Abstract
This study aimed to investigate Korean nurses' level of awareness of pain and skin tearing in wound bed and/or peri‐wound skin at dressing change. A descriptive study was performed. Convenience sampling was employed and registered nurses were recruited from attendees of continuing education program. A total of 399 participants (RN) completed questionnaire. Data was collected from September to November 2014. Many of them perceived skin tearing and wound related pain associated with dressing changing, but most of them did not assess and record pain and skin tearing at dressing change. More than half of respondents reported that they did not provide nursing intervention to prevent pain and skin tearing. Many of them reported that a systematic educational program for preventing pain and skin tearing at dressing change was needed. In conclusion, many of respondents were aware of pain and skin tearing at dressing change, but did not take any further necessary measures, including nursing intervention, for the most appropriate, systematic pain and skin tearing management. Therefore, this study suggested that a systematic and comprehensive educational program for Korean healthcare professions needs to be developed and implemented in Korea's hospital settings.
Keywords: Pain, Skin tearing, Registered nurses
Introduction
Throughout their lifetime, humans may sustain a variety of forms of chronic and acute wounds to the skin in all areas of the body. These inevitably causes them to experience discomfort, distress, and consequentially reduced quality of life due to entailed pain, maceration, and foul odor 1, thus making it necessary for nurses to provide nursing intervention for the most appropriate healing strategies tailored to each of patients.
Dressing has been a universal wound care method in which wounds are covered and protected and an optimum environment for healing is provided. So, dressing material with adhesive contact layers or adhesive tape has been used as one of its integral components to seal wounds. One problem of adhesives is that it adheres directly to wound or peri‐wound skin. In proportion to aggressiveness and repeated use of adhesives, such wound dressing can cause significant levels of trauma to wound and surrounding skin and at the same time pain in patients when it is removed 2, 3. Especially chronic wound requires long‐term dressing and frequent dressing changes. This inevitably entails trauma and pain. Soon and Acton and Price et al. reported that many patients complained extremely severe pain at dressing change 4, 5. Many medical doctors and nurses observed that patients experienced pain at dressing change. It was reported that this pain and skin tearing occurred due to adhesives at dressing change 6. Mason revealed that patients reported skin tearing due to adhesive dressing. He also reported that the skin tearing was found in peri‐wound of or skin adjacent to chronic wounds such as mostly pressure ulcers 7. Dressing products with traditional adhesives, strong adhesiveness of tape, repetitive application and removal of dressing, and medical care professionals' careless care service were identified as the primary cause for skin tearing 6, 8. Nevertheless, many healthcare professionals were not aware of pain in wound bed and/or peri‐wound skin and failed to effectively control pain and skin tearing while changing dressing. Pain accompanied by dressing change may have a harmful impact on physical function and trigger the psychological discomfort which is very likely to hinder the wound healing. Skin tearing may also cause inflammation, edema and pain. This will eventually enlarge the wound size and obstruct the wound recovery 9, 10. To minimize trauma and pain at dressing change, therefore they need to pay attention to addressing pain and skin tearing by resorting to a professional and holistic approach for wound treatment.
In Korea, there have been few studies on incident rate of dressing‐related pain and skin tearing, appropriate intervention for prevention, and awareness of these on the part of nurses who play the most important role in this field. This is why this study attempted to survey these nurses' level of awareness regarding dressing change‐related pain and skin tearing in wound bed and/or peri‐wound skin as a basic study for further studies in the future.
Method
Design
A descriptive study was performed.
Sample
Convenience sampling was adopted and registered nurses were recruited from attendances of continuing education program. An inclusion criterion for sampling required that registered nurses had to have at least one year of clinical experience in ward or home care, but not in out‐patient department. Four hundred and five of four hundred and fifty invited nurses responded to questionnaire. Six respondents were excluded because they did not state the demographic data in the questionnaire. 399 (or 89%) were finally chosen as sample.
Instrument
A questionnaire was developed to assess the perception of skin tearing and pain at dressing change. It comprised two parts. Part I was devoted to identifying nurse's demographic details, including gender, age, clinical experience, education level, working hospital, position, working department, and main dressing provider. Part II was assigned to ask 13 closed questions and 5 open questions. Of 13 closed questions, three, associated with factors contributing to wound‐related pain and skin tearing and dressing type that caused pain and skin tearing, were given in rank order format. Other questions were asked to assess pain and skin tearing at dressing change, check whether or not pain and skin tearing was documented at dressing change, whether or not skin tearing classification tool was used, and whether or not patients' complaining about pain and skin tearing was monitored at dressing change, examine whether or not intervention to overcome pain and skin tearing at dressing change was provided and need educational program to prevent pain and skin tearing at dressing change. Open questions were designed to find out per‐week frequency of pain and skin tearing, strategies and contents for educational program in order to prevent pain and skin tearing at dressing change.
