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 injury education for older adults and carers living in community settings: A scoping review

Older adults are at increased risk of pressure injuries (PIs) due to age-related changes. Traditionally, PI knowledge and education have been delivered in hospitals and residential aged care facilities, however, there remains a critical gap in understanding how PI knowledge on prevention and management is shared with older adults and their carers living in the community. We aimed to describe the nature and characteristics of structured and unstructured PI education programs available to community-dwelling older adults and their carers. As coping review was undertaken. We searched five databases: CINAHL, Medline, Scopus, Cochrane Library and ProQuest from 2009 to August 2023. The review was guided by Arksey and O'Malley's six-step framework and adhered to the PRISMA-ScR guidelines. It included primary peer-reviewed papers published in English, which focus on PI education for older adults and/or their carers living in community settings. Data extraction was organised in a table, and findings presented as a narrative summary. One-hundred and thirty-six papers were screened and four included in the review. Results indicate that consideration was placed on literacy levels and cognitive status of older adults and their carers when designing PI education materials. Educational materials such as leaflets/brochures, in-person training sessions or a combination of both were used. However, duration of these interventions varied, lasting for 1-4 weeks while others were completed over 12 months. Some improvements in PI knowledge such as how to treat PI, dietary requirements and importance of mobility were noted. However, information retention and its translation into effective long-term behaviour change remained unclear. In conclusion, adopting a multifaceted educational approach increases the effectiveness of PI knowledge translation. Continuous education, support and reinforcement on PIs over time are necessary when interacting with older adults and caregivers to ensure long-term management and prevention success. Conversations on PIs should start at the primary care levels when older adults and carers are visiting their GP clinics and accessing support services for other healthcare needs. Understanding older adults' and carers' literacy levels, cognitive status and cultural background can assist clinicians in designing and delivering fit-for-purpose PI educational interventions that are accessible, relatable and effective in promoting knowledge transfer and behaviour change. Carers are vital conduits in the care continuum. These factors will lead to a more informed, collaborative and person-centred approaches to PI management and prevention.

Insights into pressure injury prevention: Assessing the knowledge, attitudes, and practices of Palestinian nursing students

AIM

To assess the knowledge, attitudes, and practices of Palestinian nursing students towards pressure injury prevention.

MATERIALS AND METHODS

A descriptive cross-sectional study was conducted with 455 nursing students recruited from Arab American University-Palestine, employing a total population sample. Data collection forms include socio-demographic information, the Pressure Ulcer Knowledge Assessment Tool, Attitude towards Pressure Ulcer Prevention Instrument and Pressure Injury Preventive Practices scale.

RESULTS

The study found that students had a mean knowledge score of 54% (14.04/26), a positive attitude score of 75.8% (39.42/52), and demonstrated a fair level of practice 75.3% (30.12/40). Significant differences were observed in the Knowledge, Attitude, and Practice total scores, linked to academic year, clinical experience, and the number of attended departments during clinical training (p < 0.001). Additionally, weak but significant positive relationships were found between practice and attitude scores (r = 0.303, p < 0.001), practice and knowledge score (r = 0.211, p < 0.001), and a moderate positive significant relationship between knowledge and attitude scores (r = 0.567, p < 0.001).

CONCLUSION

The study revealed insufficient knowledge, positive attitudes, and somewhat unsafe practices among nursing students regarding pressure injury prevention. It highlights the need for specific revisions in the nursing curriculum. Improvements can be achieved through detailed coverage in classrooms and laboratories, integrating simulation methods. Additionally, ensuring that students gain adequate experiences in clinical units, with a specific emphasis on pressure injury prevention, is crucial for improving students' capability and contribute to better pressure injury management.

Improving Patient Safety: Learning from Reported Hospital-Acquired Pressure Ulcers

Introduction

A hospital-acquired pressure ulcer (HAPU) is a localized lesion or injury to the underlying tissue (wound) while the patient is on admission. It occurs when standardized nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardized care for pressure ulcers or manage HAPUs results in patient harm. We aim to share lessons from a reported HAPU incident and address the knowledge gap in patient safety risk assessment, identification, and wound management at Nyaho Medical Centre (Accra, Ghana).

Methods

A review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyze and evaluate the interventions over 12 weeks (Aug-Oct 2021).

