International Wound Journal ISSN 1742-4801
ORIGINAL ARTICLE
Nursing staff induced repositionings and immobile patients’ spontaneous movements in nursing care Ulrika Källman1,2 , Sara Bergstrand1,3,4 , Anna-Christina Ek1 , Maria Engström1 & Margareta Lindgren1 1 Department of Medical and Health Sciences, Linköping University, Linköping, Sweden 2 Department of Dermatology, Södra Älvsborgs Sjukhus, Borås, Sweden 3 Department of Hand Surgery, Plastic Surgery, and Burns, Linköping University, Linköping, Sweden 4 Department of Biomedical Engineering, Linköping University, Linköping, Sweden
Key words Immobility; Nursing care; Patient repositioning; Pressure ulcer; Prevention
Källman U, Bergstrand S, Ek A-C, Engström M, Lindgren M. Nursing staff induced repositionings and immobile patients’ spontaneous movements in nursing care. Int Wound J 2015; doi: 10.1111/iwj.12435
Correspondence to U Källman, RN, PhD Student Division of Nursing Science, Faculty of Health and Science Linköping University Linköping Sweden E-mail: [email protected]
Abstract The aim of this study was to investigate nursing staff induced repositionings and the patients’ spontaneous movements during the day and night among older immobile patients in nursing care. Furthermore, the aim was to identify factors associated with the nursing staff induced repositionings and the patients’ spontaneous movement frequency. An observational cross-sectional design was used. Spontaneous movements among patients (n = 52) were registered continuously using the MovinSense monitoring system. The nursing staff documented each time they repositioned the patient. Patients spontaneous movements were compared with nursing staff induced repositionings. There were large variations in the patients’ spontaneous repositioning frequency during both days and nights, which shows that, although immobilised, some patients frequently reposition themselves. Analgesics were positively related to the movement frequency and psycholeptics were negatively related. The nursing staff more often repositioned the patients who were assessed as high risk than those assessed as low risk, but the patients’ spontaneous movement frequency was not correlated to the risk score. This may be important when planning repositioning schedules. A monitoring system may be useful in decision making with regard to planning repositioning and positions used in the prevention of pressure ulcers among elderly immobile patients.
Introduction
Healthy individuals make spontaneous movements whilst awake and during sleep to redistribute pressure (1). This is a natural, often sub-conscious, action taken to avoid pain or discomfort. Individuals with impaired sensory perception or mobility limitations may not feel this discomfort or cannot reposition themselves when it is actually needed. Previous research has shown a clear relationship between the amount of spontaneous nocturnal movements of older individuals and the development of pressure ulcers (2). Patients who repositioned themselves 50 or more times during the night had no pressure ulcers, whereas 90% of patients who repositioned themselves 20 times or less developed ulcers. A failure to reposition may cause a reduction in tissue oxygenation, sustained deformations of cells and potential tissue damage (3–6). © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd doi: 10.1111/iwj.12435
Thus, the turning and repositioning of patients who are immobile is a vital and effective measure to prevent pressure
Key Messages
• turning and repositioning patients who are immobile is regarded as a vital and effective measure to prevent pressure ulcers • nursing staff induced repositionings and patients’ spontaneous movements were investigated among elderly immobilised patients • there was a large variation seen in the extent the elderly patients made spontaneous movements and the movement frequency was significantly related to two types of
1
U. Källman et al.
Nursing staff repositionings and patients’ spontaneous movements
Methods
medication groups; analgesics were positively related and psycholeptics were negatively related • patients assessed as high risk were repositioned by nursing staff more frequently than patients assessed as low risk, but the patients’ spontaneous movement frequencies were not associated with the risk scores
Study design
The study is of a cross-sectional design.
