EUROPEAN PRESSURE ULCER ADVISORY PANEL

EMPOWERING THE NURSE SPECIALIST IN HER ROLE AS CHANGE AGENT

Drs P.C.Grijns, nurse, sociologist.
Consultant in the Decubitus project of the Netherlands Institute for Health Promotion and Disease Prevention (NIGZ)
Woerden, Holland.

Introduction
The Ministry of Health (VWS), asked the NIGZ to develop a national support structure for prevention of Decubitus. As we know dissemination of knowledge on decubitus in the form of guidelines is not enough to change actual behaviour of healthcare workers. We believe that a combined strategy on personal, institutional, local and national level is necessary to come to real changes in the prevalence of decubitus. In a project of three years the NIGZ tries to stimulate nurses, their managers, national nursing organisations and politicians to put extra effort in decubitus prevention. Dissemination of evidence based tools such as a decubitus pocket book is one of the interventions on national level.

Workshops on regional or local level, plus developing networking between institutions is another intervention.

The national prevalention research (by the University of Maastricht) is an active instrument to stimulate the policy on decubitus on the level of institutions. But awareness and agendasetting should be followed by practical and personal support of key actors. And isn’t the specialist nurse the key actor in prevention of decubitus?

Training the specialised nurse
The specialist-nurse on pressure sores, plays a crucial role in dissemination of knowledge, and in monitoring actual behaviour of colleagues in prevention of pressure ulcers. The Dutch Network of Decubitus Nurses developed a profile of this function. A combination of tasks: patient care, innovation of care and policy, education, consultation research are the main items they describe in their ‘Profile’. On the base of this task description and a need assessment of participants and their managers, NIGZ developed with a trainer of Gooi Consult an intensive five-day course for Nurse Specialists.

The course
The central issue in the course is how to stimulate implementation of knowledge, The course emphasises the development of personal competency of the nurse student and offers the student a training in coaching and feedback skills, and in the first steps of project management. The course stimulates the empowerment of the nurse as a change agent.

In the workshop we will discuss the structure of the course. Your input will be appreciated. Next year we can tell you more about the results of the first group.

CHALLENGES IN NURSING FOR ELDERLY PATIENTS WITH PRESSURE ULCERS

Jacquerye, A., PhD, RN*, Holtzer, L., MSN, RN†, Vrebos, M., MSN, RN‡ and the Belgian Group for Prevention and Treatment of Pressure Sores. Survey supported by the Belgian Ministry of Social Affairs, Public Health and Environment

* Project coordinator, Quality Assurance Department, Erasmus Hospital, University of Brussels, Belgium.
† Project coordinator. Continuing Education Dept, University Hospitals Leuven, Catholic University of Leuven, Belgium.
‡ Project coordinator, University Hospitals Leuven, Catholic University of Leuven, Belgium.

The remarkable improvement in life expectancy all around the world has as consequence led to an ageing of the population on a world-wide scale. The fall off in mortality rates has brought about a great increase in the proportion of the population aged sixty-five and over. This phenomenon has brought with it a rise in the needs for health care for elderly people threatened by numerous risks. Some examples of these include: falls, malnutrition, the gradual loss of physical and mental capacity, faecal and urinary incontinence. These risks are very often inter-linked.

Taking 1998 photo-fit picture of elderly patients hospitalised in geriatric units and in long term care facilities in Belgium as a starting point, the aim of this paper is to discover whether the nursing profession is providing good or poor nursing quality care when comparing it with that received by other patients hospitalised in surgery, medicine and acute care as far as prevention of pressure ulcers is concerned.

The data is based on the last national audit carried out on 4 June 1998, collected in 202 voluntary health institutions and where 33,967 patients were observed. The sample of hospitalised geriatric patients represented a rate of 12.8% (4,335 patients) and that of patients in long term care facilities 14.6% (6,544 patients). They represented 66.6% of the hospitalised population in geriatrics and 26.2% of the sector of hospitalised patients in long term care facilities respectively.

As a second objective, this study aims to see if a quality programme introduced over a period of four years has given opportunities to improve the quality of nursing care for this elderly population. The data is based on four national audits carried out in Belgium since 1995. This data was recorded cross sectionally on one random day per year. This study has been supported by the Ministry of Social Affairs, Public Health and Environment and co-ordinated by two universities.

