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A Nurse-Led Approach to Preventing Pressure Ulcers
This article discusses a nurse-led multidisciplinary approach that care providers can use to reduce pressure ulcers (PUs) within their organizations. Given the current understanding of PU etiology and prevention, evidence-based prevention protocols and pressure-relief strategies serve as critical foundational principles that must be applied to significantly influence PU prevalence and incidence. Because nursing plays an important role in rehabilitation facility management, nurses’ expertise, leadership, and knowledge make nursing the most appropriate discipline to design protocols, implement innovative solutions, and lead the charge for PU prevention.
Defining the Issue
Between August 2002 and July 2005, quality improvement organizations examined processes within long-term care (LTC) facilities, focusing primarily on the reduction of pain, physical restraints, and pressure ulcers (PUs; Centers for Medicare & Medicaid Services, 2007). Although the care quality measures of pain and physical restraints have been steadily improving, reducing the national prevalence of PUs has proven more difficult. The presence of PUs is a marker of poor overall prognosis and quality of care (Lyder, 2003), and there is universal agreement that PU prevention is a serious concern. Failure to prevent or heal PUs also can lead to litigation (Bennett, O’Sullivan, DeVito, & Remsberg, 2000). Controversy and litigation will continue to be associated with PUs until healthcare providers recognize that the body’s largest organ (the skin) is vulnerable and that it will eventually fail, just as any other organ in the body. Consequently, proactive prevention strategies that adhere to National Pressure Ulcer Advisory Panel standards must be developed and implemented.
Early identification of skin integrity needs is a primary concern, especially to rehabilitation nurses whose knowledge and expertise are used to maximize patients’ functional levels. Care providers constantly strive to improve the quality of patient care, and these efforts, along with imperatives from government and private entities, have resulted in increased emphasis on PU prevention. Numerous strategies that can reduce the number of PUs have been identified, but providers have not successfully achieved a PU-free environment.
PUs present a common but preventable condition seen most often in high-risk populations, such as elderly people and those living with mobility impairments. If PU prevention is considered an important quality-of-care focus, why do dismal PU prevalence and incidence rates persist? The authors of this article postulate that nursing leadership does not fully realize its potential, and through a nurse-led interdisciplinary approach, quality of care can be improved as evidenced by decreased PUs. A nurse-led approach that involves the participation of all nurse and nonnurse staff has not been reported in the literature. Nurses need to recognize the wealth of “people power” that is available to support implementation of mobility and other prevention strategies, and they must take steps to integrate these people into a well-organized team. Nurses are the appropriate practitioners to lead prevention teams because their role is to coordinate the nursing plan of care. How can nurses make changes at the organizational level to enhance interdisciplinary prevention efforts and improve quality of care related to PUs? Given the frequent interdisciplinary interactions among rehabilitation nurses, other staff, and administration, nurses have a unique role in fostering organizational changes that may contribute to PU prevention through education. Moreover, nurses need to redefine their roles with regard to influencing the organizational processes and policies that characterize educational programs, cultural changes, and actions designed to reduce the prevalence and incidence of PUs.
System-Wide, Nurse-Led Response
Envision information as the machine and knowledge as the people who make the machine function. Information becomes knowledge only when it takes on a “social life.” As Brown and Duguid (2000) noted, “For all information’s independence and extent, it is people, in their communities, organizations, and institutions, who ultimately decide what it all means and why it matters” (p. 18); additionally, Brown and Duguid noted that, “Knowledge is something we digest rather than merely hold. It entails the knower’s understanding and some degree of commitment” (p. 120). Nurse leaders must consider that information only becomes valuable and usable in a social context. Consequently, nurses should share information about PU prevention with all willing nurse and nonnurse staff and family members. Leading in a culture of change requires shifting the current context, helping create new settings conducive to learning, and sharing the idea that learning is important (Fullan, 2001). Allowing all voices to be heard within the organization is imperative because this integrates diversity and capitalizes on the power of collective minds. Table 1 addresses risk factors that influence the development of PUs and prevention strategies; in addition, it presents nurse-led multidisciplinary approaches that care providers can use to reduce PUs within their organization.
