Barriers and enablers to the implementation of evidence-based practice in pressure ulcer prevention and management in an integrated community care setting: A qualitative study informed by the theoretical domains framework

Pressure ulcer reduction is a healthcare priority. Good clinical guidelines have the potential to transform pressure ulcer prevention and management practices. However, evidence suggests these guidelines are inconsistently utilised. The aim of this study was to explore health practitioners' perceived barriers and enablers to the implementation of evidence-based pressure ulcer prevention and management recommendations in an integrated community care setting. The study used a qualitative exploratory design. It took place in a community Trust in London, England. Semi-structured interviews were conducted with a purposive sample of registered nurses and allied healthcare professionals (AHPs). The Theoretical Domains Framework (TDF) informed both data collection and data analysis. Analysis followed a five-step process including deductive coding of the transcripts and inductive generation of specific belief statements. Nine nurses and four AHPs took part in the study. Six TDF domains were identified as most relevant to the implementation of best practice in pressure ulcer prevention and management: Goals, Knowledge, Skills, Beliefs about capabilities, Environmental context and resources and Social influences. All participants felt it was important to prevent pressure ulcers and were motivated to do so. Key enablers to the implementation of evidence-based practice included high levels of self-reported pressure ulcer knowledge and skills (nurses), responsive community equipment provision, the introduction of novel Pressure Ulcer Implementation Facilitator roles and integrated team working. Barriers included self-reported deficits in knowledge and skills (AHPs), worries about inspecting intimate anatomical locations (AHPs), difficulties initiating conversations with patients about risk and behaviour change, high workloads and clutter in the home. Family members and mobile working solutions were identified as both enablers and barriers. Potential routes to addressing implementation challenges are identified and recommendations made for future research.

Patient and lay carer education for preventing pressure ulceration in at-risk populations

BACKGROUND

Pressure ulcers (PUs) are injuries to the skin and underlying tissues that occur most commonly over bony prominences, such as the hips and heels as a result of pressure and shear forces. PUs cause pain, discomfort, longer hospital stays, and decreased quality of life. They are also very costly to treat and consume substantial parts of healthcare budgets. PUs are largely preventable, and education targeted at patients and their carers is considered important.

OBJECTIVES

To assess the effects of patient and/or lay carer education on preventing pressure ulceration in at-risk people, in any care setting.

SEARCH METHODS

In June 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; Ovid PsycINFO and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies.  There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that recruited people of any age at risk of pressure ulceration, and RCTs that recruited people who informally care for someone at risk of pressure ulceration.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment, and GRADE assessment of the certainty of the evidence.

