Pressure ulcers or decubitus ulcers are a major problem in field of nursing practice. The effectiveness of the different types of mattresses and cushions in the prevention are very important subject to deal with but is poorly studied.
In this essay, I will be look briefly at the therapeutic structure from nursing perspective and explore the use of cognitive behaviour therapy (CBT) in the acute in-patient psychiatric ward (AIPPW) at the South Kensington and Chelsea Mental health unit SK&C MHU .
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The clients group at the SK&C MHU is predominately people with complex psychiatric needs (CNWL NHS Foundation Trust) characterised by schizophrenics, depression personality disorder OCD and a raft of other diagnosis and co existing diagnosis. The acute psychiatric inpatient wards are predominately staffed by registered psychiatric nurses (RMN) and health care assistance (HCA). The combination of these two category of nurses staff the ward on a 24 hour bases. On the global multidisciplinary team are 5 consultant psychiatrist, 2 occupational health professional and one occupational health assistance and a half of a psychologist.
CBT Cognitive-behavioural therapy (CBT) is a short- term, problem-focused psychosocial intervention. Evidence from randomised controlled trials and meta- analyses shows that it is an effective intervention for depression, panic disorder, generalised anxiety and obsessive-compulsive disorder (Department of Health, 2001).
Increasing evidence indicates its usefulness in a growing range of other psychiatric disorders such as anxiety, hypochondriasis, social phobia, schizophrenia and bipolar disorders and others. CBT is also of proven benefit to patients who attend psychiatric clinics (Paykel et al, 1999). The model is fully compatible with the use of medication. Studies examining depression have tended to confirm that CBT used together with antidepressant medication is more effective than either treatment alone (Blackburn et al, 1981). CBT treatment may lead to a reduction in future relapse (Evans et (as cited Chris Williams and Anne Garland)(Advances in Psychiatric Treatment (2009) 15: 306-317. doi: 10.1192/apt.bp.107.003731)
current nursing tools in SK&C
The nursing tools used at the SK&C MHU for assessment and structure of treatment is the nursing models. (Rambo, 1984) defines nursing model as a collection of interrelated concepts that provides direction for nursing practice. In nursing practice, nursing models approach the nursing process in a logical, systematic way; the model influences the very data the nurse collects. Nursing models have become far more prevalent since the 1970s. Prior to this, nursing care was largely dependent on the medical model (Rambo, 1984) and nurses practised largely by intuition and experience (Leddy & Pepper, 1993). Tiedeman, Mary E. PhD, RN; Lookinland, Sandra PhD, RN, looked in to the models of nursing and concluded that there is little or no evidence to determining which model of care is most effective in any given situation considering quality of care, cost, and satisfaction for the models of care, despite lack of evidence, newer models continue to be implemented. June 2004 – Volume 34 – Issue 6 Traditional Models of Care Delivery: What Have We Learned?
The case for CBT in AIPPW
mental health policy implementation guide: acute inpatient care provision (2002b) points out the fact that clinical psychology input needs to be increased and training to assist ward staff in acquiring skills. The desire for psychological improvement in AIPPW in long standing the and long over due Manpower Advocate Service
Anthony Morrison wrote in his foreword in the book cbt for acute inpateint mental health unit pg xv1 that thought there is limited evidence to suggest the provision of cbt in the inpatients setting, there is sufficient evidence to show that it will speed up recovery in the AIPPW. the current medical/nursing model of care by them self is is flawed. An investigating In CBT in the inpatient psychiatric wards (2005) survey by the Sainsbury centre, reported that less that 20 per cent of the wards surveyed reported patients having assess to CBT. A random survey of 263 APIPW with a total of 5971 beds in England and Wales by the Mental Health Act Commission found that there was a mean on 0.3 staff per patient. On the day on the survay there were no staff, patients interacting BMJ 1998;317:1279-83. B. Lloyd-Evans, PhD and S. Johnson, DM 2010 found on significant change in patient contact even in inpatient setting with significant more psychologist.
