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.
Keywords: Immobility, Nursing care, Patient repositioning, Pressure ulcer, Prevention
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, 4, 5, 6.
Thus, the turning and repositioning of patients who are immobile is a vital and effective measure to prevent pressure ulcer development 7. However, there is still weak evidence supporting specific turning regimes 8, 9, 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, 24, 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.
Methods
Study design
The study is of a non‐experimental observational cross‐sectional design.
Participants
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 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.
Figure 1.
The MovinSense transmitter attached on the chest with adhesive dressing.
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 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.
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.
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).
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.
Table 1.
Demographics, clinical characteristics and descriptive statistics of pressure prevention aids in patients who were included in the analysis (n = 52)
| Variable | N (%) | Mean (SD) |
|---|---|---|
| Demographics | ||
| Age (years) | 85 (7·3) | |
| Female | 33 (64) | – |
| Patients in hospital | 24 (46) | – |
| Clinical charateristics | ||
| RAPS score | 24 (3·1) | |
| BMI | 26 (5·3) | |
| Pressure ulcer | 12 (23) | – |
| Category I | – | – |
| Category II | 4 (8) | – |
| Category III | 1 (2) | – |
| Category IV | 7 (14) | – |
| Sacral pressure ulcer | 7 | |
| Heel pressure ulcer | 5 | |
| Diagnoses | ||
| Cardiovascular disease | 26 (50) | – |
| Hypertension | 21 (40) | – |
| Cognitive dysfunction | 17 (33) | – |
| Cerebrovascular disease | 14 (27) | – |
| Cancer | 14 (27) | – |
| Pulmonary dysfunction | 13 (25) | – |
| Diabetes | 12 (23) | – |
| Muscle/joint disease | 9 (17) | – |
| Hip fracture | 5 (10) | – |
| Parkinson | 4 (8) | – |
| Others | 25 (48) | |
| Medications | ||
| Number of medications/participants | 7 (3·3) | |
| Antithrombotic agents | 31 (60) | – |
| Analgesics | 30 (58) | – |
| Antianimetic preparations | 24 (46) | – |
| β‐Blocking agents | 24 (46) | – |
| Psychoanaleptics | 21 (40) | – |
| Diuretics | 20 (38) | – |
| Drugs for acid‐related disorders | 18 (35) | – |
| Psycholeptics | 18 (35) | – |
| Antibacterials for systemic use | 13 (25) | – |
| Corticosteroids for systemic use | 11 (21) | – |
| Antiepileptics | 10 (19) | – |
| Others | 41 (79) | – |
| Pressure prevention aids | ||
| Powered air fluid mattress | 17 (33) | – |
| Non‐powered pressure‐reducing mattress | 25 (48) | – |
| Positioning pillows | 18 (35) | – |
| Heel protection | 10 (19) | – |
| Slide sheet | 34 (65) | – |
| Pressure‐reducing cushion in chair | 25 (48) | – |
| Pre‐planned repositioning in bed | ||
| Hourly | 6 (11) | |
| Every second hour | 1 (2) | – |
| Every third hour | 10 (19) | – |
| Every fourth hour | 3 (6) | – |
| Individual regulary planned | 17 (33) | – |
| Not planned | 15 (29) | – |
| Pre‐planned repositioning in chair | ||
| Hourly | 5 (13) | – |
| Every second hour | 3 (8) | – |
| Every third hour | 1 (3) | – |
| Every fourth hour | 3 (8) | – |
| Individual regulary planned | 10 (27) | – |
| Not planned | 15 (41) | – |
BMI, body mass index; RAPS, risk assessment pressure ulcer scale.
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 <0·001) (Table 2). The periods between REP were a median of 3 hours and 12 minutes (Q1 2 hours and 41 minutes, Q3 3 hours and 56 minutes) with a maximum of 14 hours and 24 minutes. In total, the nursing staff repositioned patients in a >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).
Table 2.
