Abstract
The aim of the study was to evaluate whether a multi‐faceted, unit‐tailored intervention using evidenced‐based pressure ulcer prevention affects (i) the performance of pressure ulcer prevention, (ii) the prevalence of pressure ulcers and (iii) knowledge and attitudes concerning pressure ulcer prevention among registered and assistant nurses. A quasi‐experimental, clustered pre‐ and post‐test design was used. Five units at a hospital setting were included. The intervention was based on the PARIHS framework and included a multi‐professional team, training and repeated quality measurements. An established methodology was used to evaluate the prevalence and prevention of pressure ulcers. Nurses' knowledge and attitudes were evaluated using a validated questionnaire. A total of 506 patients were included, of whom 105 patients had a risk to develop pressure ulcer. More patients were provided pressure ulcer prevention care (P = 0·001) and more prevention care was given to each patient (P = 0·021) after the intervention. Corresponding results were shown in the group of patients assessed as being at risk for developing pressure ulcers. Nurses' knowledge about pressure ulcer prevention increased (P < 0·001). Positive attitudes towards pressure ulcer prevention remained high between pre‐ and post‐test surveys. This multi‐faceted unit‐tailored intervention affected pressure ulcer prevention. Facilitation and repeated quality measurement together with constructed feedback of results seemed to be the most important factor for pressure ulcer prevention.
Keywords: Implementation, Nursing care, PARIHS, Pressure ulcer, Prevention
Introduction
Pressure ulcers cause substantial health burdens for the patient, for example constant pain and anxiety 1, 2. Pressure ulcers are common in hospital settings, and in Europe the prevalence ranges between 12% and 17% 3, 4, 5. The costs of treating pressure ulcers are high. The cost for healing one deep ulcer has been estimated between €9917 and €45 436 6.
Evidence‐based pressure ulcer prevention guidelines have been available for a long time 7, 8. The latest international guideline was published in 2009 9. Effective prevention consists of a set of strategies based on early risk and skin assessments. The prevention should focus on patients at risk and on reduction of the magnitude and duration of pressure on the skin by using higher specification foam mattresses 10, repositioning in bed and chair, protecting heels and using sliding sheets in bed 11. Although guidelines are available, knowledge among nurses has been described as insufficient 12, 13, and pressure ulcer prevention has been shown to be lacking 13, 14.
In Sweden, a national patient safety initiative was launched in 2008 by the Swedish Association of Local Authorities and Regions (SALAR) 15. One of the prioritised areas was pressure ulcer prevention. National goals was set and nation‐wide prevalence surveys were introduced and performed twice a year with public reporting and benchmarking of results. Furthermore, evidence‐based guidelines were disseminated to hospitals and community settings free of charge. Despite great efforts, the prevalence of pressure ulcers remains at 16% (n = 14 540) 14. Gunningberg et al. 5 conclude that strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.
A Cochrane review stated that there is a lack of research on key mechanisms for successful implementation of evidence 16. Relevant and applicable implementation theories can be supportive in different ways, for example in the development of an intervention 17, 18, 19. One important suggestion is to tailor the intervention to any barriers found 20.
The Promoting Action on Research Implementation in Health Service (PARIHS) framework was developed to encompass the complex nature of implementation by identifying positive and negative indicators of support or barriers in clinical practice. The framework describes three core components of implementation: (i) evidence (research, clinical practice, patient and local data), (ii) context (culture, leadership and evaluation) and (iii) facilitation (role and skill). Successful implementation occurs when evidence is robust, the context is receptive to change and the process of change is facilitated appropriately 19, 21.
To summarise, pressure ulcers are a well‐known problem in healthcare, and evidence‐based guidelines are available. Yet patients are suffering from pressure ulcers, and the healthcare costs are high. Thus, there is a need to increase knowledge about adequate implementation strategies related to pressure ulcer prevention. In one county council in Sweden, top management decided to implement evidence‐based pressure ulcer prevention at the hospital units. Therefore, the aim of this study was to evaluate whether a multi‐faceted, unit‐tailored intervention related to evidence‐based pressure ulcer prevention affects (i) the performance of pressure ulcer prevention, (ii) the prevalence of pressure ulcers and (iii) the knowledge and attitudes concerning pressure ulcer prevention among registered and assistant nurses.