Chris Williams & Anne Garland stated in their article (A cognitive-behavioural therapy assessment model for use in everyday clinical practice) that CBT can be part of an integrated treatment biopsychosocial modelled assessment in a joint up manner of medical, nursing and psychological management approach,
Kim SY out lined these situations in which CBT should be particularly considered
” Where the patient prefers to use psychological interventions, either alone or in addition to medication The target problems for CBT (extreme, un- helpful thinking; reduced activity; avoidant or unhelpful behaviours) are present No improvement or only partial improvement has occurred on medication Side-effects prevent a sufficient dose of medication from being taken over an adequate period, Significant psychosocial problems (e.g. relation- ship problems, difficulties at work or un- helpful behaviours such as self-cutting or alcohol misuse) are present that will not be adequately addressed by medication alone” Kim SY. In the March 2007 Am J Psychiatry article 164:428-436, they found a modest improvements in psychosocial functioning after the introduction of anti psychotic medication in all treatment groups. This improvements is a gate way for the introduction of CBT . (Kuipers et al. 1998; Tarrier et al. 1998a) demonstrated in a controlled studies that CBT can significantly benefit chronic psychotic patients. CBT is not globally available in SK&C MHU.
(National institute of clinical excellence (NICE)
CBT: to meet the criteria for CBT, interventions had to have a component which involved recipients establishing links between their thoughts, feelings or actions with respect to the target symptoms; and the correction of their miss perceptions, irrational beliefs or reasoning biases related to those symptoms. At least one of the following was also required: self-monitoring of the treated person’s thoughts, feelings or behaviours with respect to the target symptoms; and the promotion of alternative ways of coping with the target symptoms. Anthony Morrison1 describes resistance from the medical team for this approach.
The CBT Assessment and formulation in the AIPPW
CBT assessment aimed at collation of clients past, present and current information via afferent modes(Hawton, Salkovskis, Kirk and Clark 2010) of assessment direct observation in clinical setting, physiological measures, behavioural interview, self-monitoring self-reporting , information from others . In the inpatient wards, the initial assessment, is characterised by clients feeling consumed by the severity of their symptoms, fear and uncertainty Gillian Haddock & Peter D Slade 2000, pg75
“It is common for people admitted to psychiatric care to lack the mental capacity to make
decisions on treatment, particularly if they have mania, schizophrenia or have been detained using the Mental Health” This put the nurse in a position to do a thorough assessment from the initial welcoming of the client where the nurses observational skills will aid the assessing and recording of clients responses mainly emotions, behaviour, cognitive and physiological. While the patient is in an acutely phase of ill, this has become possible comparing to the “cognitive revolution” proposed by Mahoney (1974,1984) as sighted Sharon Morgillo freeman and arthur Freeman 2005, to the advent of third wave paradigm of CBT where a the path way to change lies in altering feelings and not thought (Segal et al 2000) by assisting patents in managing distressing feelings though mindfulness (Chadweick et al 2005)
Sharon Morgillo freeman and arthur Freeman 2005, pg 62 suggest the the aim of the initial assessment is in the preparation of therapy, assessment of person and the presenting problem, the conceptualization of problem according to the cognitive model, socializing the person to the cognitive model and identifying goals and appropriate interventions consistent with the model
Nurses are in the best position to begin the construct of clients problem conceptualization as expressed by Judith S. Beck 1995 page 13 ” A cognitive conceptualization provides the framework for the therapist’s in understanding of a patient” “Conceptualizing a patient in cognitive terms is crucial in order to determine the most efficient and effective course of treatment”. Currently there is a disjointed approach in that, the medics have a ward round with or without the nurses thought nurses do give them hand overs, the psychologist have their meetings excluding the medics and the nurses thought points of interest are disclosed. Of the three professional groups, the nurse is in a 24 hour loop placing them in a better position to captures the present and previous medical and psychiatric treatment histories and also invaluable brings the ever changing present history together, will capture the case formulation. Mayer and Turkat (1979:261-262) defines case formulation as ” a hypothesis which (1) relates all the clients complains of one another (2) explains why the individual developed this difficulty and (3) provide predictions concerning the clients behaviour given any stimulus condition. The accuracy of the formulation depends on a sound therapeutic alliance to foster collaboration and active participation in the formulation, it is essential for there to be complete collaboration so the information collated during the acute phase should be treated sensitively as it may be embarrassing and distressing. Anthony (1993) emphasis is to be placed on person rather than illness as the level of insight may vary and their views and belief of their illness or problem may not be congruent with that of the therapist. in a trail in 1999 by G. Haddock á N. Tarrier á A.P. Morrison á R. Hopkins R. Drake á and S. Lewis. Of 21 client that started Cbt for a year, 20 completed treatment
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Butler (2006) point out and reasoned that two different CBT given the same client could develop different case formulations. This will not be the case with nursing team case formulation. Once insight is regained, the nurse team are in a better position to measure and assist with the different techniques of assessment like the use of daily mood logs, activity scheduling, behavioural surveys etc. The CBT approach is the use of recognised approaches and techniques of CBT to treat or deal particular issues. These employ the use of keeping of diary of events and feelings and the possible links, behaviours and thoughts, questioning and testing cognitions and assumptions, evaluating unhelpful and unrealistic beliefs, gradual exposure to activities that may have been avoided, trying out other ways of reacting and behaving and the use of medications to adjunct CBT to treat conditions like bipolar disorder. The sessions are structued useing J Beck’s 5 essentially elements of CBT session namely 1, agenda setting 2, identification of and dealing with problems, 3, periodic feedback 4, homework 5 summary (J. Beck 1995) there will be consistency of treatment from the team..
