Article Appraisal

This article provides an appraisal of a systematic review on pressure ulcers. It discusses the role of introduction, literature search, quality of review, data synthesis, results, discussion, and conclusion in a systematic review. The study focuses on the prevention strategies for pressure ulcers and proposes the need for more effective guidelines in clinical settings.

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Article Appraisal
Student’s Name
University

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Article Appraisal
Introduction
The role of an introduction is to provide the background of the research problem by
highlighting the general and the specific knowledge about the topic. This relates to studies that
have been done and the existing knowledge on how to deal with the issues. This introduction is
supposed to open up the introduction to existing literature linking it to the research problem and
identifying the gaps that the study will address. A good research study builds on the existing
practice knowledge to address the existing gaps or to add knowledge to existing research. In their
study, Tayyib & Coyer (2016) have introduced the research topic by giving the background
information on pressure ulcers and the existing prevention measures in critical care. This study is
developed from the gap that there is little evidence of strategies for integrating routine strategies
of care to prevent pressure ulcers. By synthesizing the best available evidence on single
strategies for pressure ulcer prevention, and reduction of clinical incidences the authors have
analyzed the previous research studies that have been done on the problem. The gaps,
recommendations, and limitations of these studies form the basis of the review which is used to
determine the way this study will be done.
The study was built on research studies that had been done on single prevention strategy
for pressure ulcers. The studies that qualified to be reviewed are the ones that used the adult
patient population who had been admitted in hospital wards. In every study, the researcher must
identify the appropriate population that reflects the requirements of the population. Different
patient populations can yield different results which means that the researcher must narrow down
to a specific patient cohort (Zhao, Tian, Cai, Claggett, & Wei, 2013). Patient cohorts are
effective in collecting data since they share common medical and issues and the data collected

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can be easily generalized to the larger population within this cohort. This is the reason why the
study focused on studies with adult patient populations admitted in hospital wards. To achieve
clear results, the patient cohorts have to be based on patients who fall within the same category
and meet the same clinical settings. Further, the clinical setting of the population is important in
determining the reliability of the results since they increase the uniformity of the findings in
different populations.
Literature search
In a systematic review, caution needs to be put on the type of papers that are included in
the study. This implies that the inclusion/exclusion criteria must focus on the research topic and
the type of population under study. Further, the level of evidence used in systematic reviews has
to be high to provide reliable data that is used in developing the review. This is why this study
was based on randomized controlled trials that offer the best evidence involving the use of
control groups within the population (Booth & Tannoc, 2014). The role of controlled randomized
trials is to provide a high level of research findings through using the general and the controlled
group where the findings between the two are compared with each other to determine the
effectiveness of the interventions. These studies offer the best evidence for use in systematic
reviews since they form the basis of for future research implications to determine the areas that
need to be addressed. Marx, Milley, Cantor, Ackerman, & Hammerschlag (2013) add that these
studies were extracted from the relevant databases, appraised to determine their effectiveness and
then the data synthesized to determine trends and themes that formed the findings of the review.
The common medical and nursing databases that were used in the study were MEDLINE
(PubMed) and CINAHL for published articles and New York Academy of Medicine Library
Gray Literature Report, Agency for Healthcare Research and Quality (AHRQ), National Institute

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for Health and Care Excellence (NICE), Centers for Disease Control and Prevention (CDC), and
National Guideline Clearing House. These databases offer different research studies which
require the researcher to use specific search terms based on the research topic.
Quality of the review
Did the authors assess the quality/rigor of the including/ excluding studies?
When gathering data for a systematic review, the way research studies are collected using
the exclusion/inclusion criteria plays an important role in determining the quality of the review.
The articles are supposed to be extracted and then assessed using a standardized critical appraisal
tool. This study used the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and
Review Instrument (JBI-MAStARI) to appraise the research studies and choose the ones that
meet the requirements of the study (Munn, Moola, Riitano, & Lisy, 2014). This tool has a
checklist for appraising research studies and allows the reviewer to capture their bias so that it
can be reviewed by a third reviewer. The quality of acceptance for studies that are appraised by
the JBI-MAStARI tool is 50% and above. Thus the studies with a score that is less than the
required amount are dropped and not included in the study.
Data synthesis
According to Phan, Tian, Cao, Black, & Yan (2015) data synthesis is determined by the
nature of studies that have been extracted by the researcher. The heterogeneous nature of the
studies used in this review made it difficult to pool the results together which forced the
researchers to use the narrative form to present the findings. The JBI-MAStARI tool was
effective in the selection and synthesis of the findings. From the extraction, only 24 studies were
found to be appropriate to provide the right type of evidence required for the study. A qualitative
narrative review was used due to the difference like studies that were used. In this case, it was

