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.

Wound tissue segmentation by computerised image analysis of clinical pressure injury photographs: a pilot study

OBJECTIVE

Wound tissues can provide ample information about the wound development and healing process. However, the manual identification and measurement of wound tissue types is time-consuming and challenging due to the complexities of pressure injuries (PI). This study aims to develop an image analysis algorithm to automatically identify and differentiate wound tissue types from PI wound beds.

METHOD

This was a cross-sectional algorithm development study. PI photographs were obtained from a western Pennsylvania hospital. We used our previously developed wound bed segmentation tool to identify PI wound beds. We then used the k-means clustering method to classify the subzones on the wound beds. Finally, the support vector machine classifier was used to identify the classified subzones to certain types of wound tissue.

RESULTS

An image analysis algorithm was developed, using 64 selected PI photographs, to automatically identify different wound tissues for PIs.

CONCLUSION

Validation of the wound tissue identification of the PIs by image analysis algorithm demonstrated that our image analysis algorithm is a reliable and objective approach to monitoring wound healing progress through clinical PI photographs, and offers new insight into PI evaluation and documentation.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Evaluation of an educational film as a learning tool for nurses caring for seniors with pressure ulcers

Background:  Pressure ulcers last to be a severe and prevalent health condition in hospitals; they have been considered the most physically debilitating and expensive problems of the twentieth century. Advanced pressure ulcers are common in the elderly; about 70% happen in cases 65 years or older, peaking range from 70 and 80. Many pressure ulcers are considered preventable or even treatable with the proper procedures to preserve skin integrity. Objectives: This work aims to evaluate the influence of an instructional film on nurses caring for seniors with pressure ulcers in terms of attitude and knowledge. Materials and Method. The research employed a quasi-experimental design and was conducted in intensive care Units of the General Mansoura Hospital, Specialized Medical Hospital, and Emergency Hospital in Dakhalia governorate. The research surveyed 69 nurses. Two instruments were utilized in this research: the Braden Scale and a two-part structured interview schedule sheet. Results: Following the educational film, the nurse's practice and knowledge increased, plus there was an enhancement in wound healing of pressure ulcers for older adults. Conclusion: This study concluded that nurses' knowledge and attitude have improved after displaying the educational film program.

Legal implications of pressure injuries: experience of a tissue viability nurse expert

NHS Resolution manages the Clinical Negligence Scheme for Trusts, and aims to reduce the cost of litigation in terms of clinical negligence claims. To achieve this, potential clinical negligence claims are screened to assess whether to defend the claim or to provide an out-of-court settlement. Nurse experts from all nursing specialties are engaged to review all documentation and patient records to offer an opinion on the viability of a claim. This article describes the processes involved in assessing tissue viability clinical negligence claims, providing examples of evidence that guided decisions and advice on how nurses can protect their organisation from costly litigation.

The impact of an educational intervention on home support workers' ability to detect early pressure ulcer damage

OBJECTIVE

To investigate the impact of an educational intervention on home support workers' ability to detect early pressure ulcer damage.

METHOD

A repeated measure design was employed to quantify the effectiveness of an educational intervention, consisting of one pre-test and two post-tests.

RESULTS

Education was provided to home support workers and this was followed by an assessment of their ability to correctly classify 20 photographs detailing varying stages of skin damage severity. At the baseline (pre-education), 58% of the photographs were classified correctly. At post-test 1, 55% of the photographs were classified correctly. In post-test 2 this increased to 58%, achieving the original baseline scores. There was a moderate negative relationship between pre-training and post-test 2 scores (r=-0.44; n=27; p=0.02).

CONCLUSIONS

The educational intervention has been shown not to have a statistically significantly positive effect on home support workers' ability to detect early pressure ulcer damage. The moderate negative relationship between pre-training and post-test 2 scores concur with the aforementioned qualitative findings, and similarly indicate behaviour associated with individuals experiencing difficulty comprehending new health terms.

Ongoing nursing training influence on the completion of electronic pressure ulcer records

INTRODUCTION

Pressure ulcer (PU) care in nursing at the Hospital Clínico Universitario de Valladolid (HCUV) in Spain includes basic care and its registration through the electronic GACELA Care tool. To assess and evaluate the nursing intervention in PU evolution, a training programme was carried out to unify criteria on PU assessment, treatment, evaluation and monitoring.

OBJECTIVE

To assess the influence of training on the completion of PU records in the GACELA Care application, and identify the level of satisfaction of the nurses after its use.