non-experimental
observational
Participants
ulcer development (7). However, there is still weak evidence supporting specific turning regimes (8–10). Traditionally, guidelines and common practice state that intervals between repositionings should not exceed 2 hours (11). This is mainly based on animal research where tissue damage has been detected after 1–2 hours of high pressure exposure (12,13). However, for patients who are critically ill and in an unstable condition, or who require uninterrupted sleep, the 2-hour turning interval is not always desirable. Furthermore, turning regimes can impose high demands on nurses, and sometimes it is claimed that because of staff shortages, nurses do not have enough time to devote to turning (14,15). A recent clinical study supports that the time frame could be extended to 3 or 4 hours among nursing home residents with limited mobility who are at risk of pressure ulcer development without resulting in an increased incidence of pressure ulcers (16). The results of clinical surveys report that the majority of patients at risk of pressure ulcer development are turned or repositioned every second to third hour (15,17), but potentially, there could be discrepancies between documented and performed nursing actions. An increasingly common practice is to have individually planned schedules with a variety of time intervals (18). This approach is in accordance to guidelines (19); repositioning frequency should be based on professional judgement that takes into account the patient’s tissue tolerance, level of activity and mobility, medical condition, treatment plan, comfort and support surface used. Little research has been performed on movement patterns among the most high-risk patients, such as the elderly and immobilised, although immobility is considered one of the most important risk factors for pressure ulcer development (20,21). Schnelle et al. (22) evaluated sleep and bed mobility among incontinent nursing home residents during night time and counted the number of resident-initiated movements of the hip or shoulder to be larger than 45. They found that 33% of the participants made almost no spontaneous movements or turns during the night. Other studies evaluating different turning schedules have shown that patients do make minor movements spontaneously (23–25). However, the extent of spontaneous movements between nursing repositionings during the day and night and in different positions has to our knowledge not been studied. Thus, the aim of the present study was to investigate nursing staff induced repositionings and the patients’ spontaneous movements during the day and night among older immobile patients in nursing care. Furthermore, the aim was to identify the factors associated with the nursing staff induced repositionings and the patients’ spontaneous movement frequency. 2
A convenience sample of 62 participants (38 females, 24 males) were recruited during the period of June 2012 to May 2014 from eight nursing homes (29 participants) and seven hospital departments (33 participants); Pulmonary Medicine, Internal Medicine, Rehabilitation, Hematology and Oncology, Geriatric Orthopedic, Surgery and Palliative care. The inclusion criteria were 65 years of age or older; 1 or 2 points on the risk assessment pressure ulcer scale (RAPS) (26) regarding physical activity, that is confined to wheelchair or bed all day; and 1 or 2 points on the RAPS regarding mobility, that is cannot change position themselves. Exclusion criteria were skin sensitivity towards the adhesive dressing used to fixate the monitoring transmitter or if it was obvious that the participant would not be able to complete the observational period. Informed consent was obtained from the participants or, when appropriate, next of kin. The study was approved by the Regional Ethical Review Board in Linköping, Sweden (Dnr: 2012/165-31), and the study was performed according to the World Medical Association Declaration of Helsinki (27). Data collection protocol
One of the researchers (UK) completed the study protocol for each patient in collaboration with the nursing staff. The protocol, based on the European Pressure Ulcer Advisory Panel (EPUAP) minimal data set (28), consisted of four categories; background data such as age, weight and height; medical history and current medication; pressure ulcer prevention measures such as mattress, planned interval for repositioning and aids, for example positioning pillows, slide sheet, heel support, location and category I–IV of pressure ulcer if any (19); and risk assessment for pressure ulcer development using the RAPS (26). The RAPS is composed of the following variables: general physical condition, activity, mobility, moisture, food intake, fluid intake, sensory perception, friction and shear and body temperature. Each variable has scores ranging from 1 (very poor) to 4 (good), except the friction and shear category that has a score range of 1–3. The maximum score of the RAPS is 35 with a recommended cut-off level of ≤29 for pressure ulcer risk (26,29). Registration of patient movements
To register the patient’s movements, the MovinSense (MiS) care management system (Kinematix, Porto, Portugal) was used. The MiS is a microelectronic device developed to automatically monitor and document the patient’s movements and to support the nursing staff in their pressure ulcer prevention routines. The system consist of three parts: the MiS software, transmitter and receiver. The transmitter (Figure 1), which is small and lightweight (measuring 5⋅0 × 4⋅2 × 1⋅0 cm and weighing © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd
U. Källman et al.
Nursing staff repositionings and patients’ spontaneous movements
Figure 2 Number of participants included in the study, number and reasons of dropouts and number of 12 hours episodes per participants included in the analysis.
Figure 1 The MovinSense transmitter attached on the chest with adhesive dressing.
17 g), is secured onto the patient’s upper sternum with adhesive tape (Figure 1). The transmitter registers when (date and time) and how (angle and position) the patient, either with help from the staff or spontaneously, makes a position change. The data are stored in a log file and downloaded from the transmitter via the receiver to the software after the measurement period is completed. For this study, the device was configured to register only the movements of more than 25∘ in any direction and with a duration of more than 5 seconds. The alarm function in the MiS was turned off and the nursing staff had no access to the MiS data. A validation test of the congruence between MiS and nursing staff notes was performed based on 26 participants in the study. In 363 cases, the nursing staff noted if the patient was positioned in a lateral (left or right), supine or sitting up position and estimated the angle. The congruence of position was 92⋅3%. Data collection
The data collection was planned for a 3-day and -night period using MiS. During the same period, the nursing staff documented each occasion they helped the patient change position in the study protocol. Time, position, position angle and daily activity if any in connection with the position change were noted. The measurements made by the MiS and the manual documentation began on the afternoon of day 1 and ended in the morning of day 4. The researcher (UK) performed all installations, that is transmitter configuration, attachment to the patient, starting the device, and completed the procedure. Data analysis
