Geriatric Nursing xx (2013) 1e8
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Pressure ulcer prevention in nursing homes: Nurse descriptions of individual and organization level factors Mary Ellen Delleﬁeld, PhD, RN a, *, Jennifer L. Magnabosco, PhD b, c a
Department of Veterans Affairs, VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA Department of Veterans Affairs, Center for Implementation Practice & Research Support (CIPRS), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA c Yo San University of Traditional Chinese Medicine, Los Angeles, CA, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 March 2013 Received in revised form 28 September 2013 Accepted 7 October 2013 Available online xxx
Sustaining pressure ulcer prevention (PUP) in nursing homes has been difﬁcult to achieve. Implementation science researchers suggest that identiﬁcation of individual staff and organizational factors inﬂuencing current practices is essential to the development of an effective and customized plan to implement practice changes in a speciﬁc setting. A mixed methods approach was used to describe nurses’ perceptions of individual and organization-level factors inﬂuencing performance of PUP in two Veterans Health Administration (VHA) nursing homes prior to implementation of a national VHA initiative on Hospital Acquired Pressure Ulcers (HAPUs). Individual interviews of 16 nursing staff were conducted. Individual factors inﬂuencing practice were a personal sense of responsibility to Veterans and belief in the effectiveness and importance of preventive measures. Organizational factors were existence of cooperative practices between nursing assistants and licensed nurses in assessing risk; teamwork, communication, and a commitment to Veterans’ well-being. Integration and reinforcement of such factors in the development and maintenance of customized plans of PUP initiatives is recommended. Ó 2013 Mosby, Inc. All rights reserved.
Keywords: Pressure ulcers Nursing home Implementation Clinical guidelines Nursing
Globally, nursing home (NH) consumers and other stakeholders assume that the incidence and prevalence of pressure ulcers (PUs) are indicators of poor nursing care quality.1,2 This is largely due to a longstanding rationale in the healthcare ﬁeld that most PUs are preventable, especially if nurses routinely perform basic nursing responsibilities.3 Evidence-based guidelines for prevention of PUs have been widely disseminated in the United States (US) and European countries, including England, Germany, Italy, the Netherlands, Belgium, and Sweden.4,5 The Joint Commission, as the accrediting agency for US healthcare facilities receiving federal healthcare funding, has included effective PU prevention (PUP) and treatment as a national safety goal for several years. In spite of these efforts, reducing the incidence of PU development for at-risk NH residents has been difﬁcult to achieve.6e9 Difﬁculties in reducing the incidence of PU risk have been linked to multiple factors that may inﬂuence nurses’ behaviors, including staff attitudes, beliefs, knowledge, clinical practice requirements, managerial behaviors, and unit infrastructure. Addressing these factors is key to formulating a plan to more easily and effectively * Corresponding author. Tel.: þ1 858 692 8553; fax: þ1 858 552 1246. E-mail addresses: mary.delleﬁ[email protected]
, delleﬁ[email protected]
(M.E. Delleﬁeld). 0197-4572/$ e see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.10.010
implement evidence-based guidelines and practices for PUP care.10 Researchers have found that prior to developing a plan to implement a practice change e such as the implementation of evidencebased guidelines e it is important to assess existing individual and organizational factors perceived by staff that may be positive and negative inﬂuences on the practices targeted for change.11 This assessment is useful in tailoring a unit or facility speciﬁc approach to implementation of evidence-based practice changes. Given the complexities of performing PUP care, and the variance in knowledge, attitudes, and beliefs that underlie clinical staff’s delivery of such care, we explored individual and organizational factors associated with PUP using both qualitative and quantitative data. In order to gain a more comprehensive understanding of PUP care delivery, triangulation of these two data types allowed us to explore the multi-dimensional nature of PUP. Our purpose in asking open-ended (qualitative) and close-ended (quantitative) questions was to “get at” the “whats” and “hows” of PUP care delivery, and to be able to compare domains and dimensions of care that lent themselves best to qualitative and/or quantitative measurement.12 While we were primarily interested in the uninﬂuenced descriptive expressions that nurses could provide (through answers to openended questions), we were also cognizant of the fact that nurses might conceal “real” knowledge, attitudes, and behaviors. Hence,
M.E. Delleﬁeld, J.L. Magnabosco / Geriatric Nursing xx (2013) 1e8
we created close-ended questions that were similar to the openended questions to provide an additional avenue for expression, and comparison among participants. Background Study constructs Evidence-based guidelines and implementation science provided the conceptual foundations for this study.4,13 Healthcare implementation is deﬁned as a planned process and systematic introduction of a change in clinical practice that is evidence-based, and incremental.11 The rigorous study of this process is termed implementation science (IS). IS seeks to establish greater understanding of how empirically based strategies are effectively used to improve healthcare practices, with special emphasis on how strategies are implemented to incorporate changes into routine and/or management practices.11,14 One common exploratory goal of IS has been to determine how the adoption of evidence-based guidelines takes place, and to identify and describe which characteristics of care practices may be associated with the achievement of positive clinical outcomes. Individual level factors and PUP Individual factors of nurses such as knowledge, attitudes, motivation, beliefs and values are known to inﬂuence behaviors of healthcare staff.11 