Methods
Design
The study had a quasi‐experimental, clustered pre‐ and post‐test design. Five units in a hospital setting were included at different points in time (Figure 1).
Figure 1.
The process in time of inclusion, intervention and pre‐and post‐measurement for each unit.
The primary outcome was pressure ulcer prevention. Secondary outcomes were the prevalence of pressure ulcers and the nurses' knowledge and attitudes concerning pressure ulcer prevention.
Settings
The study was performed at a 344‐bed general hospital in Sweden. Three surgical and two medical units were included from January 2012 to June 2013. The units consisted of 18–26 patient beds. The staff consisted of 22–32 registered nurses (n = 169) (3 years higher education diploma, bachelor's degree) and 1–11 assistant nurses (n = 39) (upper secondary education). The registered nurses were responsible for nursing care, which includes establishment of care plans, evaluation and nursing documentation. It was primarily assistant nurses who carry out bedside work. A physiotherapist, occupational therapist and dietician support the registered and assistant nurses in daily work at the units. A guideline for pressure ulcer prevention, based on international 9 and national guidelines 22, was available at the hospital.
Sample
Patients
Adult patients (≥18 years), admitted to the units before midnight on the days when pressure ulcer prevalence surveys were conducted, were included. In total, 251 patients participated in the pre‐test and 255 in the post‐test surveys (Figure 2). Demographic data on the patients are presented in Table 1.
Figure 2.
Inclusion and exclusion of patients and nurses. (Values inside parentheses indicate percent participated.)
Table 1.
Demographic data on patients
| Total | At‐risk patients | |||
|---|---|---|---|---|
| Units (n = 5) | Pre‐test | Post‐test | Pre‐test | Post‐test |
| Gender | ||||
| Man, n (%) | 131 (52) | 122 (48)* | 31 (58) | 28 (54) |
| Women, n (%) | 120 (48) | 131 (52) | 22 (42) | 24 (46) |
| Age, mean (±SD) | 69 (±17) | 68 (±17) | 76 (±12) | 75 (±14) |
| Days at the hospital, mean (±SD) | 8·1 (±9·7) | 8·6 (±12) | 12 (±13) | 12 (±12) |
| Days at the unit, mean (±SD) | 7·3 (±8·7) | 7·8 (±11) | 11 (±13) | 9·4 (±9·6) |
| Risk patients (modified Norton ≤20), n (%) | 53 (21) | 52 (21) | NA† | NA† |
| Total modified Norton, mean (±SD) | 23 (±3·8) | 23 (±3·7) | 17·7 (±2·6) | 17·2 (±2·0) |
Two missing data on gender.
Not applicable.
Nurses
Nurses working at the units were invited to answer a knowledge and attitudes questionnaire. In total, 145 nurses participated in the pre‐test and 130 in the post‐test surveys (Figure 2). The participants' mean age was 39 ± 12 (mean ± SD), years in care 15 ± 11 and years at the unit 7 ± 7.
The study was designed to detect significant intervention effects within each unit separately. Calculations showed that, under the assumption that 40% of the at‐risk patients would receive prevention pre‐intervention and that 80% of the at‐risk patients would receive prevention post‐intervention, a sample of 22 risk patients would be required to reach a power of 80% at a 5% significance level. We estimated that performing measurements at three different days within each unit would yield the target number of risk patients. Analysis of the data showed that the improvement did not reach the estimated 80%; therefore, the units were analysed together to increase power.
Intervention
The PARIHS framework 19, 21 was prospectively applied in the development of the intervention. One or two contact nurses was appointed at each unit. A multi‐professional team was formed, which supported, taught and coached the units. The team consisted of one registered nurse (ES), one physiotherapist, one occupational therapist and one dietician. Barriers to evidence‐based pressure ulcer prevention in the organisation (using PARIHS) were identified by the team as lack of: knowledge and awareness, time for quality improvement work and equipment for pressure relief.