Descriptive statistics of nursing staff position change intervals and patients spontaneous movements registered by MiS
| Variables | N | Median (Q1, Q3) | Minimum–Maximum |
|---|---|---|---|
| Nursing staff repositionings | |||
| Number of REP during day | 50 | 5 (4, 6) | 3–9 |
| Number of REP during night | 52 | 2 (2, 3) | 0–5 |
| Duration between repositionings (h:min) | 52 | 03:12 (02:41, 03:56) | 00:15–14:24 |
| Duration in different positions (h:min): | |||
| Supine position | 44 | 02:56 (02:03, 03:56) | 00:15–14:24 |
| Supine position with HOB elevated > 20° | 42 | 2:30 (1:36, 3:25) | 00:15–11:45 |
| Lateral 30° | 42 | 03:24 (02:53, 04:04) | 00:20–13:30 |
| Lateral 60° | 29 | 03:29 (02:33, 05:05) | 00:45–12:40 |
| Lateral 90° | 26 | 03:50 (02:26, 04:38) | 00:15–09:00 |
| Sitting in chair | 38 | 02:20 (01:29–03:29) | 00:24–14:02 |
| Movements registered by MiS | |||
| Number of MOV during day | 50 | 16 (7, 52) | 0–168 |
| Number of MOV during night | 52 | 10 (4, 33) | 0–135 |
| Duration in same position and angle (hh:mm) | 52 | 00:23 (00:12, 00:44) | 00:00*–14:18 |
| Number of MOV in: | |||
| Supine position | 44 | 2 (1, 3) | 0–36 |
| Supine position with HOB elevated > 20° | 42 | 4 (1, 8) | 0–33 |
| Lateral 30° | 42 | 4 (1, 11) | 0–78 |
| Lateral 60° | 29 | 3 (1, 9) | 0–34 |
| Lateral 90°† | 26 | 6 (3, 20) | 0–56 |
| Sitting in chair‡ | 38 | 4 (1, 10) | 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 | Night | Total | |
|---|---|---|---|---|
| Number of observations (%) | Number of observations (%) | |||
| 0°Supine | 68 (47) | 77 (53) | 145 | |
| % of total | – | – | 18·60 | |
| Supine position with HOB elevated >20° | 108 (68) | 51 (32) | 159 | |
| % of total | – | – | 20·40 | |
| Sitting in chair | 145 (93) | 11 (7) | 156 | |
| % of total | – | – | 20·00 | |
| 30° Lateral | 73 (42) | 103 (58) | 176 | |
| % of total | – | – | 22·50 | |
| 60° Lateral | 37 (43) | 49 (57) | 86 | |
| % of total | – | – | 11·00 | |
| 90° Lateral | 30 (51) | 29 (49) | 59 | |
| % of total | – | – | 7·60 | |
| Total REP | 461 (59) | 320 (41) | 781 | |
| % of total | – | – | 100·00 |
HOB, head of bed elevated; REP, nursing staff induced repositionings.
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, 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 <0·001. The number of MOV in the 90° lateral position was significantly higher than that in supine, >20° HOB and 60° lateral positions (P ≤0·043). The number 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).
Variables associated to nursing staff induced repositionings
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 <0·001, of the variance in REP during the night (Table 5). The total RAPS score, cognitive dysfunction, cancer and psycholeptics were independently related to REP of which the RAPS score had the highest coefficient of determination in the model (Table 5).
Table 4.
Correlation coefficients of nursing staff induced repositioning frequency and patients' spontaneous movement frequency during the day or night in relation to background data and clinical characteristics
| Day | Night | |||
|---|---|---|---|---|
| REP | MOV | REP | MOV | |
| MOV | −0·106 | – | 0·055 | – |
| Type of health care* | 0·178 | −0·013 | 0·468** | 0·129 |
| Gender | 0·045 | −0·235 | 0·088 | −0·250 |
| BMI | −0·098 | 0·035 | 0·131 | 0·153 |
| RAPS score | −0·029 | 0·153 | −0·352* | −0·041 |
| RAPS sub‐category General health | −0·023 | 0·029 | −0·405** | −0·081 |
| RAPS sub‐category Mobility | −0·035 | 0·228 | 0·145 | 0·220 |
| RAPS sub‐category Activity | −0·044 | 0·217 | −0·384** | 0·133 |
| RAPS sub‐category Moister | −0·033 | −0·084 | −0·372** | −0·167 |
| RAPS sub‐category Friction and shear | 0·117 | 0·263 | 0·165 | 0·368** |
| RAPS sub‐category Food intake | 0·123 | 0·122 | −0·236 | −0·017 |
| RAPS sub‐category Sensory perception | 0·127 | −0·173 | 0·126 | −0·038 |
| Existing pressure ulcer | 0·279* | 0·201 | 0·089 | 0·160 |
| Cognitive dysfunction | 0·004 | −0·072 | −0·354* | −0·011 |
| Cerebrovascular disease | 0·010 | 0·017 | 0·082 | −0·009 |
| Cancer | 0·205 | −0·074 | 0·374** | −0·061 |
| Muscle/joint disease | −0·002 | −0·359* | 0·106 | −0·130 |
| Parkinson | −0·270 | 0·184 | 0·007 | 0·012 |
| Hip fracture | 0·128 | 0·035 | −0·151 | 0·137 |
| Mattress † | −0·154 | 0·163 | −0·137 | 0·129 |
| Slide sheet | −0·209 | −0·107 | −0·345* | −0·187 |
| Analgesics | 0·277 | 0·207 | 0·085 | 0·350* |
| Psychoanaleptics | 0·092 | 0·036 | −0·122 | 0·090 |
| Psycholeptics | 0·054 | −0·183 | −0·282* | −0·298* |
BMI, body mass index; MOV, patient spontaneous movements; RAPS, risk assessment pressure ulcer scale; REP, nursing staff induced repositionings.