European nurse researchers have used qualitative methods to study relations between individual staff characteristics and PUP nurse performance.15e21 For example, Beeckman et al and Samuriwo (2010) found that the variation in value placed by nursing staff on PUP care affected the delivery of their PUP practices.2,19 In other words, nurses prioritized PU care by comparing it with other types of care that needed to be delivered. In a study of 9 NHs and 154 Belgian nurses, Demarre et al (2012) found that nurses had more positive attitudes toward PUP care than nursing assistants. A more positive attitude was a signiﬁcant predictor of compliance with PU prevention practices.20 Globally, however, quantitative empirical evidence that links individual factors and actual compliance with PUP practice guidelines in NHs, is limited.2,16,21 This is because individual factors have been understudied compared to organizational factors; few instruments have been developed; and existing instruments are not considered psychometrically rigorous.18 However in 2010, Beeckman et al published a psychometric evaluation of a new instrument e the Attitude towards Pressure Ulcer Prevention (APuP). Testing of the APuP has shown that individual performance of PUP care delivery can be inﬂuenced by perceptions of personal competence and responsibility for PUP.21 Organization-level factors and PUP Although studies have been limited by small staff or facility sample sizes, trends are emerging about organizational factors reported as facilitators and barriers to performance of PUP care in NHs.22e27 Factors related to effective organizational practices include use of standardized risk assessment forms and wound nurse specialists; consultation with interdisciplinary team members; ongoing staff education; use of higher speciﬁcation foam mattresses to provide effective support; and use of ‘turn schedules’ or speciﬁc times at which at-risk residents are re-positioned, either in bed or in a chair, to relieve pressure.22e27 Strategies consistently identiﬁed as important components of successful PUP programs in the US and Europe in a range of settings and across populations include administrative support; active involvement of direct care
staff; bundling of care processes that are integrated into routine practice (e.g. performing risk assessment, repositioning, skin care, and skin inspections); using a systematic approach that is tailored to the unique features of a care setting; and ongoing staff education.7,8,28 Conversely, researchers have identiﬁed organization-level factors found to impede successful delivery of PUP care. These include under-utilization of risk assessment tools; lack of dissemination of clinical guidelines to all levels of clinical staff; lack of systematic approaches to guideline implementation29; use of documentation formats that do not record clinical data consistent with guideline content30; nursing staff perception of a lack of time for prevention,19 absence of family advocacy; inadequate stafﬁng; and lack of clinical supervision of nursing care associated with activities of daily living.31 In addition, Rosen et al (2005) found that when targeted performance feedback on preventive care and incentives were not sustained, the level of adherence to PUP guidelines declined.32 Similarly, inadequate nurse stafﬁng levels have been shown to impede performance of preventive nursing care. Horn et al (2005) found that increased PU incidence was associated with lower nursing staff of all skill levels and less direct care performed by registered nurses (RNs).30 Niederhauser et al (2012) reported that program sustainability was reduced if too many changes were made at one time; staff was inadequately educated; resistance to new practices was not addressed; equipment was inadequate; and a supportive infrastructure was absent.8 Methods Study aim The purpose of this study was to describe nurses’ perceptions of individual and organization-level factors inﬂuencing performance of pressure ulcer prevention (PUP) care in 2 VHA Nursing Home Community Living Centers (CLCs) to help identify existing factors perceived as facilitators and barriers to delivering PUP care. The study was conducted in concert with the beginning phases of the VHA’s national Hospital Acquired Pressure Ulcer (HAPU) Initiative “Getting to Zero.” Started in 2011, the Initiative’s purpose was to implement updated and comprehensive evidence-based practices processes as deﬁned in VHA Handbook 1180.02 “Prevention of Pressure Ulcers,” to prevent PUs in all clinical settings, including 135 CLCs.33 A national HAPU interdisciplinary workgroup was established and charged with “creating a culture of change, communication, and commitment to support eliminating HAPUs throughout VHA.”33 Study design and sample The study employed an exploratory qualitative interview study design, triangulating qualitative and quantitative data to study individual and organization level factors associated with three domains of interest: nurses’ general perceptions and feelings about PUP; PUP practices, including staff, residents, and family; and performance.12 A convenience sample of 2 VHA CLCs was selected because these facilities had the largest bed capacity of 5 VHA-operated CLCs in southern California. The sites were most representative of CLCs nationally in the types of services offered and nursing skill mix used. The study sites were comprised of 3 and 2 units, respectively, and provided a range of clinical services-palliative, dementia, rehabilitation, and traditional long-term care. The CLCs were staffed with 3.9e4.1 care hours per patient day (HPRD) that were at a higher level, on average, than non-governmental nursing homes.34