Movements registered by the MiS were compared with the nursing staff notes, and the movements were coded to be either spontaneous or induced by the nursing staff. A movement was coded as being induced by the nursing staff if the movement registered by the MiS was from supine to sitting up, from left to right, etc. and if the movement was in congruence with the nursing staff notes, for example time, position, activity in connection to care and the position change. All other movements © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd
registered by the MiS were coded as being spontaneously made by the patient. If more than 10% of the data in any day or night could not be defined as either spontaneous or induced by the nursing staff, the period was excluded from the analysis. The number of nursing staff repositionings (REP) and patients’ spontaneous movements (MOV) were divided into 12 hours episodes; daytime (from 08:00 to 20:00) and night time (from 20:00 to 8:00). The intervals were chosen to include breakfast and evening meals during daytime and the standard routines of preparing for night rest before the end of the staff’s evening shift that finished at 9 pm. The data collected before 8 pm on day 1 and after 8 am on day 4 were not analysed. The participants were included in the analysis if both MiS data and nursing staff notes were complete for at least one 12 hours episode, which caused a dropout of 10 participants (Figure 2). In total, the analysis was based on 52 participants with a range of one to five 12 hours episodes. The following calculations per patient were made: the average number of REP during the day and night was calculated as the total REP divided by the total number of complete days and nights, the average number of MOV during the day and night was calculated as the total MOV divided by the total number of complete days and nights, the average duration in each position was calculated as the total time in each position divided by the total number of occasions in each position, the average number of MOV in each position was calculated as the total MOV in each position divided by the total number of occasions in each position and the body mass index (BMI) was calculated as weight in kilograms divided by height in square metres. The positions were divided into categories according to staff notes and defined as follows: • 0–19∘ supine position = 0∘ supine position, • supine position with head of the bed elevated (HOB) > 20∘ = ≥ 20∘ HOB, • 20–40∘ lateral position = 30∘ lateral position, • 41–70∘ lateral position = 60∘ lateral position, • >71∘ lateral position = 90∘ lateral position, • sitting in chair. All analyses were performed using PASW statistics, 22.0, 2013 (IBM SPSS Inc., Armonk, NY). 3
U. Källman et al.
Nursing staff repositionings and patients’ spontaneous movements
Statistics
Descriptive statistics of demographics, clinical characteristics and pressure prevention aids are presented as frequency and percentage or as means and standard deviations. Descriptive statistics of REP, MOV and duration are presented in median form, with first and third quartile and with their range. Wilcoxon signed-rank test was used to compare REP and MOV day and night results. A general linear model analysis was carried out to examine if there was any difference in MOV between the positions and between the individuals. The assumptions of equality of variances and normal distribution of residuals were checked. Tukey’s post hoc test was carried out for comparison between the positions. Spearman’s correlation coefficient was used to express the relationship between REP and/or MOV and type of health care, gender and factors potentially related to REP or MOV; BMI, total RAPS score and relevant RAPS variables, presence of pressure ulcer, cognitive dysfunction, cerebrovascular disease, cancer diagnosis, muscle/joint disease, Parkinson, hip fracture, analgesics, psychoanaleptics, phsycoleptics, mattress and slide sheet. A multiple regression analysis with backward method was performed using variables that showed a significant correlation (P value ≤0⋅05) with REP and MOV during the night. Because of non-normality distribution, the dependent variable MOV during the night was logarithmically transformed (Log10 ) before the analysis (30). Results
Demographics, clinical characteristics and descriptive statistics of pressure prevention aids are shown in Table 1. The mean age of the patients was 85 years (SD 7⋅3) and 33 of the 52 patients were females. All of the patients were identified as being at risk of pressure ulcer development according to the RAPS scale. Of the total 52 patients, 12 had an existing pressure ulcer located on the sacrum or heels, 42 patients had a pressure prevention mattress on their bed and 14 of the participants were confined to bed during both day and night during the measurement period. Nursing staff induced repositionings
The patients were repositioned by the nursing staff a median of five times (Q1 4, Q3 6) during the day and two times (Q1 2, Q3 3) during the night (P 20∘ HOB position during the day (108 occasions) twice as often as during the night (51 occasions) (Table 3). The nursing staff repositioned patients in a 30∘ lateral position (176 occasions) two to three times as often as in a 60∘ lateral position (86 occasions) or 90∘ lateral position (59 occasions). Patient spontaneous movements
The patients moved spontaneously a median of 16 times (Q1 7, Q3 52) during the day and 10 times (Q1 4, Q3 33) during the night (Table 2). The difference between day and night was significant (P = 0⋅011). Durations spent in the same position and angle were a median of 23 minutes (Q1 12 minutes, 4
Table 1 Demographics, clinical characteristics and descriptive statistics of pressure prevention aids in patients who were included in the analysis (n = 52) Variable Demographics Age (years) Female Patients in hospital Clinical charateristics RAPS score BMI Pressure ulcer Category I Category II Category III Category IV Sacral pressure ulcer Heel pressure ulcer Diagnoses Cardiovascular disease Hypertension Cognitive dysfunction Cerebrovascular disease Cancer Pulmonary dysfunction Diabetes Muscle/joint disease Hip fracture Parkinson Others Medications Number of medications/participants Antithrombotic agents Analgesics Antianimetic preparations β-Blocking agents Psychoanaleptics Diuretics Drugs for acid-related disorders Psycholeptics Antibacterials for systemic use Corticosteroids for systemic use Antiepileptics Others Pressure prevention aids Powered air fluid mattress Non-powered pressure-reducing mattress Positioning pillows Heel protection Slide sheet Pressure-reducing cushion in chair Pre-planned repositioning in bed Hourly Every second hour Every third hour Every fourth hour Individual regulary planned Not planned Pre-planned repositioning in chair Hourly Every second hour Every third hour Every fourth hour Individual regulary planned Not planned
N (%)
Mean (SD)
33 (64) 24 (46)
85 (7⋅3) – –
12 (23) – 4 (8) 1 (2) 7 (14) 7 5 26 (50) 21 (40) 17 (33) 14 (27) 14 (27) 13 (25) 12 (23) 9 (17) 5 (10) 4 (8) 25 (48)
24 (3⋅1) 26 (5⋅3) – – – – –
– – – – – – – – – –
31 (60) 30 (58) 24 (46) 24 (46) 21 (40) 20 (38) 18 (35) 18 (35) 13 (25) 11 (21) 10 (19) 41 (79)
7 (3⋅3) – – – – – – – – – – – –
17 (33) 25 (48) 18 (35) 10 (19) 34 (65) 25 (48)
– – – – – –
1 (2) 10 (19) 3 (6) 17 (33) 15 (29)
6 (11) – – – – –
5 (13) 3 (8) 1 (3) 3 (8) 10 (27) 15 (41)
– – – – – –
BMI, body mass index; RAPS, risk assessment pressure ulcer scale.
