Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers

Background. In the Netherlands much attention has been paid to pressure ulcer prevention. National guidelines on pressure ulcer prevention were developed in 1985 and adapted in 1992 at the request of a national organization for quality assurance in health care. Several studies indicate that nurses seem to be insufficiently informed about pressure ulcer preventive activities. There is, however, no information available about the reasons why nurses seem to be insufficiently informed. Aims and objectives. This study was planned to elucidate the views and beliefs of health care workers (especially enrolled nurses) in Dutch nursing homes about pressure ulcer prevention and about issues related with pressure ulcer prevention. Design. A qualitative study with semi‐structured, tape‐recorded interviews. Method. Interviews were conducted with enrolled nurses, team leaders, head nurses, staff nurses and physicians. The interviews were coded and analysed. Results. Analysis of the interviews revealed that today's pressure ulcer preventive activities are very much based on old traditions in nursing. It also showed that enrolled nurses have no intention to change the care they deliver with regard to pressure ulcer prevention. Conclusions. It is concluded that a systematic approach is necessary to change nursing thinking and acting with regard to pressure ulcer prevention. Relevance to clinical practice. This study gives an overview of the views and beliefs of health care workers (especially enrolled nurses) in Dutch nursing homes about pressure ulcer prevention. These views and beliefs can be used as a starting point for effective implementation of guidelines regarding the prevention of pressure ulcers.     

Knowledge of pressure ulcer prevention: a cross-sectional and comparative study among nurses

Background  

Pressure ulcers are a common, painful and costly condition. Results of a 1991 study into the knowledge among Dutch hospital nurses on the usefulness of measures to prevent pressure ulcers showed moderate knowledge. Results were confirmed by subsequent studies. In recent years, Dutch guidelines have been updated and the attention given to pressure ulcer care has been increased. This was expected to improve pressure ulcer care and to increase nurses' knowledge. The aims of the current study were to investigate (1) how much nurses employed in Dutch hospitals know about the usefulness of 28 preventive measures considered in the most recent national pressure ulcer guideline; (2) whether differences in knowledge exist between nurses working in hospitals that audit pressure ulcers and those employed in hospitals that do not; and (3) to study whether knowledge among Dutch hospital nurses regarding the usefulness of preventive measures had changed between 1991 and 2003.     

Guidance on pressure ulcer risk assessment and prevention

Pressure ulcers remain a problem throughout Europe, with prevalence figures ranging from 8.3 per cent to 22.9 per cent (Clark and deFlour, 2002). In 2001 the National Institute for Clinical Excellence issued a clinical guideline on pressure ulcer risk assessment and prevention (NICE, 2001). However, this guidelines has recently been reissued with additional information on pressure-relieving devices (NICE, 2003a; NICE, 2003b).     

Differences in prevalence of pressure ulcers between the Netherlands and Germany--associations between risk, prevention and occurrence of pressure ulcers in hospitals and nursing homes

Aim. This study compares pressure ulcer prevalence and prevention activities in nursing homes and hospitals within two European countries. Background. Over three years stable differences have been found between the Netherlands (NL) and Germany (GER) with higher pressure ulcer rates in the NL. As previous analyses have shown, the differences cannot be entirely explained by differences in the population’s vulnerability to pressure ulcers because they still remain after risk adjustment. Therefore, the differences in prevalence must be caused by other factors. The purpose of this study is to analyse if any potential differences in preventive activities can account for the varying occurrence of pressure ulcers. Method. In both countries, nation-wide surveys were conducted annually using the same standardised questionnaires. Trained nurses examined all consenting patients of the voluntarily participating facilities. This examination included a skin assessment of the entire body. Data regarding risk factors, prevention and details about wounds were then collected. Results. In-patients of 29 German (n = 2531) and 71 Dutch (n = 10 098) nursing homes and 39 German (n = 8515) and 60 Dutch (n = 10 237) hospitals were investigated. The use of pressure-reducing devices was more common in the NL than in GER, but all other interventions were more frequently provided to German risk patients than to their Dutch counterparts. The pressure ulcer prevalence was significantly higher in the Dutch sample. After adjusting for gender, age, Braden Score and prevention, the probability of having a pressure ulcer was 8·1 times higher for Dutch nursing home residents than for German residents. Conclusion. Some of the variance in pressure ulcer prevalence between the two countries can be explained by varying pressure ulcer prevention. However, some remarkable differences still remain unexplained. Relevance to clinical practice. The extent of pressure ulcer prevention, especially repositioning and nutrition intervention provided to patients at risk, is not in accordance with international guidelines.     