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Each unit had a nurse manager who was accountable for unit-level performance of PUP practices. We sought to capture a purposeful stratiﬁed sample of nursing staff in the 2 sites, representative of the 3 skill levels of nursing staff [i.e. registered nurses (RNs), licensed vocational nurses (LVNs), and nursing assistants (NAs)]. Nursing staff employed for at least 90 days were eligible for participation in the study. The principal investigator conducted a series of recruitment meetings accessible to all shifts. Recruitment materials were made available in staff lounges throughout the duration of the study in 2011. Research staff coordinated subject and interviewer schedules with nurse managers to make appointments for either in-person or telephone interviews. The interviews were 45e60 min in length, conducted before, during or after a nursing shift in a private area on each nursing unit by one investigator, and another experienced interviewer. Interviews were audio-taped. Measures The interview guide development was based on content of published PUP clinical guidelines and IS concepts related to individual and organization level factors known to inﬂuence nursing staff behaviors. We acquired evidence of the face validity of the interview guide by piloting it with a small group of colleagues and nursing staff. A cross-section of open and close-ended questions
related to staff attitudes, values, feelings, knowledge, and practices were based on ﬁndings reported by non-European, and European nurse researchers.16,18e21 The ﬁnal interview guide included open and close ended questions presented to subjects under three domains: general perceptions and feelings, PUP practices (i.e. staff, residents, family), and performance. There were 22 semi-structured open ended questions and 16 close-ended questions (i.e. 3 yes/no; 13 scored with a 1e10 range, where 1 was lowest and 10 was highest). The same interview guide was used with all subjects to provide a basis for comparison amongst nursing staff. Tables 1 and 2 display open ended questions; Table 3 displays close ended questions. All questions are grouped by domains. The study was approved by the University of California San Diego (UCSD) and VHA Institutional Review Boards. Each participant was asked to sign a consent form before participation. Written and verbal assurances were given about protecting the anonymity of individuals and their employers. Analyses Content analysis was used to analyze interview responses to identify themes and calculate frequency counts of codes.35,36 Descriptive statistics were used to analyze responses for questions with yes/no or 1e10 responses.
Table 1 Individual-level factors categorized by domains and open-ended questions. Questions and themes
General perceptions and feelings What contributes to PU care being interesting or not? “For me, what the skin actually goes through and the fact that we can prevent something like that. That’s interesting Level of interest in providing PUP care grounded in to me.that it just only takes turning to prevent it.” (NA) recognition that prevention works to improve “It’s interesting because it’s important to Veterans’ health.we can do something to help with problems.” (NA) Veteran health “It has a total impact, a 100% impact. I remind my coworkers all the time that Christopher Reeves had a ton of money and the best healthcare on earth. It was a decubitus ulcer that went down bone, got in his bloodstream, and ultimately killed him. So, I mean, he was Superman, he was a superstar, and so, bacteria did not respect him as an individual. Prevention is better than cure.” (NA) “Prevention enhances their life. It makes them more comfortable when your skin’s intact and you have less infections. The skin is the largest organ, so deﬁnitely if you break down the largest organ, you’re going to have major problems. So just looking at it at that aspect alone, you can see the devastation of skin break down.” (RN) “I would give it an 8 (out of 10 points) because if there are some who need palliative care, hospice care, your body is then shutting down.” (LVN) “I’ll say they’re preventable because that the whole key in nursing care, especially when you have totals.” (NA) Practices e staff residents, family In what ways is the Braden Scale score helpful to you to identify Veterans at risk for PUs? “It’s mildly helpful. I think it’s only because I know what the risk factor are already so Braden kind of incorporated Usefulness of the Braden scale score for risk into my practice, so I guess it kind of goes hand-in-hand, but I don’t look at the Braden score and then say oh good, assessment varied, and linked to knowledge now I know they’re at high risk. I already know that they’re at high risk and then I see that the Braden score matches about it my assessment of that.” (RN) It’s very good.” (LVN) “I don’t think so. The NAs are doing it maybe; the LVN and the RN are doing that. As I said before, we have very limited knowledge about it.” (NA) How does usual care differ for at-risk Veterans? A more intense level of care provided for at-risk “The at-risk, you know, I’m going to make is sure I check them a lot more thorough and just take a lot more time Veterans because you since they’re at risk, the possibility of something developing is a lot more intimate than a person who is not at risk. Probably the care I’d give might be a little slower too so I can observe a little better.” (NA) “Everybody has different levels of ability to perform activities of daily living (ADLS) so you assess your patient’s ability to do self-care and if they’re able to properly maintain their hygiene and they don’t need any intervention then they’re at low risk.” (RN) In what ways do you encourage a Veteran to be involved in their PU care? A Veteran’s family? Veteran and family involvement varies but is “Some of the patients don’t even know what a PU is e right? So we have to explain to them what it means because important to Veteran health patients say, no, I want to stay in bed.” (NA) “All the things that we would do for the patients or encourage the patient to do we would talk to the family members about but also explain that depending on the age of the patient sometimes the patient’s skin becomes more fragile and susceptible to tears.” (RN) “I think for me it’s just a judgment call depending on the person’s cognitive status. If they’re alert and currently understanding what is going on, you know, like I said their input about what makes them comfortable helps. It goes just the opposite if they’re not alert, and unresponsive and doesn’t know what’s going on. Then I need to actually do what I need to do to prevent a PU from developing.” (NA) Note: NA ¼ nursing assistant; LVN ¼ licensed vocational nurse; RN ¼ registered nurse.