Data collection and analysis
Data was collected from September to November 2014. Questionnaire and cover letter with information on the study were distributed to nurses who attended the continuing education program by the researcher. Participants were requested to complete the questionnaire individually. Time given to complete the questionnaire was estimated at 15–20 minutes. Participants submitted their questionnaires to researcher's assistants. All questionnaires were reviewed and evaluated for possible missing answers. All analyses were performed using IBM SPSS 18.0 (SPSS Inc., Chicago, IL). Descriptive statistics (means, standard deviation, frequencies and percentages) was used for all questionnaire items.
Ethical considerations
This study was granted approval by the institutional review board of Seoul National University Bundang Hospital (IRB Approval Number : B‐1407‐260‐301). The principles set out in the Declaration of Helsinki, as well as national and local guidelines for research, were followed. The purpose and procedure of the study, the voluntary nature of participation and the assured confidentiality were explained to participants in detail. Consent was obtained on the return of the completed questionnaires, and participation were absolutely voluntary.
Results
All participants were women, and the means of age was 34·4 years. The major proportion of participants (65·4%) had more than 5years of clinical experience. The majority of the participants had degree above bachelor (70·4%). Most of them worked in secondary hospitals (58·6%) and surgical ward (55·1%). 71·4% of participants were staff nurses, and main dressing providers were nurses working in their hospitals (58·1%) (Table 1).
Table 1.
Demographic data of registered nurses (RNs) (N = 399)
| Variables | Characteristics | n (%) or Mean ± SD |
|---|---|---|
| Gender | Female | 399 (100) |
| Age | 34·4 ± 8·70 | |
| Clinical experience (years) | <5 | 138 (34·6) |
| 5–10 | 104 (26·1) | |
| >10 | 157 (39·3) | |
| Education | Diploma | 118 (29·6) |
| Bachelor | 203 (50·9) | |
| Master degree or higher | 78 (19·5) | |
| Hospital | Long term care facility | 128 (32·1) |
| Secondary hospital | 234 (58·6) | |
| Tertiary hospital | 37 (9·3) | |
| Position | Staff nurse | 285 (71·4) |
| Charge or head nurse | 67 (16·8) | |
| Nurse practitioner | 47 (11·8) | |
| Department | Surgical ward | 220 (55·1) |
| Medical ward | 118 (29·6) | |
|
Special department (ICU, ER) |
58 (14·5) | |
| Home care nurse | 3 (0·8) | |
| Main dressing provider | Doctor | 167 (41·9) |
| Nurse | 121 (30·3) | |
| Nurse practitioner | 111 (27·8) |
ER, emergency room, ICU, intensive care unit.
Factors contributing to wound‐related pain and skin tearing
Table 2 reveal the assessment through rank order questions, and the average score for each was calculated and arranged in descending order. The score with lowest mean generally indicates the one ranked most high. Therefore, prime causes of pain were operative pain and procedure pain. Skin tearing usually occurred due to patient's transfer and dressing change.
Table 2.
Factors contributing to wound‐related pain and skin tearing (N = 399)
| Characteristics | Mean ± SD | |
|---|---|---|
| Factors contributing to wound‐related pain | Operative pain (e.g. debridement) | 1·90 ± 1·20 |
| Procedure pain (e.g. dressing change, wound irrigation, etc) | 2·55 ± 1·06 | |
| Background pain (e.g. infection, ischemia) | 2·72 ± 0·97 | |
| Incidence pain (e.g. pain related to activity, cough, etc) | 2·82 ± 1·01 | |
| Factors contributing to skin tearing | Patient transfer | 2·65 ± 1·39 |
| Dressing change | 2·94 ± 1·40 | |
| Medical devices (wheel chair, bed, etc) | 2·97 ± 1·43 | |
| Fall down | 3·13 ± 1·40 | |
| Activities of daily living (ADL) | 3·31 ± 1·37 |
Evaluation and documentation of pain and skin tearing at dressing changing
Many nurses did not assess pain (56·9%), but evaluated skin tearing (66·2%) at dress changing. More than half of the respondents reported that they did not record pain (57·9%) and skin tearing (66·9%) at dressing change and did not use scale or classification tool related to skin tearing (82·2%) either. However most respondents responded that they frequently observed pain (81·5%) and skin tearing (64·4%) at dressing change. With regard to frequency of pain and skin tearing, most of them observed above 20 cases (74·1%) and 10 cases (54·5%) per week (Table 3).
Table 3.