Pressure ulcer prevention in intensive care patients: guidelines and practice

Background  Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention.
Design  The design of this study was a cross-sectional study (point prevalence).
Setting  The study setting was intensive care units. The sample consisted of 169 patients – 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards.
Results  The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients.
Conclusions  The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines.     

Explaining the national differences in pressure ulcer prevalence between the Netherlands and Germany – adjusted for personal risk factors and institutional quality indicators

Background Pressure ulcers have a known impact on quality of life as well as on morbidity and mortality of the persons affected. Remarkable differences in pressure ulcer prevalence between the Netherlands and Germany have been found during the last 6 years. This study explores to what extent the individual risk of the population and quality indicators of the institutions can explain the variation in national prevalence. Methods Data of a binational multi‐centred cross‐sectional study in 103 hospitals (n = 21 378 patients) and 129 nursing homes (n = 15 579 residents) were analysed using random effects regression models to calculate the differences in national prevalences within the nursing homes and hospitals, adjusted for personal risk for pressure ulcer and quality indicators. Results The prevalence of pressure ulcers among the at‐risk group (Bradenscore ≤20) in nursing homes was 30.8% in the Netherlands and 8.3% in Germany [OR: 4.9 (CI 95%: 4.2–5.7)]. In hospitals, the prevalence among the at‐risk group was 26.1% in the Netherlands and 21.2% in Germany [OR: 1.3 (CI 95%: 1.2–1.5)]. After adjusting for individual risk factors (age, gender, Bradenscore) as well as for quality structures (use of prevention and treatment protocols, experts groups, information leaflets, nurses training, central pressure ulcer statistics and regular updating of protocols), the chance of developing a pressure ulcer was 6.05 times higher (CI 95%: 4.0–9.2) in a Dutch nursing home than in a German nursing home. Within the hospitals, the OR for Dutch patients was 2.03 (CI 95%: 1.4–3.0). Conclusion A remarkable national variation exists in pressure ulcer prevalence and nursing practice. Neither the populations vulnerability for pressure ulcers nor pressure ulcer management as measured in this study could explain this national variation. Therefore, other risk factors should be taken into consideration. Additionally, it is possible that quality indicators are implemented in differing ways with varying levels of effectiveness. Therefore, further research is needed to examine prospectively and in more detail the reality of care within facilities in both countries.     

Pressure ulcer: Prevention protocols and prevalence

Aims and objectives The aim of this paper is to analyse the protocols used in German hospitals and nursing homes for the prevention of pressure ulcers with regard to their contents and accordance with the national standard of the Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (DNQP) and the European Pressure Ulcer Advisory Panel (EPUAP) and Royal College of Nursing (RCN) guidelines. Additionally, it is to show the relation between the existence and contents of the protocols of pressure ulcer prevention and pressure ulcer prevalence in the institutions. Methods On a fixed date trained nursing staff gathers data regarding the frequency of pressure ulcers during a prevalence survey. The existence of a pressure ulcer is established by physical examination after the risk assessment with the Braden‐Scale. The patient’s or resident’s informed consent is a precondition for his or her participation in the survey. The protocols are available as hard copies on paper or electronic files. Results Only two out of the 21 protocols developed in‐house are completely concurrent with the expert standard. The EPUAP and RCN guidelines include the aspect of training and further education that is missing in the in‐house protocols and the DNQP expert standard. Evaluation of the data reveals that there is no relation between the availability of protocols and pressure ulcer prevalence. Neither is there any relation between the contents and pressure ulcer prevalence. The institutions currently developing protocols have the lowest prevalence rates. Conclusion It is obvious that, while developing in‐house protocols, the discussion about pressure ulcer prevention has led to a higher problem awareness in nurses and thus to an increased attentiveness in daily nursing practice which then results in improved outcomes. Two years after its publication, the expert standard is still not very well known, therefore this concentrated form of the most up‐to‐date knowledge is not available to all nursing staff as a basis for evidence‐based practice. In addition, the sometimes outdated knowledge of nursing staff impedes the implementation of evidence‐based practice guidelines. A systematic implementation strategy that assists guidelines being applied in practice is therefore required.     

Interrater reliability using Modified Norton Scale, Pressure Ulcer Card, Short Form-Mini Nutritional Assessment by registered and enrolled nurses in clinical practice