The intervention consisted of an introduction for the first‐line manager, 1‐day training for the nurses and monthly quality measurements with feedback (n = 6). The intervention for each unit is described in Figure 3, and details concerning activities, goals and the connection to PARIHS are presented in Table 2. Between 75% and 100% of the registered and assistant nurses at the units participated in the 1‐day training. Quality measurements were performed once in a month (n = 6) and included pressure ulcer preventions and prevalence of pressure ulcers (Figure 3). Data were registered in a tablet computer application, which allowed feedback on results to be given on the same day. The results were presented over time such that each patient's unique data could be seen. The team supported the nurses and first‐line managers, and the nurses could tailor the prevention and quality improvement needed at their units. These decisions were discussed and facilitated by the multi‐professional team.
Figure 3.
The process of the intervention for each unit.
Table 2.
Description of the intervention, the target group, activities done, who performed the activities, the goal and how the intervention was linked to the PARIHS framework
| Target group | Activities in the unit | Responsible | Goal | PARIHS |
|---|---|---|---|---|
| Introduction | ||||
| First‐line manager | Information/discussions of factors to consider for successful implementation (1 hour) | Team nurse |
To increase knowledge about implementation and the PARIHS framework To identify barriers to quality improvement To create good partnership/learning climate, manager and team |
E, C, F |
| RN/AN | One/two internal facilitators were identified and appointed | First‐line manager |
To facilitate implementation To lead and support staff with knowledge To work in partnership with first‐line manager and team |
C, F |
| Unit | Inventory of equipment for pressure ulcer prevention | Team members | To optimise and support prevention | C, F |
| One‐day training | ||||
| RN/AN | Discussions of the unit's routines regarding prevention | Team nurse | To create awareness of routines at the unit | E, C |
| RN/AN | Feedback on unit data on pressure ulcer prevention and prevalence of pressure ulcers | Team nurse |
To increase knowledge and awareness, and reflections on prevention and prevalence of pressure ulcers To create readiness for change |
E, C |
| RN/AN/first‐line manager | Lecture on evidence‐based pressure ulcer prevention combined with practical training | All team members |
To increase knowledge To reflect on routines/changes needed |
E C |
| RN/AN/first‐line manager | Recommendation for equipment available to reduce pressure on the skin |
Occupational therapist |
To increase staff's knowledge about adequate pressure‐reducing support surfaces in bed and in chair | E, C |
| Quality measurement and feedback: repeated once a month | ||||
| RN/AN/first‐line manager | Assessment of pressure ulcer prevalence and prevention once in a month (n = 6) |
Team nurse Contact nurse |
To implement and follow quality improvement To create awareness To create readiness for change |
C, F |
| Contact nurse/RN/AN | During quality measurement education, support and coaching related to evidence‐based prevention were provided | Team nurse |
To increase knowledge and the use of evidence‐based prevention in daily practice To create awareness To support changes in care routines To create readiness for change |
E, C, F |
| Contact nurse | Information to the RN and AN responsible for patients on patients' needs and prevention | Team nurse |
To create awareness among all RNs and ANs To increase knowledge To support changes in routines |
E, C, F |
| First‐line manager | Feedback on results on the same day |
Team nurse Contact nurse |
To create knowledge and awareness of performed prevention To create opportunity for first‐line manager to discuss prevention and changes needed |
E, C, F |
| RN/AN | Feedback on results together with discussions of quality improvement | First‐line manager |
To support first‐line manager in leading the quality improvement work To create readiness for change |
C |
E, evidence; C, context; F, facilitation; RN, registered nurses; AN, assistant nurses.
Data collection
Patients
A method for assessment of pressure ulcer prevalence outlined by the European Pressure Ulcer Advisory Panel (EPUAP) 3 was used. The method includes data collection on risk and skin assessments, observation of preventive activities at the bedside and a review of patients' records.
Patients at risk for developing pressure ulcers were assessed using the Modified Norton Scale, which consists of seven subscales: mental health, activity, mobility, food intake, liquid intake, incontinence and general physical condition. The subscales are scored 1 to 4: 1 indicating lack of function and 4 normal function. A total score of ≤ 20 is considered to indicate risk for developing pressure ulcers 23.
In this study, the definition of pressure ulcer prevention was as follows: (i) risk and skin assessment documented within 24 hours of admission to the unit, (ii) use of pressure redistributing material in bed and in chair, (iii) pressure relief/offload of heels, (iv) following a turning schedule in bed and in chair (having a turning schedule at the bedside), (v) use of sliding sheets in bed and (vi) use of other equipment to reduce pressure on the skin.