Factor that may hinder Commitment to CBT
length of stay in hospital, patients being detained rather than being willing participants of a process. Cost of hospitalization crisis teams to facilitate early discharge from hospital and treatment many patient admission are involuntary hence their willingness to engaged may be affected lack of insight engagement may be a problem looking forward to early discharged with the crises team early discharge in that with the advent of criss resolution teams (CRT), unwillingness to discuss painful issues
Case Against CBT on the ward,
The Guardian, Thursday 18 October 2007, Andrew Samuels ” if anyone seriously believes that all levels of mental-health issues can be fixed by CBT alone they are seriously mistaken”
Marion Rickett a psychotherapis expresses There is a case to be made that NHS emphasis on CBT distorts the evidence about the complex factors that are important in psychological therapies
A dark age for mental health, October 13 It is welcome news that funding for talking therapy is to be increased cited in the 18 October issue the idea that there is open discussion in a respected news paper opens the further research and hence attract funding.
Andrew Samuels Everyone has been seduced by CBT’s apparent cheapness.”He considers CBT, “a second-class therapy for citizens deemed to be second class.”
The average stay on an acute psychiatric ward is 28 days but corresponding average length of a Cbt treatment is 12 weeks is
In a meta-analytical review of well-controlled trials in a 2009, the question of CBT for major psychiatric disorder: does it really work was asked the authors argued that no trials using blinding and psychological placebo has found data suggest CBT to be effective in schizophrenia. The was a further findings that concluded that fewer well-controlled studies of CBT in depression found the therapy to be effective, and that CBT is not effective in the prevention of relapses in bipolar disorder.
Dr Andrew Keen concluded that Reliable assessment of standard competencies in CBT is a complex and resource intensive. There would need to be a marked increase in the number of samples of clinical work assessed to be able to make reliable judgements about proficiency” The British Journal of Psychiatry (2008) 193: 60-64. doi: 10.1192/bjp.bp.107.038588 this will not be an issue as CBT Skills, cases and supervision will be used on a 24/7 basis cases in the clinical.
CBT is a viable clinical tool that will be effective in the AIPPW NICE has guidelines covering almost all illness areas covered on the AIPPW CBT is seen as a short-term effective therapy. The nurse is in the clinic area 24 hours 7 days a week, training and incorporating the nursing team will a, reduce the waiting list problem in client having to wait for treatment b, improve clients satisfaction for treatment c, cost effectiveness of treatment.(Centre for Economic Performance 2006)
Clack and Wilson (2009) pg 23 point out that the usefulness of psychological approach is highlighted in several Department of Health documents(DH 1996, 200 1b, 2004a, 2004b, 2006a) and that Service users are increasingly demanding psychological services. They also point out that other department namely Department of Work and Pensions have seen the cost effectiveness CBT
as is reflects in randomized controlled trials. ( Layard 2004, 2006).
guided discovery Socratic questioning
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In this paper, evidence based practice will be the foundation in the management and change process. It is an important in nursing field, nursing action requires updated information which needs to be put into practice in that sense nurses need to question the quality of the studies and credibility of findings so it is important to develop critical skills, critique is often seen as first step in learning research process. Evidence-based practice involves a combination of many disciplines, including aspects of multidisciplinary sciences to promote the restoration and maintenance of health in our clients (Davies, 2005). Much literature has been published on this topic in recent years, an evolving subject and concept for specific practices that promote more effective, safer and more efficient ways of caring (Drenkard & Cohen, 2004). According to Kleinman (2004), health care professionals are striving constantly to improve and develop the standards of care. Meeting the challenges require health care providers to be effective leaders who foster a culture and develop partnerships that embraces innovation (Salsberg, 2008).