M.E. Delleﬁeld, J.L. Magnabosco / Geriatric Nursing xx (2013) 1e8
Table 2 Organization-level factors categorized by domains and open-ended questions. Questions and themes
Practices e staff, residents, family How do you routinely learn/know that a Veteran is at risk? Who decides that a Veteran is at risk? Which nursing staff might assist you in knowing which Veterans are at risk? Teamwork required to “.Well, upon admission, we inspect patients with wound care nurse, which is an LVN, and then a skin inspection asses Veteran’s level of risk further down the road comes during routine assessments and that’s just with myself. Any time the nursing aide may be changing the patient; I will do a quick visual assessment and if the nurse’s aide, the NA said, I need you to come look at this, then that’s a priority.” (RN) “Typically it would come from often our NAs front line because they would say his buttocks looks red, I need you to come see this. They’ll notice something on the skin that is out of norm from what was observed the last few days and they will say I need you to come look at this. That’s the biggest trigger. Or another thing also might be he’s had diarrhea for a couple of days or he’s not been using the urinal, so urinating on himself.” (RN) “Constant vigilance. You have to be proactive and not reactive. Once you ﬁnd out that something needs to be done, direct it to the right person, so that they can do a care plan that you can execute. And once that’s done, that is 90% of it because you do not want to wait and then it is a little red spot. Next thing you know it’s an open wound. However, Veteran characteristics and workload could limit your ability to perform.”(NA) Performance What types of recognition have you received, whether from the nurse manager, Veteran, or family for the PU preventive care you deliver? Feedback received for individual “When it comes to giving the patient care, the best care I’m capable of I mean sure, it would be nice (getting versus group performance varied feedback), but if I didn’t get it or got it negatively or whatever. I would still try to deliver the best care possible that it would not impact it a lot because for me preventive measures is part of the nursing care for me.” (NA) “I care and plan for each and every patient. So it wouldn’t impact my care and I try not to ever let anything impact my care. I am human, that I am, but you know it wouldn’t impact my care.” (NA) “I will tell you that I am intrinsically motivated and I’m motivated to do what’s best for the patient, regardless of what anyone says, so while it might be nice to have the LVN, the NA and the patient and even a family member or the nurse manager say wow, that was good, I’m still going to do what I’m supposed to do.” (RN) “Cause they tell you constantly.” (NA) “She’ll show us may be like what pressure ulcers we’ve had during the month and let’s see what else, and I know that it doesn’t seem to be an issue. I mean we’re just all over.we have a wound care LVN, a wound care treatment of all types of wounds everyday, so I know it’s a big focus for us and we don’t use diapers, you know, there’s just different criteria, we use certain mattresses, all kinds of things that are about PU prevention.” (RN) Practices e staff, residents, family What are the factors that contribute to the unit’s success in preventing PUs? “Well, I think the wound team demonstrates when you call them they come and they do an in-service to you right Teamwork, communication, and commitment there. So they are not just coming and doing it themselves only. They are involving you in how to do it when they are to Veterans contributed to unit success; not there. Cuz they are only here on the day shift.” (NA) communication between wound care team “It’s like in our agenda, everyday agenda to make sure that we prevent it in every way we can like by putting them and staff perceived as teamwork up, change the diapers on time, giving the shower twice a week, right, and helping them in every way we can.” (NA) “Yes and also like every morning when they give us our assignment, we talk about every patient, okay, this patient had this. Well, they email us. I’m off tour, you know meaning I work at night so anything that’s addressed at the interdisciplinary team meeting and they email us so we can read about what’s going on with the patient. The wound team, anything they do is also emailed us too, what the plan of care is.” (RN) “I noticed this change in that patient, you know even the behavior, any slight changes we see in