© 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd
U. Källman et al.
Nursing staff repositionings and patients’ spontaneous movements
Table 2 Descriptive statistics of nursing staff position change intervals and patients spontaneous movements registered by MiS Variables Nursing staff repositionings Number of REP during day Number of REP during night Duration between repositionings (h:min) Duration in different positions (h:min): Supine position Supine position with HOB elevated > 20∘ Lateral 30∘ Lateral 60∘ Lateral 90∘ Sitting in chair Movements registered by MiS Number of MOV during day Number of MOV during night Duration in same position and angle (hh:mm) Number of MOV in: Supine position Supine position with HOB elevated > 20∘ Lateral 30∘ Lateral 60∘ Lateral 90∘ † Sitting in chair‡
N
Median (Q1, Q3)
Minimum–Maximum
50 52 52
5 (4, 6) 2 (2, 3) 03:12 (02:41, 03:56)
3–9 0–5 00:15–14:24
44 42 42 29 26 38
02:56 (02:03, 03:56) 2:30 (1:36, 3:25) 03:24 (02:53, 04:04) 03:29 (02:33, 05:05) 03:50 (02:26, 04:38) 02:20 (01:29–03:29)
00:15–14:24 00:15–11:45 00:20–13:30 00:45–12:40 00:15–09:00 00:24–14:02
50 52 52
16 (7, 52) 10 (4, 33) 00:23 (00:12, 00:44)
0–168 0–135 00:00*–14:18
44 42 42 29 26 38
2 (1, 3) 4 (1, 8) 4 (1, 11) 3 (1, 9) 6 (3, 20) 4 (1, 10)
0–36 0–33 0–78 0–34 0–56 0–106
HOB, head of bed elevated; REP, nursing staff induced repositionings; MiS, MovinSense; MOV, patient spontaneous movements. *6 seconds. Univariate general linear model analysis with Tukey’s HSD test for post hoc comparison: †Significantly different from 0∘ supine, >20∘ HOB and 60∘ lateral positions. ‡Significantly different from 0∘ supine position.
Table 3 Total number of nursing staff induced repositionings during the day and night into the different positions Position
Day Number of observations (%)
Night Number of observations (%)
Total
% of total
68 (47) – 108 (68)
77 (53) – 51 (32)
145 18⋅60 159
% of total
–
–
20⋅40
145 (93) – 73 (42) – 37 (43) – 30 (51) – 461 (59) –
11 (7) – 103 (58) – 49 (57) – 29 (49) – 320 (41) –
156 20⋅00 176 22⋅50 86 11⋅00 59 7⋅60 781 100⋅00
0∘ Supine Supine position with HOB elevated >20∘ Sitting in chair % of total 30∘ Lateral % of total 60∘ Lateral % of total 90∘ Lateral % of total Total REP % of total
Variables associated to nursing staff induced repositionings
HOB, head of bed elevated; REP, nursing staff induced repositionings.
Q3 44 minutes) with a range of 6 seconds to 14 hours and 18 minutes. The MOV frequency was significantly different between positions F(5, 164) = 2⋅43, P = 0⋅037 and patients F(51, 164) = 4⋅17, P 20∘ HOB and 60∘ lateral positions (P ≤0⋅043). The number © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd
of MOV was also significantly higher when the patient was sitting in a chair compared with lying in the 0∘ supine position (P = 0⋅006).