Municipality = 0; hospital = 1.
Powered air fluid mattress = 1; non‐powered pressure‐reducing mattress = 2; standard mattress = 3.
Correlation is significant at the 0·05 level (two‐tailed).
Correlation is significant at the 0·01 level (two‐tailed).
Table 5.
Factors associated to nursing staff induced repositionings during the night from final multiple linear regression analysis based on backward method
| B | SE, B | β | 95% CI for B | P | ||
|---|---|---|---|---|---|---|
| Total RAPS score | −0·099 | 0·041 | −0·285 | −0·182 | −0·016 | 0·021 |
| Phsychoeleptics | −0·538 | 0·262 | −0·242 | −1·065 | −0·012 | 0·045 |
| Dementia | −0·596 | 0·276 | −0·264 | −1·151 | −0·041 | 0·036 |
| Cancer | 0·655 | 0·289 | 0·274 | 0·073 | 1·236 | 0·028 |
| Constant | 5·093 | 0·986 | ||||
| Adj. R 2 = 0·31 | ||||||
CI, confidence interval; RAPS, risk assessment pressure ulcer scale.
Variables associated with patients' spontaneous movement frequency
Muscle and/or joint disease was significantly correlated with MOV frequency during the day (Table 4). The RAPS scale's variable friction and shear and analgesics were significantly positively correlated with MOV during the night and psycholeptics were significantly negatively correlated. These significant variables were entered in the multiple regression analysis and the final model explained 29%, F(3, 48) = 8·0, P <0·001, of the variance in MOV during the night (Table 6). Analgesics and psycholeptics were independently related to MOV and analgesics had the highest coefficient of determination in the model (Table 6).
Table 6.
Factors associated to patients' spontaneous movement frequency during the night from the final multiple linear regression analysis based on backward method
| B | SE, B | β | 95% CI for B | P | ||
|---|---|---|---|---|---|---|
| Analgesics | 0·398 | 0·116 | 0·416 | 0·164 | 0·632 | 0·001 |
| Phsycholeptics | −0·317 | 0·127 | −0·319 | −0·573 | −0·06 | 0·017 |
| Constant | 0·695 | 0·2 | – | |||
| Adj. R 2 = 0·29 | ||||||
CI, confidence interval.
Discussion
This study contributes new knowledge on what turning and repositioning patterns, both staff induced and spontaneously made by the patient, appear in the ordinary day‐to‐day care of elderly immobilised patients. The results show that there was a large variation in the frequency of the MOV during both day and night. Although older and regarded as immobile, some of the patients made many spontaneous movements while others did not. Based on the theories that pressure ulcers are caused by ischaemia and/or sustained cell deformation, these movements, although minor, are important to redistribute pressure and thus increase the blood flow supply and reduce the strain stress 31, 32. The large variation may thus have clinical implications; patients who spontaneously make minor movements of up to 168 times during a 12‐hour period may not need to be repositioned with the same frequency as patients who make few or no spontaneous movements. There was, however, no clear relationship between the nursing staff induced repositionings and the frequency of the MOV, neither during the day nor at night. One possible explanation for this could be that there are ongoing activities, especially during the day, which influence the repositioning frequency. It may also be that the staff are not aware of to what extent the patients make minor movements, and therefore, do not take this into account.
The results show that most often the patients had a pre‐planned turning regime and were repositioned on an average every 2–4 hours, they had a pressure‐reducing or ‐relieving mattress and they were positioned in a lateral position 30° when a side lying position was appropriate. Furthermore, the results show that patients were repositioned to a lesser extent during the night than during the day, which may characterise an individually planned repositioning schedule. However, Moore et al. 33 found that similar turning regimes resulted in a higher incidence of pressure ulcers than that in a regular repositioning frequency of every third hour, which may question this approach. Furthermore, the interval between repositionings varied greatly and in some cases was unacceptably long, up to 14 hours. All patients were at risk of pressure ulcer development, immobilised, and in need of regular repositioning. This highlights the importance of having a structured approach and pre‐planned individualised turning schedules that ensure that patients are repositioned within specified time frames.