Background and Significance
PUs are among the most common conditions encountered in patients who are acutely hospitalized or require long-term institutional care. The epidemiology of PUs differs among settings, with incidence rates ranging between 0.4% and 38% in acute care, 2.2% and 23.9% in LTC, and 0% and 17% in home care (incidence rates lower than 2% are ideal; Reddy, Gill, & Rochon, 2006). Researchers and care providers previously have directed their efforts toward understanding the physiological basis for PU etiology and identifying mechanisms to prevent PUs. As a result, it has become “common knowledge that pressure, and the ensuing obstruction of capillary flow, is the main cause of these wounds” (van Rijswijk & Lyder, 2005, p. 7). Because circulatory disease is one of the leading admission diagnoses in LTC, it is a major contributing factor to the continued rise in PU incidence (Dunham-Taylor & Pinczuk, 2010).
Exposure to pressure for extended periods of time is the main cause of PUs; impaired mobility is the most common reason people are exposed to unrelieved pressure. When people are admitted to rehabilitation facilities, their condition is not static; PU examinations must be ongoing. Evidence demonstrates that PU development is not selective based on age and length of stay (Park-Lee & Caffrey, 2009). Attention needs to focus on the design and investigation of interdisciplinary prevention approaches that consider the organizational climate and culture and are inclusive of all patients. A lack of both knowledge and compliance with prevention protocols is a major concern.
Despite the fact that numerous well-designed prevention protocols have been developed for staff and adopted for use in rehabilitation facilities, incidence and prevalence data suggest that PUs remain a significant problem (Park-Lee & Caffrey, 2009). Additional factors such as tissue tolerance, skin moisture resulting from sweating or incontinence, and nutrition are known to increase risk for developing PUs, but the physiological basis for tissue ischemia is produced by pressure (Lyder & van Rijswijk, 2005). The primary prevention focus must be twofold: an organizational culture that embraces investigations of interdisciplinary prevention approaches to reduce pressure for all patients, and an integration of strategies to guide care delivery that results in effective prevention protocols (Table 1).
The use of prevention protocols increases staff awareness of mobility interventions including pressure-shifting prevention strategies (repositioning/moving the patient every 2 hours or more often when seated) that can enhance care delivery and result in decreased PU incidence (Thomas & Osterweil, 2005). Pressure shifting can be accomplished by intervening on a regular basis to increase patient movement (spontaneous or assisted). Mobility activities such as repositioning, turning, and walking are recognized as appropriate methods to change or eliminate a patient’s point of contact with a surface. Other effective strategies that reduce PU incidence include regular periodic shifting of an extremity or body weight or active or passive movement of a body part. Prevention protocols play an instrumental role in guiding the use of these and other preventive strategies.
When developing and identifying strategies to foster adherence to PU prevention protocols, nursing involvement is needed if these strategies are to be appropriate, logical, and effective within the organization. Such strategies may include development of visual reminders of prevention protocols, such as posters; re-engineering of the nurse and certified nursing assistant (CNA) subcultures to enhance team functioning; and providing education about the rationale for specific interventions. Educational programs must be comprehensive and available to all. Successful implementation of PU-prevention standards and processes requires that the program be periodically reinforced and administered to all levels of current and incoming clinical staff. Establishing partnerships with members of other disciplines through sharing of existing strategies and designing new strategies can go a long way toward contributing to a positive organizational culture. In addition, these strategies encourage mobility and also can be performed or reinforced by occupational therapy and physical therapy during patient visits; these tasks should not be viewed as the sole responsibility of nursing, however. Nurses should include other disciplines in the nursing plan of care to optimize PU-prevention outcomes.
High staff turnover (especially CNA turnover) has been a concern because rehabilitation facilities are inherently labor intensive and lack of knowledgeable staff can have far-reaching consequences such as increased PUs. Castle and Engberg (2006) contend that turnover rates interfere with continuity of care and increase the number of inexperienced workers who lack adequate knowledge, weakening the standard of care. Knowledgeable CNAs can positively influence PU prevention because they primarily are responsible for the care of patients with regard to mobility and activities of daily living.
PU-prevention program information should include, but is not limited to, the following (National Pressure Ulcer Advisory Panel, 2007):
PUs can interfere with functional recovery, cause pain, decrease quality of life, and lead to a significant increase in prolonged hospital stays; conseqeuently, the systematic evaluation of a PU-prevention program is critical. It is necessary to understand the effectiveness of the overall program and the point at which the program breaks down if ongoing quality improvement is to occur.
