Literature Review on Analgesia Administration in Limb Trauma

Introduction

This assignment aims to establish a critique of a published academic paper in relevance to paramedic practice. There are clear foundations that this assignment is based upon which include the systematic process regarding the development of a search strategy. In addition, this assignment also intends to explain and justify the relative robustness of the chosen research and the trustworthiness of its findings. The research methodologist utilised is Helen Aveyard as she provides clarity and a stepwise approach in regard to the research process. In relation to paramedic practice, this assignment will also establish a distinct link between the relevance and implications of the research to clinical practice. The published paper that this assignment is based upon is the ‘Efficacy of Intravenous Paracetamol Versus Intravenous Morphine in Acute Limb Trauma’ (Jalili et al, 2016). As this piece of research is an attempt to revolutionise analgesia administration in limb trauma, the common theme throughout this assignment will be evidence based practice in healthcare.

Evidence based practice

Evidence based practice refers to the most suitable resolutions and clinical decisions for the betterment of patient care as a whole (Ellis, 2016). Decisions in clinical practice are based upon using the most valid, current and best available evidence to implement practice (Ellis, 2016). Evidence based practice is integrated to consider and satisfy patient values and preferences along with other clinical considerations (University Health Sciences Library,2019) (See Appendix 1.1). Along with gaining better solutions to healthcare, research aims to provide insight into the justification of common practice (Parahoo, 2014). A clear definition of research regarding clinical practice is difficult to obtain as the role is constantly expanding and evolving in order to meet the demands of society (Parahoo, 2014). The concept of clinical ‘know how’ is considered a conventional perspective while exploring research (Parahoo, 2014). This nature of research leads to a tendency to leave medical interventions or processes the way they are and does not leave room for further progress in the field of clinical practice enhancements (Parahoo, 2014). In contrast the ‘know why’ approach is considered the more superior and contemporary perspective of informing and revolutionising practice (Parahoo, 2014). Overall, both concepts are regarded a necessity for the enhancement of paramedic practice.

 In contrast, other researches explain how evidence based practice in healthcare is individualistic and involves uncertainties (Ellis, 2016). Ellis (2016) demonstrates how evidence based practice is simply the adherence of medical processes that superior clinicians have practiced for generations. In reference to paramedic practice, it is regarded compulsory for paramedics to engage in evidence based practice and evaluate their own clinical practice (Ramsden & Curtis, 2011). The adaption to following a good evidence base has resulted in healthcare professionals to provide justifications and acknowledge the evidence behind any medical intervention performed (Thurston, 2014). Parahoo (2014) illustrates the need for critiquing research; the research process ensures that the researcher can individually select reliable research which can be considered applicable to informing clinical practice.

 Moving into the ambulatory care environment, this enables the clinicians to apply their own professional judgement on the foundation of a robust body of research evidence (Mooney & Griffiths, 2011). Moule & Hek (2011) implies the necessity of basing care on current practice as it results in the betterment of patient care. The Health and Care Professionals Council (2014) recognises paramedics to be evidence based practitioners. Similarly, the HCPC (2014) require all paramedics to engage in evidence based practice throughout their careers as it is a requirement which must be achieved in order to gain registration. Moreover, under the Standards of Proficiency developed by the HCPC (2014), it clearly demonstrates that the paramedic has an individualised responsibility to ‘recognise the value of research to the critical evaluation of practice.’ Additionally, the College of Paramedics- Scope of Practice Policy (2017) articulates that the paramedic should individually progress and update their own clinical knowledge using evidence based practice, with a particular focus upon patient outcomes. Therefore, finalising the importance of evidence based practice in relation to paramedicine.

Search strategy

The initial phase in discovering a relevant research paper which can be critiqued and discussed is to identify a topic area of personal interest (Aveyard, 2018). Aveyard (2018) explains the usefulness of selecting an incident which has already occurred in the clinicians own practice. Research projects which arise as the direct result of a particular incident, prompts the researcher to explore the chosen topic area in more detail (Aveyard, 2018). Aveyard (2018) also supports the notion of exploring previous incidents as it allows the student to develop his professional portfolio. The topic area chosen was analgesia in limb trauma. A particular research focus was placed upon to compare and contrast the efficacy of intravenous paracetamol against intravenous morphine. This topic area was selected as there is an insignificant quantity of research based upon comparing both forms of analgesia against each other. The interest of analgesia in limb trauma had been commenced as a result of a previous incident whilst being on an ambulance placement. When investigating by exchanging dialogue with other healthcare professionals, it was apparent that both forms of analgesia have their own strengths and weaknesses. After conferring, it also became evident to see that there is a deficiency of academic research conducted prehospitally for both forms of analgesia.