If a pressure ulcer was observed during the skin inspection, it was classified as category 1–4 9. A unit‐acquired pressure ulcer was defined as an observed pressure ulcer not documented in the patient record within 24 hours of admission to the unit.
Nurses
A questionnaire, Knowledge Assessment Tool (PUKAT) 24 and Attitudes towards Pressure ulcer (APuP) 25, was used. The questionnaire was previously translated to Swedish 12.
The knowledge questions include 26 items in six different domains: (i) etiology and development, (ii) classification and observation, (iii) nutrition, (iv) risk assessment, (v) reduction of the magnitude and (vi) reduction of the duration of pressure and shearing. The questions on attitudes towards pressure ulcer prevention include 13 items and cover the following domains: (i) personally competent to prevent pressure ulcers, (ii) priority of pressure ulcer prevention, (iii) impact of pressure ulcer, (iv) responsibility in pressure ulcer prevention and (v) confidence concerning the effectiveness of pressure ulcer prevention. A mean knowledge score of ≥60% and a mean attitudes score of ≥75% were considered acceptable 13.
Procedure
The intervention was tested at four units (which did not participate in this study). An evaluation was performed and some minor changes were made, for example more information about implementation to the first‐line management and specifying the role of the contact nurse. At study outset, permission to participate was obtained from the heads of department. Then, the team nurse gave the information to the first‐line managers, and thereafter the first‐line managers were responsible for informing nurses at the unit.
Patients
The data collection procedure followed at each unit was presented. For the pre‐test survey, pressure ulcer prevalence was measured on three different days at 2‐week intervals. These three pre‐tests were compiled and presented as one in the results. The same procedure was carried out for the post‐test survey. Data collection sessions were conducted by a skin expert nurse from the dermatology clinic at the hospital together with the unit's contact nurse. The skin expert nurse was the same person at all the units and had the role of being objective and deciding whether there were any disagreements during data collection.
The day before data collection, the patients received information about the study and gave their consent to participate. On the day of data collection, the expert nurse and the contact nurse visited each patient at the bedside, gathered data on risk and skin assessments and provided pressure ulcer prevention care. Afterwards, a review of patients' records was conducted.
Nurses
For the pre‐test, nurses who took part in the 1‐day training were invited to complete the questionnaires. Oral and written information about the study were given, and the questionnaires were completed before the onset of training. For the post‐test, the questionnaires were handed out by the first‐line management at each unit. Participants submitted their questionnaires to a person working in the education/research department at the hospital.
Data analysis
Statistical analyses were performed using SPSS 22.0 (SPSS Inc., Chicago, IL).
Patients
Logistic regression models were used to evaluate the intervention effect on dichotomous variables, with time point (pre‐ versus post‐intervention measurements) and unit as explanatory variables.
Nurses
The answer to each knowledge question was dichotomised (correct–incorrect). Missing data and duplicated answers were considered ‘incorrect’. A mean score was calculated by dividing the number of correct answers by the number of questions and multiplying by 100. Negatively worded attitude questions were reversed to obtain a total score, so that a higher score indicated more positive attitudes 25. The total score of attitude questions for each person was calculated, divided by the maximum total score and multiplied by 100. Incomplete/duplicate responses were replaced by the mean value for the respective questions. Between‐group differences were tested using Student's t‐test. The significance level was set at 0·05 (two tailed).
Ethical considerations
The study was approved by the Regional Ethical Review Board (Reg. no. 2011/397). Ethical standards for scientific work described in The Declaration of Helsinki and national and local ethical standards were followed 26. All patients and nurses received verbal and written information about the study, and were told that it was voluntary and that they could withdraw at any time. Both patients and nurses gave their written consent to participate.
Results
Patients
Results for the patients are first presented for the whole group, then for at‐risk patients (Table 3).
Table 3.
