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Pressure Ulcer Prevention: Performance and Implementation in Hospital Settings
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Pressure ulcers are related to reduced quality of life for patients and high costs for health care. Guidelines for pressure ulcer prevention have been available for many years but the problem remains. Aim: The overall aim of this thesis was to investigate hospital setting factors that are important to the performance of pressure ulcer prevention and to evaluate an intervention focused on implementing evidence-based pressure ulcer prevention. Methods: Four studies with a qualitative and quantitative approach were conducted.  Registered nurses’ performance of pressure ulcer prevention for patients at risk was investigated. Factors related to pressure ulcer prevention at different levels in hospital organizations were examined (hospital and ward type, workload, and nurse staffing) in two hospitals. A quasi-experimental study evaluated the effects of an intervention focusing on pressure ulcer prevention and a descriptive study with interviews examined nurses and first-line managers’ experiences of this intervention. Results: All of the studies show that quality improvement was needed for patients at risk of pressure ulcer. Registered nurses attention to pressure ulcer prevention was low and the caring culture of the wards ranged from organized work to unorganized work. Factors related to pressure ulcer prevention were patients’ age (risk and skin assessment) and patients’ risk (skin assessment, pressure reducing mattresses and planned repositioning), type of hospital (university and general), and ward (geriatric, medical, and surgical). Nurse staffing and workload played a minor role. Significantly more patients received pressure ulcer prevention after the intervention. Important factors for improvement were the support nurses and managers received by external and internal facilitators. Another important factor was interpersonal communication on the care provided by the nurses and first-line managers. Conclusion: Quality improvement regarding evidence-based pressure ulcer prevention was needed. Factors associated with pressure ulcer prevention were related to all levels in the hospital settings. A comprehensive intervention showed statistically significant improvement in the care. Interpersonal communication among the staff based on quality measurements was the key factor. Managers from the micro- to the macro-level have to know the conditions for pressure ulcer prevention and, given their position, ensure that the necessary prerequisites are in place.

  

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. , 73 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1042
Keyword [en]
Pressure ulcer prevention, nursing care, implementation
Keyword [sv]
Trycksårsprevention, omvårdnad, implementering
National Category
Nursing
Research subject
Caring Sciences in Social Sciences
Identifiers
URN: urn:nbn:se:uu:diva-234028ISBN: 978-91-554-9073-7 (print)OAI: oai:DiVA.org:uu-234028DiVA: diva2:755637
Public defence
2014-11-28, Brömssalen, Gävle sjukhus, ingång 11, Centrum för Forskning och Utveckling, Uppsala Univsersitet/Landstinget Gävleborg. Gävle, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2014-11-07 Created: 2014-10-13 Last updated: 2015-02-03
List of papers
1. Registered nurses' attention to and perceptions of pressure ulcer prevention in hospital settings
Open this publication in new window or tab >>Registered nurses' attention to and perceptions of pressure ulcer prevention in hospital settings
2012 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 21, no 9-10, 1293-1303 p.Article in journal (Refereed) Published
Abstract [en]

Aim: To describe how registered nurses perform, document and reflect on pressure ulcer prevention in a specific nurse-patient care situation, as well as generally, on hospital wards.

Background: Registered nurses should provide safe and qualified pressure ulcer prevention, but pressure ulcers remain a problem. Compliance with evidence-based guidelines impedes pressure ulcer formation.

Design: A descriptive design with a multimethods approach.

Method: Nine registered nurses at three wards and hospitals participated. The registered nurses were observed in a specific nurse-patient care situation with patients at risk for pressure ulcers. Interviews followed and patients' records were reviewed. Quantitative and qualitative data analysis methods were used.

Results: Pressure ulcer prevention performed by the registered nurses was dependent on the cultural care, which ranged from planned to unplanned prevention. Diversity was found in compliance with evidence-based guidelines across the wards. Although all patients involved were at risk and the nurses described pressure ulcer prevention as basic care, the nurses' attention to prevention was lacking. Few prevention activities and no structured risk assessments using risk assessment tools were observed, and few care plans were identified. The lack of attention was explained by registered nurses' trust in assistant nurses' knowledge, and prevention was seen as an assistant nurse task.

 Conclusion: Registered nurses paid little attention to pressure ulcer prevention among patients at risk. The planned and unplanned care structures affected the prevention. The nurses trusted and largely delegated their responsibility to the assistant nurses.

Relevance to clinical practice: Evidence-based pressure ulcer prevention is fundamental to patient safety. Care quality is created in situations where patients and care providers meet. How registered nurses work with pressure ulcer prevention, their role and communication, particularly with assistant nurses, should be of major concern to them as well as to healthcare managers.

