Authors:

Trudie Young (Lecturer in Tissue Viability, University of Wales at Bangor)
Clare Williams (Senior Nurse Tissue Viability, NE Wales NHS Trust)
Menna Lloyd-Jones (Senior Nurse Tissue Viability, NW Wales NHS Trust)
Barbara Pritchard (Tissue Viability Nurse, NE Wales NHS Trust)

Introduction

The prevalence of pressure ulcers in acute hospital settings varies from 8% – 22 % (Clark et al 2004). Therefore it is of utmost importance that individuals who are deemed to be at risk are assessed and subsequently receive preventative care. If an individual has a pressure ulcer then the treatment they receive should prevent further damage and aid the healing process.

National guidelines (England and Wales) have been produced on the topic of pressure ulcer prevention and management (for example NICE 2001). The Tissue Viability Nurses from three trusts have adapted these guidelines to meet local needs, resulting in uniformity of practice across North Wales. However the impact of the guidelines is difficult to measure as no baseline of current practice has been established. In addition the proposed theme for the EPUAP conference in Budapest 2002 ‘Have we made a difference?’ had stimulated a review of nursing practice. Therefore the Tissue Viability Nurse’s have completed an observational study across the three trusts in order to define current nursing practice in relation to pressure ulcer prevention and treatment. The findings were verified by identifying which nursing practices are deemed to be pressure ulcer preventing or pressure ulcer treating in nature using a Delphi technique with the members of The European Pressure Ulcer Advisory Panel. It was hoped that the work would produce definitive criteria of what constituted nursing practice in relation to pressure ulcer prevention and treatment; it was the first time this has been completed in the United Kingdom since 1992.

The investigation sought to replicate an earlier observational study (Clark et al 1992). In which the authors produced a list of nursing practices that were deemed to be pressure ulcer preventing and treating in nature. The purpose of the replication is to identify whether, and how, nursing practices relating to pressure ulcer prevention and treatment have altered over the last ten years.

Aim and objectives of the study

The aim of the study was to define a set of clinical nursing practices that together comprise pressure ulcer prevention and treatment. The objectives of the study are as follows:

Methodology

Prior to commencement of the study ethical approval was obtained from all three Trusts. Observation is a research method in which the investigator systematically watches, listens to and records phenomena of interest. In this study the researchers adopted a non-participant role to ensure they concentrated on recording all nursing practices. They completed a series of over one hundred episodes of four-hourly observations in the medical wards within the three acute Trusts in North Wales. The medical units were chosen due to the nature of the patient population with a large majority of patients being deemed as at risk of developing pressure damage according to their pressure ulcer risk assessment score. Each Tissue Viability Nurse sat within one six-bedded area on a medical ward and recorded all nursing practice. The observations were unstructured to prevent any preconceptions influencing the data collection process. The periods of observation were divided to cover the majority of the patients day; 7am – 11am, 11am – 1pm, 1pm – 3pm, 3 pm – 7pm and 7pm – 11pm. Following each period of observation the data from all three trusts was collated centrally at one site and a bank of nursing practices developed. Following the format utilised by Clark et al (1992) the initial observations of all observed nursing practices were recorded. When the equation 1 – (number of activities seen once/total number of activities) > = 0.95 (Clark et al 1992) was satisfied, observations of practice ceased as it was considered that a complete behavioral catalogue has been established.

Analysis

The purpose of the study was to define nursing practice relating to pressure ulcer prevention and treatment. Given the observational design of the study no formal statistical analysis was undertaken. The data naturally classified itself into six categories (toileting, hygiene, nutrition, positioning, skin care and miscellaneous). This was then transcribed into formic layout which is a tick box form that can be analysed using a computer programme thus easing the examination of the data. The forms were sent along with a covering letter explaining the rationale for the study to the 391 members of The European Pressure Ulcer Advisory Panel as at June 2003.

The members were asked to allocate the observed practices into one of four categories; pressure ulcer prevention/ pressure ulcer treatment, general nursing care, a combination of pressure ulcer prevention/treatment and general nursing care or unsure. The respondent had the option of choosing unsure if they did not understand the nature of the activity. Pressure ulcer preventing was defined as a nursing activity that prevents tissue damage to the skin resulting from pressure, shear or friction. Pressure ulcer treatment was defined as nursing activity that relieves or reduces the effect of pressure, shear or friction on areas of establishes damaged or to promote healing of damaged tissue. Additional definitions were provided if the terminology was potentially confusing e.g. toileting.

Of the 391 forms distributed 86 were returned, one return was a refusal to participate as the respondent did not think the work would contribute to the body of knowledge on the subject and one individual received the form too late to participate in the study.

Results

Of the 86 respondents 78% were nurses, 19% non-nurses and 3% did not state their profession. The distribution of the respondents is displayed in the following table.

In the majority of the results the activities were evenly spread across the three main categories. The following results represent categories in which over sixty-five percent of EPUAP members were in agreement with the categorization of the activity.