In this paper, the author change the research question to pressure relieving mattresses and cushion in the relieving of pressure ulcer to provide more specific views and some practical discussions concerning the cushion and mattresses choice that is best for each patient. The pressure ulcer prevention is essential for both the psychological and physical wellbeing of the patient and it will avoid any delay in the rehabilitation process and programmes. The cutaneous and subcutaneous tissue protection on the bone prominence area is very important for those patients who are bedridden or seated in a wheelchair all day (Biondo & Haber, 2006).
Moreover, quality of life factors are important considerations for patients especially those with pressure ulcer problems because such condition affects important bodily functions. The significant effect of pressure ulcer on the quality of life of the patient serves as the impetus for this paper which seeks to examine changes in quality of care after the care provider, has undergone change (Brancato, 2006).
Summary and Critiques of Existing Literatures
A clinical study conducted by Mukai et al (2010) entitled Physiological and care monitoring of anti-decubitus mattress patients presented a well designed an ultrasonic physiological and monitoring system for care that has been designed and developed physiological monitoring especially for the parameters of anti-decubitus (anti-bedsore) in the hospital beds used by the patients. Moreover, they discussed that the bed’s mattresses and cushions are intended to prevent the pressure on the patient’s body surface especially those immobilized patients. Quantitative type of research method was utilized in the study and result was statistically presented. The abstract provides general view and captures reader’s attention swiftly. It is concise in wording and the purpose of the study was clearly mentioned. The abstract also reveals strong statistical significance of anti-decubitus mattresses and significantly mentioned the assumptions. Although abstract encompasses the purpose as well as major findings of the study, some features and information like sample size, method of sampling, place of study were missing. A good example of abstract contains brief information of article representing all the essential details like purpose of the study, design setting, sample size, sampling method, major results and conclusion.
The second article by Melnyk (2005) showed a data and literature review regarding the idea that beds with that lack conventional springs and low-repulsion mattresses can alter the body movements of the patient and can cause ulcer pressure. Data presented that comfortable bed mattresses and cushions indicate improvements relative patient medical condition. The conceptual idea draws mainly from the resource-based view of the researcher which possess valuable, scarce, inimitable, and non-substitutable resources created and sustained competitive advantage. Previous research study was also included. The author also mentioned about another study using hydro fibre dressings which more beneficial but there was no evidence of their cost effectiveness. With the synthesis of previous studies, evidence about the idea that beds with that lack conventional springs and low-repulsion mattresses can alter the body movements of the patient and can cause ulcer pressure needs to be proved thus author clearly stated the aim of the study. Using the critical review of these literatures, the author reveals some prominent features of the present practices in the field. Even though the aim of the study was clearly mentioned, there was a total inadequacy of back ground information. It would be beneficial if author adds his own personal experiences or observations in the introductory part to support the rationale for the study. The introduction of any article should set a scene which identifies the research problem thus providing rationale for the work.
The third article by Wolsley and Hill (2000) discussed the systematic review interface pressure measurement in establishing a protocol for the assessment of support surfaces of the patient. It is being used in the assessment or evaluation of pressure relieving devices to prevent pressure sores. They presented a review of the literature showing the most effective devices to relieve pressure sore for patient care, as well as associated with the decision making in selecting devices including cushions and mattresses. This paper admitted that there is an existing gap in research in this specific filed that need to be assessed with patients in a hospital setting. Their findings suggested an improvement in the use better devices/ materials for probing the effectiveness of different support surfaces clinically.
The fourth article showing clinical evidences of two cushions effectiveness in the heel pressure ulcers prevention by Heyneman et al (2010) aimed in determining the effectiveness of two cushions in the heel pressure ulcers prevention especially in a geriatric population. In this research study, the researchers utilized two various cushions in preventing heel pressure ulcers named as a bedwide, wedge-shaped, an ordinary pillow and viscoelastic foam cushion. All the 162 participating patients were repositioned every 4 hours lying on a viscoelastic foam mattress. The result of the study shows significant evidences that a bedwide, wedge-shaped and the viscoelastic foam cushion lower the risk of a heel pressure ulcer development compared with the conventional use of a pillow.