Aim. Examine the interrater reliability between and among registered and enrolled nurses using Modified Norton Scale, Pressure Ulcer Card and Short Form‐Mini Nutritional Assessment. Background. In Sweden, registered nurses and enrolled nurses usually co‐operate in patient care. National guidelines emphasize that reliable and valid assessment tools should be used. Interrater reliability for regular use of assessment tools is seldom studied. Design cross‐sectional. Registered nurses and enrolled nurses made 228 assessments of patients’ skin, risk for pressure ulcer and malnutrition, in patients with hip fracture and patients who had suffered a stroke. Results. The interrater reliability of the Modified Norton Score total score was very good among registered nurses, good among enrolled nurses and between both groups. There was good, moderate and fair agreement on the subscales. Interrater reliability of Short Form Mini‐Nutritional Assesment screening score was very good between both groups, good among registered nurses and moderate among enrolled nurses. There was good and moderate agreement on the items. There was good, moderate and fair agreement between and among registered nurses and enrolled nurses when using the Pressure Ulcer Card. Conclusion. The Modified Norton Scale and Short Form Mini‐Nutritional Assessment were reasonably understandable and easy to utilize in clinical care. Therefore, it seems possible for nurses to accomplish assessment using these tools. The agreement level was low for most skin sites except sacrum when nurses assessed patients’ skin with the Pressure Ulcer Card. Relevance to clinical practice. The utilize of reliable and valid assessment tools is important in clinical practice. The tools could be used as an aid to the clinical judgement and therefore identify patients at risk for pressure ulcers and malnutrition. Pressure ulcer grading is a difficult skill that requires training and time to develop.     

The first national pressure ulcer prevalence survey in county council and municipality settings in Sweden

Aim To report data from the first national pressure ulcer prevalence survey in Sweden on prevalence, pressure ulcer categories, locations and preventive interventions for persons at risk for developing pressure ulcers. Methods A cross‐sectional research design was used in a total sample of 35 058 persons in hospitals and nursing homes. The methodology used was that recommended by the European Pressure Ulcer Advisory Panel. Results The prevalence of pressure ulcers was 16.6% in hospitals and 14.5% in nursing homes. Many persons at risk for developing pressure ulcers did not receive a pressure‐reducing mattress (23.3–27.9%) or planned repositioning in bed (50.2–57.5%). Conclusions Despite great effort on the national level to encourage the prevention of pressure ulcers, the prevalence is high. Public reporting and benchmarking are now available, evidence‐based guidelines have been disseminated and national goals have been set. Strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.     

Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice

Aims and objectives. To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention. Background. Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care. Methods. A cross‐sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence. Results. There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6·8%. The age‐, sex‐ and risk‐standardized prevalence per regional department varied between 4·9% and 9·1%. Of the 744 subjects at risk, 33 (4·4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64·8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30·8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4·8% adherence, 76·6% no adherence and 18·6% no prevention. A proportion of 22·2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21·4% of all risk cases. Conclusions. The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. Relevance to the clinical practice. The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers.     

The Effectiveness of Massage in Preventing Pressure Sores: A Literature Review

The prevention of pressure sores is a major concern of rehabilitation nurses. Through the years, several methods have been used to prevent pressure sores. One of the most commonly used methods is massage of bony prominences and pressure areas. However, according to most contemporary clinical guidelines, massage should be avoided. This article analyzes the extent to which these guidelines are based on research findings through a literature review on the effectiveness of massage in the prevention of pressure sores. The results of the studies that were analyzed led to the conclusion that massage as therapy for preventing pressure sores in subjects at risk for developing them is not recommended.     

Prevalence, prevention, and treatment of pressure ulcers: descriptive study in 89 institutions in the Netherlands

The purpose of the present study was to assess the prevalence of pressure ulcers and the use of Dutch guidelines for the prevention and treatment of pressure ulcers. A survey of 16,344 patients in 89 health care institutions on 1 day showed a mean prevalence of pressure ulcers of 23.1%. It was found that Dutch guidelines on some aspects of prevention and treatment of pressure ulcers were not being followed. Only 53% of the patients who should have been positioned on a support surface were positioned on such a device. Fewer than one-third of the patients who should have been repositioned, should have received nutritional support, or should have been educated received these interventions, and only 33.6% of all pressure ulcers were dressed as recommended. More attention to the dissemination and implementation of the guidelines is needed to reduce this high prevalence of pressure ulcers.     

Pressure ulcer prevention and management: the current evidence for care

Pressure ulcers, a common occurrence across healthcare settings, are a costly phenomenon. Since the publication of the AHCPR Guidelines on Pressure Ulcer Prevention and Treatment in the 1990s, additional attention has been focused on pressure ulcer prevention and management. This article discusses current evidence regarding known causes of pressure ulcers, pressure ucler prevention, pressure ulcer classification and assessment, and interventions to effectively manage pressure ulcers.     

Pressure ulcers: etiology and prevention

Pressure ulcers are a major health care problem that nurses can directly impact by identifying contributing factors and taking measures to determine patients at risk. Prevention of pressure ulcers is based on an understanding of their origin. The purpose of this article is to review the etiology of pressure ulceration and to explore recent advances toward prevention of this clinically significant problem.     