a patient, we discuss about it. Like we get a ﬁrsthand experience, ﬁrsthand knowledge with our peers about our patients.” (NA) “Good teamwork, positive peer support, and well organized wound care program.” (RN) Performance How do you keep up to date or learn new practices for PU prevention? If you were working with a new employee, what resources would you use to teach them about the PU prevention program on this unit? Diverse educational strategies for PUP useful “So I think that the NAs’ education or refresher course [should have] language that they understand.not medical terminology over their head. I think it would be better.” (LVN) “So I think that if there was a video of an actual person you know that would make it a little bit more personal. I personally have seen where they have 1 or 2 wounds. It has changed me forever.” (LVN) Performance What type of equipment or supplies does your unit have to provide PU care? What might you need to provide more effective care? Amount and type of equipment needed varied “We have enough quality equipment and supplies 99% of the time. It’s just for certain times, especially on weekends, where we don’t have the things we need and it’s more of a stocking issue.” (NA) “Well with the beds here at the CLC, we’ve got like ﬁve different types of beds, four different types of mattresses. All of them don’t match.” (NA) Note: NA ¼ nursing assistant; LVN ¼ licensed vocational nurse; RN ¼ registered nurse.
Interviews were transcribed verbatim and transcripts were compared to audiotapes to assess their descriptive validity.35 Transcripts were analyzed using the categories established a priori (e.g. domain category, study site, question type (i.e. open or closed ended), and type of staff (i.e. RN, LVN, NA)) to determine themes, similarities, and possible differences. Each investigator independently read the transcripts and coded them. Themes were categorized using the rubrics for individual or organization level factors. One investigator calculated frequency counts for codes and descriptive statistics for the close-ended questions. Differences between investigators regarding coding and categorization of content were easily resolved through discussion.
Results Demographics Twenty-ﬁve nurses signed consents and 16 (3 RNs, 4 LVNs, and 9 NAs) participated in the study. Nurses who signed consents but did not participate could not make time in their schedule due to personal commitments, (e.g. dropping off or picking up children from school), transitioned out of their job position, or developed health issues. The majority of study participants worked day shift (81%), were female (88%), middle-aged (average age 50 years), ethnically diverse (white/non-white), experienced
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Table 3 Close-ended responses grouped by domain. Domains General perceptions and feelings How interesting is PU nursing care to you? How high a priority is PU care, given all your other responsibilities? Are all PUs preventable? How conﬁdent are you that preventive measures are effective? What degree of impact do you think PU prevention care has on Veterans’ quality of life? How effective do you feel you are in preventing PUs? Practices e staff, residents, family How different is usual care for all residents compared to care provided to at-risk Veterans? How difﬁcult or easy is it for you to routinely inspect skin of at-risk Veterans? (1 ¼ not difﬁcult at all) How involved ought a resident to be in preventing PUs? How involved ought a family member to be in preventing PUs? How likely are you to talk with another nursing staff member about a nursing care plan for PUP that is not working?
Do you have enough quality equipment or supplies to provide effective care? Do you think that the Braden Scale score is helpful to others? Is the score of the Braden Scale helpful to accurately identify at-risk Veterans?
14 12 15 16 13 16
7.85 8.66 7.73 9.21 7.77 8.62
2.03 1.30 1.45 1.55 1.60 1.50
15 16 15 15 16
4.00 1.50 9.00 7.07 8.13
2.41 1.07 1.79 2.81 2.22
n ¼ No. of responses
12 13 11
11 9 6
1 0 1
0 4 4
Performance How much recognition/praise do you personally receive for your preventive care? How important is the wound care program in contributing to your unit’s success at PU prevention?
(average 16 years in nursing), and stably employed at the VHA (average 7 years).
n ¼ No. of responses
n ¼ No. of responses
commented: “No. I’m sure the wound team is probably using it.” RNs differed in how they assessed the usefulness of the Braden Scale scores.