MATERIALS AND METHODS

A quasi-experimental prospective study consisting of a specific training programme assessed pre- and post-training was carried out on the records of PU documentation at the HCUV. The PU records included in the study were collected using the electronic nursing healthcare management computer tool GACELA Care and belonged to patients admitted for >48h, excluding venous, arterial and stage I PUs. The pre-training sample consisted of 65 records collected between 1 April and 30 June 2014, and there were 57 post-training records, completed from 1 January to 31 March 2015. The training programme consisted of thirty-minute theoretical and practice training sessions. The study variables were ulcer type, location, stage, length and diameter, perilesional skin, cure type, products used and cure frequency, in addition to the number of actions taken in the records in correlation to the days of hospitalisation. To identify the nurses' opinions, a satisfaction survey about the management platform of ongoing Castilla y León training was administered.

RESULTS

The variations from the pre- to the post-training PU-sample completion rates were the following: from 23% to 40% for PU diameter, from 11% to 38% for PU length and from 57% to 79% for perilesional skin condition records. There was also a significant increase in the number of form updates after the training activity. The nurses' level of satisfaction with the training activity showed a positive outcome, with an average score of 8.84 over 10.

CONCLUSION

The training activity improved PU record completion significantly and was deemed positive by the nurses, mainly for its applicability in clinical practice.

The relationship among pressure ulcer risk factors, incidence and nursing documentation in hospital-acquired pressure ulcer patients in intensive care units

AIMS AND OBJECTIVES

To explore the quality/comprehensiveness of nursing documentation of pressure ulcers and to investigate the relationship between the nursing documentation and the incidence of pressure ulcers in four intensive care units.

BACKGROUND

Pressure ulcer prevention requires consistent assessments and documentation to decrease pressure ulcer incidence. Currently, most research is focused on devices to prevent pressure ulcers. Studies have rarely considered the relationship among pressure ulcer risk factors, incidence and nursing documentation. Thus, a study to investigate this relationship is needed to fill this information gap.

DESIGN

A retrospective, comparative, descriptive, correlational study.

METHOD

A convenience sample of 196 intensive care units patients at the selected medical centre comprised the study sample. All medical records of patients admitted to intensive care units between the time periods of September 1, 2011 through September 30, 2012 were audited. Data used in the analysis included 98 pressure ulcer patients and 98 non-pressure ulcer patients. The quality and comprehensiveness of pressure ulcer documentation were measured by the modified European Pressure Ulcer Advisory Panel Pressure Ulcers Assessment Instrument and the Comprehensiveness in Nursing Documentation instrument.

RESULT

The correlations between quality/comprehensiveness of pressure ulcer documentation and incidence of pressure ulcers were not statistically significant. Patients with pressure ulcers had longer length of stay than patients without pressure ulcers stay. There were no statistically significant differences in quality/comprehensiveness scores of pressure ulcer documentation between dayshift and nightshift.

CONCLUSION

This study revealed a lack of quality/comprehensiveness in nursing documentation of pressure ulcers. This study demonstrates that staff nurses often perform poorly on documenting pressure ulcer appearance, staging and treatment. Moreover, nursing documentation of pressure ulcers does not provide a complete picture of patients' care needs that require nursing interventions.

RELEVANCE TO CLINICAL PRACTICE

The implication of this study involves pressure ulcer prevention and litigable risk of nursing documentation.

Pressure injury prevention strategies in acute medical inpatients: an observational study

BACKGROUND

Pressure injuries are a patient safety issue. Despite the suite of prevention strategies, sustained reductions in pressure injury prevalence rates have not been achieved. Generally, nurses are usually responsible for assessing patients' pressure injury risk, and then implementing appropriate prevention strategies. The study aim was to describe five planned and implemented pressure injury prevention strategies (risk assessment, management plan, support surface, repositioning, and education), and determine if a relationship existed between the planning and implementation of support surfaces and regular repositioning.

METHOD

An observational study collecting data using chart audits and semi-structured observations. Data were analysed using descriptive and inferential statistics. This study was set in four medical units across two Australian metropolitan hospitals. The sample comprised adult medical inpatients with reduced mobility. A subsample of participants assessed at pressure injury risk on admission was drawn from this sample. Participants were aged ≥18 years, had a hospital length of stay of ≥3 days prior to recruitment, provided an informed consent, and had reduced mobility.

RESULTS

There was suboptimal planning and implementation of pressure injury prevention strategies for the sample and subsample. There was a significant relationship between planned and implemented support surfaces at both hospitals; however, no relationship existed between the planned and implemented of regular repositioning at either site.

CONCLUSION

The planning and implementation of pressure injury strategies is haphazard. Patients received support surfaces; however, gaps exist in pressure injury risk assessment, management planning, regular repositioning, and patient education.