Results

Development of policies and a standard operating procedure for pressure ulcers and wounds improved accuracy in identifying pressure ulcer risks and management of wounds. Eighty-three patients were assessed with the pressure ulcer assessment tool. Complete (100%) adherence to the pressure ulcer and wound policy and standard operating procedure (SOP) was achieved, and the number of HAPUs decreased from five to one during the study period.

Conclusion

This study demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.

Barriers and facilitators of evidence-based physiotherapy practice in Iran: A qualitative study

BACKGROUND

To facilitate evidence-based practice (EBP) in physiotherapy in Iran and guide future improvements, it is crucial to identify what barriers and facilitators exist in the current system from the physiotherapist's perspective. Therefore, the purpose of this study was to explore the barriers and facilitators of EBP in physiotherapy in Iran.

METHODS

This qualitative study was conducted using a phenomenological approach from January to July 2023 in Iran. The sampling process started with a purposive approach, and then an attempt was made to identify and interview more potential samples with the snowball approach. Thematic analysis was used to analyse the collected qualitative data.

RESULTS

44 individuals, including 37 physiotherapists and seven faculty members, participated in this study. Several barriers and facilitators to evidence-based physiotherapy practice in Iran were found and then put into three themes: (1) individual factors, (2) practice environment factors, and (3) extra-organisational factors. The most common barriers were time/workload pressures, financial incentives, lack of motivation, weakness in English, managers' pressures, inadequate awareness among patients, infrastructure limitations, poor economic situation, Internet restrictions, inappropriateness of the educational curriculum, difficult access to scientific research, and lack of insurance coverage for up-to-date therapies.

CONCLUSIONS

Although most of the participants had a very positive view of physiotherapy based on scientific evidence, various obstacles have prevented this approach from being well implemented in Iran. Therefore, it is necessary to move towards minimising the existing barriers at the individual, practice environment, and extra-organisational levels by adopting effective multilateral policies.

Psychosocial factors impacting community-based pressure ulcer prevention: A systematic review

BACKGROUND

Pressure ulcers are a major health concern. They have a significant impact on the healthcare system and individuals, reducing quality of life across several domains. In community settings, self-management behaviours are central to their prevention. However, adherence with pressure ulcer prevention guidelines remains low, with little evidence guiding the relationship between patients and healthcare professionals to establish a concordant partnership.

OBJECTIVE

To synthesise evidence on factors contributing to community-based pressure ulcer prevention using the Theoretical Domains Framework and the Capability, Opportunity, Motivation, Behaviour (COM-B) model of behaviour.

DESIGN

Mixed methods systematic review and narrative synthesis.

METHOD

Systematic searches were conducted in the CINAHL, Cochrane, EMBASE, PsycINFO, PubMed, Scopus, and Web of Science databases on 14th December 2022. Studies were eligible if they contained data on the factors associated with adherence and concordance with pressure ulcer prevention guidelines in the community for patients, caregivers, and healthcare professionals. Methodological quality was assessed using the Hawker tool. Findings were synthesised using the Theoretical Domains Framework. The resulting themes were mapped onto the Capability, Opportunity, Motivation, Behaviour (COM-B) model.

RESULTS

Thirty studies were included in the review, including quantitative, qualitative, and mixed methods research. The synthesis identified 12 of the 14 Theoretical Domains Framework domains, with knowledge, social influences, beliefs about consequences, and beliefs about capabilities the most prevalent. Although knowledge appears to be an important contributor to adherence with prevention guidelines, knowledge alone does not appear sufficient to achieve concordance. A concordant relationship was facilitated by healthcare professionals' knowledge, motivation to work alongside patients and their priorities, and interpersonal skills to build rapport and trust, whilst barriers included lack of healthcare professional skills to navigate sensitive issues, paternalistic views of patient compliance and organisational processes that impact building rapport.

CONCLUSIONS

Several psychosocial factors may affect the ability to achieve concordance between individuals, caregivers and healthcare professionals with pressure ulcer prevention guidelines in the community. However, data regarding the efficacy of behaviour change interventions targeting these constructs is limited, with further research required to guide intervention development in this area.

Barriers and facilitators to implementing pressure injury prevention and management guidelines in acute care: A mixed-methods systematic review

BACKGROUND

Evidence-based pressure injury prevention and management is a global health service priority. Low uptake of pressure injury guidelines leads to compromised patient outcomes. Understanding clinicians' and patients' views on the barriers and facilitators to implementing guidelines and mapping the identified barriers and facilitators to the Theoretical Domains Framework and behaviour change techniques will inform an end-user and theoretically informed intervention to improve guideline uptake in the acute care setting.