The existence of a pressure ulcer was significantly positively correlated with the REP during the day (Table 4). During the night, the REP frequency was significantly positively correlated with hospital care as was having a cancer diagnosis; while the use of a slide sheet, the total RAPS score, three of the RAPS variables (general health, activity and moister), having a cognitive dysfunction and psycholeptic medication were significantly negatively correlated. No other variables had a significant correlation to REP, neither during the day nor at night. The variables that significantly correlated with REP during the night were added in the multiple regression model. The final model explained 31%, F(4, 51) = 6⋅7, P
ORIGINAL ARTICLE
Nursing staff induced repositionings and immobile patients’ spontaneous movements in nursing care Ulrika Källman1,2 , Sara Bergstrand1,3,4 , Anna-Christina Ek1 , Maria Engström1 & Margareta Lindgren1 1 Department of Medical and Health Sciences, Linköping University, Linköping, Sweden 2 Department of Dermatology, Södra Älvsborgs Sjukhus, Borås, Sweden 3 Department of Hand Surgery, Plastic Surgery, and Burns, Linköping University, Linköping, Sweden 4 Department of Biomedical Engineering, Linköping University, Linköping, Sweden
Key words Immobility; Nursing care; Patient repositioning; Pressure ulcer; Prevention
Källman U, Bergstrand S, Ek A-C, Engström M, Lindgren M. Nursing staff induced repositionings and immobile patients’ spontaneous movements in nursing care. Int Wound J 2015; doi: 10.1111/iwj.12435
Correspondence to U Källman, RN, PhD Student Division of Nursing Science, Faculty of Health and Science Linköping University Linköping Sweden E-mail: [email protected]
Abstract The aim of this study was to investigate nursing staff induced repositionings and the patients’ spontaneous movements during the day and night among older immobile patients in nursing care. Furthermore, the aim was to identify factors associated with the nursing staff induced repositionings and the patients’ spontaneous movement frequency. An observational cross-sectional design was used. Spontaneous movements among patients (n = 52) were registered continuously using the MovinSense monitoring system. The nursing staff documented each time they repositioned the patient. Patients spontaneous movements were compared with nursing staff induced repositionings. There were large variations in the patients’ spontaneous repositioning frequency during both days and nights, which shows that, although immobilised, some patients frequently reposition themselves. Analgesics were positively related to the movement frequency and psycholeptics were negatively related. The nursing staff more often repositioned the patients who were assessed as high risk than those assessed as low risk, but the patients’ spontaneous movement frequency was not correlated to the risk score. This may be important when planning repositioning schedules. A monitoring system may be useful in decision making with regard to planning repositioning and positions used in the prevention of pressure ulcers among elderly immobile patients.
Introduction
Healthy individuals make spontaneous movements whilst awake and during sleep to redistribute pressure (1). This is a natural, often sub-conscious, action taken to avoid pain or discomfort. Individuals with impaired sensory perception or mobility limitations may not feel this discomfort or cannot reposition themselves when it is actually needed. Previous research has shown a clear relationship between the amount of spontaneous nocturnal movements of older individuals and the development of pressure ulcers (2). Patients who repositioned themselves 50 or more times during the night had no pressure ulcers, whereas 90% of patients who repositioned themselves 20 times or less developed ulcers. A failure to reposition may cause a reduction in tissue oxygenation, sustained deformations of cells and potential tissue damage (3–6). © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd doi: 10.1111/iwj.12435
Thus, the turning and repositioning of patients who are immobile is a vital and effective measure to prevent pressure
Key Messages
• turning and repositioning patients who are immobile is regarded as a vital and effective measure to prevent pressure ulcers • nursing staff induced repositionings and patients’ spontaneous movements were investigated among elderly immobilised patients • there was a large variation seen in the extent the elderly patients made spontaneous movements and the movement frequency was significantly related to two types of
1
U. Källman et al.
Nursing staff repositionings and patients’ spontaneous movements
Methods
medication groups; analgesics were positively related and psycholeptics were negatively related • patients assessed as high risk were repositioned by nursing staff more frequently than patients assessed as low risk, but the patients’ spontaneous movement frequencies were not associated with the risk scores
Study design
The study is of a cross-sectional design.
