Introduction
Pressure ulcers (PU) are also known as decubitus ulcers occur due to the presence of pressure on a particular location of the body for an elongated period of time leading to scarring or other skin injuries. They have been one of the major concerns for several years for nursing professionals especially in the intensive care units because the physical consequences associated with it ranges from mild to severe tissue damage. The major risk factors of HAPUs are long term immobility, old age, sensory deficiency, abnormal circulation, inadequate nutrition, dehydration and other comorbidities . Internationally, PU is a patient safety issue and in clinical practice, the quality care provided by the hospital can be judged by analyzing the efficiency of the nursing professionals in preventing PUs.
Comparing several U.S. acute care units, VanGlider (2009) found that PU prevalence varied from 14.2% to 8.9% to 6.4% in the medical, surgical and orthopedic units, respectively. Vanderwee (2011) reported that the PU prevalence in the Belgium hospital wards ranged from 11.1% to 8.1% to 18.9% in the medical, surgical, and geriatric wards, respectively. Evidence- based practice can result in 50% reduction in the prevalence of PU . This is only possible when PU is detected at an early stage. The EPUAP and NPUAP (2009) published guidelines that recommends the use of assessment tools along with skin assessment test and valid clinical judgment while strategizing care plan for high-risk PU patients. Several important measures such as repositioning and providing support surfaces at regular intervals are important. Studies have pointed out that adequate nutrition supplementation to the old patients who just recovered from their acute illness, effectively reduced PU risks (Langer, 2003). Regular application of moisturizer can help in protecting skin from dryness and moisturizer, which in turn reduces the occurrence of PU .
Irrespective of known effective strategies for PU prevention, implementing these strategies in everyday practice is one of the biggest challenges for nursing professionals. The PARiHS framework suggests that evidence- based practice, regular assessment, encouraging management and fair working culture enables implementation of appropriate care strategies for PU prevention . Irrespective of the presence of effective guidelines, the PU prevalence still remains high in the Swedish hospitals . Nurses work in a clinical micro- system, in which when a patient is admitted, the information about the patient or a population is shared among the healthcare providers and appropriate treatment is planned. In such scenario, it is the registered nurses (RN) responsibility to educate and enable their assistant nurses (AN) to identify the risks of PU sooner. However, several surveys have revealed that most nurses lack interest in detecting the risks and take appropriate measures to treat PU . This further results in negative impact on the education imparted on ANs by RNs.
It can be thus hypothesized that effective planning, documentation, and reflection by RNs and effective training provided to ANs can minimize PU prevalence. Consequently, it stands important for the RNs to strategize effective plans using which they can spread the awareness of the importance of early detection of PU in patients among ANs. There is still a dearth of strategies using which RNs can effectively increase the awareness and commitment in their ANs. Additionally, there is no evidence- or studies that have evaluated the presence of appropriate set up in the hospital that effectively works in preventing PU. Therefore, it becomes important to conduct a research in order to evaluate and assess the performance of the RNs and their process of documentation and reflection when a situation arises, which requires careful management of PU in hospital wards.
Study Design:
A qualitative and quantitative study was conducted, which included descriptive design, semi- structured interviews, observation of RNs and reviewing patient records. 9 nurses (aged 26 – 54 years) from different central hospitals of Sweden were selected from three different departments (geriatric, orthopaedic and medical ward). The RNs supervises ANs, who are responsible for bedside care. All patient related information are documented electronically in these wards (each ward consisted 20 -22 patients). The participating RNs were briefed about the study and later were handed with written information. Data from each ward was collected within a span of two weeks (January – April, 2009). The steps in the data collection were as follows: 1) Risk assessment was performed and the nursing care for PU prevention was observed for all high-risk patients. Field observation protocol (included assessment of skin and risk, activities related to pressure relief, information provided to patients, skin and nutrition care) and field notes noted the activities (interaction between RNs and ANs) of all RN. 2) Post few days’ observation, RN’s were interviewed. 3) Following the observation, all patient records were retrospectively reviewed for all wards. The nursing care steps taken for PU prevention in high-risk patients by each of the RNs were carefully assessed and along with clinical judgment, the risk assessment was done using the Modified Norton Scale (MNS). Patients were considered to be at risk of PU if he/she scored ≤ 20. Out of 83 patients, 32 were at risk for PU. Nurses in- charge of these patients were under observation. The observation was done for 74 hours. Based on the EPUAP guidelines, the semi-structured interviews were conducted and which lasted for 37- 70 minutes. The questions were specific to the nurse- patient scenario and all discussion were recorded and verbally transcribed. Within 4 – 8 days of post observation, 6 interviews were conducted and rest 3 interviews were conducted 11, 13 and 18 days post observation. 32 patient records were carefully reviewed. All nursing documentation was examined. All quantitative data and interview data were analyzed using statistical software SPSS 19.0 and quantitative content analysis, respectively.