OBJECTIVES

To synthesise quantitative and qualitative evidence on i) hospital clinicians' and inpatients' perceptions and experiences of evidence-based pressure injury practices and ii) barriers and facilitators to implementing guidelines.

DESIGN

A convergent integrated mixed-methods systematic review was conducted using the JBI approach.

DATA SOURCE

English language peer-reviewed studies published from 2009 to August 2022 were identified from MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Central Library.

REVIEW METHODS

Included studies reported: i) acute care hospital clinicians' and patients' perceptions and experiences of evidence-based pressure injury practices and ii) barriers and facilitators to implementing guidelines. The Mixed Methods Appraisal Tool was used for critical appraisal. Quantitative data was transformed into qualitised data, then thematically synthesised with qualitative data, comparing clinicians' and patients' views. Barriers and facilitators associated with each main theme were mapped to the Theoretical Domains Framework and allocated to relevant behaviour change techniques.

RESULTS

Fifty-five out of 14,488 studies of variable quality (29 quantitative, 22 qualitative, 4 mixed-methods) met the inclusion criteria. Four main themes represent factors thought to influence the implementation of evidence-based guidelines: 1) nurse-led multidisciplinary care, 2) patient participation in care, 3) practicability of implementation and 4) attitudes towards pressure injury prevention and management. Most barriers identified by clinicians were related to the third theme, whilst for patients, there were multiple barriers under theme 2. Barriers were mainly mapped to the Knowledge domain and Environmental Context and Resources domain and were matched to the behaviour change techniques of "instruction on how to perform a behaviour" and "restructuring the physical environment". Most facilitators mentioned by clinicians and patients were related to themes 1 and 2, respectively, and mapped to the Environmental Context and Resources domain. All patient-related attitudes in theme 4 were facilitators.

CONCLUSIONS

These review findings highlight the most influential factors related to implementing evidence-based pressure injury care from clinicians' and patients' views and mapping these factors to the Theoretical Domains Framework and behaviour change techniques has contributed to developing a stakeholder-tailored implementation intervention in acute care settings.

PROSPERO REGISTRATION

CRD42021250885.

The implementation of a community-centered first aid education program for older adults-community health workers perceived barriers

BACKGROUND

Older adults are a high-risk group for accidental injuries, and strengthening training in first aid for older adults can improve their first aid capabilities and minimize their post-accident mortality. Community health workers are the greatest option to equip older adults with first aid instruction and training. However, the development of first aid education for the public by community health workers fails to take into account the elderly population. In view of this, this study aims to explore the barriers and challenges of first aid training for older adults from the perspective of community health workers and to provide a basis for better first-aid training for older adults in the community.

METHODS

This study adopted a qualitative research design. A total of 18 community health workers were recruited from two community health service centers in Qujing and one community health service center in Guangzhou from May to July 2022 to participate in the study. Participants were interviewed face-to-face using semi-structured in-depth interviews. The interview data were analyzed using Krippendorff's thematic clustering technique.

RESULTS

The results of the study identified community health workers' perceived challenges and barriers to providing first aid training to older adults in the community as older adults-level barriers, community health workers-level barriers, management systems-level barriers, and society-level barriers.

CONCLUSIONS

Community health workers are highly aware of multiple barriers and challenges in providing first aid training to community-based elderly populations. In particular, lack of professional training, heavy workloads, and limited resources and financial support. Therefore, supportive training, policies, and government funding are crucial for community health workers to conduct first aid training for older adults.

Acceptability and Impact of an Educational App (iCare) for Informal Carers Looking After People at Risk of Pressure Ulceration: Mixed Methods Pilot Study

Background

Pressure ulcers are areas of skin damage resulting from sustained pressure. Informal carers play a central role in preventing pressure ulcers among older and disabled people living at home. Studies highlight the paucity of pressure ulcer training for informal carers and suggest that pressure ulcer risk is linked to high levels of carer burden.

Objective

This pilot study evaluated a smartphone app with a specific focus on pressure ulcer prevention education for informal carers. The app was developed based on the principles of microlearning. The study aimed to explore carer perspectives on the acceptability of the app and determine whether the app increased knowledge and confidence in their caring role.