non-experimental
observational
Participants
ulcer development (7). However, there is still weak evidence supporting specific turning regimes (8–10). Traditionally, guidelines and common practice state that intervals between repositionings should not exceed 2 hours (11). This is mainly based on animal research where tissue damage has been detected after 1–2 hours of high pressure exposure (12,13). However, for patients who are critically ill and in an unstable condition, or who require uninterrupted sleep, the 2-hour turning interval is not always desirable. Furthermore, turning regimes can impose high demands on nurses, and sometimes it is claimed that because of staff shortages, nurses do not have enough time to devote to turning (14,15). A recent clinical study supports that the time frame could be extended to 3 or 4 hours among nursing home residents with limited mobility who are at risk of pressure ulcer development without resulting in an increased incidence of pressure ulcers (16). The results of clinical surveys report that the majority of patients at risk of pressure ulcer development are turned or repositioned every second to third hour (15,17), but potentially, there could be discrepancies between documented and performed nursing actions. An increasingly common practice is to have individually planned schedules with a variety of time intervals (18). This approach is in accordance to guidelines (19); repositioning frequency should be based on professional judgement that takes into account the patient’s tissue tolerance, level of activity and mobility, medical condition, treatment plan, comfort and support surface used. Little research has been performed on movement patterns among the most high-risk patients, such as the elderly and immobilised, although immobility is considered one of the most important risk factors for pressure ulcer development (20,21). Schnelle et al. (22) evaluated sleep and bed mobility among incontinent nursing home residents during night time and counted the number of resident-initiated movements of the hip or shoulder to be larger than 45. They found that 33% of the participants made almost no spontaneous movements or turns during the night. Other studies evaluating different turning schedules have shown that patients do make minor movements spontaneously (23–25). However, the extent of spontaneous movements between nursing repositionings during the day and night and in different positions has to our knowledge not been studied. Thus, the aim of the present study was to investigate nursing staff induced repositionings and the patients’ spontaneous movements during the day and night among older immobile patients in nursing care. Furthermore, the aim was to identify the factors associated with the nursing staff induced repositionings and the patients’ spontaneous movement frequency. 2
A convenience sample of 62 participants (38 females, 24 males) were recruited during the period of June 2012 to May 2014 from eight nursing homes (29 participants) and seven hospital departments (33 participants); Pulmonary Medicine, Internal Medicine, Rehabilitation, Hematology and Oncology, Geriatric Orthopedic, Surgery and Palliative care. The inclusion criteria were 65 years of age or older; 1 or 2 points on the risk assessment pressure ulcer scale (RAPS) (26) regarding physical activity, that is confined to wheelchair or bed all day; and 1 or 2 points on the RAPS regarding mobility, that is cannot change position themselves. Exclusion criteria were skin sensitivity towards the adhesive dressing used to fixate the monitoring transmitter or if it was obvious that the participant would not be able to complete the observational period. Informed consent was obtained from the participants or, when appropriate, next of kin. The study was approved by the Regional Ethical Review Board in Linköping, Sweden (Dnr: 2012/165-31), and the study was performed according to the World Medical Association Declaration of Helsinki (27). Data collection protocol
One of the researchers (UK) completed the study protocol for each patient in collaboration with the nursing staff. The protocol, based on the European Pressure Ulcer Advisory Panel (EPUAP) minimal data set (28), consisted of four categories; background data such as age, weight and height; medical history and current medication; pressure ulcer prevention measures such as mattress, planned interval for repositioning and aids, for example positioning pillows, slide sheet, heel support, location and category I–IV of pressure ulcer if any (19); and risk assessment for pressure ulcer development using the RAPS (26). The RAPS is composed of the following variables: general physical condition, activity, mobility, moisture, food intake, fluid intake, sensory perception, friction and shear and body temperature. Each variable has scores ranging from 1 (very poor) to 4 (good), except the friction and shear category that has a score range of 1–3. The maximum score of the RAPS is 35 with a recommended cut-off level of ≤29 for pressure ulcer risk (26,29). Registration of patient movements
To register the patient’s movements, the MovinSense (MiS) care management system (Kinematix, Porto, Portugal) was used. The MiS is a microelectronic device developed to automatically monitor and document the patient’s movements and to support the nursing staff in their pressure ulcer prevention routines. The system consist of three parts: the MiS software, transmitter and receiver. The transmitter (Figure 1), which is small and lightweight (measuring 5⋅0 × 4⋅2 × 1⋅0 cm and weighing © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd
U. Källman et al.
Nursing staff repositionings and patients’ spontaneous movements
Figure 2 Number of participants included in the study, number and reasons of dropouts and number of 12 hours episodes per participants included in the analysis.
Figure 1 The MovinSense transmitter attached on the chest with adhesive dressing.
17 g), is secured onto the patient’s upper sternum with adhesive tape (Figure 1). The transmitter registers when (date and time) and how (angle and position) the patient, either with help from the staff or spontaneously, makes a position change. The data are stored in a log file and downloaded from the transmitter via the receiver to the software after the measurement period is completed. For this study, the device was configured to register only the movements of more than 25∘ in any direction and with a duration of more than 5 seconds. The alarm function in the MiS was turned off and the nursing staff had no access to the MiS data. A validation test of the congruence between MiS and nursing staff notes was performed based on 26 participants in the study. In 363 cases, the nursing staff noted if the patient was positioned in a lateral (left or right), supine or sitting up position and estimated the angle. The congruence of position was 92⋅3%. Data collection
The data collection was planned for a 3-day and -night period using MiS. During the same period, the nursing staff documented each occasion they helped the patient change position in the study protocol. Time, position, position angle and daily activity if any in connection with the position change were noted. The measurements made by the MiS and the manual documentation began on the afternoon of day 1 and ended in the morning of day 4. The researcher (UK) performed all installations, that is transmitter configuration, attachment to the patient, starting the device, and completed the procedure. Data analysis