Individual and organization-level factors and PUP Tables 1 and 2 display open ended questions categorized by domains, and include themes and supporting quotations. Table 3 displays close ended questions categorized by domains and descriptive statistics. Individual level factors and PUP Level of interest in providing effective PUP care was grounded in recognition that prevention works to improve Veteran health The importance and effectiveness of PUP nursing care was reﬂected in individual staff’s descriptions of attitudes, beliefs, and values. The majority of nurses thought PU care was a high priority, given all other nursing responsibilities. They described PUP as having a high impact on Veterans’ quality of life and as interesting to perform. However, PUP care was not perceived as interesting if the care did not include feedback or interaction with Veterans about PUs. In general, LVNs and NAs described PU care in terms of performing speciﬁc and separate tasks. RNs, on the other hand, described the process of PUP care more holistically, taking into account the overall goals associated with providing care in related steps. Participants had a nuanced understanding of the preventability of PUs. All nurses believed they were effective in preventing avoidable PUs. While they thought PU care was an effective practice for most Veterans, they acknowledged the possibility that some PUs were unavoidable because of the clinical state of the Veteran.37 Usefulness of the Braden Scale score for risk assessment varied, and was linked to knowledge about it Nurses had mixed responses about the importance of the Braden Scale score, the most widely used PU risk assessment tool instrument.13 Half of the participants reported that they checked the medical record for the Braden Scale score and thought it was helpful in assessing risk more quickly. One NA said: “The NAs are doing it maybe; the LVN and the RN are doing that. As I said before, we have very limited knowledge about it.” Another NA
More intense level of care was provided for at-risk Veterans Participants described preventive care as the foundation upon which all nursing care was delivered. Nurses articulated differences between providing “usual” preventive care versus “at-risk” preventive care. At-risk care was described as more thorough, careful, frequent, and extensive for all aspects of PUP care (e.g. skin inspections, hygiene and bathing, assistance with meals/eating, and toileting). Veteran and family involvement varied, but was important to Veteran health Participants reported that they liked Veterans and families to participate in the delivery of PU care in various ways. For example, Veterans and/or family members helped staff provide PU care and staff talked with Veterans and family members about health issues related to good skin care. Staff emphasized the importance of highrisk Veterans routinely observing their skin for changes and instructed them in post-discharge skin care. Most participants expressed appreciation of Veterans who were able to compliment the staff’s care and give other types of feedback. However, two participants reported that they felt that their care was not valued if a Veteran or family member complained about the care. It is noteworthy that participants characterized PUP care as less interesting if it did not involve interaction and feedback with Veterans.
Organization level factors and PUP Teamwork required to assess Veteran’s level of risk RNs described their reliance upon the observational and reporting skills of NAs in maintaining early detection of Veteran risk. The NAs identiﬁed various ways in which they assessed risk, including direct observation of the Veteran, checking the chart for the Braden Scale score, being informed by the Veterans directly, discussing residents in morning report, and/or speaking with individual nurses, including wound care nurses, throughout the day. Half of participants inspected skin with other nursing staff, while
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one quarter reported that they generally inspected skin by themselves. Several barriers to inspection were identiﬁed, including balancing the task of inspecting skin with other on-the-job responsibilities (e.g. number of patients to care for; other job responsibilities) and/or other considerations, such as patients’ weight (heaviness or obesity) or cognitive status. Yet, when asked if they experienced any difﬁculties in having opportunities during the shift to inspect Veterans’ skin for PUs, nurses reported that they did not have any difﬁculties at all. Feedback received for individual versus group performance varied Each participant expressed conﬁdence in their ability to provide PUP care and described being primarily motivated to do so because of their own commitment to “provide good care to Veterans no matter what.” However, almost 100% of nurses indicated they believed that they would be further motivated if they received individual “recognition” from others (e.g. team members, supervisors, Veterans and families). Almost 100% of nurses thought that nurse managers valued their PUP care. They based this perception on their experiences of being praised and encouraged as a group; given information about Veterans and unit-level feedback about staff performance; and provided with clinical supplies by managers. An NA provided an example of positive feedback given by nurse managers and NPs. (Managers) “say wow, you guys are doing a good job. There’s no problem here with PUs and keep up the good work.” Two-thirds of participants also reported receiving positive responses from families and Veterans. Those who did not think that managers valued their care described feeling as if their good care was taken for granted or not noticed. Nurses indicated that they “know” that their unit was successful in preventing PUs because nurse managers told them; they could tell from the patients directly. Managers’ routine reporting of incidence rates was identiﬁed as providing important group performance feedback. For example, nurses received a weekly update on the incidence of facility-acquired PUs. Teamwork, communication, and commitment to Veterans ranked as factors that contributed most to unit success; communication between wound care team and staff perceived as