At the dawn of the third millennium, the results of this study should lead to success in taking up challenges in different domains of care. There should be an introduction of key indicators of performance in health care and particularly in nursing care, the bringing in of legislation and accreditation for institutions taking responsibility for the elderly, a setting up of key indicators of quality of life; the granting of a charter of rights and obligations for patients and families who often become powerless when confronted with the difficulties brought about by old age.

IS DOCUMENTATION OF PRESSURE ULCER CARE STILL A PROBLEM

Lena Gunningberg, Christina Lindholm, Marianne Carlsson and Per-Olow Sjödén
Uppsala University, Uppsala, Sweden

The aims of the study were to investigate, on a daily basis, (i) the development and progress of pressure ulcers, (ii) the documented nursing interventions for prevention and treatment of pressure ulcers, and (iii) when nursing interventions regarding prevention and treatment of pressure ulcers, in relation to the patients risk status and the development of pressure ulcers were documented.

The study design was prospective, comparative and descriptive. A total of 55 patients with hip fracture were included. To facilitate the nurse’s assessment, a ‘Pressure Ulcer Card’ was developed, consisting of the Modified Norton Scale (MNS) and descriptions of the four stages of pressure ulcers. The incidence of pressure ulcers was 46%. The mean rank of the lowest MNS score was significantly lower for patients who developed pressure ulcers than for patients without pressure ulcers. The majority of the pressure ulcers occurred between admission to the ward and the fourth day after surgery. Documented interventions regarding prevention and treatment were: repositioning, overlays, cushions, use of lotion and observation. The mean number of interventions per patient was 2.2 for patients who developed pressure ulcers during their hospital stay. The comprehensiveness and quality of the nursing record was unsatisfactory, and only three nursing records reached the level required by Swedish law. Preventive interventions such as repositioning were documented when the pressure ulcer had already occurred. The lack of nursing documentation regarding prevention and treatment of pressure ulcers may indicate that nurses did not identify pressure ulcers as a prioritised nursing problem for this patient group. The Modified Norton Scale could be a valuable tool for nurses, both identifying the patient at risk and as a guide to nursing interventions. The study was approved by the Ethics Committee of the Faculty of Medicine at Uppsala University.

THE UNDER-REPORTING OF PRESSURE SORES

Richard Buckland , Eileen Scott and David J Leaper

North Tees and Hartlepool NHS Trust Professorial Unit Surgery
North Tees General Hospital Stockton-on-Tees, TS19 8PE

Pressure ulcers remain a problem despite the considerable amount of research and knowledge gathered. Different populations have different levels of risk but the elderly are those with the greatest numbers of risk factors.

The prevention and treatment of pressure ulcers are still seen mainly as the remit of nurses. Feelings of guilt and inadequacy often lead to the under-reporting of the problem. This happens within acute, community and private care. One of the greatest challenges in nursing practice is to remove these feelings of guilt and inadequacy so that patients with pressure damage can be given the most up to date, research based care.

This problem and our attempts to rectify it have become highlighted during the completion of two projects.

Firstly the Pressure Damage Register is the tool used to monitor the prevalence and incidence of pressure damage across the whole Trust. Despite ward based link nurses and the publicity around the project there are still problems with under-reporting. This appears to happen more if patients develop damage whilst an in-patient or if the nurses consider the damage to be transient. We have attempted to address this problem through education, at formal study days and informal meetings with ward staff.

The second project is a multi-centred clinical trial involving patients with pressure sores. The clinical trial, although very well designed, relied on the recruitment of patients with full thickness pressure ulcers. Recruitment has remained the biggest problem to its success throughout Europe. Within our unit attempts have been made to overcome nurses reluctance to report pressure ulcer occurrence. We have ‘advertised’ the department and the services and skills available across the whole region, which includes three acute and community Trusts and 95 residential and private nursing homes.

We have found a lack of up-to-date knowledge exists amongst nurses in all settings. This lack of knowledge often compounds the feelings of guilt. The opportunity exists for these problems to be addressed through education and promotion of units such as ours so that all nurses are encouraged to seek help and admit they cannot know everything about everything.