Evaluation and documentation of pain and skin tearing at dressing change (N = 399)
| Variables | Characteristics | n (%) |
|---|---|---|
| Assessment of pain | Yes | 172 (43·1) |
| No | 227 (56·9) | |
| Assessment of skin tearing | Yes | 264 (66·2) |
| No | 135 (33·8) | |
| Documentation of pain | Yes | 168 (42·1) |
| No | 231 (57·9) | |
| Documentation of skin tearing | Yes | 132 (33·1) |
| No | 267 (66·9) | |
| Use scale or classification tool related to skin tearing | Yes | 71 (17·8) |
| No | 328 (82·2) | |
| I observe frequently patients feel pain at dressing change | Yes | 325 (81·5) |
| No | 74 (18·5) | |
| I observe frequently skin tearing at dressing change | Yes | 257 (64·4) |
| No | 142 (35·6) | |
| Frequency of observing pain (per week) | >20 | 84 (25·8) |
| 20–40 | 200 (61·5) | |
| <40 | 41 (12·6) | |
| Frequency of observing skin tearing (per week) | <10 | 117 (45·5) |
| 10–20 | 123 (47·9) | |
| >20 | 17 (6·6) |
Dressing type causing pain and skin tearing at dressing change
Table 4 shows that each characteristic was assessed through rank order questions and that the scores represent the average for each calculated. The score with lowest mean generally represents the one ranked most high.
Table 4.
Dressing type causing pain and skin tearing at dressing change (N = 399)
| Characteristics | Mean ± SD |
|---|---|
| Soft cloth tape (Adhesive non‐woven fabric) | 2·51 ± 1·61 |
| Transparent film | 2·96 ± 1·35 |
| Hydrocolloid | 3·23 ± 1·41 |
| Foam dressing with acrylate adhesion on polyurethane foam based | 3·38 ± 1·51 |
| Soft silicone adhesive | 4·05 ± 1·81 |
The dressing type or the primary cause contributing to pain and skin tearing when changing dressing was soft cloth tape (2·51 ± 1·61), transparent film (2·96 ± 1·35) and hydrocolloid (3·23 ± 1·41).
Strategies to overcome pain and skin tearing at dressing change
More than half of respondents reported that they did not provide the nursing intervention to prevent pain (59·9%) and skin tearing (61·9%). For pain prevention management, majority of respondents answered that they used strategies such as soaking old dressing in normal saline before removal (30·0%) or providing pain medication (28·8%). With regard to skin tearing prevention, most participants responded that they removed dressing by using normal saline (37·5%) or used non‐traumatizing dressing (19·7%). Many participants (95·7%) reported that a systematic educational program for preventing pain and skin tearing at dressing change was needed (Table 5). In response to open questions on education program, they suggested that the program include varied case studies demonstrating or showing method and timing for assessing pain, ways to document it, skin tearing classification tool and its documentation, types and application period of a traumatic dressing, and prevention of pain and skin tearing.
Table 5.
Strategies to prevent pain and skin tearing at dressing change (N = 399)
| Variables | Characteristics | n (%) |
|---|---|---|
| Use intervention to prevent pain | Yes | 160 (40·1) |
| No | 239 (59·9) | |
| Use intervention to prevent skin tearing | Yes | 152 (38·1) |
| No | 247 (61·9) | |
| Strategies to prevent pain | Soak or spray old dressing in N/S before removal | 48 (30·0) |
| Use pain medication | 46 (28·8) | |
| Support surrounding skin (e.g. Window using hydrocolloid, skin sealant, skin barrier cream, crusting method) | 5 (3·1) | |
| Select non traumatizing dressings | 19 (11·9) | |
| Slowly remove dressing along skin texture direction | 19 (11·9) | |
| Use medical adhesive remover | 13 (8·1) | |
| Emotional support (encouraging the patient to get involved, distraction) | 10 (6·3) | |
| Strategies to prevent skin tearing | Soak or spray old dressing in N/S before removal | 57 (37·5) |
| Select non‐traumatizing dressings | 30 (19·7) | |
| Support surrounding skin (e.g. Window using hydrocolloid, skin sealant, skin barrier cream) | 29 (19·1) | |
| Slowly remove dressing along skin texture direction | 26 (17·1) | |
| Non adhesive fixation (bandage) | 5 (3·3) | |
| Frequently Change location for fixing or sealing dressing | 5 (3·3) | |
| Need education for preventing pain and skin tearing | Yes | 382 (95·7) |
| No | 17 (4·3) |
N/S, normal saline.
Discussion
Pain is very common in patients with wounds. It is often exacerbated by local treatment such as dressing change or procedure. Skin tearing also occurs during the removal of adhesive tapes and the repeated dressing application and removal. This damage and pain may lead to reduced overall healing rates, prolonged hospital stays, and unnecessary cost to treat it 1. Therefore, nurses' main concern should be focused on preventing wound trauma and then reducing patients' pain and keeping the surrounding skin from being damaged.