Movements registered by the MiS were compared with the nursing staff notes, and the movements were coded to be either spontaneous or induced by the nursing staff. A movement was coded as being induced by the nursing staff if the movement registered by the MiS was from supine to sitting up, from left to right, etc. and if the movement was in congruence with the nursing staff notes, for example time, position, activity in connection to care and the position change. All other movements © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd
registered by the MiS were coded as being spontaneously made by the patient. If more than 10% of the data in any day or night could not be defined as either spontaneous or induced by the nursing staff, the period was excluded from the analysis. The number of nursing staff repositionings (REP) and patients’ spontaneous movements (MOV) were divided into 12 hours episodes; daytime (from 08:00 to 20:00) and night time (from 20:00 to 8:00). The intervals were chosen to include breakfast and evening meals during daytime and the standard routines of preparing for night rest before the end of the staff’s evening shift that finished at 9 pm. The data collected before 8 pm on day 1 and after 8 am on day 4 were not analysed. The participants were included in the analysis if both MiS data and nursing staff notes were complete for at least one 12 hours episode, which caused a dropout of 10 participants (Figure 2). In total, the analysis was based on 52 participants with a range of one to five 12 hours episodes. The following calculations per patient were made: the average number of REP during the day and night was calculated as the total REP divided by the total number of complete days and nights, the average number of MOV during the day and night was calculated as the total MOV divided by the total number of complete days and nights, the average duration in each position was calculated as the total time in each position divided by the total number of occasions in each position, the average number of MOV in each position was calculated as the total MOV in each position divided by the total number of occasions in each position and the body mass index (BMI) was calculated as weight in kilograms divided by height in square metres. The positions were divided into categories according to staff notes and defined as follows: • 0–19∘ supine position = 0∘ supine position, • supine position with head of the bed elevated (HOB) > 20∘ = ≥ 20∘ HOB, • 20–40∘ lateral position = 30∘ lateral position, • 41–70∘ lateral position = 60∘ lateral position, • >71∘ lateral position = 90∘ lateral position, • sitting in chair. All analyses were performed using PASW statistics, 22.0, 2013 (IBM SPSS Inc., Armonk, NY). 3
U. Källman et al.
Nursing staff repositionings and patients’ spontaneous movements
Statistics
Descriptive statistics of demographics, clinical characteristics and pressure prevention aids are presented as frequency and percentage or as means and standard deviations. Descriptive statistics of REP, MOV and duration are presented in median form, with first and third quartile and with their range. Wilcoxon signed-rank test was used to compare REP and MOV day and night results. A general linear model analysis was carried out to examine if there was any difference in MOV between the positions and between the individuals. The assumptions of equality of variances and normal distribution of residuals were checked. Tukey’s post hoc test was carried out for comparison between the positions. Spearman’s correlation coefficient was used to express the relationship between REP and/or MOV and type of health care, gender and factors potentially related to REP or MOV; BMI, total RAPS score and relevant RAPS variables, presence of pressure ulcer, cognitive dysfunction, cerebrovascular disease, cancer diagnosis, muscle/joint disease, Parkinson, hip fracture, analgesics, psychoanaleptics, phsycoleptics, mattress and slide sheet. A multiple regression analysis with backward method was performed using variables that showed a significant correlation (P value ≤0⋅05) with REP and MOV during the night. Because of non-normality distribution, the dependent variable MOV during the night was logarithmically transformed (Log10 ) before the analysis (30). Results
Demographics, clinical characteristics and descriptive statistics of pressure prevention aids are shown in Table 1. The mean age of the patients was 85 years (SD 7⋅3) and 33 of the 52 patients were females. All of the patients were identified as being at risk of pressure ulcer development according to the RAPS scale. Of the total 52 patients, 12 had an existing pressure ulcer located on the sacrum or heels, 42 patients had a pressure prevention mattress on their bed and 14 of the participants were confined to bed during both day and night during the measurement period. Nursing staff induced repositionings
The patients were repositioned by the nursing staff a median of five times (Q1 4, Q3 6) during the day and two times (Q1 2, Q3 3) during the night (P 20∘ HOB position during the day (108 occasions) twice as often as during the night (51 occasions) (Table 3). The nursing staff repositioned patients in a 30∘ lateral position (176 occasions) two to three times as often as in a 60∘ lateral position (86 occasions) or 90∘ lateral position (59 occasions). Patient spontaneous movements
The patients moved spontaneously a median of 16 times (Q1 7, Q3 52) during the day and 10 times (Q1 4, Q3 33) during the night (Table 2). The difference between day and night was significant (P = 0⋅011). Durations spent in the same position and angle were a median of 23 minutes (Q1 12 minutes, 4
Table 1 Demographics, clinical characteristics and descriptive statistics of pressure prevention aids in patients who were included in the analysis (n = 52) Variable Demographics Age (years) Female Patients in hospital Clinical charateristics RAPS score BMI Pressure ulcer Category I Category II Category III Category IV Sacral pressure ulcer Heel pressure ulcer Diagnoses Cardiovascular disease Hypertension Cognitive dysfunction Cerebrovascular disease Cancer Pulmonary dysfunction Diabetes Muscle/joint disease Hip fracture Parkinson Others Medications Number of medications/participants Antithrombotic agents Analgesics Antianimetic preparations β-Blocking agents Psychoanaleptics Diuretics Drugs for acid-related disorders Psycholeptics Antibacterials for systemic use Corticosteroids for systemic use Antiepileptics Others Pressure prevention aids Powered air fluid mattress Non-powered pressure-reducing mattress Positioning pillows Heel protection Slide sheet Pressure-reducing cushion in chair Pre-planned repositioning in bed Hourly Every second hour Every third hour Every fourth hour Individual regulary planned Not planned Pre-planned repositioning in chair Hourly Every second hour Every third hour Every fourth hour Individual regulary planned Not planned
N (%)
Mean (SD)
33 (64) 24 (46)
85 (7⋅3) – –
12 (23) – 4 (8) 1 (2) 7 (14) 7 5 26 (50) 21 (40) 17 (33) 14 (27) 14 (27) 13 (25) 12 (23) 9 (17) 5 (10) 4 (8) 25 (48)
24 (3⋅1) 26 (5⋅3) – – – – –
– – – – – – – – – –
31 (60) 30 (58) 24 (46) 24 (46) 21 (40) 20 (38) 18 (35) 18 (35) 13 (25) 11 (21) 10 (19) 41 (79)
7 (3⋅3) – – – – – – – – – – – –
17 (33) 25 (48) 18 (35) 10 (19) 34 (65) 25 (48)
– – – – – –
1 (2) 10 (19) 3 (6) 17 (33) 15 (29)
6 (11) – – – – –
5 (13) 3 (8) 1 (3) 3 (8) 10 (27) 15 (41)
– – – – – –
BMI, body mass index; RAPS, risk assessment pressure ulcer scale.