Methods

In this concurrent mixed methods study, participants completed quantitative questionnaires at baseline and at the end of weeks 2 and 6, which examined caregiving self-efficacy, preparedness for caregiving, caregiver strain, pressure ulcer knowledge, and app acceptability and usability. A subsample of participants participated in a “think aloud” interview in week 1 and semistructured interviews at the end of weeks 2 and 6.

Results

Of the 32 participants, 23 (72%) participants completed the week 2 and 16 (50%) completed the week 6 questionnaires; 66% (21/32) of carers participated in qualitative “think aloud” interviews, and 18 (56%) also participated in semistructured interviews at week 2, and 13 (41%) at week 6. Pressure ulcer knowledge scores significantly changed (F1,6.112=21.624; P=.001) from baseline (mean 37.5; SE 2.926) to the second follow-up (mean 59.72, SE 3.985). Regarding the qualitative data, the theme “I’m more careful now and would react to signs of redness” captured participants’ reflections on the new knowledge they had acquired, the changes they had made to their caring routines, their increased vigilance for signs of skin damage, and their intentions toward the app going forward. There were no significant results pertaining to improved preparedness for caregiving or caregiving self-efficacy or related to the Caregiver Strain Index. Participants reported above average usability scores on a scale of 0 to 100 (mean 69.94, SD 18.108). The app functionality and information quality were also rated relatively high on a scale of 0 to 5 (mean 3.84, SD 0.704 and mean 4.13, SD 0.452, respectively). Overall, 2 themes pertaining to acceptability and usability were identified: “When you’re not used to these things, they take time to get the hang of” and “It’s not a fun app but it is informative.” All participants (n=32, 100%) liked the microlearning approach.

Conclusions

The iCare app offers a promising way to improve informal carers’ pressure ulcer knowledge. However, to better support carers, the findings may reflect the need for future iterations of the app to use more interactive elements and the introduction of gamification and customization based on user preferences.

Efficacy of Human-Recombinant Epidermal Growth Factor Combined with Povidone-Iodine for Pressure Ulcers and Its Influence on Inflammatory Cytokines

Purpose

To determine the clinical efficacy of recombinant human epidermal growth factor (rh-EGF) combined with povidone-iodine (PVI) on patients with pressure ulcers (PUs).

Methods

One hundred and five PU patients treated between January 2018 and January 2021 were enrolled and retrospectively analyzed. Of them, 50 patients who received conventional treatment were assigned to the control group (Con group), while 55 patients treated with rh-EGF combined with PVI were assigned to the observation group (Obs group). The two groups were compared in clinical efficacy, PU alleviation (total area reduction rate, total depth reduction rate, and total volume reduction rate), healing time, pain degree (Visual Analog Scale [VAS] score), inflammatory indexes (interleukin-8 [IL-8], tumor necrosis factor-α [TNF-α], and hypersensitive C reactive protein [hs-CRP]), and hydroxyproline content in the wound.

Results

The Obs group yielded a higher total effective rate than the Con group (P < 0.05). The Obs group also experienced statistically shorter healing time and milder pain, with better PU alleviation and lower levels of inflammation indexes compared with the Con group (all P < 0.05). In addition, a higher hydroxyproline content in the wound was found in the Obs group.

Conclusions

All in all, rh-EGF combined with PVI has a definite curative effect on patients with PUs. It can promote PU alleviation and hydroxyproline secretion in the wound and inhibit pain and inflammatory reactions, which is worthy of clinical promotion.

Critical care nurses' knowledge, attitudes, and practices of pressure injury prevention in China: A multicentric cross-sectional survey

Pressure injury is a serious and preventable problem in intensive care units. Translating guidelines into clinical practice can reduce the incidence of pressure injury. Identifying clinical status, barriers and facilitators contribute to guideline implementation. To identify the knowledge, attitudes, and practices of pressure injury prevention in Chinese critical care nurses. Secondary data were extracted from a multicentric clinical trial. Knowledge and attitudes toward pressure injury prevention were assessed by a fourteen-item questionnaire. The observed practices were recorded using a case report form. The report complies with the STROBE statement. A total of 950 critical care nurses in 15 hospitals from six provinces of China were investigated. A total of 53.1% of nurses received a median score of 6 points or less. Knowledge regarding the repositioning procedure, risk assessment, and heel pressure injury prevention was insufficient. Over 99% of nurses strongly or somewhat agreed that pressure injury prevention was very important and that they were willing to take measures to prevent pressure injury. A total of 27 781 patient days of pressure injury prevention practice were recorded. Repositioning was the most commonly used prevention measure, followed by support surfaces and prophylactic dressings. A combination of repositioning, support surface, and prophylactic dressing was lacking. Chinese critical nurses showed a low level of knowledge and a positive attitude toward pressure injury prevention. Practices of pressure injury prevention were unsatisfactory. There is a clear gap between the guidelines and clinical practices. The barrier (low-level knowledge) and facilitator (positive attitude) were identified in this study. According to these findings, strategies need to be developed to promote guideline implementation.