teamwork When asked to rank the most and least important factors associated with CLC unit PUP success, nurses indicated that teamwork, communication (with other nurses, CLC unit team, nurse care managers, and wound team members), and commitment to Veterans were the three most important factors. Licensed nurses and NAs thought that successful teamwork was required to perform ongoing skin inspections and surveillance of at-risk residents. While participants only rated the wound care program overall as being moderately important to their unit’s success when asked as an open-ended question, it was described as very important (9.20/10) when asked as a close-ended question. Communications with wound team members were identiﬁed as one of the best examples of successful teamwork among staff. Descriptions of other instances of communication between nurses, and other CLC staff, took several forms. They included discussions with team members during the course of providing care, use of e-mail communication, weekly wound rounds, and morning meetings, weekly and monthly updates about performance by nurse managers, shift reports, and interdisciplinary team meetings. For example, NAs noted that nurse care managers “e-mail us about what happened at the interdisciplinary team meeting” and “to attend.” However, although performance reports were ranked high when asked in open ended questions, nurses ranked peer pressure and performance reports as the 2 least important factors contributing to unit PUP success. Only one participant mentioned the written plan
of care as a method used to obtain PUP related clinical information. She explained, “Once you ﬁnd out that something needs to be done, direct it to the right person, so that they can do a care plan and you can execute. And once that’s done, that is 90% of it.” Commitment to veterans was expressed in various ways. Quality of life for Veterans was linked with PUP care. One NA said: “Well, ﬁrst you have to care.” Another NA commented: “Just for their general well-being and state of mind, having a pressure ulcer is probably very concerning to a resident, so it’s very important.” Diverse educational strategies for PUP useful Nurses explained that they learned and updated their knowledge on PU practice information from a variety of sources. They participated in meetings where PU statistics were discussed, received information from nurse managers, and directly assessed Veterans. Nurses explained that new employees learned about PUP care in several ways. They talked with wound care nurses; learned about equipment and electronic chart documentation; read the VA handbook and national guidelines on PU prevention; attended VA trainings; and conducted Internet searches. All nurses emphasized the importance of ongoing education about PUP. They recommended that teaching should be tailored to the unique educational background of each type of nursing staff. Licensed nurses explained that the use of concrete and informal language, rather than language used in published guidelines, would be an effective strategy to use when teaching NAs. NAs noted that more education about PUs would make the delivery of preventive care more interesting. The right amount and type of equipment needed to provide effective PUP varied at times Nearly all nurses thought that they had enough quality equipment and supplies to provide effective PUP care. However, they indicated that they still needed newer equipment; more uniformity between beds and available support surfaces; greater availability of equipment and supplies on weekends; and more education about operating some equipment. Discussion The aim of this study was to describe participants’ perceptions of individual and organization level factors inﬂuencing delivery and performance of PUP care. Although the investigators were not asked to assist in the development of a customized implementation plan of the VHA national HAPU initiative our study’s ﬁndings may be helpful to its continued planning, implementation, and evaluation. PUP care is complex; it involves the individual nurse, the organizational context in which practice occurs, and their interactions. Because of the nature of this phenomenon, and the fact that nurses at different levels (RN, LVN, NA) may describe their knowledge, attitudes and beliefs about PUP care differently, we triangulated the collection of data (i.e. both qualitative and quantitative data) to help “bring out” nuances of delivering PUP care in descriptive (open-ended questions) and more quantiﬁable (closeended questions) ways. Data triangulation provided an opportunity to uncover similarities, and some variances, among respondents, which otherwise might not have been possible. While individual nurse and organization-level factors identiﬁed in this study were consistent with ﬁndings from other studies that examined such factors separately, triangulating data collection in this study enabled us to identify nuances, and better understand the delivery of PUP care holistically.8,11,12,15e21 By using mixed methods, study ﬁndings revealed the complexity of participants’ perceptions of PUP care. The variations in how nurses perceived the importance of single versus multiple
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components of the PUP program; described contributions of each component to effective PUP care delivery; articulated their understanding of evidence-based elements of PUP care; and perceived how performance of PUP care was measured and communicated are noteworthy. For example, while participants ranked the wound care program as very important (9.20/10), the wound team was not singled out as one of the overall top three factors contributing to unit success. Instead, teamwork, communication, and commitment to Veterans were ranked as the overall top three factors; communication between wound team and staff was singled out as an example of successful unit teamwork. Similarly, while receipt of reports on unit-level performance was identiﬁed as a measure of unit success (e.g. a way in which success was communicated), weekly reports were rated as a “2/10,” or not very important, in contributing to overall success in performing PUP. While all nurses described their intrinsic motivation to help Veterans as their main motivation and appreciated