Keyword
caring culture, interviews, nursing care, observations, pressure ulcer prevention, records review
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-171937 (URN)10.1111/j.1365-2702.2011.04000.x (DOI)000302721700011 ()22429848 (PubMedID)
Available from: 2012-03-29 Created: 2012-03-29 Last updated: 2017-12-07Bibliographically approved
2. Factors contributing to evidence-based pressure ulcer prevention. A cross-sectional study
Open this publication in new window or tab >>Factors contributing to evidence-based pressure ulcer prevention. A cross-sectional study
2014 (English)In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 51, no 5, 717-725 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND

Implementation of evidence-based care for pressure ulcer prevention is lacking. As the hospital organization is complex, more knowledge is needed to understand how nursing care in this area can be improved.

OBJECTIVES

The present study investigated the associations between variables on different levels in the healthcare setting (patient, unit, hospital) and the documentation of (1) risk assessment and (2) skin assessment within 24h of admission, the use of (3) pressure-reducing mattresses and (4) planned repositioning in bed.

DESIGN

A cross-sectional study.

SETTINGS

One university hospital and one general hospital.

PARTICIPANTS

Geriatric (n=8), medical (n=24) and surgical (n=19) units. All adult patients (>17 years), in total 825, were included.

METHODS

A one-day prevalence study was conducted using the methodology specified by the European Pressure Ulcer Advisory Panel, together with the established methods used by the Collaborative Alliance for Nursing Outcomes. Independent variables were patient characteristics, hospital type, unit type, nurse staffing and workload. Dependent variables were documented risk and skin assessment within 24h of admission, pressure-reducing mattresses and planned repositioning in bed. The data were analysed with Logistic regression using the Generalized Estimating Equation (GEE) approach.

RESULTS

Patients at risk of developing pressure ulcers (Braden<17) had higher odds of having risk assessment documented, and of receiving pressure-reducing mattresses and planned repositioning. Patients at the general hospital were less likely to have risk and skin assessment documented and to receive pressure-reducing mattresses. On the other hand, planned repositioning was more likely to be used at the general hospital. When total hours of nursing care was lower, patients had higher odds of having pressure-reducing mattresses but were less likely to have planned repositioning.

CONCLUSION

Patient characteristics (high age and risk score) and hospital type were associated with pressure ulcer prevention. Surprisingly, nurse staffing played only a minor role. Leaders in healthcare organizations should establish routines on different levels that support evidence-based pressure ulcer prevention, and registered nurses need to assume responsibility for bedside care.

National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:uu:diva-214686 (URN)10.1016/j.ijnurstu.2013.09.007 (DOI)000335206900005 ()24144274 (PubMedID)
Available from: 2014-01-09 Created: 2014-01-09 Last updated: 2017-12-06Bibliographically approved
3. Getting evidence-based pressure ulcer prevention into practice: a multi-faceted unit-tailored intervention in a hospital setting
Open this publication in new window or tab >>Getting evidence-based pressure ulcer prevention into practice: a multi-faceted unit-tailored intervention in a hospital setting
2016 (English)In: International Wound Journal, ISSN 1742-4801, E-ISSN 1742-481X, Vol. 13, no 5, 645-654 p.Article in journal (Refereed) Published
Abstract [en]

The aim of the study was to evaluate whether a multi-faceted, unit-tailored intervention using evidenced-based pressure ulcer prevention affects (i) the performance of pressure ulcer prevention, (ii) the prevalence of pressure ulcers and (iii) knowledge and attitudes concerning pressure ulcer prevention among registered and assistant nurses. A quasi-experimental, clustered pre- and post-test design was used. Five units at a hospital setting were included. The intervention was based on the PARIHS framework and included a multi-professional team, training and repeated quality measurements. An established methodology was used to evaluate the prevalence and prevention of pressure ulcers. Nurses' knowledge and attitudes were evaluated using a validated questionnaire. A total of 506 patients were included, of whom 105 patients had a risk to develop pressure ulcer. More patients were provided pressure ulcer prevention care (P = 0·001) and more prevention care was given to each patient (P = 0·021) after the intervention. Corresponding results were shown in the group of patients assessed as being at risk for developing pressure ulcers. Nurses' knowledge about pressure ulcer prevention increased (P < 0·001). Positive attitudes towards pressure ulcer prevention remained high between pre- and post-test surveys. This multi-faceted unit-tailored intervention affected pressure ulcer prevention. Facilitation and repeated quality measurement together with constructed feedback of results seemed to be the most important factor for pressure ulcer prevention.

National Category
Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-232191 (URN)10.1111/iwj.12337 (DOI)000387667600060 ()25060416 (PubMedID)
Available from: 2014-09-15 Created: 2014-09-15 Last updated: 2017-12-05Bibliographically approved
4. Getting evidence-based pressure ulcer prevention into practice – looking into the ‘black-box’ of a multi-faceted intervention in a hospital setting
Open this publication in new window or tab >>Getting evidence-based pressure ulcer prevention into practice – looking into the ‘black-box’ of a multi-faceted intervention in a hospital setting
(English)Manuscript (preprint) (Other academic)
Keyword
Pressure ulcer prevention, nursing care, implementation
National Category
Nursing
Identifiers
urn:nbn:se:uu:diva-234514 (URN)
Available from: 2014-10-20 Created: 2014-10-20 Last updated: 2015-02-03Bibliographically approved

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