Moving forward, the importance of attaining a clear focused initial question is considered compulsory as it provides structure for the research review process (Aveyard, 2018). Parahoo (2014) supports the formulation of an initial research question as it is described as the first step in the research process, A valid initial research question will allow the researcher to be directed to literature which is most suited to answer the question (Aveyard, 2018). The initial question selected investigated the comparison of the effectiveness of intravenous paracetamol against intravenous morphine in limb trauma. Aveyard (2018) also explains the consequences of not initiating research with a clear question. The use of a question which is too vague, broad or undefined will leads the researcher to be led in many different directions; most often it will produce a high quantity of information which is impossible to process (Aveyard, 2018). Aveyard (2018) also guides researchers by highlighting acronym tools which aid the development of the initial research question (See appendix 1.2) The most common is the PICO tool (Population, intervention or issue, comparison or context and outcome (Aveyard, 2018). These prompts are a guide to aid a balanced and focussed research question (Aveyard, 2018). Following this, keywords from the PICO tool were selected as they allow a broader spectrum of results to be attained by the researcher (Aveyard, 2019). The patients (P) studied would be those who are over the age of eighteen and have suffered limb trauma. The intervention (I) investigated was analgesia. The comparison (C) included the trial of intravenous paracetamol against intravenous morphine sulphate. Lastly, the outcome (O) examined the effectiveness and the safety of both drugs on reducing pain after a traumatic limb injury. The wide selection of keywords proposed by the PICO tool allows the researcher to conduct an appropriate search on literature using a suitable data base. Aveyard (2018) recommends utilising the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database for healthcare professionals as it allows a search to be commenced, which only selects research articles. Mooney & Griffiths (2011) supports Aveyard (2018) by also directing healthcare professionals to develop their search based upon the CINAHL database.

Progressing on to the search strategy resulted in the formation of a structured search. Aveyard (2018) clarifies the need for a structured search strategy as it allows the researcher to identify and locate academic papers which are highly relevant and correspond to the research question. Similarly, Aveyard (2018) illustrates the significance of a structured search by advising against random literature searching. Aveyard (2018) describes that without a thorough search strategy, searching will be unsystematic and random. Furthermore, the concept of ‘cherry picking’ when searching for literature, demonstrates how researchers may only select relevant literature which has been produced from a primary search (Aveyard, 2018). Correspondingly, the concept of ‘cherry picking’ is best supported by Parahoo (2014) who suggests that the reduction of researcher selection bias is solely dependent on a structured search strategy.

The commencement of an initial search, allows the researcher to determine whether the body of literature is accessible to address the research question (Aveyard, 2018). Aveyard (2018) also clarifies that whilst it is possible to undertake a systematic search of literature which may show very little in relation to the research question, or undertaking a review on a vast amounts of literature is not ideal as it is unlikely that a successful critical appraisal of literature will be demonstrated (Aveyard, 2018). Aveyard (2018) warned researchers of performing a basic search as it can produce very limited and incomprehensible results. Research into the topic base was initially conducted using a primary scoping search, using Boolean operators (‘and’, ‘or’, ‘not’) (See appendix 1.3). Utilising Boolean operators coincides with the advice of (Aveyard, 2018) as the use of them results in the development of a basic to advanced search.