The last article by Grioni et al (1996) present a series of evidences and previous literatures regarding the selection of anti-decubitus cushion seats for patients to relieve the pressure sores. In the article, they mentioned that anti-pressure cushion choices have two significant requisites; firstly, there is a need for a correct patient assessment and a complete understanding of the aids properties available. The prescription of the cushions discussed in this paper is not a simple task in that the clinical and physical needs of the patient must be taken into consideration. Overall, the research approach is appropriate to the nature of the study. The description of quantitative research method and experimental design in the literatueres which utilized to find out the relationship between the variables are explicit. The variable clearly identified anti-decubitus cushion sheets and traditional beds as independent variables (or cause), bed sore/ ulcers as dependent variable (or effect). This study is used to find out from existing literatures the relationship between variables as well as previous studies regarding the selection of anti-decubitus cushion seats for patients to relieve the pressure sores. Objectives were mentioned in the tables.
In these articles evidences that pressure ulcer prevention and healing is a complex process that can be complicated by a certain factors. Although with right and appropriate care, some wounds failed to heal in an appropriate fashion and may become more chronic. From different researches and studies reported in literature effective utilization of effective cushion and mattress material for the prevention and healing is important. This will help patients with complicated and non- healing chronic ulcers. Clinical Evidences from these articles and previous studies can be used in the change process in clinical settings.
Proposed Change Method and Assessment of Rationale
Conceptual model for translating evidence into clinical practice by Kurt Lewin will be used to promote change process. This model recognized that translation of research into practice requires a solid grounding in change theory, principles of research utilization, and use of standardized nomenclature. The model has the following six phases: Unfreeze, Change and Freeze (Marquis and Huston, 2008).
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The stage 1 of Kurt Lewin’s Change model is the unfreezing. This involves process of understanding that there is a necessary need for a change. The process involved preparation of a situation in which there is a need for a change (Marquis and Huston, 2008). In this stage, orientation to a new set of clinical evidenced-based knowledge about the pressure relieving mattresses and cushion in the relieving of pressure ulcer including a written orientation packet prepares clinical practitioner to possess general skills needed to be competent in caring patients in a clinical setting. They must possess good assessment skills and have good insight and judgment skills in order to anticipate or interpret the needs of the client in health care practice (Hewson M G.2000). The actual clinical preparation for health provider is very essential to learn actual clinical practice and the orientation in new protocols and policies in handling patients’ needs, this method of learning is termed as evidenced-based practice education (Davies 1999, p. 109). In preparing for change process, the discussion of each procedure of pressure ulcers management interventions includes necessary background information, with carefully chosen photographs of actual mattresses and cushions with technically precise illustrations; they can fully understand the topics and enhance the imagination when performing the required skills in practice. Instructions are also presented in format when the skill is one that is used with patients and when the process is appropriate to the skill. This emphasis reinforces the preparation to an organized process is relevant to practice to ensure the patient’s safety and rehabilitation.
The second stage is called Change or transition in which there is a need for a movement to facilitate changes. In this stage training is a part of the process. Possession of knowledge and competency in performing skills and interventions which can be acquired in actual or hands on trainings is essential in this stage (Marquis and Huston, 2008). It involves a combination of many disciplines, including aspects of multidisciplinary sciences to promote the restoration and maintenance of health in our clients (Davies, 1999). The challenges in this stage includes difficulty gaining support financially for the programs and trainings that ensure the effectiveness of skills, practice, leadership and integration of the program with existing practice of care through trainings and seminars and sustainable momentum during the shift of culture. These challenges are not limited to those who implement the change (Young, 2004). Some of the activities practiced in a clinical setting are the provision of the most current information possible for the client and co-professionals using the collaborative approach. During the teaching session and actual learning practice we have provided with clear explanations of the pathophysiological condition and processes of human illness and injury. It integrates information as vital component of clinical practice and evidenced based practice. These activities emphasizes the role of nurses as essential member of health care team, working together to achieve highest possible recovery for every patient. By means of prioritizing diagnoses and interventions specific to altered responses to illnesses and disease conditions, we provide them quality care. Providing case studies for each case so that we can envision the client as a person needing and requiring care and acquire knowledge regarding the specific case is also a factor. We can also foster critical thinking and decision making which very important for every health care professional in clinical practice. These are abilities and skills I have acquired in terms of patient management specifically wound care (Closs, 2004).