This study attempted, for the first time in Korea, to assess the Korean registered nurses' perception of pain and skin tearing associated with dressing. The data show many Korean nurses believe that skin tearing and pain happen primarily at dressing change. They also reported they frequently observed that skin tearing and pain occurred when changing dressing. The findings in this study were remarkably similar to those of Hollinworth and Collier. who conducted a systematic study on pain and skin tearing, in which a sample of 3918 nurses from 11 countries were surveyed. The findings revealed that nurses rated dressing removal to be the time of greatest pain 6. Other researches also reported similar perspective of patients about dressing related pain. These studies noted many patients experienced pain and trauma due to repeated application and removal of adhesive tapes and dressings mechanically during dressing 2, 5, 11. Likewise, also in Korea, many patients complained pain and skin tearing at dressing change. Nevertheless, many nurses neglected to assess and document pain and skin tearing even though they frequently observed pain and skin tearing at dressing change. Woo et al. reported that many health professionals found it difficult to assess pain and often were not sure of what appropriate method had to be used for effective management 12. Moffatt et al. also reported that using a pain assessment tool before or after dressing change to assess pain was ranked as low priority. In other words, nurses were reluctant to recognize the amount of pain endured by patients during dressing change. However, he reported that patients' outcomes were improved and communication between health professionals was enhanced when well‐developed pain assessment tools were used during dressing change 13. Therefore, it is necessary to teach nurses the usefulness and importance of assessing and documenting pain and skin tearing in order to improve their wound care and compliance with instructions given by clinician.
The findings in this study demonstrated that acrylic adhesives such as soft cloth tape, transparent film and adhesive foam were rated as being the most common factor contributing to pain and skin tearing at dressing change. Dykes et al. also reported that some traditional adhesive based dressings which use acrylic‐based adhesives can present more aggressive pain than others using non‐traumatic dressing such as soft silicon adhesive dressing 2. Hydrocolloid was also associated with more significantly impaired skin barrier function than dressing utilizing soft silicone adhesive 14. There was wide biological variations in the levels of adhesion of the same product to normal skin of different patients. It is important to acknowledge that this variation exists as this is prerequisite to matching the adhesive dressing to the skin type of any given patient for optimum adhesion. Accordingly, nurses need to determine choosing dressing and time to remove dressing by considering sebum levels, dryness, sweating, hair and the presence of residues of any cream and ointments 15.
Many nurses use pain killer prior to dressing change or soak old dressing in normal saline before removal. Using pain medication is the most effective method for overcoming pain at dressing, while soaking old dressings before removal was found to have quite a limited evidence in supporting this practice 16, 17. Therefore, more studies are needed to obtain more concrete evidence about this practice.
Most nurses recognized the need for a systematic educational program to prevent pain and skin tearing at dressing change. Increased knowledge of skin tear and pain prevention and management may enhance patient's comfort, lessen pain and suffering, and improve the quality of life of individuals. This study identified the need to develop the program which encompasses nurses' suggestions and demands. For the most appropriate, effective wound care, in particular, the findings of this study underlined the program has to be a comprehensive one which surely considers the influence and management of pain and skin tearing, pain assessment timing (e.g. before, during, or after dressing, or during rest), assessment method (pain assessment tailored to unconscious patients and their ages), documentation method, skin tearing classification tool, non‐traumatic dressing, appropriate time to remove dressing on the basis of patients' tissue condition and wound characteristics, and ways to prevent pain and skin tearing (emollient soap, moisturizer, medical adhesive remover, surrounding wound protection, and varied methods to hold dressing in place by using bandage). The program should be the one that focuses on the practical application in the clinical field, but not the one that merely provides the information to nurses.
Study limitation
This is the first study to find out Korean nurses' perception of pain and skin tearing when changing dressing. This study finds a limitation in that only a limited number of Korean nurses was surveyed and thus it is difficult to generalize its findings to the entire Korean nursing population.
Conclusion
In the past, wound research largely placed a stress on healing rather than the quality of life of patients with wound. It is undeniable that there has been few empirical researches related to the quality of life. Now it's time to do something about that. First of all, healthcare professionals need to have a holistic view regarding wound care. That is, the utmost consideration need to be given to both patients‐centered outcomes and wound‐centered outcomes in order to achieve the outcome of successful treatment.
This study targeted at surveying the nurses' perception of pain and skin tearing at dressing change so that its findings may provide basics or best clues for intervention study and other varied researches associated with the most idealistic cure for pain and skin tearing which is compatible with the Korean culture.
Acknowledgements
We are grateful to the all committee members of Korean Association of Wound Ostomy Continence Nurses for support this study and all nurses participated in continuing education program by Korean Association of Wound Ostomy Continence Nurses. The authors declare no conflicts of interest.
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