Pressure Ulcer in Norway-A Snapshot of Pressure Ulcer Occurrence across Various Care Sites and Recommendations for Improved Preventive Care

Pressure ulcers (PU) are common in all care settings, although most ulcers are preventable. Much evidence exists on Hospital Acquired Pressure Ulcers (HAPU), however, few studies describe PU in community care. From a Norwegian perspective, little is known about pressure ulcer prevalence and prevention strategies across the variety of healthcare sectors. Therefore, this study explored PU prevalence and preventive care in home care, nursing homes and hospitals. Seventeen postgraduate wound care students collected data. A data collection instrument by Jordan O’Brien and Cowman was used together with an online forum in which students described how to improve practice to reduce PU incidence. This study showed that pressure ulcers are a problem across all care settings in Norway; however, nursing homes had the highest proportion of at risk patients and the highest prevalence. By implementing the care bundle provided by the Patient Safety Programme across all care settings, increasing staff competency and make sure that access to appropriate equipment for beds and chairs is readily available, a structured and evidence based approach to prevention could be ensured.

Reduction in wound healing times, cost of consumables and number of visits treated through the implementation of an electronic wound care system in rural Australia

Globally, wound care costs the health care system 2-3% of the total expenditure on health, which equates to several billion dollars annually. To date, there are little data on the cost and healing rates of various wounds. This has been partly because of the difficulty in tracking wound management as the majority of wound care data has been focused on retrospective data from hospitals, general practice clinics and aged care facilities. This study reports on wound healing and cost of wounds collected from a larger project using the mobile wound care (MWC) electronic documentation system, which has been described elsewhere. The study involved 2350 clients from four health service districts in the Gippsland region in rural Australia who received treatments as part of the MWC research project (2010-2012), with a total of 3726 wounds identified (so an average of 1·6 wounds per client). By the end of the data collection period, 81% of these wounds had healed. A significant drop in healing time, cost of consumables and number of visits was found across the 3-year period.

The prevalence, aetiology and management of wounds in a community care area in Ireland

This study aimed to establish the prevalence and aetiology of wounds, allowing an insight into the management of wound care, the use of dressings and the nursing time allocated to the provision of wound care in a community setting in Ireland. A cross-sectional survey was used, with data collected on all clients in the community who received treatment from public health nurses or community registered general nurses for wound care over a 1-week period in April 2013. A 98.9% response rate was realised, and 188 people were identified as having wounds, equating to a crude prevalence of 5% of the active community nursing caseload. A total of 60% (n=112) had leg ulcers, 22% (n=42) had pressure ulcers, 16% (n=30) had an acute wound (surgical or traumatic wounds), 1% (n=2) had a diabetic foot wound and a further 1% (n=2) had wounds of other aetiologies. The mean duration of wounds was 5.41 months. A total of 18% of wounds were identified as infected; however, 60% (n=112) of wounds had antimicrobial products in use as either a primary or secondary dressing. The study established that there is a significant prevalence of wounds in this community care area. There was absence of a clinical diagnosis in many cases, and evidence of inappropriate dressing use, risking an increase in costs and a decrease in good clinical outcomes. It also highlighted the importance of ongoing education and auditing in the provision of wound care.

Pressure ulcer prevention knowledge among Jordanian nurses: a cross- sectional study

Background

Pressure ulcer remains a significant problem in the healthcare system. In addition to the suffering it causes patients, it bears a growing financial burden. Although pressure ulcer prevention and care have improved in recent years, pressure ulcer still exists and occurs in both hospital and community settings. In Jordan, there are a handful of studies on pressure ulcer. This study aims to explore levels of knowledge and knowledge sources about pressure ulcer prevention, as well as barriers to implementing pressure ulcer prevention guidelines among Jordanian nurses.

Methods

Using a cross-sectional study design and a self-administered questionnaire, data was collected from 194 baccalaureate and master’s level staff nurses working in eight Jordanian hospitals. From September to October of 2011, their knowledge levels about pressure ulcer prevention and the sources of this knowledge were assessed, along with the barriers which reduce successful pressure ulcer care and prevention.

ANOVA and t-test analysis were used to test the differences in nurses’ knowledge according to participants’ characteristics. Means, standard deviation, and frequencies were used to describe nurses’ knowledge levels, knowledge sources, and barriers to pressure ulcer prevention.

Results

The majority (73%, n = 141) of nurses had inadequate knowledge about pressure ulcer prevention. The mean scores of the test for all participants was 10.84 out of 26 (SD = 2.3, range = 5–17), with the lowest score in themes related to PU etiology, preventive measures to reduce amount of pressure/shear, and risk assessment. In-service training was the second source of education on pressure ulcer, coming after university training. Shortage of staff and lack of time were the most frequently cited barriers to carrying out pressure ulcer risk assessment, documentation, and prevention.