Pressure ulcer prevention and prevalence of pressure ulcers
| Total | At‐risk patients | |||||||
|---|---|---|---|---|---|---|---|---|
| Pre‐test (n = 251) | Post‐test (n = 255) | OR‡ (95% CI) | P‐value† | Pre‐test (n = 53) | Post‐test (n = 52) | OR‡ (95% CI) | P‐value† | |
| Prevention activities | n (%) | n (%) | n (%) | n (%) | ||||
| Patients with prevention* | 21 (8) | 46 (18) | 2·7 (1·6, 4·8) | <0·001 | 15 (29) | 27 (52) | 3·4 (1·4, 8·1) | 0·009 |
| Three or more prevention activities | 4 (1·6) | 13 (5·2) | 3·9 (1·2, 12·3) | 0·021 | 4 (7·8) | 13 (25) | 7·7 (1·8, 31·9) | 0·005 |
| Documented skin assessment | 200 (79) | 229 (90) | 2·3 (1·4, 3·9) | 0·002 | 44 (83) | 47 (90) | 1·9 (0·6, 6·5) | 0·311 |
| Documented risk assessment | 151 (60) | 211 (84) | 3·5 (2·2, 5·3) | <0·001 | 32 (60) | 45 (86) | 4·1 (1·4, 11·6) | 0·008 |
| Pressure‐reducing or power‐driven mattresses | 249 (99) | 254 (99) | 0·833 (0·14, 5·1) | 0·843 | 52 (98) | 51 (98) | 1·10 (0·60, 20·01) | 0·949 |
| Offloading on heels | 6 (2,4) | 36 (14) | 7·7 (3·1, 18·9) | <0·001 | 4 (7·8) | 17 (32) | 8·5 (2·3, 31·3) | 0·001 |
| Cushion in chair | 4 (1·6) | 6 (2·4) | 1·6 (0·4, 5·6) | 0·501 | 3 (5·9) | 6 (11) | 1·9 (0·4, 8·4) | 0·401 |
| Sliding sheet | 2 (0·8) | 10 (4·0) | 5·8 (1·2, 26·9) | 0·026 | 2 (3·9) | 10 (19) | 8·1 (1·6, 42·6) | 0·013 |
| Other equipment | 8 (3·2) | 6 (2·4) | 0·7 (0·3, 2·3) | 0·660 | 6 (12) | 6 (12) | 1·2 (0·3, 4·6) | 0·765 |
| Turning schedule in bed | 8 (3·2) | 8 (3·2) | 1·1 (0·4, 3·1) | 0·850 | 7 (14) | 8 (15) | 1·5 (0·4, 5·2) | 0·505 |
| Turning schedule in chair | 1 (0·4) | 0 | 0·0 (0·0) | 0·994 | 1 (1·9) | 0 | 0·0 (0·0) | 0·997 |
| Patients with pressure ulcer | ||||||||
| Categories 1–4 | 28 (11) | 29 (11) | 1·0 (0·6, 1·8) | 0·887 | 18 (34) | 18 (34) | 1·0 (0·4, 2·3) | 0·959 |
| Categories 2–4 | 15 (6·0) | 22 (8·7) | 1·5 (0·8, 3·0) | 0·240 | 11(21) | 14 (27) | 1·2 (0·5, 3·2) | 0·639 |
| Unit‐acquired PU categories 1–4 | 25 (8·4) | 23 (9·0) | 1·1 (0·6, 2·0) | 0·762 | 16 (30) | 15 (29) | 1·0 (0·4, 2·3) | 0·960 |
Offloading heels, preventive cushion in chair, sliding sheets in bed, turning schedule in bed and chair or other equipment.
Binary logistic regression.
Pre‐test used as reference time point.
Almost 100% of patients had pressure‐reducing mattresses both pre‐ and post‐intervention. In the group of all patients, significantly more patients had pressure ulcer prevention at post‐test (pressure‐reducing mattresses excluded) (18% versus 8%, P = 0·001). Significantly more prevention care for each patient was provided at post‐test (P = 0·021). While 5·2% of the patients received three or more prevention activities post‐intervention, the corresponding pre‐intervention figure was 1·6%. Risk and skin assessments documented within 24 hours of admission were performed significantly more often at post‐test. Furthermore, offload of heels was performed more often post‐intervention (P = 0·001), as was the use of sliding sheets in bed (P = 0·026). The prevalence of categories 1–4 ulcers was not significantly improved at post‐test (11% versus 11%), nor was the prevalence of categories 2–4 (8·7% versus 6·0%) or unit‐acquired pressure ulcers (9·0% versus 8·4%) (Table 3). In the pre‐test, 7 of 25 patients had unit‐acquired pressure ulcer categories 3–4, corresponding figure in the post‐test was 2 of 23 patients.