Patients made a median of 16 spontaneous movements during the day and 10 during the night. An earlier study showed that patients making less than 20 spontaneous movements during the night were more likely to develop pressure ulcers 2. This implicates that in this study, approximately half of the patients had an increased risk of developing pressure ulcers because of too few spontaneous moments. Owing to changes in routines in clinical care over the years, and some methodological discrepancies between these studies, the relationship between immobile MOV and the incidence of pressure ulcers needs to be re‐evaluated in the context of today's nursing care.
There was a significant relationship between the patients' total RAPS scores and the frequency of the nursing staff's repositioning during the night. A low total RAPS score, indicating a high risk of pressure ulcer development, was associated with a higher repositioning frequency; a finding in accordance with previous research 34, 35. However, the patients' spontaneous movement frequency was not associated with the risk scores, indicating that some immobile patients assessed as low risk according to the RAPS scale may need to be repositioned as often as the patients assessed as high risk.
Analgesics had a positive impact on the patients' ability to move spontaneously during the night. Chronic pain is a major issue among older patients and, in addition to causing a decreased quality of life, it may lead to an increased risk of sleep disturbance and immobility 36, 37. Our results support that it is necessary to treat patients' pain adequately to increase their ability to reposition themselves. In contrast to analgesics, psycholeptics were significantly negatively correlated to the MOV at night. This is an important finding, because most of the older people are prescribed these medications 38. Notably, psycholeptics were negatively correlated with the nursing staff induced repositionings as well, indicating that the staff repositioned these patients less frequently than patients who are not using psycholeptics. From a pressure ulcer preventive perspective, this is unfortunate, as patients who are prescribed psycholeptics seem to need to be repositioned more frequently than other patients because of a lower frequency of spontaneous movements.
Interestingly, patients made few spontaneous movements while in a 0° supine position. This may contribute to an increased exposure to pressure at the same sites, especially over the sacrum and heels. It is possible that this position is too stable, so that the patients find it difficult to make minor movements by themselves. Because the sacrum and heels are the most common sites for pressure ulcers 18, 29, and our findings show that the patients spent much time on their back, it may be important to take this into account when repositioning patients into this position.
This study shows that within a patient group of elderly, immobilised patients who are at risk of pressure ulcer development, a sub‐group that cannot make minor spontaneous movements exists. Identifying patients in this sub‐group is of particular importance to nursing staff, because these patients very likely need more intensive repositioning interventions than others. In addition to the risk assessment and clinical judgement of the nursing staff, a device such as the MiS, with the alarm function turned on, might be a helpful tool, both to identify these fragile patients particularly at risk and also in decision making regarding the planning of repositioning frequencies and positions used. Because turning and repositioning requires the nursing staff efforts, a tool such as the MiS may also have the potential to enhance the clinical effectiveness by the fact that the nursing staff are targeting interventions where they are most needed.
Study considerations
The data collection was planned to last two and a half days to capture day‐to‐day variations in movement pattern if any, but this design resulted in some loss of data for reasons mentioned in Figure 2. If the sample size had been larger, a possible solution would have been to include only those with data for the whole period in the analysis. However, the amount of data was large; the 52 patients included generated 223 12‐hour periods. Furthermore, to minimise the effect of unequal measurement periods, each patient's REP and MOV data were calculated by dividing the REP and MOV by the number of complete 12‐hour periods of the individual.
Did the measurement with MiS affect ordinary nursing care? The MiS data were blinded for the staff. Furthermore, the long duration between some of the nursing staff induced repositionings indicates that this seems not to be the case.
Conclusion and relevance to nursing practice
There were large variations in the patients' spontaneous repositioning frequencies during both day and night, which shows that, although immobilised, some patients frequently reposition themselves while others do not. Analgesics were positively related to the movement frequency and psycholeptics were negatively related. The nursing staff more often repositioned patients who were assessed as high risk than those assessed as low risk, but the patients' spontaneous movement frequency was not correlated with the risk score. These findings may be important when planning repositioning schedules. A monitoring system may be helpful in the decision‐making process with regard to planning repositioning frequencies and positions used in the prevention of pressure ulcers among elderly immobile patients.
Acknowledgements
The authors thank the study participants for their patience and cooperation and the staff at the nursing homes and hospital for their contribution during the research project. Thanks to Photo media service, Södra Älvsborgs Hospital, Borås, Sweden, for help with photos; Kinematix, Porto, Portugal, for technical support and 3 M, Stockholm, Sweden, for adhesive dressings. This research project was funded by the Research Council Södra Älvsborg Borås Sweden; the Research Council Östergötland Linköping Sweden; the SwedBank Sjuhärad foundation for research at the Södra Älvsborg Hospital Borås Sweden; the Södra Älvsborgs Hospital Borås Sweden; the King Gustaf V and Queen Victoria's Freemason Foundation; Faculty of Health Science Linköping University, Linköping, Sweden. The authors state that that they have no conflicts of interest to declare.
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