Conclusions

This study highlights concerns about Jordanian nurses’ knowledge of pressure ulcer prevention. The results of the current study showed inadequate knowledge among Jordanian nurses about pressure ulcer prevention based on National Pressure Ulcer Advisory Panel guidelines. Also, the low level of nurses’ pressure ulcer knowledge suggests poor dissemination of pressure ulcer knowledge in Jordan, a suggestion supported by the lack of relationship between years of experience and pressure ulcer knowledge.

A review of PU prevalence and incidence across Scandinavia, Iceland and Ireland (Part I)

OBJECTIVE

To provide a critical appraisal and synthesis of the published literature pertaining to pressure ulcer (PU) prevalence, incidence and prevention practices from the context of Scandinavia, Iceland and Ireland.

METHOD

An integrative research review following Cooper's five stages. Studies published in peer-reviewed journals, involving any study design, but specifically exploring PU prevalence or incidence in adults or children, in any care setting, were included.

RESULTS

Fifty-five papers were data extracted, quality appraised and included in the qualitative synthesis of the review. Mean prevalence in Norway was 17% (4.8-29%) in Ireland was 16% (4-37%), in Denmark was 15% (2.2-35.5%) and in Sweden was 25%, (0.04-42.7%). Prevalence in Iceland was 8.9%. In acute care, mean prevalence was 21% (0-42.7%) and in long stay was 12% (2.4-23.7%). Prevalence among hospice patients was 35.7%, and in community care was 0.04% and 4%. No incidence study from Iceland was identified; the single incidence study from Norway noted a figure of 16.4%. The mean incidence from Ireland was 11% (8-14.4%) from Sweden was 20% (3.1-49%) and Denmark was 1.8% (1.4-2.7%). Mean incidence in acute care setting was 17.6%, (1.4-49%); in long stay was 6.63% (3.1-8.4%). Incidence in the hospice setting was 20.4%. No study reported PU incidence figures from the community setting.

CONCLUSION

Figures for both prevalence and incidence were similar in Ireland and Norway and highest in Sweden, whereas Denmark demonstrated the lowest incidence rates and Iceland demonstrated the lowest prevalence rates. Figures were consistently highest in acute care and hospice settings, and lowest in the care of the older person setting.

A review of PU risk assessment and prevention in Scandinavia, Iceland and Ireland (part II)

OBJECTIVE

To provide a critical appraisal of nurses risk assessment and pressure ulcer (PU) preventive practices across Scandinavia, Iceland and Ireland.

METHOD

An integrative research review following Cooper's five stages. Studies published in peer-reviewed journals, involving any study design, but specifically exploring PU risk assessment or preventative practices, in any care setting, were included.

RESULTS

Risk assessment practice was primarily investigated in the acute care setting and was found to be irregular, based on both numeric scales and clinical judgments. This irregular practice means that some vulnerable patients are not screened for pressure ulcer risk, conversely, when risk assessed, a care plan is not necessarily provided.A significant gap in nurse documentation, together with a lack of supporting evidence for repositioning and use of appropriate redistribution devices was also identified,indicating a lack of a standardised approach to pressure ulcer prevention.

CONCLUSION

Despite an abundance of literature exploring this subject, it is clear that current practice in pressure ulcer prevention is not embedded within best practice recommendations. Therefore, to address the potential patient safety implications, clinical practice could benefit from exploration and identification of practical methods for improving actual pressure ulcer preventive practice.

Implementation of a successful electronic wound documentation system in rural Victoria, Australia: a subject of collaboration and community engagement

To describe the steps needed for a successful implementation of an e-health programme (the Mobile Wound Care system) in rural Victoria, Australia and to provide recommendations for future e-health initiatives. Wound care is a major burden on the health care system. Optimal wound care was found to be impeded by issues that included the limited access to health care providers, incomplete and inconsistent documentation and limited access to expert review. This study trialled the use of a shared electronic wound reporting and imaging system in combination with an expert remote wound consultation service for the management of patients with chronic and acute wounds in Gippsland. The trial sites included four rural Home and Community Health Care providers. Considerable effort was put into designing a best practice e-health care programme. There was support from managers and clinicians at regional and local levels to address an area of health care considered a priority. Various issues contributing to the successful implementation of the wound care project were identified: the training model, quality of data collected, demands associated with multiple sites across a vast geographic region, computer access, hardware and computer literacy.