An organizational culture (shared beliefs, perceptions, and expectations of members) that promotes PU prevention can buffer PU threats through the dissemination of knowledge. Because of the shared nature and implicit understanding of the norms and values within an organization, the culture can have a dramatic effect on efforts to change PU procedures and processes. Over time, facility staff will have shared experiences and a history that forms a culture. The organizational culture affects any effort to implement change. In addition, leaders from the top down must demonstrate a commitment to change—it is only when leaders are visibly committed to change that staff are enabled to openly embrace change. When this culture does not exist, staff are unwilling to share possibilities for improvement. Because organizational culture has been associated with nursing care and patient safety in the healthcare environment (Boan & Funderburk, 2003), a nurse-led course of action geared toward decreasing prevalence and incidence of PU is the logical approach to engaging management and staff in a culture of change that has zero tolerance for PUs.
Nurses also must be actively involved in planning the essential care factors needed to provide quality and cost-efficient care and sustain the resulting organizational transformation. Nurses should begin by developing a strong planning process; they must work with all staff to understand the needs of the facility in relation to patient needs. Keeping in mind the strong base of the nursing process (assessment, planning, implementation, and evaluation), nurses can effectively move within the organizational system and create positive change within the facility. Historical information and staff and administration assumptions are important to the process. For example, if nurses have had poor experiences changing the system in the past, they may assume that change cannot occur.
The opinions of experienced staff members should not be overlooked; additionally, PU trends are important to consider and will help determine the results to be achieved and the interventions that need to be in place. Organizational support should address explicit competencies for caring for adults with complex needs (enhancing the foundation of knowledge), and resources staff will need to deliver that quality care. Flexibility is a key component to immediate and future success, and sustainability of changes over time is best accomplished through a well-guided team effort.
A nurse-led multidisciplinary approach to PU reduction provides individualized care that enhances quality of life. Patients in rehabilitation facilities often are frail and highly dependent upon caregivers for their physical needs. A nurse-led, team-based approach is needed to help staff time, pace, and direct care that will optimize patient movement (allowing for assessment) and lead to enhanced PU-prevention outcomes. Housekeeping staff, for example, are well suited to notice whether patients remain in the same ¨position for an extended period of time. If these staff members are made aware of the need for patients to move, they can serve as valuable resources to the nursing staff. This cost-effective approach will have a near-zero budget impact and contribute to cost savings ranging from $500 to $40,000 that otherwise may be used to treat a single ulcer (Lyder, 2003). Finally, because a facility is both a social and clinical setting, the patient’s visiting family member(s) also should become aware and involved. Nurses can educate family members about PU awareness and prevention strategies, such as the need to shift body weight and increase mobililty.
Increased longevity means that the likelihood a person will need some form of care is much higher today than in the past. With these demographic changes and the added requirements of specialized care, the standard of care that patients receive must be optimal. Even though PU development is widely recognized as a key indicator of quality of care, especially in rehabilitation and skilled LTC facilities, PU prevalence and incidence continue to increase, especially in these settings (Park-Lee & Caffrey, 2009; Wurster, 2007).
Based on current understanding of PU etiology and prevention, adherence to evidence-based prevention protocols and pressure relief is critical to reduce PU prevalence and incidence. Because nurses play important roles as managers in rehabilitation facilities, their expertise, leadership, and knowledge makes nursing the most appropriate discipline to design protocols, implement innovative solutions, and lead the charge to prevent PUs. PU development has been identified as a nurse-sensitive indicator of quality outcomes in all care settings, and especially in rehabilitation (Wurster, 2007). Reducing PU prevalence and incidence is possible through a well-designed, innovative, nurse-led, multidisciplinary, team-based approach.
About the Authors
Tracey L. Yap, PhD RN, is an assistant professor and deputy director of nursing at the NIOSH Educational Research Center at the University of Cincinnati in Cincinnati, OH. Address correspondence to her at firstname.lastname@example.org.
Susan M. Kennerly, PhD RN, is an associate professor at College of Nursing, University of Cincinnati in Cincinnati, OH.
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