Pressure ulcers or sores are also referred to as decubitus. Critical care patients have a high risk of developing these pressure sores. Unpreventable terminal pressure sores, however, are almost exclusively observed in patients for whom death is imminent. Prevalence among intensive care patients is at 10% to 41% (Lyon, 2010). Prevalence rates are higher among hip fracture patients at 55% and are even higher in nursing homes at 83% (Shahin, Dassen & Halfens, 2008). Not only are these patients vulnerable, but the care of pressure ulcers can also be prohibitively expensive, reaching up to US$50, 000 (Lyon, 2010).
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The European Pressure Ulcer Advisory Panel defines the term “pressure ulcer” as “a localized injury to the skin or the underlying tissue commonly over a boney prominence as a result of pressure or in combination with shear” (EPUAP, 2009) and lists certain factors that predispose to their formation. Shear is defined as the force applied laterally to the skin surface (EPUAP, 2009). Pressure intensity and duration variably affect the pressure ulcer development process. Standard anatomical sites for pressure sores are those around the heels, trochanters, ears, and the occipital, sacral, and coccygeal regions. Additional predisposing factors are moisture, friction, poor nutritional status, old age, and critical care. On the other hand, bariatric patients have higher risks due to poor spontaneous mobility, presence of moisture on skin folds, impaired peripheral vascularization, and higher BMI scores.
Critical care refers to patients that cannot readily ambulate. These patients have co-morbidities that decrease their hemodynamic status and are unable to perform regular, un-assisted position changes. They also suffer from anorexia and decreased sensory perception. Therapy and quality of life interventions include medication, use of medical devices, and prolonged bed stays for monitoring. Ca. 10% of pressure sores are medical device-related (Shahin, Dassen & Halfens, 2008).
The pathological physiology of pressure sores is as follows: unrelieved pressure over body surfaces leads to gradual tissue ischemia and compression of the circulatory bed. The latter prevents oxygenation and evacuation of cellular waste: these occasion biochemical waste accumulation, and trigger local vasodilation and eventual edema and ischemia. The resultant cellular death manifests as a pressure ulcer. Reduced mobility leads to unrelieved pressure on the affected body parts, while moisture predisposes epidermal degeneration via maceration. Shear erodes these epidermal layers, predisposing to further physical damage. Poor nutrition lowers the oncotic pressure, just as hypotensive medication leads to reduced distal perfusion.
The Problem Area
Prevention of pressure ulcers is an integral part of critical nursing care. Evidence-based interventions provide the framework for the adequate provision of care. Research has established that not only is there a gap between and its implementation, but that most decubitus sores are entirely preventable. Despite these advances, and the added emphasis on proper training, pressure ulcers continue to be prevalent, and treatment costs continue to rise. Furthermore, registered nurses do not adequately document care and persist in giving pressure sore prevention a low priority. Research examining this inconsistency in healthcare settings has focused on the attitude of care providers. Do nurses fail to provide adequate skincare because they do not care, or is it because they are unaware of the guidelines?
This study utilizes an empirical qualitative approach and uses participant observations and semi-structured interviews to identify the nurses’ familiarity with decubitus ulcer prevention measures. Deductive content analysis and grounded theory were then used to analyze the research findings. This deductive approach is essential in aligning content with theory (Elo & Kyngas, 2008).
Describing registered nurses’ performance, knowledge, and documentation of pressure ulcer intervention in patient-specific and general ward situations can be considered the key aim of the study.
- What is the nurse’s level of knowledge regarding pressure sore interventions?
- How familiar is the nurse with pressure ulcer risk or predisposing factors?
- How did the nurse gain this knowledge?
- What is the nurse’s opinion about their knowledge of these interventions?
Access to the Participants
Access to the participants was facilitated by the local Nursing College. A letter of introduction and a summary of the research aims were sent to the healthcare institution.