In the group of at‐risk patients, significantly more patients received pressure ulcer prevention care (pressure‐reducing mattresses excluded) (52% versus 29%, P = 0·009) and significantly more prevention care per patient were provided (P = 0·005) at post‐test. Moreover, risk assessments within 24 hours of admission were documented significantly more frequently (P = 0·008), and offload of heels was performed more frequently (P = 0·001), as was the use of sliding sheets in bed (P = 0·013), post‐intervention. The prevalence of pressure ulcers did not show any significant differences (Table 3). In the pre‐test, 4 of 16 patients had unit‐acquired pressure ulcer categories 3–4, and the corresponding figure in the post‐test was 0 of 15 patients.
Nurses
Nurses' knowledge about pressure ulcer prevention increased at post‐test (63% versus 57%, P = 0·001). At post‐test, registered nurses' mean knowledge scores were 64% versus 50% and assistant nurses' score were 59% versus 51%. The mean score for attitude questions was almost 90% at both pre‐ and post‐test Table 4.
Table 4.
Pressure ulcer knowledge and attitudes among registered nurses (RN) and assistant nurses (AN)
| Pre‐test (n = 145), mean (±SD) | Post‐test (n = 130), mean (±SD) | P‐value | |
|---|---|---|---|
| Knowledge score | |||
| RN and AN | 57 (±12) | 63 (±12) | <0.001* |
| RN | 60 (±11) | 64 (±11) | 0.003* |
| AN | 51 (±11) | 59 (±14) | 0.015* |
| Attitude score | |||
| RN + AN | 88 (±6.1) | 90 (±6.9) | 0.389* |
| RN | 89 (±6.1) | 90 (±6.6) | 0.197* |
| AN | 88 (±6.0) | 89 (±8.1) | 0.515* |
Student's t‐test.
Discussion
The results showed that pressure ulcer prevention was significantly improved between pre‐ and post‐tests, among the total group of patients and patients at risk. Improvement was observed in the following areas: risk and skin assessment, documentation within 24 hours of admission, offloading of heels and use of sliding sheets. Nurses' knowledge about pressure ulcer prevention increased between the tests.
The multi‐faceted unit‐tailored intervention performed in this study had a positive effect on pressure ulcer prevention. Repeated quality measurement and rapid feedback of results from the team nurse, who acted as a facilitator, were seen as essential to the intervention. Discussions between the team nurse, contact nurse and first‐line manager could take place directly after the quality measurement owing to the tablet computer application developed for the intervention. Graphs and statistics regarding patients could be discussed by the nurse(s) and first‐line manager. In this study, the first‐line manager's role was to lead the implementation based on results from the quality measurement. According to Kitson et al. 19, first‐line managers are a key component in successful implementation. Sullivan and Schoellers 27 discussed the importance of leadership in improving pressure ulcer prevention. Even if the first‐line manager is aware of the quality improvement needed, successful implementation is dependent on several other factors, such as teamwork based on democratic decisions, multiple sources of information and a learning organisation 19. It is also important to identify the barriers to the implementation process 20. It is possible that the first‐line managers in this study needed more support/knowledge concerning how to detect barriers and how to deal with any barriers found.
In this study, significant improvement was seen at post‐test in offloading of heels and use of sliding sheets. Focus on the use of correct equipment for pressure ulcer prevention was one of the activities discussed during the intervention. Adequate resources and equipment have previously been highlighted as a factor for successful implementation 19. No significant improvement was seen as a result of following turning schedules, although more patients were bedridden at post‐test. While making quality measurements at the units, the nurses argued that patients in need of repositioning would be repositioned anyway, with or without a turning schedule. This can be seen as the prevailing attitude towards turning schedules. In a study by Sving et al. 28, registered nurses reported trusting assistant nurses, who perform task‐driven pressure ulcer prevention without planning it. When prevailing attitudes towards the evidence are negative, this is described as a barrier to successful implementation in the form of a culture that does not support evidence‐based care 19.