MAIN RESULTS

We included 10 studies with 11 publications (2261 participants analysed). Seven targeted their intervention at people at risk of ulceration and measured outcomes on these at risk people; two targeted those at risk and their family carers and measured outcomes on the at risk people cared for by their families; and one targeted lay carers only and measured outcomes on the at risk people they cared for. There were two main types of interventions: the provision of information on prevention of pressure ulcers, and the use of different types of education programmes. Provision of information on the prevention of pressure ulcers Three studies (237 participants) reported data for this comparison: two provided information directly to those at risk and their carers, and the third provided information to lay carers. As data could not be pooled we present individual study data. The evidence for primary outcomes is of very low certainty (downgraded twice for study limitations and twice for imprecision). We are uncertain whether the combined use of a self-instruction manual and one-to-one patient training and counselling versus a self-instruction manual alone reduces the proportion of at risk people developing a new PU (risk ratio (RR) 0.40, 95% confidence interval (CI) 0.14 to 1.18), or whether carer self-instruction and one-to-one counselling versus self-instruction alone reduces the proportion of at risk people developing a new PU (RR 2.05, 95% CI 0.19 to 21.70). We are uncertain whether the use of home-based training, compared with routine ward-based training, reduces the proportion of at risk people developing a new PU (RR 0.53, 95% CI 0.27 to 1.02). One study explored the secondary outcome patient knowledge of pressure ulcer prevention; however, as usable data were not provided, we were unable to carry out further analysis, and no effect estimate could be calculated. Educational programmes on the prevention of pressure ulcers Seven studies (2024 participants analysed) provided data for this comparison. In all studies the intervention was aimed at people at risk of ulceration. Risk of pressure ulceration One secondary report of an included study reported the primary outcome as time to PU development or occurrence and three studies and one secondary report of an included study reported this as the proportion of at risk people developing a new PU. One study reported the secondary outcome grade of PU and five studies and one secondary report of an included study reported on patient knowledge. There is low certainty evidence of there being no clear difference in the proportion of participants developing a new PU between use of a pressure ulcer prevention care bundle (PUPCB) and standard care: HR 0.58, 95% CI 0.25 to 1.33 (downgraded twice for imprecision). One secondary report of an included study explored whether individualised PU education and monthly structured telephone follow-up reduces the mean time to PU occurrence. Not all participants in this study developed a pressure ulcer, therefore the mean time to pressure ulcer occurrence could not be calculated from the data. We are uncertain whether the following three interventions reduce the proportion of at risk people developing a new PU as we assessed the certainty of evidence as very low: individualised PU education and monthly structured telephone follow-up (RR 0.55, 95% CI 0.23 to 1.30), education delivery (RR 3.57, 95% CI 0.78 to 16.38), (downgraded twice for risk of bias and twice for imprecision); and computerised feedback and one-to-one consultations (no clear data provided), (downgraded twice for risk of bias and once for indirectness). Grade of pressure ulcer There is low certainty evidence that use of a PU prevention care bundle may make no difference to the severity of new PU development when compared with standard care. Patient knowledge We are uncertain whether the following interventions improve patient knowledge: enhanced educational intervention and structured follow-up (mean difference (MD) 9.86, 95% CI 1.55 to 18.17); multi component motivational interviewing/self-management with a multi component education intervention (no clear data provided); Spinal Cord Injury Navigator programme (no clear data provided); individualised PU education and monthly structured telephone follow-up (no clear data provided); computerised feedback (no clear data provided), structured, patient-centric PU prevention education event (MD 30.15, 95% CI 23.56 to 36.74). We assessed the certainty of the evidence for this outcome as low or very low (downgraded for risk of bias, imprecision, or indirectness).

AUTHORS' CONCLUSIONS

We are uncertain whether educational interventions make any difference to the number of new PUs that develop, or to patient knowledge based on evidence from the 10 included studies, which we assessed as of low or very low certainty due to problems with risk of bias, serious imprecision and indirectness. The low certainty of evidence means that additional research is required to confirm these results.

Evaluation of a formal care worker educational intervention on pressure ulceration in the community

AIMS AND OBJECTIVES

To develop and evaluate an educational intervention for formal care workers on pressure ulceration in the community.

BACKGROUND

Pressure ulcers are a major burden to health care and with an ageing population likely to increase. Formal care workers are ideally placed to identify high risk but lack standardised educational provision.

DESIGN

An insider approach to action research in one provider organisation, November 2014-May 2015.

METHODS

Number and categorisation of pressure ulcers, within three community nursing teams before and four months after intervention was delivered to a purposive sample (n = 250) of formal care workers, were assessed and the taught element evaluated using a questionnaire and verbal feedback.

RESULTS

Total number of pressure ulcers reduced from 28-20, category II, 19-11, III unchanged at 6 and IV from 2-0 following the educational intervention. Key risk factors included impaired mobility (71%), urinary incontinence (61%) and previous pressure damage (25%), and 71% had formal care worker input. The intervention was highly rated 4·95/5 by 215 (86%) formal care workers in the evaluation questionnaire.

CONCLUSIONS

Formal care workers receive little, if any, education on pressure ulceration. An educational intervention can have a positive effect within community care, with the potential to reduce direct costs of care. However, a standardised approach to education is required; an urgent review of the education provision to formal care workers, in the UK and around the world, is therefore essential if the potential that formal care workers offer is to be realised.

RELEVANCE TO CLINICAL PRACTICE

Formal care workers are ideally placed to help identify and alert healthcare professionals about patients at high risk of developing pressure ulcers. If this potential is to be realised, a standardised approach to education is required.