A systematic scoping search has often been utilised in order to distinguish relevant literature from a particular evidence base (Aveyard, 2018). An initial scoping search is useful as it allows an overview of the range and depth of research regarding a topic of interest (Aveyard, 2018). Aveyard (2018) indicates that if after conducting an initial scoping search there appears to be very little on the chosen topic or if there is a widely extensive amount of literature, then the researcher should refine the research question. The CINAHL database was originally searched with the use of keywords such as ‘limb trauma’ OR ‘analgesia’. This basic search resulted in the production of nine hundred and one academic papers by the search engine. Aveyard (2018) advises against a large production of literature and directs researchers to refine the initial question. Following this, through the process of trial and error and the correct utilisation of Boolean operators; the advanced search resulted in the production of six primary researchers based academic papers. The keywords and booleans utilised in the final search included ‘emergency medicine’ AND ‘intravenous paracetamol’ AND ‘intravenous morphine’. The search figure of six academic papers satisfies Aveyard’s recommendation. Aveyard (2018) implies a figure of between six to fifteen articles is appropriate for an undergraduate assignment. All six articles produced were parallel to one another as they all compared both forms of analgesia in the emergency setting. Aveyard (2018) proposes that research articles which are discovered after a systematic search, which collectively focuses on the researchers chosen topic, is evidence of an adequate search.

Following the database search which provided the selected academic research paper, an inclusion/exclusion criterion was developed. This criterion was established as it allows the researcher to identify and demonstrate the scope of the literature itself (Aveyard, 2018). Also, the inclusion/exclusion criterion is viewed as mandatory practice and is responsible for the development of high quality research (East, 2018). Furthermore, it is of high importance that the researcher is able to define and produce an appropriate inclusion/exclusion criterion as it may possibly impact the external validity of the research results (Supino & Borer, 2012). A few examples which demonstrate what the inclusion criteria shows are as follows; post 2009 research, adults, primary quantitative research and emergency medicine (See appendix 1.4). This inclusion criterion was chosen as post 2009 era research ensures best up to date practice is being investigated. Furthermore, adults instead of children were included in the inclusion criteria as the pain reduction scores are clearer and can be utilised as a significant finding for the research. Children were excluded as they possess a natural inability to understand and correctly convey pain to researchers on a number rating scale. A few examples of which the exclusion criteria are based upon includes; pre 2009 era research, children, secondary quantitative research and non-emergency medicine. Aveyard (2018) implies that it is of high importance that the researcher is able to justify the selection of the criteria and must not be based on the researchers own convenience. Overall throughout this process the initial question has been refined to; ‘efficacy of intravenous paracetamol and intravenous morphine sulphate in the presentation of acute limb trauma.’ The revision of the initial question to one that is not leading or too broad is supported by Aveyard (2018).

 Appendix

1.1

1.2

1.3

1.4

References

• Aveyard, H. (2018) Doing a Literature Review in Health and Social Care: A practical Guide, 4th edition.England: Open University Press.
• College of Paramedics (2017) Paramedic- Scope of Practice Policy. Available online: https://www.collegeofparamedics.co.uk/downloads/171121_Paramedic_-_Scope_of_Practice_Policy.pdf Accessed [17/04/2019].
• East, C. (2018) Developing a Successful Clinical Research Program. USA: Springer.
• Ellis, P (2016) Evidence- based Practice in Nursing, 3rd edition. London: SAGE Publications.
• Health and Care Professionals Council (2014) Standards of Proficiency- Paramedics. Available online: https://www.hcpc-uk.org/resources/standards/standards-of-proficiency-paramedics/ Accessed [20/04/2019].
• Mooney, G. & Griffiths, P. (2011) The Paramedic’s Guide to Research: An Introduction. Berkshire: Open University Press.
• Moule, P. & Hek, G. (2011) Making Sense of Research : An Introduction For Health and Social Care Practitioners, 4th edition. London: SAGE Publications Ltd.
• Parahoo, K. (2014) Nursing Research Principles, Process and Issues, 3rd edition. London: Palgrave Macmillan
• Ramsden,C. & Curtis, K. (2011) Emergency and Trauma Care for Nurses and Paramedics. Australia: Elsevier.
• Supino, P. & Borer, J. (2012) Principles of Research Methodology: A Guide for Clinical Investigators. Brooklyn: Springer.
• Thurston, M. (2014) Key Themes in Public Health. New York: Routledge
• University Health Sciences Library (2019) Evidence based practice. Available online: https://guides.lib.unc.edu/c.php?g=498016&p=3418079 Accessed [21/04/2019].