The nurses' knowledge about pressure ulcer prevention increased significantly, from 57% at pre‐test to 63% at post‐test. More knowledge was acquired even though only 60% of the nurses in the post‐test had participated in the 1‐day training. Other multi‐faceted studies about education have shown small changes in knowledge acquired 29, 30. The 1‐day training used in this study was tailored to the specific needs of each unit and included practical training. It was complemented by continuing the training during every performed quality measurement. According to a Cochrane review, it is difficult to increase knowledge among health care professionals through, for example, lectures, workshops and seminars 31. Thus, it is important to consider duration of training and opinion of leaders and tailor the training to specific needs 20. The intervention in this study could have benefited more if it had been tailored specifically to the units.
Even if improvement of pressure ulcer prevention was achieved in this study, pressure ulcer prevention was still insufficient for at‐risk patients. Forty‐eight percent of at‐risk patients received only the single preventive activity of a pressure‐reducing mattress, which can be an explanation for the figures concerning the prevalence of pressure ulcers. Quality improvement of pressure ulcer prevention is therefore still needed. Implementing evidence‐based guidelines for pressure ulcer prevention involves all levels in the organisation, such as nursing care and leadership. The workplace culture, for example teamwork among professionals, needs to be incorporated into evidence‐based pressure ulcer prevention 28. New routines need to become the normal way of working 18. Establishing such conditions for improvement takes time.
Strength and limitations
This study was quasi‐experimental and had a pre‐ and post‐test design. The units were included at different points in time, which was a strength. A randomised study with a control group would have improved the design, but was not possible to conduct in our clinical setting. Pressure ulcer prevention is part of the national patient safety initiative, and action plans are required from all county councils. However, the research group had no influence over what units would be included and at what time.
Patients
The methodology outlined by EPAUP 3 is a standardised method for conducting pressure ulcer prevalence surveys. Comparing groups over a period of time using this methodology entails that patients in the pre‐ and post‐tests are not the same individuals.
Nurses
To increase the response rate, the questionnaires were not coded to allow questionnaire responses for each nurse to be compared pre‐ and post‐test, which was a limitation. Independent sample t‐tests were performed, assuming – erroneously – that the nurses performing the pre‐ and post‐test were completely independent of each other. In fact, approximately 60% of the participants performed the test on both occasions. The P‐values of these hypothesis tests should therefore be interpreted with caution. However, statistical dependence between an individual's pre‐ and post‐test results, generated by the partially paired design, should generate conservative independent sample t‐tests, that is the P‐values would have been lower if a paired analysis method had been used. The knowledge questions were incomplete/duplicate in 3% of the items, and the attitude questions were incomplete in 8% of the items, which could have affected the results. Many respondents also believe that the wording of the questions (PUKAT, APuP) was complicated.
A theoretical framework (PARIHS) was used in planning and evaluating the intervention, which was a strength. Giving more support to the first‐line managers, for example training on factors that facilitate successful implementation, would have strengthened the intervention. Increasing the length of the intervention period would have improved the results. The results could have also been affected by quality improvement work taking place at the national level.
Conclusion
The findings of this study showed that the multi‐faceted unit‐tailored intervention had an effect on pressure ulcer prevention. Significantly more patients received pressure ulcer prevention after the intervention, but the prevalence of pressure ulcers was unchanged. Nurses' knowledge about pressure ulcer prevention improved. Facilitation and repeated quality measurement together with immediate and constructed feedback of results seem to be important factors for improvement. It is essential to make thoughtful decisions about the best time to perform an evaluation after the onset of an intervention, as changing the workplace culture and establishing new routines take time. The PARIHS framework was useful in identifying areas of importance for implementation, and in planning and evaluating the intervention. More research evaluating different interventions aimed at implementing evidence‐based pressure ulcer prevention is still needed, not only on the effects of the interventions but also on why different interventions are or are not successful.
Acknowledgements
We want to thank all the units who participated in the intervention. Financial support for the study was provided by the Centre for Research & Development, Uppsala/County Council of Gävleborg and Uppsala–Örebro Regional Research Council in Sweden.
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