feedback given to them as a group, participants indicated that a lack of performance feedback by a nurse manager could potentially affect one’s level of motivation to perform. While stafﬁng was not explicitly targeted as an issue for exploration, related concepts of workload and acuity were described. For example, nurses cited that cognitively impaired or obese Veterans presented greater challenges to providing care (e.g. harder to turn resident). Although several barriers to performing skin inspections were identiﬁed in response to an open-ended question, they were described as not difﬁcult at all to perform in response to a close-ended question. These ﬁndings suggest that the nature and dimensions of communication, teamwork, performance feedback, and workload experienced by staff related to PUP warrant further examination. It is likely that speciﬁc components of perceptions of nursing staff’s knowledge, experiences, beliefs, and attitudes need to be identiﬁed and better understood if evidence-based PUP interventions are to be effectively modiﬁed or improved, and/or maintained. A mixed methods approach is uniquely suited to examination of complex phenomenon such as PUP care. In light of such variations in PUP care delivery attitudes, beliefs and practices, several suggestions can be made to help reinforce facilitators for delivering effective PUP care in nursing home settings. Bringing the staff’s attention to existing practices perceived as effective is recommended to maintain staff awareness and increase appreciation of their reported strengths. As noted, one of the greatest strengths of the nurses and CLCs was their strong sense of mission for and worth of PUP nursing care, and commitment to Veterans. Although PUP is comprised of discrete tasks that involve little technology, the overarching goal of supporting Veterans’ quality of life by preventing PUs was understood as the ultimate goal. Wound care nurse specialists, facility and unit-level wound teams, leadership support, ongoing education, above average stafﬁng, and practical means used to share clinical information (e.g. e-mail, posting of performance measures, rounds) can help to continue to foster routine and meaningful communication between RNs and NAs, and among the NAs, to focus on early detection, and treatment, of PUs. Likewise, several additional factors related to delivery of quality PUP practice may beneﬁt from targeted attention. These included providing matching beds and support surfaces, with special attention to the adequacy of weekend supplies; providing both individual and unit performance feedback to help increase individual nurses’ awareness of PUP performance and levels of motivation3; and providing training on the Braden Scale score and how it contributes to risk assessment, with special emphasis on education for NAs. Ongoing discussion of competing care priorities (in meetings and individually) that may potentially interfere with
delivering usual care effectively, and more intense care for those at risk for developing PUs,38,39 is also recommended since researchers have reported that patterns of communication are signiﬁcantly different in high and low performing NHs.40,41 Examination of information exchange and patterns of communication between a manager and an individual staff member, among nursing staff collectively on a shift or unit level, and communication among interdisciplinary team members, Veterans, and signiﬁcant others are likely to increase our understanding of speciﬁc processes associated with better care. We recommend further study of patient safety strategies, such as teamwork, communication openness, performance feedback, and situation monitoring related to effective PUP care delivery.28,42e44 Similarly, use of social network analysis may also be a particularly effective method to increase our understanding of the relationship between effective PUP care and patterns of communication. Study limitations This pilot study had several limitations. It was conducted using a convenience sample of 2 governmental NHs providing services exclusively to Veterans, and a small sample of nurses. Some responses were missing for some of the close-ended questions due to participants’ preference to answer questions descriptively, and not quantitatively. The 2 CLC sites were historically high performers with a PUP program strongly supported by leadership. The exclusive focus on nursing care participants, without interviewing additional team members about the process of care, is also a limitation. Because of union related constraints, nurses had to be interviewed at work, whether it was before, during, or after the shift, which constrained opportunity to solidify interview times, and decreased the pool of participants. Conclusion Examination of both individual and organization-level factors associated with PUP care using data triangulation enabled us to develop a more holistic and nuanced understanding of the complexities of PUP care. Further study of how evidence based PUP care is learned, used in practice, and measured, can help to further the knowledge base for clinical care givers, family members, recipients of care and other stakeholders who wish to achieve quality of life outcomes that include “zero” pressure ulcers in CLC nursing home facilities, and similar settings. Acknowledgements This material is based in part on work supported by the Department of Veterans Affairs, Veterans Health Administration, ofﬁce of Research and Development, health Services Research and Development (CD2 06-015). References 1. Lyder CH, Ayello EA. Chapter 12 e pressure ulcers: a patient safety issue. In: Hughes RG, ed. Patient Safety and Quality: an Evidence-based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality; 2008. 2. Beeckman D, Vanderwee K, Demarre L, Paquay L, Van Hecke A, Deﬂoor T. Pressure ulcer prevention: development and psychometric validation of a knowledge assessment instrument. Int J Nurs Stud. 2009;47:399e410. 3. Nightingale F. Notes on Nursing. Philadephia: Lippincott; p. 1859. 4. National Pressure Ulcer Advisory Panel, European Pressure ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel. Retrieved 01.05.13. http://www.npuap.org/Final_Quick_Prevention_for_web_2010.pdf.
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