Selection of Participants
In choosing information-rich respondents, Polit & Beck (2010) recommended that researchers (s) develop trust with their prospective participants. For this purpose, I took part in the daily nurse ward rounds for an initial 19 days and then verbally informed the potential respondents about the objectives and methods of the study. Shadowing, as a nurse, also provided me with the opportunity to observe skin care nursing up-close. Willing nurses then made appointments for interviews. The inclusion criteria were professional certification and work experience in critical care units for two years. A total of twenty-one nurses were requested to participate, but thirteen declined, and eight eventually participated. One registered did not participate in the interview.
The interview respondents were between the ages of 29 and 58. Six were women and two males. All had work experiences in critical care above ten years, while seven worked in the female unit.
Pre-selected questions were drafted but served only as a guide. Emphasis was placed on facilitating free-flowing interviews. Interviews lasted between 10 and 18 minutes and were recorded. The preparation phase involved drafting the guidelines and follow-up questions. The respondent then received orientation about the study, with care taken not to lead on the participant. Orientation was then closed off by a finishing phase, where the respondent was asked if s/he had any other material to add.
Methods of Quantitative and Qualitative Data Analysis
The recorded interviews were transcribed verbatim, and further editing performed to avoid transcription errors.
Five possible qualitative analytical techniques such as deductive theory, phenomenology, ethnography, symbolic interactionism, case study method, the Straussian grounded theory, and the historical method have been used in nursing studies extensively (Elo & Kyngas), 2008). Direct Content analysis via the deductive theory is performed in this study.
Five other methods of quantitative analysis, though less frequently used in nursing research, include positivism, antipositivism, conflict theory, functionalism, structuralism, and social construction.
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Hsieh & Shannon (2005) provide the structure for conducting this form of analysis. In following their recommendations, an initial analysis of the transcriptions was performed with uncertainties reconstructed together with an independent researcher/scholar. The EPUAP guidelines were used to validate the findings. The transcription data were then categorized into the critical areas of care: Pressure on anatomical body parts, Patient mobility levels, Physical forces (mainly friction), Patient Hygiene, Skin moisture, Education for nurses and the patient, Nutritional status, Nursing documentation, and Risk factors. Themes arising from this analysis were then matched against the EPUAP framework and were further categorized. Interventions and opinions that conflicted with the framework (“the codes”) were a part of the nurses’ misconceptions.
Participants had the opportunity to air any misgivings or opt-out at any point in the study. Explicit permission was sought in the use of the members’ verbatim transcripts. Furthermore, identifying information was made anonymous. In addition, informed consent was acquired from every single research participant before to the study.
Results and Discussion
A study of the evidence supplied by the nursing staff has shown that the enhancement of patient mobility rates and the application of physical forces, friction in particular, can be considered the key method of preventing and managing ulcers in patients. The study has shown that ulcers occur due to the lack of motion and the continuous pressure. Specifically, the pressure that results from lying on a comparatively hard surface for a large amount of time, as well as the ulcers that emerge as a result of friction and careless movement of patients across sheets, deserves to be mentioned. In the first case, the pressure triggers congestion of blood and the formation of an ulcer; in the second scenario, the patient’s skin suffers a considerable damage by rubbing across it and, therefore, contributes to the development of ulcers.
Hence, the movement of the patient is essential for preventing the development of ulcers in bed-ridden patients. In addition, the reduction of friction rates should be viewed as one of the key strategies for addressing the development of ulcers. It should be noted, though, that the emphasis should lie on the former method as the key tool for handling the issue, as the lack of movement has been identified as the primary cause of ulcers development. By introducing the specified practices in the setting in question, one may expect a considerable increase in the efficacy of the nursing services.
Elo, S. & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. Web.
European Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: quick reference guide. National Pressure Ulcer Advisory Panel. Web.
Hsieh, H., Shannon, E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. Web.
Lyon, K. (2010). High-tech/high-touch team-centered care provides best outcomes for wound prevention in critically ill patients. Critical Care Nursing Quarterly, 33(4), 317–323. Web.
Polit, D. & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice. Wolters Kluwer: Philadelphia, PA. Web.
Shahin, S. M., Dassen, T. & Halfens, R. J. G. (2008). Pressure ulcer prevalence and incidence in intensive care patients: a literature review. Review, 13(2), 71–79. Web.