Study Results:
32 patients (28 had ≤ 20 MNS score and 4 were immobile) were considered to be at risk for PU. Approximately 50% of the patients had incontinence and poor physical condition. In Ward II, few patients were assessed and supported by the RN’s. Their food and fluid intake was low. Each patient was subjected to frequent repositioning during their daily activities and was given both food and medicinal support. Risk assessment scale wasn’t used. The RNs, ANs, and other medical staffs discussed the PU reports post- patient admission and took appropriate measures in case of risks. In regard to the specific nurse-patient situation, the interviews pointed out five patients from Ward I was at risk. Similarly, 4 patients in Ward II were found to be at risk and 2 of them needed pressure relief. Thus, the ANs were guided by the RNs to keep their skin dry and facilitate pressure relief. The interview data pointed out the obstacles and possibilities during pressure relief (lack of prioritization for pressure relief due to heavy workload, patient disagreement, etc). Caring culture greatly influenced the PU prevention in clinical practice. In Ward I, MNS was reported as a holistic approach to the nursing care plan. The RNs emphasized that structured working techniques enable safe nursing practice and helped in early PU detection, which was further strengthened by patient’s nutritional status. This helped them in planning appropriate care plans. Cross-disciplinary collaboration (e.g. occupational therapist and physiotherapists) provided additional information. RNs and ANs shared a strong bonding and often discussed the turning and repositioning schedules of high-risk patients. In Ward II, the MNS risk assessment was not performed. They focused on providing sufficient nutrition to each patient but found forms unnecessary. They also focused more on mobilization and were totally dependent on the ANs. The decision of using the air mattress or normal mattress was taken collaboratively by RNs and ANs only after performing risk assessments. The RNs of Ward III had no specific policies for PU relief as all were experienced. The pressure relief tactics were applied to only those who showed signs of PU and regular repositioning was rarely performed especially upon relatives influence. As compared to the other two wards, the RNs of this ward were also dependent on the ANs.
The findings of this study indicate that the caring culture highly influences the PU prevention measures. In most cases, it’s been observed that the RN takes very few preventive measures and was solely dependent on the ANs. Additionally; the findings suggest that sticking to the evidence- based guidelines can effectively prevent PU. It also indicates that the adherence to the guidelines differed among different wards. Additionally, there is a huge difference between knowing the preventive measures and following it. This suggests that an appropriate nursing care can be effective only in the presence of the supportive structure. Not only does it helps in successful implementation but also facilitates effective teamwork. Furthermore, this study indicates that evidence- based practice for preventing PU is a fundamental process. Additionally, in clinical practice, prioritizing the communication and roles of ANs in order to facilitate effective PU prevention. Strengthening teamwork, knowledge and communication in all sectors of nursing can result in better quality care and its outcomes among patients.
Ethical Considerations
Each hospital clinical board and Regional Ethical Review Board had approved the study. The working protocol was designed following The Declaration of Helsinki and national and local ethical guidelines for research (CODEX, 2009). Informed consent was obtained from both patients and the nursing professionals. Confidentiality of both patients and nurses was aptly maintained by the researchers. There were no ethical considerations regarding the treatment or lack of it.
Conclusion
This outcome of this study indicates that awareness and attention of hospital administration, RNs and ANs needs to be strengthened in order to reduce the prevalence of PU. Both structured and unstructured caring culture highly affects the RN’s reflection and the quality of care. Practicing evidence- based guidelines can increase compliance. The results also indicated that the ANs had adequate knowledge of PU prevention and were dependable. The results of this study can used to improve nursing care for preventing PU.
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