© 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd
U. Källman et al.
Nursing staff repositionings and patients’ spontaneous movements
Table 2 Descriptive statistics of nursing staff position change intervals and patients spontaneous movements registered by MiS Variables Nursing staff repositionings Number of REP during day Number of REP during night Duration between repositionings (h:min) Duration in different positions (h:min): Supine position Supine position with HOB elevated > 20∘ Lateral 30∘ Lateral 60∘ Lateral 90∘ Sitting in chair Movements registered by MiS Number of MOV during day Number of MOV during night Duration in same position and angle (hh:mm) Number of MOV in: Supine position Supine position with HOB elevated > 20∘ Lateral 30∘ Lateral 60∘ Lateral 90∘ † Sitting in chair‡
N
Median (Q1, Q3)
Minimum–Maximum
50 52 52
5 (4, 6) 2 (2, 3) 03:12 (02:41, 03:56)
3–9 0–5 00:15–14:24
44 42 42 29 26 38
02:56 (02:03, 03:56) 2:30 (1:36, 3:25) 03:24 (02:53, 04:04) 03:29 (02:33, 05:05) 03:50 (02:26, 04:38) 02:20 (01:29–03:29)
00:15–14:24 00:15–11:45 00:20–13:30 00:45–12:40 00:15–09:00 00:24–14:02
50 52 52
16 (7, 52) 10 (4, 33) 00:23 (00:12, 00:44)
0–168 0–135 00:00*–14:18
44 42 42 29 26 38
2 (1, 3) 4 (1, 8) 4 (1, 11) 3 (1, 9) 6 (3, 20) 4 (1, 10)
0–36 0–33 0–78 0–34 0–56 0–106
HOB, head of bed elevated; REP, nursing staff induced repositionings; MiS, MovinSense; MOV, patient spontaneous movements. *6 seconds. Univariate general linear model analysis with Tukey’s HSD test for post hoc comparison: †Significantly different from 0∘ supine, >20∘ HOB and 60∘ lateral positions. ‡Significantly different from 0∘ supine position.
Table 3 Total number of nursing staff induced repositionings during the day and night into the different positions Position
Day Number of observations (%)
Night Number of observations (%)
Total
% of total
68 (47) – 108 (68)
77 (53) – 51 (32)
145 18⋅60 159
% of total
–
–
20⋅40
145 (93) – 73 (42) – 37 (43) – 30 (51) – 461 (59) –
11 (7) – 103 (58) – 49 (57) – 29 (49) – 320 (41) –
156 20⋅00 176 22⋅50 86 11⋅00 59 7⋅60 781 100⋅00
0∘ Supine Supine position with HOB elevated >20∘ Sitting in chair % of total 30∘ Lateral % of total 60∘ Lateral % of total 90∘ Lateral % of total Total REP % of total
Variables associated to nursing staff induced repositionings
HOB, head of bed elevated; REP, nursing staff induced repositionings.
Q3 44 minutes) with a range of 6 seconds to 14 hours and 18 minutes. The MOV frequency was significantly different between positions F(5, 164) = 2⋅43, P = 0⋅037 and patients F(51, 164) = 4⋅17, P 20∘ HOB and 60∘ lateral positions (P ≤0⋅043). The number © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd
of MOV was also significantly higher when the patient was sitting in a chair compared with lying in the 0∘ supine position (P = 0⋅006).
The existence of a pressure ulcer was significantly positively correlated with the REP during the day (Table 4). During the night, the REP frequency was significantly positively correlated with hospital care as was having a cancer diagnosis; while the use of a slide sheet, the total RAPS score, three of the RAPS variables (general health, activity and moister), having a cognitive dysfunction and psycholeptic medication were significantly negatively correlated. No other variables had a significant correlation to REP, neither during the day nor at night. The variables that significantly correlated with REP during the night were added in the multiple regression model. The final model explained 31%, F(4, 51) = 6⋅7, P
