valid and reliable, responsive to changes following intervention, and practical for a given population.

Evidence From Other Publications

Compression is an essential component in prevention and treatment of venous leg ulcers. However, long-term adherence to compression is poor. Three nurse researchers reported the influence of psychosocial factors in the Journal of Clinical Nursing.2 They evaluated 122 participants with histories of 1 or more venous leg ulcers to determine psychosocial factors that enhance or diminish adherence to use of long-term compression devices. Seventy-one percent reported using compression to prevent recurrence but less than half (41%) reported wearing compression devices on a daily basis. Factors that enhanced adherence included knowledge of the cause of their condition and the role compression plays in preventing recurrence, and higher self-efficacy scores. Depression emerged as the main factor-reducing adherence. While adherence to self-care is influenced by multiple factors such as cost, access to devices, and support, this study is valuable because it explores one aspect of the low adherence rates to compression and provides a basis for designing interventions, such as education about the rationale for wearing compression and skin training to ensure self-efficacy when applying these devices.

Ostomy Care

Robotic laparoscopic surgery continues to increase in popularity for a variety of urologic surgeries, including radical cystectomy and urinary diversion. Pruthi and associates3 report results of a 100 consecutive cystectomies managed by either ileal conduit (n = 61) or orthotopic neobladder (n = 38). The overall complication rate was 36%, and 8% had major complications (graded using the Claiven system). These rates are slightly less than those published among patients managed using open surgical techniques. Nevertheless, when combined with the perceived advantages of robotic assisted laparoscopic surgery, including shorter hospital length of stays and differences in surgical incisions, it is likely that this approach will be used more and more frequently. This likely trend has several important implications for the WOC nurse. Patient-centered advantages include smaller incisions with less postoperative pain, reduced need for opioid analgesics, and more rapid recovery of bowel function. Nevertheless, it will also present unique challenges, including shortening the already-limited time available for teaching patients to cope with and care for their new ostomy while in hospital.

Continence Care

Improvement in the care of infants and children has undoubtedly saved lives and greatly extended the life span among many children such as those with myelodysplasia and related disorders. However, these successes have posed unforeseen challenges as these individuals enter adulthood. In a recent issue of BJU International, Davies and coworkers4 evaluated bowel and bladder function in a group of 74 adults born with anorectal malformations. In contrast to popular conceptions among pediatric care providers, the prevalence and severity of both urinary and fecal incontinence was high, and it was especially elevated among those with higher defects. Incontinence was found to have a negative impact on sexual function, quality of life, and body image. These data are important to WOC nurses because they serve as a reminder that we are increasingly likely to care for adult survivors of congenital defects that previously resulted in early death. They also remind us of the significant challenges we will face as we work with these resilient individuals in order to maximize their bowel and bladder function and the associated psychosocial dimensions.

References