In the toileting category 64% of the respondents identified toileting with movement as part of general nursing care. In the hygiene category: oral hygiene and giving the patient a preparatory wash in which the nurse prepares the environment and the patient washes themselves were categorized as general nursing care.

Within the nutritional category the highest level of agreement (61%) was in allocating the giving of nutritional supplements as a combination of general nursing care and pressure ulcer preventing and treating activity. Six activities in the miscellaneous section were categorized as general nursing care; administration of medicines (68%), assisting medical staff with a procedure (66%), care of the nauseous patient/patient producing sputum (74%), care of the deceased patient (79%), administration of oxygen/suction (68%), taking a blood sample (65%). The activities that included repositioning and the use of pressure relieving/redistributing support surfaces were categorized as a combination of general nursing care and pressure ulcer prevention/treating (50 – 68%). However, this section contained the highest number of responses (7 – 33%) categorizing activities as specifically pressure ulcer preventing/treating. The final section on skin care the application of emollients/barrier products was categorized by 57% of the respondents as a combination of pressure ulcer preventing/treating and general nursing care as was the application of wound dressings (52%).

Limitations

The nursing care that was observed was undoubtedly influenced by the pressure ulcer risk status of the patients along with ward activity, staff patient ratios and patient dependency levels. The variations in care may have been influenced by the knowledge and experience of staff being observed. At times some of the observations were lost due to nursing actions that took place out of sight of the researcher.

It was not possible to control these variables but an attempt to reduce their potential impact was made by time-sampling thus varying the time-periods of the observations to cover the morning, afternoon and evening shift patterns. An attempt to reduce observer bias was undertaken by recording actual observations rather than perceived or inferred events.
The observers were the Tissue Viability Nurses for the areas being observed and the Hawthorn effect of this situation also has to be acknowledged.

Discussion

None of Clark et al’s 14 criteria that were deemed to be solely pressure ulcer preventing or treating were categorized as such in this study, four of the previously recorded activities were never seen as such in the current study, patient being made comfortable, application of sheepskin boots or pad to the heel or sacral area, use of donut devices to raise heels off the support surface, inspection of plaster of Paris. The first category was not identified in this study as the components of making a patient comfortable were broken down and the detail recorded, the latter activity was probably due to the observations taking part on medical and not orthopaedic wards.

The remaining activities that were categorized in the earlier study as pressure ulcer preventing or treating were viewed as a combination of pressure ulcer prevention, treatment and general nursing care.

It appears that the specific part played by nursing care in pressure ulcer prevention and treatment has become subsumed with general nursing care and not viewed as an entity in itself. Therefore can this loss of identity be seen as progression towards holistic care or a regression due to its loss of status? If pressure ulcer prevention and treatment are not obviously demonstrated to the observer then how is the importance of its role to be identified and performed by nursing staff. It also would thwart the auditing of pressure ulcer prevention guidelines as the specific components of care would be difficult to identify. Worryingly the loss of pressure ulcer prevention and treatment may be more due to an absence of care rather than it being subsumed into general nursing care. If staff are not educated and aware of the value of pressure ulcer prevention and treatment its significance may be lost and thus eventually this aspect of care omitted.

Although not an intended outcome of the study, a consensus of opinion between the researchers was that the majority of hands-on basic nursing care was delivered by unqualified and student nurses. In this instance basic nursing care relates to washing, toileting, feeding and repositioning. Secondly, the observers were aware of long periods of time when the bays were without any nurse presence at all. However, it has to be noted that these were informal observations and were not formally documented as part of the original study. Nonetheless, it highlights the need for a more formal study to be undertaken investigating what nurses do.

Conclusion

The nursing activities that are involved in pressure ulcer prevention and treatment appear to have changed little over the last twelve years. However the mechanism of care delivery appears to have moved from specific pressure ulcer care to being subsumed within general nursing care. EPUAP and national bodies have produced guidelines for the prevention and management of pressure ulcers. The researchers thought that during the periods of non-participative observation they would see visual evidence of their implementation, however a dearth of pressure ulcer care was observed. The value of the study was in experiencing the clinical reality rather than the perceived version of what constitutes clinical practice and the researchers would urge other clinicians to repeat the study in their own areas and thus validate the findings to date.
The authors would like to acknowledge the advice given by Dr Michael Clark and the support from the EPUAP office.

References

Clark M, Watts S, Chapman RG, Field K, Carey G. The financial costs of pressure sores to the National Health Service: A case study. Final report to the Department of Health. Nursing Practice Research Unit, University of Surry, Guildford, 1992.

Clark M, Defloor T, Bours G. A pilot study of the prevalence of pressure ulcers in European hospitals. In Pressure Ulcers: Recent Advances in Tissue Viability (Ed M Clark), Quay Books, Salisbury, 2004. pp8–22.

National Institute for Clinical Excellence. Inherited Clinical Guideline B. Pressure Ulcer Risk Assessment and Prevention. London: National Institute for Clinical Excellence, 2001