Interventions for the treatment and prevention of pressure ulcers

Pressure ulcers can affect multiple aspects of an individual's life. Though preventable, pressure ulcers place a substantial economic burden on healthcare services. Countries around the world have set pressure ulcer prevention and treatment as a high priority. National Clinical Guidelines recommend a wide range of preventative and curative treatments. However, there is still much uncertainty regarding the effectiveness of preventative and curative treatments. This overview of systematic reviews aims to describe the findings of 15 Cochrane reviews on the treatment and prevention of pressure ulcers included in a previous umbrella review and to expand upon their findings in the context of clinical practice.

The efficacy of continuing nursing interventions on intraoperative pressure ulcer-related complications in breast cancer patients: systematic review and meta-analysis

BACKGROUND

This study systematically reviewed the effects of continuous nursing intervention on intraoperative pressure ulcers (PUs) and related complications in breast cancer patients. The effectiveness of continuous nursing intervention for intraoperative pressure ulcers related complications in breast cancer patients is highly controversial. Therefore, it is necessary to systematically review and address this issue by means of meta-analysis.

METHODS

By searching the Cochrane Library, PubMed, Web of Science, Embase, and Chinese Biomedical Literature Database (CBM) were screened. Quality evaluation and data extraction were performed for the included studies, and meta-analysis was performed for the included RCTs using Review Manager 5.2 software. Literature was included in strict compliance with the PICOS principle, and bias risk was analyzed by t-test and funnel plot.

RESULTS

A total of 1,431 patients were enrolled in 9 studies, and meta-analysis showed that there was a significant statistical difference between the experimental group and the control group in the incidence of PUs [odds ratio (OR) =0.18, 95% confidence interval (95% CI): 0.13-0.24, P<0.00001], the Braden pressure ulcer risk score after nursing [mean difference (MD) =2.64, 95% CI: 1.47-3.81, P<0.0001], and the quality of life after nursing (MD =9.76, 95% CI: 6.82-12.69, P<0.00001).

DISCUSSION

Continuous care can reduce the incidence of PUs in patients with advanced breast cancer, reduce the severity of wounds in the healing process of PUs, and improve the knowledge of PUs in patients with advanced breast cancer risk.

Knowledge of pressure injury in medical and surgical nurses in a tertiary level hospital: A cross-sectional study

BACKGROUND

Nurses play a vital role in pressure injury prevention (PIP) but require foundational knowledge to ensure appropriate PIP strategies are enacted.

AIMS

To describe and compare medical and surgical nurses' knowledge of pressure injury (PI) in a tertiary level hospital in China, and to identify predictors of PI knowledge among these groups.

DESIGN

A cross-sectional survey was conducted between June and December 2020.

METHODS

Registered nurses from nine medical and fifteen surgical wards in a tertiary hospital were invited. The survey was composed of two parts; demographic and professional characteristics; and the Chinese translated version of the Pressure Ulcer Knowledge Assessment Tool 2.0 (PUKAT 2.0) where the total score ranged from 0 to 25; higher scores imply more knowledge. Medical and surgical nurses' knowledge test scores were compared using independent t-test. Multiple linear regression analysis was used to determine factors predictive of nurses' knowledge.

RESULTS

In total, 423 nurses from 24 wards participated the study and 404 nurses (95.5%) completed the knowledge test (Surgical n = 236, 58.4%; Medical n = 168, 41.6%). The PUKAT 2.0 mean score was 11.6 ± 3.0 (Surgical 12.2 ± 3.0; Medical 10.7 ± 2.8) with 335 (82.9%) nurses scoring <60%. Multiple linear regression showed working in surgical wards, nurse-in-charge position and previous PI training were significant predictors of knowledge scores.

CONCLUSION

Knowledge is a precursor to safe practice. Nurses demonstrated poor knowledge of PIP. Pressure injury related education may help improve nurses' knowledge but the extent to which it is used in place and impacts patients' outcome requires more investigation.