Teaching sessions and discussions in this stage is very important because you can maximize your learning through acquiring knowledge derived from the application of concepts and theories. You can actually discuss and clarify some information and clinical practices during these sessions. Helping one another in achieving proper knowledge and competency in nursing practice is also innate with this kind of forums. The discussion of each skills in practicing effective anti-ulcer management begins with an overview of pathophysiology followed by the manifestation and complications is very effective especially when it is being relate with the actual experience in handling wound care patients . Focuses on diversity and demonstrate the contributing factors are also a necessary to produce basic knowledge and application of nursing theories and principle (Brancato, 2006).
The last stage is termed as freezing. This stage is about the establishment of stability once the necessary changes have been made. Institutions must initiate the stability development of an effective use of mattresses and cushions to relieve or prevent the pressure ulcers. This change process must increase the knowledge, skills and competency of nurses and other health care provider and allow them to understand the importance of their new roles (Marquis and Huston, 2008).The change must help them in other transition by assisting other team members in understanding effective methods of care in the clinical setting constantly. This stage will produce knowledge and competitiveness among the people involved in the change process. Knowledge and competitiveness is a product of experience and effective learning process which is essential in actual clinical practice of nursing profession. It is largely based on innate potentials and motivations afforded by the familiarity of a learning environment. The richness or intensity of the inculcation of knowledge, positive values and skills of a person is not simply based on the innate capacity of one to evaluate, think, reason and interact in a learning situation. It equally depends on the quality of the change and experiences which are either limited by the individual’s ability and will to choose or by what is desirable to her which is readily accessible in the environment. This will determine the path of being effective and competent nursing practitioner (Davies, 1999).
This stage provided and maintained theoretical and clinical competence of the practice (Hagger & McIntyre, 2000). Nursing professionals need to prepare the next generation of nurses to provide competent and quality care to patients. To be an effective health care provider, this kind of care management provided me with individual appraisal ability of one’s self competency and enhanced my education based on practices and trainings taken previously during undergraduate, graduate studies, workshops, trainings, continuing education, and preparation for teaching seminars or modules including the written and on site orientation (Lichtman et al., 2003).
The rationale for the use of this model and the analysis of the cases mentioned in this study is geared toward a familiar setting where nurses and other health care provider will have the hospital resources knowledge needed to implement successful change process in the field of decubitus ulcer prevention. Once the phase of change concludes, they will be able to concentrate on specific needs invoking patient care process (Lichtman et al., 2003). They will become more confident in her pedagogical techniques for sharing skills, experience, and knowledge, coaching, and supporting other team members in their learning which are essential elements of effective caring process (Freiburger, 2002). These behaviours are not automatic or innate to individuals; all can be learned through education and practices of the profession. The outcome will be measured through assessment methods and tool to be utilized in order to evaluate the effectiveness and the result of the study. The assessment plan will be implemented and evaluated according to the objectives and goals of the treatment and care. The outcome will be analyzed to identify if the goal was met at the end of patient care.
According to Kozier & Erb (2008) wound prevention and management is an example of clinical skills education which refers to formal examination designed to enhance the skills or knowledge of nursing educators or practitioners. Through this new knowledge and skills about pressure relieving mattresses and cushion in the relieving of pressure ulcer, the ability to learn actual clinical practice and the orientation in hospital protocols and policies in handling patients’ needs will be achieved. Recent studies have reported gaps between nursing practice and researches (Brancato 2006) and identified different challenges that prevent the evidence to clinical practice to translate into clinical settings (Oleguo, 2005). These challenges in applying evidence-based practice such as effective used of cushion and mattresses to prevent pressure ulcer in clinical settings have been consistent across researches. One challenge is that, in the generation and development of new medical and nursing knowledge, the resistance of profession has often been incorporated with the new ways of practice (Young, 2004).
The study suggests that much recent practices are based frequently on tradition, experience and intuition, rather than validation of science. Furthermore, the growing numbers of studies and researches designed to develop and improve practice at the staff nurse level cannot make nurses improve their skills, research knowledge and understanding. They frequently lack nurse’s formal training such as scientific inquiries (Oleguo, 2005).