Pressure ulcers--prevention and treatment guidelines

Nurses deal with pressure ulcers on a regular basis, yet much of the research has yet to be put into practice. Lyn Phillips examines the implications of the European Pressure Ulcer Advisory Panel's new guidelines, dealing with prevention and treatment of pressure ulcers.     

The impact of assessing the prevalence of pressure ulcers on the willingness of health care institutions to plan and implement activities to reduce the prevalence

BACKGROUND: In 1998, 89 health care institutions (hospitals, nursing homes, residential homes, and community care institutions) participated in the first Dutch National Pressure Ulcer Prevalence Study. AIM: Based on the innovation-decision process for individuals (Rogers 1995), the effect of their participation was investigated at different levels in the institutions [prevalence assessment coordinator, director, ward management (enrolled) nurses, and the pressure ulcer committee]. METHOD: A mail questionnaire was developed and filled out by 54 coordinators of the participating health care institutions. RESULTS: Results showed that according to the coordinators most levels of the institutions were familiar with the results of the prevalence assessment, understood them, and were persuaded that their prevalence rate had to be changed. As a result, almost all of the coordinators of the institutions were planning activities to change pressure ulcer management, while half of the coordinators had already implemented some actions. The main activities planned or implemented were developing or updating the prevention and treatment protocol and educating the (enrolled) nurses. Some institutions were planning or had already implemented the appointment of a nurse specialist or a nurse paying special attention to pressure ulcers. Results showed that the different levels of the institutions took initiatives on different categories of activities. CONCLUSION: It is concluded that participating in the first national prevalence study was a positive experience for the institutions, because agenda-setting took place and most started to plan or implement activities to improve the prevention and treatment of pressure ulcers.     

Nurses' attitudes, behaviours and perceived barriers towards pressure ulcer prevention

Background. Pressure ulcers are not a plague of modern man; they have been known to exist since ancient Egyptian times. However, despite the increasing expenditure on pressure ulcer prevention, pressure ulcers remain a major health care problem. Although nurses do not have the sole responsibility for pressure ulcer prevention, nurses have a unique opportunity to have a significant impact on this problem. Aims and objectives. The specific aims of the study were to identify: ? Staff nurses’ attitudes towards pressure ulcer prevention. ? The behaviour of staff nurses’ in relation to pressure ulcer prevention. ? Staff nurses’ perceived barriers towards pressure ulcer prevention. Design. A cross‐sectional survey method was used. Methods. A randomly selected sample of staff nurses (n = 300) working in an acute care setting in an urban location was invited to participate. Data were collected using a prepiloted questionnaire. Data analysis was carried out using SPSS version 10 and SPSS Text Smart version 1.1. Results. The nurses surveyed demonstrated a positive attitude towards pressure ulcer prevention. However, prevention practices were demonstrated to be haphazard and erratic and were negatively affected by lack of time and staff. These barriers prevented the nurses’ positive attitude from being reflected into effective clinical practice. Education, although poorly accessed, or made available, was rarely cited as impeding practice in this area. Conclusion. This study suggests that positive attitudes are not enough to ensure that practice change takes place, reinforcing the complex nature of behavioural change. Implementation strategies should introduce ways in which key staff can be empowered to overcome barriers to change. Relevance to clinical practice. This study provides a unique exploration of Irish nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention, thereby contributing to the body of knowledge on this subject. As tissue viability is a new and emerging speciality, this information will contribute to evidence based practice in this area of patient care and will form the basis for the development of an educational strategy for pressure ulcer prevention and management.     

Pressure ulcer prevalence in intensive care patients: a cross-sectional study

Background  Pressure ulcers are a potential complication for intensive care patients and their prevention is a major issue in nursing care. Therefore, this study aims to assess pressure ulcer prevalence in intensive care patients, patients' characteristics and preventive measures related to pressure ulcer prevalence in intensive care patients and to determine the most common body sites of pressure ulcers.
Method  The research design was a cross-sectional study. The sample consisted of 1760 patients (298 in 2002, 408 in 2003, 453 in 2004, 368 in 2005 and 233 participants in 2006) from surgical, medical and interdisciplinary intensive care.
Results  The results revealed a mean prevalence rate of ±30% from 2002 to 2005 while it considerably decreased down to 16.2% in 2006. Half of the pressure ulcers were of grade 1. Furthermore, a significant relation was found between the presence of pressure ulcers and age ( P  ≤ 0.022), Braden score ( P  ≤ 0.01) and bowel incontinence ( P  ≤ 0.01).
Conclusion  It is crucial to select appropriate and applicable preventive material/devices and nursing care measures. Moreover, factors related to the presence of pressure ulcers should be taken into consideration in order to prevent development of further pressure ulcers.