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difficult to find correlations between the studies thus forcing the researchers to use qualitative
themes of preventive skin care, repositioning for early mobilization, medical devices, and
emerging therapies for pressure ulcer prevention, support surfaces, nutrition, and education. A
summary of the research studies used was developed to allow the reader to understand the nature
of the study that each article entailed. Cooper, Booth, Varley-Campbell, Britten, & Garside
(2018) argues that summary tables are used to present the findings of each study allowing the
researcher to develop themes from the table. Since the table is an overview of the findings of
each study, themes are supposed to be developed from this summary.
Buchholz, Janssen, Kohlmann, & Feng (2018) argues that systematic reviews are not
defined by the number of studies used but rather the type of evidence that the researchers present
to justify the research problem. This requires specificity and sensitivity in diagnosing the
findings of the study and relating them to the research topic. Since studies will have varying
population samples and clinical settings, variations in reporting of the findings create difficulties
in correlating the findings of the study. This problem is solved through the use of a forest plot for
weighing the findings and determining odd ratios of the studies used in the systematic review.
From the forest plot, only studies that have high confidence levels are the ones that are used in
the synthesis.
Results
The NPUAP, EPUAP, and PPPIA guidelines (2014) offer guidelines on how studies used
in a systematic review need to be presented and analyzed. Here studies are supposed to be
analyzed and presented based on the qualitative narrative that was used to define the themes used
in the review (National Pressure Ulcer Advisory Panel., 2018). This means that the studies are
supposed to be analyzed in with the qualitative themes of study. The study reported that no study

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reported on the effectiveness of skin and tissue assessment, one study was based on the
comparison of the three bowel management controls for pressure ulcer. One study was based on
the use of polarized light, three studies focused on dressing wounds to prevent ulcers while three
studies presented findings on the use of emerging therapies to manage ulcers.
The precision of results is how well the methods used can give the same results if the
study was tested repeatedly. This is based on measuring the random error of the method through
scatter data. In most cases, precision measures the accuracy of the study which makes the
findings reliable (Garralda, et al., 2019). The precision measures are measured using standard
deviation (SD), and coefficient of variation which determine the confidence level of the results
of the study. The confidence level is this the percentage of possible samples that can be expected
to include the true population. When the confidence level of the study is high, the findings are
reliable since they can be replicated or generalized to the whole population. In most cases, the
expected confidence level is 95% and is expressed through different means (Ahn & Kang, 2018).
In the case of this review, the heterogeneity of the results means that the researchers had to use a
forest plot to calculate the confidence level of the studies through a combination of a different
value from each study. This study had a confidence level of 95% which shows the reliability of
results and the ability of them to be true as being high.
Discussion
The NPUAP, EPUAP, and PPPIA (2014) have developed guidelines on how to develop
recommendations that guide evidence-based methods for pressure ulcer. The guidelines require
researchers to use the highest level of evidence when searching for studies that are to be used in
the review. This means that level II and III studies offer the best level of evidence that can be
used in this review (Leeflang, Deeks, Gatsonis, & Bossuyt, 2010). This level entails randomized

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controlled trials that are both qualitative and quantitative to test the effectiveness of certain study
methods. This increases the applicability of the findings since the researcher relies on the quality
of studies that are used in the review. One evident limitation that can be noted in this study is the
failure of the researchers to declare their interest in the study and their funding source.
Declaration of interests shows how the researcher bias could have influenced the study while
declaring the funding source shows the conflict of interest that can arise. This is supposed to be
shown so that the researchers can tell how this was handled. Although an external reviewer was
involved, the conflict of interest was clear on how the researcher dealt with the issues.
The applicability of findings in a systematic review can be from the way the authors have
presented rich descriptions of the settings implementation details of the setting of the studies
used and the context. This is provided in the discussion where the researcher provides the links
between different studies to draw a conclusion that forms the implications for practice (Burford,
Lewinb, Welch, Rehfuess, & Waters, 2013). Based on themes identified in the study, the
researcher provided a rich description of the studies and how they related to the research topic.
This study applies to the local population since it provides findings that have been accurately
analyzed for applicability in clinical settings. The study harm is based on the limitations that can
affect the applicability of the findings. This review did not report any harm although it was based
on studies with small sample size. There was also the challenge of the difference in stages of
pressure ulcer among the patients in different trials which can challenge uniformity of the data
collected. Despite that, this study does not offer any harm to the study population but proposes
the need for rigorous-designed randomized control trials with standardized reporting criteria to
measure the data. Therefore, the findings of this study can form the basis for future research

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where the focus will be the development of rigorous studies that reflect uniformity of clinical
settings to increase the efficiency of the results.
Conclusion
The conclusion of a review is supposed to offer a summary of the whole study and
present answers to the research question. By presenting a summary of the data collected from the
review, the researcher gives an overview of the prevention strategies that are used in the
prevention of pressure ulcers. This study proposes that there is a need for the researchers to
develop the best practices for pressure ulcer prevention with a focus on the need for proper
randomized studies that define how to prevent pressure ulcers. Generalizability of the findings to
the local population relies on the confidence level of the studies used and their reliability. In this
study, the authors propose the need for the development of more effective pressure ulcer
prevention guidelines that can be used in critical care settings. Since there are different
prevention strategies, the review revealed that the use of silicone foam dressing and pressure
mattress as the best strategy for preventing the development of pressure ulcers. Thus this study
concluded that pressure ulcers in clinical settings develop as a result of poor management
strategies within care settings. From the findings, the outcome of this review can be applied to
clinical practice by forming the basis on which future research can be based on.

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